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[IP] diabetes care of children in schools/daycare, AGAIN!

I copied this...sorry.

Diabetes Care

Volume 23 Supplement 1
American Diabetes Association:
Clinical Practice Recommendations 2000

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Care of Children With Diabetes in the School and Day Care Setting

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American Diabetes Association

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Diabetes is one of the most common chronic diseases of childhood, with an
incidence of ~1.7 affected individuals per 1000 people aged <20 years (1-4).
In the U.S., ~13,000 new cases are diagnosed annually in children (5-8).
Only asthma exceeds its prevalence in the school-aged population. There are
about 125,000 individuals <19 years of age with diabetes in the U.S. (9).
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
(10-13). Both parents and the health care team must work together to provide
school systems and day care providers with the information and training
necessary to allow children with diabetes to participate fully and safely in
the school experience.

Federal laws that protect children with diabetes include the Rehabilitation
Act of 1973, Section 504 of 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 diabetes. 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's usual school setting with as little disruption to the school's
and the child's routine as possible and allowing the child full
participation in all school activities.

Despite these protections, children in the school and day care setting still
face discrimination. For example, some day care centers may refuse admission
to children with diabetes, and children in the classroom may not be provided
the assistance necessary to monitor blood glucose and may be prohibited from
eating needed snacks. The American Diabetes Association works to ensure the
safe and fair treatment of children with diabetes in the school and day care
setting (14,15).

Appropriate diabetes care in the school and day care setting is necessary
for the immediate safety of the child and for the child's long-term well
being and optimal academic performance. The Diabetes Control and
Complications Trial showed a significant link between blood glucose control
and the later development of diabetes complications, with improved glycemic
control decreasing the risk of these complications (16,17). Achieving good
glycemic control usually requires a diabetes management regimen consisting
of frequent blood glucose monitoring, regular physical activity, and medical
nutrition therapy, and may require multiple doses of insulin per day or
insulin administered with an infusion pump. Crucial to achieving good
glycemic control is an understanding of the effects of physical activity,
nutrition therapy, and insulin on blood glucose levels.

School and day care personnel must have an understanding of diabetes and its
management to facilitate the appropriate care of the child with diabetes.
Knowledgeable personnel are essential if the child is to achieve the good
metabolic control required to decrease the 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' ability to manage
diabetes effectively (13,18,19). Consequently, diabetes education needs to
be targeted at day care providers, teachers, and other school personnel who
interact with the child, including school administrators, school coaches,
school nurses, health aides, bus drivers, secretaries, etc.

The purpose of this position statement is to provide recommendations for the
management of children with diabetes in the school and day care setting.


I. Diabetes Care Plan
An individualized Diabetes Care Plan should be developed by the parent/
guardian, the child's diabetes care team, and the school or day care
provider. Inherent in this process are responsibilities assumed by all
parties, including the parent/guardian, the school personnel, and the child.
These responsibilities are outlined in this position statement. The Diabetes
Care Plan should address the specific needs of the child and provide
specific instructions for each of the following:

Blood glucose monitoring, including the frequency and circumstances
requiring testing.
Insulin administration (if necessary), including doses/injection times
prescribed for specific blood glucose values and the storage of insulin.
Meals and snacks, including food content, amounts, and timing.
Symptoms and treatment of hypoglycemia (low blood sugar), including the
administration of glucagon, if appropriate.
Symptoms and treatment of hyperglycemia (high blood sugar).
Testing for ketones and appropriate actions to take for abnormal ketone
Figure 1 includes a sample Diabetes Care Plan. For detailed information on
the symptoms and treatment of hypoglycemia and hyperglycemia, refer to the
Medical Management of Type 1 Diabetes (20).

Figure 1 - Diabetes Care Plan

II. Responsibilities of the various stakeholders
A. The parent/guardian should provide the school or day care provider with
the following:

All materials and equipment necessary for diabetes care tasks, including
blood glucose testing, insulin administration (if needed), and urine ketone
testing. The parent/guardian is responsible for the maintenance of the blood
glucose testing 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 test
Supplies to treat hypoglycemia, including extra snacks and a glucagon
emergency kit, if indicated in the Diabetes Care Plan.
Information about diabetes and training in the performance of
diabetes-related tasks.
Emergency phone numbers for parent/guardian and the diabetes care team so
that the school can contact these individuals with diabetes-related
questions and/or during emergencies.
B. The school or day care provider should be expected to provide the

Immediate availability to treatment of hypoglycemia without the necessity
for the child to be without direct supervision by a knowledgeable adult and
without the necessity for the child to travel long distances to obtain such
An adult and back-up adult trained to be able to: 1) perform fingerstick
blood glucose monitoring and record the results; 2) take appropriate actions
for blood glucose levels outside of the target ranges as indicated in the
child's Diabetes Care Plan; and 3) test the urine for ketones, when
necessary, and respond to the results of this test.
An adult and back-up adult trained in insulin administration (if needed) in
accordance with the child's Diabetes Care Plan.
An adult and back-up adult trained to administer glucagon.
A location in the school to provide privacy during testing and insulin
administration, if desired by the child and family.
An adult and back-up adult responsible for the child who will know the
schedule of the child's meals and snacks and work with the parents to
coordinate this schedule with that of the other children as closely as
possible. This individual also will notify the parents in advance of any
expected changes in the school schedule that affect the child's meal times
or exercise routine. Young children should be reminded of snack times.
Training to all adults who provide education/care for the child on the
symptoms and treatment of hypoglycemia and hyperglycemia and other emergency
Permission for the child to see school medical personnel upon request.
Permission for the child to eat a snack anywhere, including the classroom or
the school bus, if necessary to prevent hypoglycemia.
Permission to miss school without consequences for required medical
appointments to monitor the student's diabetes management. This should be an
excused absence with a doctor's note.
Permission for the child to use the restroom and access to fluids (i.e.,
water), as necessary.
Appropriate location for insulin and/or glucagon storage, if necessary.
An adequate number of school personnel should be trained in the necessary
diabetes procedures (e.g., blood glucose monitoring, insulin and glucagon
administration) to ensure that at least one adult is available to perform
these procedures while the child is at school or on a field trip.

The child with diabetes should have immediate access to diabetes supplies at
all times, with supervision as needed. Provisions similar to those described
above must be available for field trips, extracurricular activities, and on
transportation provided by the school or day care facility to enable full

Members of the health care team should be available to provide instruction
and materials to parents to facilitate the education of school personnel. In
most circumstances, parents are able to provide the school personnel with
sufficient oral and written information to allow the school to provide a
safe and appropriate environment for the child. Materials from the American
Diabetes Association and other sources are available and have been extremely
helpful in accomplishing this goal. Table 1 includes a listing of
appropriate resources.

III. Expectations of the child in diabetes care
Children should be able to participate with parental consent in their
diabetes care at school to the extent that is appropriate for the child's
development and his/her experience with diabetes. The extent of the child'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.

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.
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.
Middle school or junior high school. The student should be able to perform
self-monitoring of blood glucose under usual circumstances when not
experiencing a low blood glucose level. By 13 years of age, most children
can administer insulin with supervision.
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, most adolescents can administer insulin with
At all ages, individuals with diabetes may require help to perform a blood
glucose test 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.

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1. LaPorte RE, Tajima N, Dorman JS, Cruickshanks KJ, Eberhardt MS, Rabin BS,
Atchison RW, Wagener DK, Becker DJ, Orchard TJ: Differences between blacks
and whites in the epidemiology of insulin-dependent diabetes mellitus in
Allegheny County, Pennsylvania. Am J Epidemiol 123:592-603, 1986

2. Libman I, Songer T, LaPorte R: How many people in the U.S. have IDDM?
Diabetes Care 16:841-842, 1993

3. Lipman TH: The epidemiology of type I diabetes in children 0-14 yr of age
in Philadelphia. Diabetes Care 16:922-925, 1993

4. Rewers M, LaPorte R, King H, Tuomilehto J: Trends in the prevalence and
incidence of diabetes: insulin-dependent diabetes mellitus in childhood.
World Health Stat Q 41:179-189, 1988

5. American Diabetes Association: Diabetes 1996 Vital Statistics.
Alexandria, VA, American Diabetes Association, 1996, p. 13-20

6. Dokheel TM, for the Pittsburgh Diabetes Epidemiology Research Group: An
epidemic of childhood diabetes in the United States? Evidence from Allegheny
County, Pennsylvania. Diabetes Care 16:1606-1611, 1993

7. Gunby P: North Dakota survey early-onset diabetes. JAMA 249:329, 1983

8. Melton LJ III, Palumbo PJ, Chu CP: Incidence of diabetes mellitus by
clinical type. Diabetes Care 6:75-86, 1983

9. LaPorte RE, Matsushima M, Chang Y-F: Prevalence and incidence of
insulin-dependent diabetes. In Diabetes in America. 2nd ed. Harris MI, Cowie
CC, Stern MP, Boyko EJ, Reiber GE, Bennett PH, Eds. Washington, DC, U.S.
Govt Printing Office, 1995, p. 37-45 (NIH publ. no. 95-1468)

10.  Digon E, Miller W: The Prevalence of Juvenile-Onset Diabetes in
Pennsylvania's Schools: Report from the Bureau of Health Research.
Harrisburg, PA, Pennsylvania Department of Health, 1976

11. Gorwitz K, Howen GG, Thompson T: Prevalence of diabetes in Michigan
school-age children. Diabetes 25:122-127, 1976

12.   Kyllo CJ, Nuttall FQ: Prevalence of diabetes mellitus in school-age
children in Minnesota. Diabetes 27:57-60, 1978

13. Wysocki T, Meinhold P, Cox DJ, Clarke WL: Survey of diabetes
professionals regarding developmental changes in diabetes self-care.
Diabetes Care 13:65-68, 1990

14.  Jesi Stuthard and ADA v. Kindercare Learning Centers, Inc., Case no.
C2-96-0185 (USCD South Ohio 8/96)

15. Calvin Davis and ADA v. LaPetite Academy, Inc., Case no.
CIV97-0083-PHX-SMM (USCD Arizona 1997)

16.   Diabetes Control and Complications Research Group: Effect of intensive
treatment of diabetes on the development and progression of long-term
complications in insulin-dependent diabetes mellitus. N Engl J Med
329:977-986, 1993

17.   Diabetes Control and Complications Research Group: Effect of intensive
diabetes treatment on the development and progression of long-term
complications in adolescents with insulin-dependent diabetes mellitus:
Diabetes Control and Complications Trial. J Pediatr 125:177-188, 1994

18. Hodges L, Parker J: Concerns of parents with diabetic children. Pediatr
Nurse 13:22-24, 1987

19.  Lindsey R, Jarrett L, Hillman K: Elementary schoolteachers'
understanding of diabetes. Diabetes Educ 13:312-314, 1987

20.   Skyler JS (Ed.): Medical Management of Type 1 Diabetes. 3rd ed.
Alexandria, VA, American Diabetes Association, 1998

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The recommendations in this paper are based on the evidence reviewed in the
following publications: Diabetes Control and Complications Research Group:
The effect of intensive treatment of diabetes on the development and
progression of long-term complications in insulin-dependent diabetes
mellitus. N Engl J Med 329:977-986, 1993; and Diabetes Control and
Complications Research Group: The effect of intensive diabetes treatment on
the development and progression of long-term complications in adolescents
with 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 the Professional Practice
Committee and the Executive Committee, November 1998. Most recent
review/revision, 1999.

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Return to Supplement Contents

Copyright  2000 American Diabetes Association
Last updated: 1/00
For ADA Related Issues contact email @ redacted

For Technical Issues contact email @ redacted

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