This is the current release of the guideline.

This guideline updates a previously version: American Diabetes Association. Diabetes care in the school and day care setting. Diabetes Care 2011 Jan;34(Suppl 1):S70-4. [36 references]

To provide recommendations for the management of children with diabetes in the school and day care settings

Children with diabetes who are in school and day care settings:

• Toddlers and preschool-aged children
• Elementary school–aged children
• Middle school– and high school–aged children

Management

1. Individualized diabetes medical management plan (DMMP), addressing:
   • Blood glucose monitoring
   • Insulin administration
   • Meals and snacks
   • Symptoms and treatment of hypoglycemia and hyperglycemia
   • Checking for and management of ketone levels
   • Participation in physical activity
   • Emergency evacuation instruction
2. Provision by the parent/guardian to the school or day care provider with the following:
   • All diabetes supplies and equipment (blood glucose monitoring, insulin administration, urine or blood ketone monitoring, logbook, source of glucose, glucagon emergency kit)
   • Information regarding diabetes and required tasks
   • The DMMP signed by the student's health care team
   • Emergency phone numbers
   • Student's meal/snack schedule
   • A signed release of confidentiality from the legal guardian
3. Provision by the school or day care provider
   • Staff training (levels 1, 2, and 3) and education regarding diabetes care, tasks, equipment usage, emergency management
   • Permissions and provisions to the student (privacy, access to help and supplies, food as needed, excused absences, storage of supplies, restroom privileges, etc.)
4. Student diabetic self-care as appropriate to age, experience, and developmental status and abilities
   • Self-monitoring of blood glucose in the classroom
   • Administration of insulin

Not stated

Not stated

American Diabetes Association's Evidence Grading System for Clinical Practice Recommendations

A

Clear evidence from well-conducted, generalizable randomized controlled trials (RCTs) that are adequately powered, including:

• Evidence from a well-conducted multicenter trial
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling nonexperimental evidence (i.e., "all or none" rule developed by the Centre for Evidence-Based Medicine at Oxford)

Supportive evidence from well-conducted RCTs that are adequately powered, including:

• Evidence from a well-conducted trial at one or more institutions
• Evidence from a meta-analysis that incorporated quality ratings in the analysis

B

Supportive evidence from well-conducted cohort studies, including:

• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study

C

Supportive evidence from poorly controlled or uncontrolled studies, including:

• Evidence from RCTs with one or more major or three or more minor methodological flaws that could invalidate the results
• Evidence from observational studies with high potential for bias (such as case series with comparison to historical controls)
• Evidence from case series or case reports

Conflicting evidence with the weight of evidence supporting the recommendation

E

Expert consensus or clinical experience

Not stated

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

The recommendations were reviewed and approved by the Professional Practice Committee and, subsequently, by the Executive Committee of the Board of Directors.

General Guidelines for the Care of the Child in the School and Day Care Setting

1. Diabetes Medical Management Plan

   An individualized diabetes medical management plan (DMMP) should be developed by the student's personal diabetes health care team with input from the parent/guardian. Inherent in this process are delineated responsibilities assumed by all parties, including the parent/guardian, the school personnel, and the student. These responsibilities are outlined in this position statement. In addition, the DMMP should be used as the basis for the development of written education plans such as the Section 504 Plan or the Individualized Education Program (IEP). The DMMP should address the specific needs of the child and provide specific instructions for each of the following:

   1. Blood glucose monitoring, including the frequency and circumstances requiring blood glucose checks, and use of continuous glucose monitoring if utilized
   2. Insulin administration (if necessary), including doses/injection times prescribed for specific blood glucose values and for carbohydrate intake, the storage of insulin, and, when appropriate, physician authorization of parent/guardian adjustments to insulin dosage
   3. Meals and snacks, including food content, amounts, and timing
   4. Symptoms and treatment of hypoglycemia (low blood glucose), including the administration of glucagon if recommended by the student's treating physician
   5. Symptoms and treatment of hyperglycemia (high blood glucose)
   6. Checking for ketones and appropriate actions to take for abnormal ketone levels, if requested by the student's health care provider
   7. Participation in physical activity
   8. Emergency evacuation/school lock-down instructions

   A sample DMMP (http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school/written-care-plans/diabetes-medical-management.html ) (see also the "Availability of Companion Documents" field) may be accessed online and customized for each individual student. For detailed information on the symptoms and treatment of hypoglycemia and hyperglycemia, refer to the American Diabetes Association (ADA) Medical Management of Type 1 Diabetes. A brief description of diabetes targeted to school and day care personnel is included in the appendix of the original guideline; it may be helpful to include this information as an introduction to the DMMP.

2. Responsibilities of the Various Care Providers
   1. The parent/guardian should provide the school or day care provider with the following:
      1. All materials, equipment, insulin, and other medication necessary for diabetes care tasks, including blood glucose monitoring, insulin administration (if needed), and urine or blood ketone monitoring. The parent/guardian is responsible for the maintenance of the blood glucose monitoring equipment (i.e., cleaning and performing controlled testing per the manufacturer's instructions) and must provide materials necessary to ensure proper disposal of materials. A separate logbook should be kept at school with the diabetes supplies for the staff or student to record blood glucose and ketone results; blood glucose values should be transmitted to the parent/guardian for review as often as requested. Some students maintain a record of blood glucose results in meter memory rather than recording in a logbook, especially if the same meter is used at home and at school.
      2. The DMMP completed and signed by the student's personal diabetes health care team
      3. Supplies to treat hypoglycemia, including a source of glucose and a glucagon emergency kit, if indicated in the DMMP
      4. Information about diabetes and the performance of diabetes-related tasks
      5. Emergency phone numbers for the parent/guardian and the diabetes health care team so that the school can contact these individuals with diabetes-related questions and/or during emergencies
      6. Information about the student's meal/snack schedule. The parent should work with the school during the teacher preparation period before the beginning of the school year or before the student returns to school after diagnosis to coordinate this schedule with that of the other students as closely as possible. For young children, instructions should be given for when food is provided during school parties and other activities.
      7. In most locations and increasingly, a signed release of confidentiality from the legal guardian will be required so that the health care team can communicate with the school. Copies should be retained both at the school and in the health care professionals' offices.
   2. The school or day care provider should provide the following:
      1. Opportunities for the appropriate level of ongoing training and diabetes education for the school nurse
      2. Training for school personnel as follows: level 1 training for all school staff members, which includes a basic overview of diabetes, typical needs of a student with diabetes, recognition of hypoglycemia and hyperglycemia, and who to contact for help; level 2 training for school staff members who have responsibility for a student or students with diabetes, which includes all content from level 1 plus recognition and treatment of hypoglycemia and hyperglycemia and required accommodations for those students; and level 3 training for a small group of school staff members who will perform student-specific routine and emergency care tasks such as blood glucose monitoring, insulin administration, and glucagon administration when a school nurse is not available to perform these tasks and which will include level 1 and 2 training as well.
      3. Immediate accessibility to the treatment of hypoglycemia by a knowledgeable adult. The student should remain supervised until appropriate treatment has been administered, and the treatment should be available as close to where the student is as possible.
      4. Accessibility to scheduled insulin at times set out in the student's DMMP as well as immediate accessibility to treatment for hyperglycemia including insulin administration as set out by the student's DMMP
      5. A location in the school that provides privacy during blood glucose monitoring and insulin administration, if desired by the student and family, or permission for the student to check his or her blood glucose level and to take appropriate action to treat hypoglycemia in the classroom or anywhere the student is in conjunction with a school activity, if indicated in the student's DMMP
      6. School nurse and back-up trained school personnel who can check blood glucose and ketones and administer insulin, glucagon, and other medications as indicated by the student's DMMP
      7. School nurse and back-up trained school personnel responsible for the student who will know the schedule of the student's meals and snacks and work with the parent/guardian to coordinate this schedule with that of the other students as closely as possible. This individual will also notify the parent/guardian in advance of any expected changes in the school schedule that affect the student's meal times or exercise routine and will remind young children of snack times.
      8. Permission for self-sufficient and capable students to carry equipment, supplies, medication, and snacks; to perform diabetes management tasks; and to have cell phone access to reach parent/guardian and health care provider
      9. Permission for the student to see the school nurse and other trained school personnel upon request
      10. Permission for the student to eat a snack anywhere, including the classroom or the school bus, if necessary to prevent or treat hypoglycemia
      11. Permission to miss school without consequences for illness and required medical appointments to monitor the student's diabetes management. This should be an excused absence with a doctor's note, if required by usual school policy.
      12. Permission for the student to use the restroom and have access to fluids (i.e., water) as necessary
      13. An appropriate location for insulin and/or glucagon storage, if necessary
      14. A plan for the disposal of sharps based upon an agreement with the student's family, local ordinances, and Universal Precaution Standards
      15. Information on serving size and caloric, carbohydrate, and fat content of foods served in the school

   The school nurse should be the key coordinator and provider of care and should coordinate the training of an adequate number of school personnel as specified above and ensure that if the school nurse is not present, at least one adult is present who is trained to perform these procedures in a timely manner while the student is at school, on field trips, participating in school-sponsored extracurricular activities, and on transportation provided by the school or day care facility. This is needed in order to enable full participation in school activities. These school personnel need not be health care professionals.

   It is the school's responsibility to provide appropriate training of an adequate number of school staff on diabetes-related tasks and in the treatment of diabetes emergencies. This training should be provided by the school nurse or another qualified health care professional with expertise in diabetes. Members of the student's diabetes health care team should provide school personnel and parents/guardians with educational materials from the ADA and other sources targeted to school personnel and/or parents. Table 1 in the original guideline document includes a listing of appropriate resources.

3. Expectations of the Student in Diabetes Care

   Children and youths should be allowed to provide their own diabetes care at school to the extent that is appropriate based on the student's development and his or her experience with diabetes. The extent of the student's ability to participate in diabetes care should be agreed upon by the school personnel, the parent/guardian, and the health care team, as necessary. The ages at which children are able to perform self-care tasks are variable and depend on the individual, and a child's capabilities and willingness to provide self-care should be respected.

   1. Toddlers and preschool-aged children: unable to perform diabetes tasks independently and will need an adult to provide all aspects of diabetes care. Many of these younger children will have difficulty in recognizing hypoglycemia, so it is important that school personnel are able to recognize and provide prompt treatment. However, children in this age range can usually determine which finger to prick, can choose an injection site, and are generally cooperative.
   2. Elementary school–aged children: depending on the length of diagnosis and level of maturity, may be able to perform their own blood glucose checks, but usually will require supervision. Older elementary school–aged children are generally beginning to self-administer insulin with supervision and understand the effect of insulin, physical activity, and nutrition on blood glucose levels. Unless the child has hypoglycemic unawareness, he or she should usually be able to let an adult know when experiencing hypoglycemia.
   3. Middle school– and high school–aged children: usually able to provide self-care depending on the length of diagnosis and level of maturity but will always need help when experiencing severe hypoglycemia. Independence in older children should be encouraged to enable the child to make his or her decisions about his or her own care.

   Students' competence and capability for performing diabetes-related tasks are set out in the DMMP and then adapted to the school setting by the school health team and the parent/guardian. At all ages, individuals with diabetes may require help to perform a blood glucose check when the blood glucose is low. In addition, many individuals require a reminder to eat or drink during hypoglycemia and should not be left unsupervised until such treatment has taken place and the blood glucose value has returned to the normal range. Ultimately, each person with diabetes becomes responsible for all aspects of routine care, and it is important for school personnel to facilitate a student in reaching this goal. However, regardless of a student's ability to provide self-care, help will always be needed in the event of a diabetes emergency.

Monitoring Blood Glucose in the Classroom

It is best for a student with diabetes to monitor blood glucose levels and to respond to the results as quickly and conveniently as possible. This is important to avoid medical problems being worsened by a delay in monitoring and treatment and to minimize educational problems caused by missing instruction in the classroom. Accordingly, as stated earlier, a student should be permitted to monitor his or her blood glucose level and take appropriate action to treat hypoglycemia and hyperglycemia in the classroom or anywhere the student is in conjunction with a school activity, if preferred by the student and indicated in the student's DMMP. However, some students desire privacy for blood glucose monitoring and other diabetes care tasks, and this preference should also be accommodated.

In summary, with proper planning and the education and training of school personnel, children and youth with diabetes can fully participate in the school experience. To this end, the family, the health care team, and the school should work together to ensure a safe learning environment.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

Not stated

Evidence is only one component of clinical decision-making. Clinicians care for patients, not populations; guidelines must always be interpreted with the needs of the individual patient in mind. Individual circumstances, such as comorbid and coexisting diseases, age, education, disability, and, above all, patients' values and preferences, must also be considered and may lead to different treatment targets and strategies. Also, conventional evidence hierarchies, such as the one adapted by the American Diabetes Association (ADA), may miss some nuances that are important in diabetes care. For example, while there is excellent evidence from clinical trials supporting the importance of achieving glycemic control, the optimal way to achieve this result is less clear. It is difficult to assess each component of such a complex intervention.

The original guideline document provides information that can be used in a school or day care setting, including: (1) background information on diabetes for school personnel (see the Appendix in the original guideline document) and (2) diabetes medical management plan (DMMP) (see also the "Availability of Companion Documents" field).

Not applicable: The guideline was not adapted from another source.

American Diabetes Association (ADA)

Not stated

Writing Group Members: William Clarke, MD; Larry C. Deeb, MD; Paula Jameson, MSN, ARNP, CDE; Francine Kaufman, MD; Georgeanna Klingensmith, MD; Desmond Schatz, MD; Janet H. Silverstein, MD; Linda M. Siminerio, RN, PhD, CDE

Not stated

This is the current release of the guideline.

This guideline updates a previously version: American Diabetes Association. Diabetes care in the school and day care setting. Diabetes Care 2011 Jan;34(Suppl 1):S70-4. [36 references]

Electronic copies: Available from the Diabetes Care Journal Web site .

Print copies: Available from American Diabetes Association, 1701 North Beauregard Street, Alexandria, VA 22311.

The following are available:

• Introduction. Diabetes Care 2012 Jan;35(Suppl 1):S1-S2.
• Diagnosis and classification of diabetes mellitus. Diabetes Care 2012 Jan;35(Suppl 1):S64-S71.

Electronic copies: Available from the Diabetes Care Journal Web site .

Print copies: Available from the American Diabetes Association, 1701 North Beauregard Street, Alexandria, VA 22311.

In addition, a sample Diabetes Medical Management Plan (DMMP) is available from the American Diabetes Association Web site .

A variety of American Diabetic Association (ADA) resources, including classroom lessons, legal and school safety information, written care plans, and school staff trainings are available for parents, children, and educators from the ADA Web site .

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

This summary was completed by ECRI on April 2, 2001. The information was verified by the guideline developer on August 24, 2001. This summary was updated by ECRI Institute on April 21, 2003, May 26, 2004, and May 17, 2010. The information was verified by the guideline developer on May 25, 2010. This summary was updated by ECRI Institute on February 24, 2011. This NGC summary was updated by ECRI Institute on May 10, 2012.

This NGC summary is based on the original guideline, which is copyrighted by the American Diabetes Association (ADA).

For information on guideline reproduction, please contact Alison Favors, Manager, Rights and Permissions by e-mail at permissions@diabetes.org.

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