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[IP] care of children w/diabetes in schools/daycare

- ----- Original Message -----
From: Ruth Schneider <email @ redacted>
To: RUTH <email @ redacted>
Sent: Thursday, May 11, 2000 9:03 PM

> Diabetes Ca
> 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
> 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
> 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
> school systems and day care providers with the information and training
> necessary to allow children with diabetes to participate fully and safely
> the school experience.
> Federal laws that protect children with diabetes include the
> Act of 1973, Section 504 of the Individuals with Disabilities Education
> of 1991 (originally the Education for All Handicapped Children Act of
> and the Americans with Disabilities Act. Under these laws, diabetes has
> considered to be a disability, and it is illegal for schools and/or day
> centers to discriminate against children with diabetes. In addition, any
> school that receives federal funding or any facility considered open to
> 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
> face discrimination. For example, some day care centers may refuse
> to children with diabetes, and children in the classroom may not be
> the assistance necessary to monitor blood glucose and may be prohibited
> eating needed snacks. The American Diabetes Association works to ensure
> safe and fair treatment of children with diabetes in the school and day
> 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
> and the later development of diabetes complications, with improved
> 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
> 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
> 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
> diabetes effectively (13,18,19). Consequently, diabetes education needs to
> be targeted at day care providers, teachers, and other school personnel
> 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
> 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
> These responsibilities are outlined in this position statement. The
> 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
> levels.
> 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
> testing. The parent/guardian is responsible for the maintenance of the
> glucose testing equipment (i.e., cleaning and performing controlled
> per the manufacturer's instructions) and must provide materials necessary
> 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
> results.
> 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
> following:
> Immediate availability to treatment of hypoglycemia without the necessity
> for the child to be without direct supervision by a knowledgeable adult
> without the necessity for the child to travel long distances to obtain
> treatment.
> An adult and back-up adult trained to be able to: 1) perform fingerstick
> blood glucose monitoring and record the results; 2) take appropriate
> 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)
> 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
> procedures.
> Permission for the child to see school medical personnel upon request.
> Permission for the child to eat a snack anywhere, including the classroom
> 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
> 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
> all times, with supervision as needed. Provisions similar to those
> above must be available for field trips, extracurricular activities, and
> transportation provided by the school or day care facility to enable full
> participation.
> Members of the health care team should be available to provide instruction
> and materials to parents to facilitate the education of school personnel.
> 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
> Diabetes Association and other sources are available and have been
> 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
> ability to participate in diabetes care should be agreed upon by the
> 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
> generally cooperate in diabetes tasks.
> Elementary school. The child should be expected to cooperate in all
> tasks at school. By age 8 years, most children are able to perform their
> 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
> glucose under usual circumstances when not experiencing low blood glucose
> levels. In high school, most adolescents can administer insulin with
> supervision.
> 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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> References
> 1. LaPorte RE, Tajima N, Dorman JS, Cruickshanks KJ, Eberhardt MS, Rabin
> 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
> 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
> 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,
> 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
> 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
> 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.
> 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
> 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
> 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,
> Francine Kaufman, MD, Desmond Schatz, MD, and William Clarke, MD. The
> 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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