Care of the child with diabetes at school

MaryKathleen Heneghan MD

Objectives • Compare Type 1 vs. Type 2 diabetes -

differences in management

• Discuss nutrition considerations

• Review administration and dosing of insulin

• Discuss monitoring of blood glucose and

treatment of hypoglycemia/hyperglycemia

• Describe sick day management

• Answer questions and facilitate discussion of

diabetes cares in a school setting

Signs & Symptoms of diabetes

• Increased thirst

• Increased urination

• “accidents” – daytime or nighttime

• Weight loss

• Abdominal pain

• Nausea / emesis

• Headaches

• Blurry vision

Diagnosis of diabetes

• Fasting blood glucose 126 mg/dL

• HgbA1c 6.5%

• Symptoms of hyperglycemia and plasma

glucose 200mg/dL

• OGTT: plasma glucose 200mg/dL 2 hours

after glucose load

T1DM vs T2DM • Type 1 diabetes mellitus

– Autoimmune in nature

– Requires insulin administration from time of

diagnosis

• Type 2 diabetes mellitus

– Typically related to obesity

– May be treated with diet, oral medications or

insulin therapy

A typical day for a child with diabetes

- Wake up

- How do I feel? – do I need to check my BG

- Get ready for school

- Time for breakfast - What am I going to eat?

- How many carbs is it?

- Will I eat it all?

- What is my blood sugar?

- How much insulin do I need?

- Where am I giving my shot today?

- Got my shot

- Time to eat

- Repeat at morning snack, lunch, before gym class,

afterschool snack, dinner and bedtime

- Is it bedtime yet??? I am exhausted

Type 1 diabetes mellitus • A lot of a child’s diabetes cares will take place

at school

• Illinois has in place the Care of Students with

Diabetes Act

– Provides requirements school must meet in

regards to care of diabetes

– Difficult for many schools to have required

training and personnel available

• A partnership between nurse, students,

parents and medical home

Diabetes Care Plan • Also known as a diabetes medical

management plan (DMMP)

• Provides direction for diabetes cares at

school

• Per Diabetes Care Act a DMMP is required: – “upon enrollment, as soon as practical following a student's

diagnosis; or when a student's care needs change during the

school year. Parents shall be responsible for informing the

school in a timely manner of any changes to the diabetes care

plan and their emergency contact numbers.”

Diabetes Care Plan • Also known as a diabetes medical

management plan (DMMP)

• Provides direction for diabetes cares at

school

• Per Diabetes Care Act a DMMP is required: – “upon enrollment, as soon as practical following a student's

diagnosis; or when a student's care needs change during the

school year. Parents shall be responsible for informing the

school in a timely manner of any changes to the diabetes care

plan and their emergency contact numbers.”

Diabetes Care Plan • Provides information on:

– Monitoring of blood glucose

– Dosing of insulin

• Authorization for insulin use

– Treatment of hypoglycemia

• Authorization for glucagon use

– Treatment of hyperglycemia

– Use of insulin pump

– Physical activity and sports

– Nutrition

Nutrition Considerations

• Type 1 diabetes – Focus is on healthy diet

– Carbohydrate counting is required

– Few limitations to patient’s diet although ALL carbs consumed need to be counted and dosed for

– Goal is healthy lifestyle

• Type 2 diabetes – Focus is on healthy diet

– Carbohydrate counting MAY be required

– Limitations should be present

• No sugar sweetened beverages

• Avoid high fat / high carb foods

– Typical goal is weight loss and healthy lifestyle

Nutrition Considerations • Determining amount of carbohydrates

– Most families are taught to count carbohydrates in grams (few families are still using diabetic exchanges)

– Request carb counts on lunches and food items from parents • Encourage parents to include a list in school lunch of grams of carbs in

each item so if a child does not want something it can easily be subtracted out

– Contact food vendors for hot lunches to provide carb counts for “hot lunches”

• Resources: – Calorie King (also available as an app)

– Allrecipes.com (recipes can be entered)

– The Daily Plate (foods by brand can be entered)

– Go Meals

Nutrition Considerations

• Food Label

– Serving size • Measurement vs weight

– Servings per container

– Total Carbohydrates • Dietary fiber

Treatment Regimens • Basal – Bolus

– Uses multiple daily injections (MDI) or continuous

subcutaneous insulin infusion (CSII)

• Must be able to count carbs, monitor BG levels and

perform the necessary calculations

– Attempts to replicate normal insulin secretion

through use of long acting insulin and rapid acting

insulin

Treatment Regimens

Diabetes Education Online Diabetes Teaching Center at the University of California, San Francisco

Treatment Regimens • Conventional Regimens (70/30 and fast acting)

– administration of an intermediate-acting

insulin twice a day with a rapid-acting insulin

two or three times a day

– regimen is fixed so the patient and family

must adjust their lifestyles so that meals (time

and quantity) and vigorous physical activity

occur on a relatively fixed daily schedule

Insulin Delivery: Syringe

http://www.diabeticlivingonline.com How to Inject Insulin By Terri Peiffer, RN, BSN, CDE

Insulin Delivery: Pens

• More accurate

dosing

– Dose is dialed in

• Convenient

• Small needle size

• Requires priming

• Administration

slightly different from

syringe

Insulin Delivery: Pens

http://www.diabeticlivingonline.com How to Use an Insulin Pen

By Terri Peiffer, RN, BSN, CDE

Continuous Subcutaneous Insulin Infusion

• Insulin pumps or pods – Provides a continuous dose of

fast acting insulin

– A basal dose is preset into device

and is constantly providing insulin

– A bolus dose is entered into

device and given at each meal

(calculations done by device)

– MUST be able to change out

device at school if failure occurs

– MUST have extra supplies

available

Dose calculations

• Parents are responsible to make school team

aware of current doses

• Dose of insulin at a meal consists of:

– Carbohydrate dose

– correction dose

Dose Calculations

• Example:

– 1 unit per 8 grams of carbs (carb ratio)

– correction of 1:40 over target (target of 120)

• If a student is eating 84 grams at lunch their food dose is

10.5 units (84 grams of carb / 8)

• If their BG is 215 the correction dose is 2.375 units (

215-120 / 40)

• The total dose the student is to receive is 12.875 which

rounds to 13 units

Dose calculations • Some students may have a dose chart or

dose grid for dosing food, correction of a

combination of both

Number of Carbs (grams)

Blood Sugar 0-11 g 12-19 g 20-25 g 26-34 g 35-40 g 41-49 g 50-55 g 56-64 g 65-70 g 71-79 g 80-85 g 86-94 g 95-100 g 101-109 g 110-115 g 116-124 g

from up to 0 1 1.5 2 2.5 3 3.5 4 4.5 5 5.5 6 6.5 7 7.5 8

80 120 0 1.5 2.5 3.5 4.5 5.5 6.5 7.5 8 9 10 11 12 13 14 15

120 160 1 2.5 3.5 4.5 5.5 6.5 7.5 8.5 9 10 11 12 13 14 15 16

160 200 2 3.5 4.5 5.5 6.5 7.5 8.5 9.5 10 11 12 13 14 15 16 17

200 240 3 4.5 5.5 6.5 7.5 8.5 9.5 10.5 11 12 13 14 15 16 17 18

Blood glucose monitoring • When to be done

– Before meals or snacks

– Before activitity (per parents)

– Before leaving for the day (per parents)

– When a student feels symptomatic

– When a teacher notices a difference in student

• Should be performed on finger-tip

• Record on log and communicated to parent

as discussed in DMMP

Continuous glucose monitoring • Student wears a

glucose sensor under

skin

– Typically on stomach

or hips

• A receiver displays a

blood glucose value

every few minutes

– Will demonstrate trends

– Alarms with low or high

blood sugar

Hypoglycemia • Blood glucose value <80

• Symptoms of hypoglycemia

NEED to be confirmed with a

check of glucose and only

treated if truly a low blood

sugar

• Causes include: •Not finishing meal

•Over-assessment of insulin

•Change in schedule

•Change in activity

• illness

Treatment of hypoglycemia

• Treat with 15 grams of fast acting sugar

(glucose tabs, 4oz juice, fruit snacks etc..)

• Recheck in 15 minutes

• If still low repeat with another 15 grams

• After treatment work to discover the cause

Severe hypoglycemia

• NOT a defined blood glucose

• Low blood glucose at which patient can not

safely eat or drink to raise blood glucose

• GLUCAGON must be used

• THIS IS A MEDICAL EMERGENCY AND

RESPONSE CAN NOT BE ONLY CALLING

911

• All staff to be trained on use of Glucagon

Glucagon • Hormone produced by pancreas

which acts opposite insulin

• Given IM

• Raises blood glucose quickly but

only a temporary fix

• Can cause nausea and emesis

• If administered EMS is typically

called as student may require

additional source of sugar

Hyperglycemia • Blood glucose value >300

• Can vary by patient

• Causes include:

• Skipped doses

• Eating food without

dosing

• Miscalculation of

carbohydrates

• Miscalculation of

insulin dose

• Illness

Treatment of hyperglycemia

• Contact parents (per plan)

• Check ketones

• Push fluids (water and non-sugar sweetened)

• Correction dose per parents

– Should be at least 2 hours since last correction

dose of insulin

• Does not always mean the student needs to

go home

Ketones

• Trace / Small – Push fluids

• Moderate / Large – Push fluids and need

extra insulin

Sick Day Management at School • What to do if a student with diabetes becomes ill

at school?

– Worrisome signs include abdominal pain, emesis or

change in respirations (fruity odor to breath)

– Contact parents for instructions

– Check ketones

• Ketones represent a deficiency of insulin

• Bodies ways to provide energy (using fat) when

carbohydrates can not be used

• If trace or small push fluids

• If moderate or large needs fluids and additional insulin

– Fluids need to be water or non-sugar containing

Thank you Now on to the discussion…