Diabetes Care in the Very Young at School and Day Care Centers

By Sobha Kollipara, MD, FAAP

Diabetes is one of the most common diseases in school-aged children. About 186,300 young people in the US under age 20 had diabetes in 2007. This represents 0.2% of all people in this age group. About 15,000 new cases are found each year (Centers for Disease Central and Prevention, 2008). At the onset, parents learn to manage their child’s daily care. Their confidence level gradually increases over several months. As most children quickly return to school and day care centers, parents are also dependent on others to provide diabetes care. It is only with this help that families are able to resume their usual routines of work and school. The school nurse can be instrumental in helping a family provide their child with diabetes as normal a childhood as possible.

As parents learn to manage their child’s diabetes, their involvement in the child’s outside activities should be limited. We have witnessed parents volunteering as classroom aides, school lunch helpers, and playground marshals in order to continuously monitor their child with diabetes. This kind of involvement can stifle the child’s development and disrupt sibling and family relationships. Confidence in school staff and sharing responsibilities with family members should be stressed by the diabetes healthcare team. The school nurse can facilitate the sharing of the diabetes information between the parents and staff at schools and the day care centers.

While there are some general issues that affect all children with diabetes when away from home, some of these issues need special consideration by the staff that cares for these young children. The younger the child is, the greater impact these issues have on their diabetes. Most need frequent blood glucose monitoring and adjustments to their activities and eating behaviors to accomplish optimal blood glucose (BG) control (Golden, et al, 1985). Both the child and the parent have psychological and emotional stresses and barriers related to diabetes care in the out-of-home environment. Going to school or day care is a difficult transition for the parent and the child. Compared with children without diabetes, these children internalize their feelings of anxiety, fear, and/or depression stemming from the diabetes care tasks (Wysocki, et al, 1989).

Parental Concerns

• Hypoglycemia awareness and recognition by the staff providing the care
• Competency and the diabetes knowledge of the staff
• Ability and willingness of the child to express to the staff how they feel
• Child’s eating behavior out of the home
• Interaction and behavior with the other children
• Peer pressure and its effects
• Illnesses and the additional care needed
• How the child copes with being different from peers

Child’s Concerns

• Unwillingness to share personal/health information
• Inability to share medical needs with the staff
• Social shyness and maturity
• Feelings that they are different
• Fear of exclusion from school or day care activities.
• Confidence in the staff ’s ability to care for their diabetes
• Level of understanding about diabetes
• Parental and staff ’s approval of their behavior
• Coping with the responsibility of diabetes

Parents worry about their child being away from home and not being able to care for their child’s diabetes. The child may feel insecure without the support of the parent. It is essential for the school nurse and child care staff to recognize these parental and children’s concerns and address them at the outset to alleviate the child’s and the parental anxiety.

Guidelines for the General Issues

The school and the day care staff should be willing and open to make accommodations for the needs of the child. They need to have empathy regarding the rigors of diabetes care and understand its complexity. Staff also need to be vigilant of how these children are treated by their peers, encourage understanding, and not tolerate negative peer pressure. The children and parents need the assurance that the child will be safe. The child needs encouragement to share feelings freely with staff. Dietary needs and special events should be discussed and updated with the parents. Diabetes care plan discussions should be facilitated by the school nurse annually and updated as needs change. Staff should have open communication with the school nurse or directly with the healthcare team. Written parental permission for the school nurse or staff to communicate with the healthcare team should be included in the plan.

Guidelines for Specific Issues

Guidelines are essential for the provision of safe and optimal diabetes care for these young children. Parents, with the help of the diabetes care team and the school nurse should provide the needed medical information. This information should be on the child’s medical management form (ADA, 2008 and NIH, 2003).

The Primary Care Provider Role

This should include (ADA, 2008 and NIH, 2003):

• The technique, timing and the frequency of BG testing
• Insulin injections, technique and timing
• Optimal meals/snack times and adjustments
• Hypoglycemia recognition and treatment
• When and how to use glucagon
• When and whom to call if the child has problems
• Information on how to reach the child’s diabetes care team
• Clearly written medical information that addresses the above

To have an optimal and practical diabetes care plan, all of the parties involved in the care of the child will need to share the responsibility (ADA, 2008).

The Parental Role

• Review with the child care staff about BG testing, insulin injections and the use of glucagon
• Supply all of the equipment as needed to the school or the day care.
• Provide hypoglycemia treatment supplies (glucose tablets/gel/quick sugar/glucagon )
• Provide instructions in case the child refuses to eat or finish meals
• Indicate how to reach the parent/ guardian/healthcare team
• Provide instructions on physical activities and the insulin and food changes needed
• Share resources and written diabetes information for staff education

The School Nurse or Child Care Staff Role

• Train all staff about hypoglycemia and its treatment
• Recognize the child’s needs for additional snacks for hypoglycemia treatment
• Allow the child to check BG as needed in a safe place (if able)
• Allow the child to use the restroom facility as needed
• Teach staff how to check BG and inject insulin if permitted by your state’s Nurse Practice Act
• Provide adult supervision at meal times
• Facilitate the child’s participation in all school extra curricular activities
• Obtain a written diabetes care plan from the healthcare team

Child’s Role and Responsibilities

Unlike the older child, the preschoolers and some elementary school-aged children are unable to manage their diabetes without adult supervision. Young children, age four and above, can only be expected to:

• Cooperate with the required diabetes care tasks
• Express their needs to the staff

Special Clinical Issues in Diabetes Care

1. Children on insulin pumps. In the recent years, younger children with type 1 diabetes are being treated with insulin pumps. Studies have shown that pump therapy improves metabolic control and especially lowers the incidence of hypoglycemia in young children. This contributes to significant reduction in parental stress (Opipari-Arrigan et. al, 2007). Pump use requires additional knowledge on the part of the child care staff. While insulin pump use lowers parental anxiety about their child’s risk of low BG, they may feel stress about the child care staff ’s knowledge. This imposes additional responsibility on the school nurse and child care staff. The school nurse needs to take an active role to educate staff regarding the basics of insulin pump use.
2. Hypoglycemia and cognition. Low BG has a deleterious effect on cognition that causes both acute and long-term problems in young children, especially children less than age five (Hershey et. al, 2005). Existing data support that in young children, BG levels should be maintained in a safe (higher) range to avoid low BG (Lteif, et. al, 1999). Younger children are unable to feel and express the symptoms of low BG. Child care staff must understand how important it is to avoid low BG. The use of insulin pumps and multiple daily insulin doses tailored to carbohydrate intake and physical activity have lessened the potential risk for low BG in young children.
3. Care during an illness. Diabetes control may be affected adversely from the added stress of acute illness and the child will need immediate, additional care. If a child becomes ill, the staff should be able to initiate:
   • additional frequent blood glucose monitoring
   • insulin dosing per blood glucose levels
   • increased fluid intake

An individual sick day plan (Gray et. al, 1991) should be part of the school plan and the school nurse should make sure that it is understood and being followed.

Diabetes Care and The Public Law

There are many federal laws that facilitate the care of the children with diabetes. These include 504 of the Rehabilitation Act, Individuals with Disabilities Education Act and the American with Disabilities Act. Under all of these it is illegal to discriminate against children with diabetes (ADA, 2008). All public schools and day care facilities that receive federal support should meet the medical needs of these children. Yet some schools and day care centers refuse to make accommodations. Barriers that may affect the care of these children are often liability-based and concern the lack of consensus about staff training such as who to train and how much training is needed. States may have different amendments, some providing schools immunity from civil liability (Gray et. al, 1991). State laws may prohibit child care centers from providing services such as insulin injections. According to these laws, the child care staff may use skilled health professionals, parents, or parent authorized persons to give insulin injections.

Because of these limitations, many parents teach their children older than six to use insulin pen devices with staff supervision and dose guidelines. Children who are unable to do this or are less than age 6 may be on insulin regimens that omit a lunchtime insulin dose. A more difficult option is to ask parents to come to inject the insulin. Many parents have opted to take advantage of the 504 plan (NIH, 2003) under which the school or day care center will provide a licensed healthcare person for insulin injections.

Summary

Care of the young child with diabetes away from home is very stressful for parents. Parents must have confidence in child care staff to manage their child’s diabetes in their absence. Young children are vulnerable and lack the maturity to understand their diabetes care needs and depend on other adults when away from home. It is crucial that school or day staff have a clear, written individualized plan and understand the components of care. It is the opinion of the author that it would be ideal to have laws or amendments that allow well-trained child care staff to provide medical services to all young children with diabetes. The school nurse plays a pivotal role in helping these young children with diabetes have as normal a childhood as possible.

REFERENCES

ADA Position Statement. (2008). Diabetes Care in the School and Day care setting. Diabetes Care, vol. 31.

Centers for Disease Control and Prevention (2007). 2008 National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the U.S.

Golden, M.P., Russell, B.P., Ingersoll, G.M., Gray, D.L., and Hummer, K.M. (1985). Management of diabetes mellitus in children younger than 5 years of age. Am J Dis Child, 139(5), 448-452.

Gray, D.L., Golden, M.P., and Reiswerg, J. (1991). Diabetes care in schools: benefits and pitfalls of Public Law 94-142, Diabetes Educ, 17(1), 33-36.

Hershey, T., Perantie, D.C., Warren, S.L., Zimmerman, E.C., Sadler, M., and White, N.H. (2005). Frequency and timing of severe hypoglycemia affects spatial memory in children with type 1 diabetes. Diabetes Care, 28(10), 2372-2377.

Lteif, A.N., and Schwenk, W.F. (1999). Type 1 diabetes mellitus in early childhood: glycemic control and associated risk of hypoglycemic reactions. Mayo Clin Proc,74(3), 211-216.

NIH Publication. (2003). National Diabetes Education Program: Helping Student with Diabetes Succeed: A Guide for School Personnel. (NIH Publication no. 03-5127).

Opipari-Arrigan, L., Fredericks, E.M., Burkhart, N., Dale, L., Hodge, M., and Foster, C. (2007). Continuous subcutaneous insulin infusion benefits quality of life in preschool-age children with type 1 diabetes mellitus. Pediatr Diabetes, 8(6), 377-383.

Wysocki, T., Huxtable, K., Linscheid, T.R., and Wayne, W. (1989). Adjustment to diabetes mellitus in preschoolers and their mothers. Diabetes Care, 12(8), 524-529.

ABOUT THE AUTHOR

Sobha Kollipara, MD, FAAP is the Director of Pediatric Endocrinology and Diabetes at the Kaiser Permanente Medical Center in Sacramento, CA. Dr. Kollipara is a member of the National Diabetes Education Program’s Diabetes in Children and Adolescent Work Group.

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