Care of Children With Diabetes in theSchool and Day Care SettingAMERICAN DIABETES ASSOCIATION

D iabetes is one of the most commonchronic diseases of childhood, witha prevalence of �1.7 affected indi-

viduals per 1,000 people aged �20 years(1–4). In the U.S., �13,000 new cases arediagnosed annually in children (4 –7).There are about 125,000 individuals �19years of age with diabetes in the U.S. (8).The majority of these young people attendschool and/or some type of day care andneed knowledgeable staff to provide a safeschool environment (9–12). Both parentsand the health care team should work to-gether to provide school systems and daycare providers with the information nec-essary to allow children with diabetes toparticipate fully and safely in the schoolexperience.

DIABETES ANDTHE LAW — Federal laws that protectchildren with diabetes include Section504 of the Rehabilitation Act of 1973, theIndividuals with Disabilities EducationAct of 1991 (originally the Education forAll Handicapped Children Act of 1975),and the Americans with Disabilities Act.Under these laws, diabetes has been con-sidered to be a disability, and it is illegalfor schools and/or day care centers to dis-criminate against children with disabili-ties. In addition, any school that receivesfederal funding or any facility consideredopen to the public must reasonably ac-commodate the special needs of childrenwith diabetes. Indeed, federal law re-quires an individualized assessment ofany child with diabetes. The required ac-commodations should be providedwithin the child’s usual school setting

with as little disruption to the school’sand the child’s routine as possible and al-lowing the child full participation in allschool activities.

Despite these protections, children inthe school and day care setting still facediscrimination. For example, some daycare centers may refuse admission to chil-dren with diabetes, and children in theclassroom may not be provided the assis-tance necessary to monitor blood glucoseand may be prohibited from eatingneeded snacks. The American DiabetesAssociation works to ensure the safe andfair treatment of children with diabetes inthe school and day care setting (13–15).

Diabetes care in schoolsAppropriate diabetes care in the schooland day care setting is necessary for thechild’s immediate safety, long-term wellbeing, and optimal academic perfor-mance. The Diabetes Control and Com-plications Trial showed a significant linkbetween blood glucose control and thelater development of diabetes complica-tions, with improved glycemic control de-creasing the risk of these complications(16,17). To achieve glycemic control, achild must monitor blood glucose fre-quently, follow a meal plan, and takemedications. Insulin is usually taken inmultiple daily injections or through an in-fusion pump. Crucial to achieving glyce-mic control is an understanding of theeffects of physical activity, nutrition ther-apy, and insulin on blood glucose levels.

To facilitate the appropriate care ofthe student with diabetes, school and daycare personnel must have an understand-

ing of diabetes and must be trained in itsmanagement and in the treatment of dia-betes emergencies. Knowledgeabletrained personnel are essential if the stu-dent is to avoid the immediate health risksof low blood glucose and to achieve themetabolic control required to decreaserisks for later development of diabetescomplications. Studies have shown thatthe majority of school personnel have aninadequate understanding of diabetes andthat parents of children with diabetes lackconfidence in their teachers’ ability tomanage diabetes effectively (12,18,19).Consequently, diabetes education mustbe targeted toward day care providers,teachers, and other school personnel whointeract with the child, including schooladministrators, school coaches, schoolnurses, health aides, bus drivers, secretar-ies, etc.

The purpose of this position state-ment is to provide recommendations forthe management of children with diabetesin the school and day care setting.

GENERAL GUIDELINES FORTHE CARE OF THE CHILD INTHE SCHOOL AND DAY CARESETTING

I. Diabetes Health Care PlanAn individualized Diabetes Health CarePlan should be developed by the parent/guardian, the student’s diabetes careteam, and the school or day care provider.Inherent in this process are delineated re-sponsibilities assumed by all parties, in-cluding the parent/guardian, the schoolpersonnel, and the student. These re-sponsibilities are outlined in this positionstatement. The Diabetes Health Care Planshould address the specific needs of thechild and provide specific instructions foreach of the following:

1. Blood glucose monitoring, includingthe frequency and circumstances re-quiring testing.

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The recommendations in this paper are based on the evidence reviewed in the following publications:Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes onthe development and progression of long-term complications in insulin-dependent diabetes mellitus. N EnglJ Med 329:977–986, 1993; and Diabetes Control and Complications Trial Research Group: The effect ofintensive diabetes treatment on the development and progression of long-term complications in adolescentswith insulin-dependent diabetes mellitus. J Pediatr 125:177–188, 1994.

The initial draft of this paper was prepared by Georgeanna Klingensmith, MD, Francine Kaufman, MD,Desmond Schatz, MD, and William Clarke, MD. The paper was peer-reviewed, modified, and approved by theProfessional Practice Committee and the Executive Committee, November 1998. Most recent review/ revi-sion, 2000.

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2. Insulin administration (if necessary),including doses/injection times pre-scribed for specific blood glucose val-ues and the storage of insulin.

3. Meals and snacks, including food con-tent, amounts, and timing.

4. Symptoms and treatment of hypogly-cemia (low blood glucose), includingthe administration of glucagon if rec-ommended by the student’s treatingphysician.

5. Symptoms and treatment of hypergly-cemia (high blood glucose).

6. Testing for ketones and appropriateactions to take for abnormal ketonelevels, if requested by the student’shealth care provider.

Figure 1 includes a sample DiabetesHealth Care Plan. For detailed informa-tion on the symptoms and treatment ofhypoglycemia and hyperglycemia, referto the Medical Management of Type 1 Dia-betes (20). A brief description of diabetestargeted to school and day care personnelis included in the APPENDIX; it may be help-ful to include this information as an intro-duction to the Diabetes Health Care Plan.

II. Responsibilities of the variouscare providers

A. The parent/guardian should providethe school or day care provider withthe following:

1. All materials and equipment neces-sary for diabetes care tasks, includingblood glucose testing, insulin admin-istration (if needed), and urine orblood ketone testing. The parent/guardian is responsible for the main-tenance of the blood glucose testingequipment (i.e., cleaning and per-forming controlled testing per themanufacturer’s instructions) andmust provide materials necessary toensure proper disposal of materials.A separate logbook should be kept atschool with the diabetes supplies forthe staff or student to record test re-sults; blood glucose values should betransmitted to the parent/guardianfor review as often as requested.

2. Supplies to treat hypoglycemia, in-cluding a source of glucose and a glu-cagon emergency kit, if indicated inthe Diabetes Health Care Plan.

3. Information about diabetes and theperformance of diabetes-related tasks.

4. Emergency phone numbers for theparent/guardian and the diabetes careteam so that the school can contactthese individuals with diabetes-relatedquestions and/or during emergencies.

5. Information about the student’s meal/snack schedule. The parent shouldwork with the school to coordinatethis schedule with that of the otherstudents as closely as possible. Foryoung children, instructions shouldbe given for when food is providedduring school parties and other activ-ities.

B. The school or day care providershould provide the following:

1. Training to all adults who provideeducation/care for the student on thesymptoms and treatment of hypogly-cemia and hyperglycemia and otheremergency procedures. An adult andback-up adult(s) trained to 1) per-form fingerstick blood glucose mon-itoring and record the results; 2) takeappropriate actions for blood glucoselevels outside of the target ranges asindicated in the student’s DiabetesHealth Care Plan; and 3) test theurine or blood for ketones, whennecessary, and respond to the resultsof this test.

2. Immediate accessibility to the treat-ment of hypoglycemia by a knowl-edgeable adult. The student shouldremain supervised until appropriatetreatment has been administered,and the treatment should be availableas close to where the student is aspossible.

3. If indicated by the child’s develop-mental capabilities and the DiabetesHealth Care Plan, an adult andback-up adult(s) trained in insulinadministration.

4. An adult and back-up adult(s)trained to administer glucagon, in ac-cordance with the student’s DiabetesHealth Care Plan.

5. A location in the school to provideprivacy during testing and insulin ad-ministration, if desired by the stu-dent and family, or permission forthe student to check his or her bloodglucose level and to take appropriateaction to treat hypoglycemia in theclassroom or anywhere the student isin conjunction with a school activity,

if indicated in the student’s DiabetesHealth Care Plan.

6. An adult and back-up adult(s) re-sponsible for the student who willknow the schedule of the student’smeals and snacks and work with theparent/guardian to coordinate thisschedule with that of the other stu-dents as closely as possible. This in-dividual also will notify the parent/guardian in advance of any expectedchanges in the school schedule thataffect the student’s meal times orexercise routine. Young childrenshould be reminded of snack times.

7. Permission for the student to seeschool medical personnel upon re-quest.

8. Permission for the student to eat asnack anywhere, including the class-room or the school bus, if necessaryto prevent or treat hypoglycemia.

9. Permission to miss school withoutconsequences for required medicalappointments to monitor the stu-dent’s diabetes management. Thisshould be an excused absence with adoctor’s note, if required by usualschool policy.

10. Permission for the student to use therestroom and have access to fluids(i.e., water) as necessary.

11. An appropriate location for insulinand/or glucagon storage, if necessary.

An adequate number of school per-sonnel should be trained in the necessarydiabetes procedures (e.g., blood glucosemonitoring, insulin and glucagon admin-istration) and in the appropriate responseto high and low blood glucose levels toensure that at least one adult is present toperform these procedures in a timelymanner while the student is at school, onfield trips, and during extracurricular ac-tivities or other school-sponsored events.These school personnel need not behealth care professionals.

The student with diabetes shouldhave immediate access to diabetes sup-plies at all times, with supervision asneeded. Provisions similar to those de-scribed above must be available for fieldtrips, extracurricular activities, otherschool-sponsored events, and on trans-portation provided by the school or daycare facility to enable full participation inschool activities.

It is the school’s legal responsibility toprovide appropriate training to school

Position Statement

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Figure 1—Diabetes Health Care Plan.

Diabetes in School and Day Care

DIABETES CARE, VOLUME 26, SUPPLEMENT 1, JANUARY 2003 S133

staff on diabetes-related tasks and in thetreatment of diabetes emergencies. Thistraining should be provided by healthcare professionals with expertise in diabe-tes unless the student’s health care pro-vider determines that the parent/guardianis able to provide the school personnelwith sufficient oral and written informa-tion to allow the school to have a safe andappropriate environment for the child. Ifappropriate, members of the health careteam should provide instruction and ma-terials to the parent/guardian to facilitatethe education of school staff. Educationalmaterials from the American Diabetes As-sociation and other sources targeted toschool personnel and/or parents are avail-able. Table 1 includes a listing of appro-priate resources.

III. Expectations of the student indiabetes careChildren and youths should be able toimplement their diabetes care at schoolwith parental consent to the extent that isappropriate for the student’s develop-

ment and his or her experience with dia-betes. The extent of the student’s ability toparticipate in diabetes care should beagreed upon by the school personnel, theparent/guardian, and the health careteam, as necessary. The ages at whichchildren are able to perform self-caretasks are very individual and variable, anda child’s capabilities and willingness toprovide self-care should be respected.

1. Preschool and day care. The preschoolchild is usually unable to perform di-abetes tasks independently. By 4 yearsof age, children may be expected togenerally cooperate in diabetes tasks.

2. Elementary school. The child should beexpected to cooperate in all diabetestasks at school. By age 8 years, mostchildren are able to perform their ownfingerstick blood glucose tests with su-pervision. By age 10, some childrencan administer insulin with supervi-sion.

3. Middle school or junior high school. Thestudent should be able to administer

insulin with supervision and performself-monitoring of blood glucose un-der usual circumstances when not ex-periencing a low blood glucose level.

4. High school. The student should be ableto perform self-monitoring of bloodglucose under usual circumstanceswhen not experiencing low blood glu-cose levels. In high school, adolescentsshould be able to administer insulinwithout supervision.

At all ages, individuals with diabetesmay require help to perform a blood glu-cose test when the blood glucose is low. Inaddition, many individuals require a re-minder to eat or drink during hypoglyce-mia and should not be left unsuperviseduntil such treatment has taken place andthe blood glucose value has returned tothe normal range.

MONITORING BLOODGLUCOSE IN THECLASSROOM — It is best for a stu-dent with diabetes to obtain a blood glu-cose level and to respond to the results asquickly and conveniently as possible.This is important to avoid medical prob-lems being worsened by a delay in testing/treatment and to minimize educationalproblems caused by missing instructionin the classroom. Accordingly, as statedearlier, a student should be permitted tomonitor his or her blood glucose level andtake appropriate action to treat hypogly-cemia in the classroom or anywhere thestudent is in conjunction with a schoolactivity, if preferred by the student andindicated in the student’s Diabetes HealthCare Plan. However, some students desireprivacy during testing and this preferenceshould also be accommodated.

In summary, with proper planning andthe education and training of school per-sonnel, children and youth with diabetescan fully participate in the school experi-ence. To this end, the family, the healthcare team, and the school should worktogether to ensure a safe learning environ-ment.

APPENDIX: BACKGROUNDINFORMATION ONDIABETES FOR SCHOOLPERSONNEL — Diabetes is a serious,chronic disease that impairs the body’sability to use food. Insulin, a hormoneproduced by the pancreas, helps the body

Table 1—Resources for teachers, child care providers, parents, and health professionals

Children with Diabetes: Information for Teachers & Child-Care Providers, Alexandria, VA,American Diabetes Association, 1999 (brochure); available online at www.diabetes.org/ada/teacher.asp.

Your School & Your Rights: Protecting Children with Diabetes Against Discrimination in Schoolsand Day Care Centers, Alexandria, VA, American Diabetes Association, 2000 (brochure);available online at http://www.diabetes.org/main/type1/parents_kids/away/scrights.jsp.*

Your Child Has Type 1 Diabetes: What You Should Know, Alexandria, VA, American DiabetesAssociation, 1999 (brochure); available online at http://www.diabetes.org/main/community/advocacy/type1.jsp*

Treating Diabetes Emergencies: What You Need to Know, Alexandria, VA, American DiabetesAssociation, 1995 (video); 1-800-232-6733.

Complete Guide to Diabetes, Alexandria, VA, American Diabetes Association, 1999; 1-800-232-6733.

Raising a Child with Diabetes: A Guide for Parents, Alexandria, VA, American DiabetesAssociation, 2000; 1-800-232-6733.

Clarke W: Advocating for the child with diabetes. Diabetes Spectrum 12:230–236, 1999.Education Discrimination Resources List, Alexandria VA, American Diabetes Association,

2000.*Wizdom: A Kit of Wit and Wisdom for Kids with Diabetes (and their parents), Alexandria, VA,

American Diabetes Association, 2000. Order information and select resources available atwww.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, SchoolPersonnel and Parents. MiniMed Professional Education, Your Clinical Coach. First Edition, May2000. MiniMed, Inc., 1-800-440-7867.

Tappon D. Parker M, Bailey W: Easy As ABC, What You Need to Know About Children UsingInsulin Pumps in School. Disetronic Medical Systems, Inc., 1-800-280-7801.

*These documents are available in the American Diabetes Association’s Education Discrimination Packet bycalling 1-800-DIABETES.

Position Statement

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convert food into energy. In people withdiabetes, either the pancreas does notmake insulin or the body cannot use in-sulin properly. Without insulin, thebody’s main energy source—glucose—cannot be used as fuel. Rather, glucosebuilds up in the blood. Over many years,high blood glucose levels can cause dam-age to the eyes, kidneys, nerves, heart,and blood vessels.

The majority of school-aged youthwith diabetes have type 1 diabetes. Peoplewith type 1 diabetes do not produce insu-lin and must receive insulin through ei-ther injections or an insulin pump.Insulin taken in this manner does not curediabetes and may cause the student’sblood glucose level to become danger-ously low. Type 2 diabetes, the most com-mon form of the disease typicallyafflicting obese adults, has been shown tobe increasing in youth (21). This may bedue to the increase in obesity and de-crease in physical activity in young peo-ple. Students with type 2 diabetes may beable to control their disease through dietand exercise alone or may require oralmedications and/or insulin injections. Allpeople with type 1 and type 2 diabetesmust carefully balance food, medications,and activity level to keep blood glucoselevels as close to normal as possible.

Low blood glucose (hypoglycemia) isthe most common immediate healthproblem for students with diabetes. It oc-curs when the body gets too much insu-lin, too little food, a delayed meal, or morethan the usual amount of exercise. Symp-toms of mild to moderate hypoglycemiainclude tremors, sweating, l ight-headedness, irritability, confusion, anddrowsiness. A student with this degree ofhypoglycemia will need to ingest carbo-hydrates promptly and may require assis-tance. Severe hypoglycemia, which israre, may lead to unconsciousness andconvulsions and can be life-threatening ifnot treated promptly.

High blood glucose (hyperglycemia)occurs when the body gets too little insu-lin, too much food, or too little exercise; itmay also be caused by stress or an illness

such as a cold. The most common symp-toms of hyperglycemia are thirst, frequenturination, and blurry vision. If untreatedover a period of days, hyperglycemia cancause a serious condition called diabeticketoacidosis (DKA), which is character-ized by nausea, vomiting, and a high levelof ketones in the blood and urine. Forstudents using insulin infusion pumps,lack of insulin supply may lead to DKAmore rapidly. DKA can be life-threateningand thus requires immediate medical at-tention.

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Cruick-shanks KJ, Eberhardt MS, RabinBS, Atchison RW, Wagener DK, BeckerDJ, Orchard TJ: Differences betweenblacks and whites in the epidemiology ofinsulin-dependent diabetes mellitus inAllegheny County, Pennsylvania. Am JEpidemiol 123:592–603, 1986

2. Libman I, Songer T, LaPorte R: How manypeople in the U.S. have IDDM? DiabetesCare 16:841–842, 1993

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