INTRODUCTION
Diabetes is one of the most common chronic diseases of childhood. There are about 176,000 individuals <20 years of age with diabetes in the U.S. The majority of these young people attend school and/or some type of day care and need knowledgeable staff to provide a safe school environment. Both parents and the health care team should work together to provide school systems and day care providers with the information necessary to allow children with diabetes to participate fully and safely in the school experience.
DIABETES AND THE LAW
Federal laws that protect children with diabetes include Section 504 of the Rehabilitation Act of 1973, the Individuals with Disabilities Education Act of 1991 (originally the Education for All Handicapped Children Act of 1975), and the Americans with Disabilities Act. Under these laws, diabetes has been considered to be a disability, and it is illegal for schools and/or day care centers to discriminate against children with disabilities. In addition, any school that receives federal funding or any facility considered open to the public must reasonably accommodate the special needs of children with diabetes. Indeed, federal law requires an individualized assessment of any child with diabetes. The required accommodations should be provided within the child??glycemic control decreasing the risk of these complications. To achieve glycemic control, a child must monitor blood glucose frequently, follow a meal plan, and take medications. Insulin is usually taken in multiple daily injections or through an infusion pump. Crucial to achieving glycemic control is an understanding of the effects of physical activity, nutrition therapy, and insulin on blood glucose levels.
To facilitate the appropriate care of the student with diabetes, school and day care personnel must have an understanding of diabetes and must be trained in its management and in the treatment of diabetes emergencies. Knowledgeable trained personnel are essential if the student is to avoid the immediate health risks of low blood glucose and to achieve the metabolic control required to decrease risks for later development of diabetes complications. Studies have shown that the majority of school personnel have an inadequate understanding of diabetes and that parents of children with diabetes lack confidence in their teachers??hool are universally available to all school personnel.
The purpose of this position statement is to provide recommendations for the management of children with diabetes in the school and day care setting.
GENERAL GUIDELINES FOR THE CARE OF THE CHILD IN THE SCHOOL AND DAY CARE SETTING
I. Diabetes Medical Management Plan
An individualized Diabetes Medical Management Plan should be developed by the parent/ guardian and the student??d glucose).
6. Checking for ketones and appropriate actions to take for abnormal ketone levels, if requested by the student??cies.
5. Information about the student??ossible.
3. If indicated by the child??ary to prevent or treat hypoglycemia.
9. Permission to miss school without consequences for required medical appointments to monitor the student??school staff on diabetes-related tasks and in the treatment of diabetes emergencies. This training should be provided by health care professionals with expertise in diabetes unless the student??g/Sept. 2002, Vol. 1, No. 1, 330-678-1601.
* Your School & Your Rights: Protecting Children with Diabetes Against Discrimination in Schools and Day Care Centers, Alexandria, VA, American Diabetes Association, 2001 (brochure); available online at http://www.diabetes.orgype1/parents_kids/away/scrights.jsp.*
* Your Child Has Type 1 Diabetes: What You Should Know, Alexandria, VA, American Diabetes Association, 2001 (brochure); available online at http://www.diabetes.org/main/community/advocacyype1.jsp.*
* Treating Diabetes Emergencies: What You Need to Know, Alexandria, VA, American Diabetes Association, 1995 (video); 1-800-232-6733.
* American Diabetes Association: Complete Guide to Diabetes, Alexandria, VA, American Diabetes Association, 2005; 1-800-232-6733.
* Raising a Child with Diabetes: A Guide for Parents, Alexandria, VA, American Diabetes Association, 2000; 1-800-232-6733.
* Clarke W: Advocating for the child with diabetes. Diabetes Spectrum 12:230??on and select resources available at http://www.diabetes.org/wizdom.
* The Care of Children with Diabetes in Child Care and School Setting (video); available from, Managed Design, Inc., P.O. Box 3067, Lawrence, KS 66046, (785) 842-9088.
* Fredrickson L, Griff M: Pumper in the School, Insulin Pump Guide for School Nurses, School Personnel and Parents. MiniMed Professional Education, Your Clinical Coach. First Edition, May 2000. MiniMed, Inc., 1-800-440-7867.
* Tappon D. Parker M, Bailey W: Easy As ABC, What You Need to Know About Children Using Insulin Pumps in School. Disetronic Medical Systems, Inc., 1-800-280-7801.
* These documents are available in the American Diabetes Association??f-care should be respected.
1. Preschool and day care. The preschool child is usually unable to perform diabetes tasks independently. By 4 years of age, children may be expected to generally cooperate in diabetes tasks.
2. Elementary school. The child should be expected to cooperate in all diabetes tasks at school. By age 8 years, most children are able to perform their own fingerstick blood glucose tests with supervision. By age 10, some children can administer insulin with supervision.
3. Middle school or junior high school. The student should be able to administer insulin with supervision and perform self-monitoring of blood glucose under usual circumstances when not experiencing a low blood glucose level.
4. High school. The student should be able to perform self-monitoring of blood glucose under usual circumstances when not experiencing low blood glucose levels. In high school, adolescents should be able to administer insulin without supervision.
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.
MONITORING BLOOD GLUCOSE IN THE CLASSROOM
It is best for a student with diabetes to monitor a blood glucose level 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 reatment 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 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 main energy source??dent with this degree of hypoglycemia will need to ingest carbohydrates promptly and may require assistance. Severe hypoglycemia, which is rare, may lead to unconsciousness and convulsions and can be life-threatening if not treated promptly.
High blood glucose (hyperglycemia) occurs when the body gets too little insulin, too much food, or too little exercise; it may also be caused by stress or an illness such as a cold. The most common symptoms of hyperglycemia are thirst, frequent urination, and blurry vision. If untreated over a period of days, hyperglycemia can cause a serious condition called diabetic ketoacidosis (DKA), which is characterized by nausea, vomiting, and a high level of ketones in the blood and urine. For students using insulin infusion pumps, lack of insulin supply may lead to DKA more rapidly. DKA can be life-threatening and thus requires immediate medical attention.
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AMERICAN DIABETES ASSOCIATION
DIABETES CARE, VOLUME 27, SUPPLEMENT 1, JANUARY 2004
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