Schools and Diabetes: Tough Match

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By Melissa Tennen

Your child has been diagnosed with type 1 diabetes. It’s terrifying and bewildering. In addition to all your concerns for your child’s future, there’s the monitoring and injected medications. You can do it at home, but what about at school?

Most schools have to do more with less. The number of kids with diabetes increases while the number of nurses, thanks to ever-tightening budgets, keeps dwindling. This can make routine care for diabetes difficult, leaving it up to the teachers, secretaries or parents to administer the daily tests and injections.

“The lack of school nurses is in crisis proportions,” says Jean Schultz, coordinator of school health and part of the professional development team at National Middle School Association.

“To optimize learning, we need to pay attention to student health by having school nurse services. To appropriately serve their needs is a full time job and not the responsibility of a secretary or teacher,” Schultz says.

Diabetes care of a child is a big job, no matter if the school has a nurse or not.

“The child’s needs impact the entire school district from the coach to the teacher. The management of diabetes can touch upon every aspect of a child’s life from eating to exercise to school performance,” says Lori M. Laffel, M.D., M.P.H., chief of the pediatric and adolescent diabetes unit at Joslin Diabetes Center and Joslin Clinic in Boston and assistant professor of pediatrics at Harvard Medical School.

Children need help

“The child with diabetes depends on external help as the child needs to be given insulin in appropriate amounts and at appropriate times. You have to pay attention to the timing of meals and exercise,” she says. “Diabetes is a very demanding disease, and it’s difficult for anyone to care for diabetes alone, especially for a child. Children and young teens are not yet old enough to drive a car. Why should they be expected to manage their diabetes?”

The constant need for care is especially tough for young children. Preschoolers, for instance, have not learned to recognize low blood glucose symptoms. They may not be able to tell others when they aren’t feeling good.

Older children with diabetes have different challenges. They do not want to be viewed as different from their peers. Teens may even skip their insulin shots and avoid blood sugar checks.

School nurses can focus

A school nurse is the best person to oversee these needs, because her primary responsibility is to take care of medical issues and the training of school staff. Teachers have little, if any, training in medical matters and are appropriately absorbed in teaching.

“A nurse who has a relationship with the child can provide the critical link to appropriate care by providing services and monitoring progress,” Schultz says. “The student/nurse link is critical to appropriate care.”

But many schools only have the services of a nurse once a week, if at all, she says.

Shots and pumps

Many children and teens manage diabetes with two or three insulin shots at regular intervals each day, possibly with different types and amounts of insulin in each shot. Others may need four or more daily injections or an insulin pump. An insulin pump provides a continuous flow of insulin throughout the day and must be programmed to give a bolus, or an extra “squirt” of insulin, whenever the child eats. The pump can be pre-set to “dribble” the background insulin but it needs the youth (if mature enough and knowledgeable) or a supervising adult to manually select and program the pump to give the extra insulin. However, blood sugars must be checked several times a day to make sure the pump and the catheter are working OK. If not, the pump will need to be adjusted accordingly to prevent hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Liability dilemma for schools

The course of providing appropriate school nurse support can be difficult for schools to navigate. Schools may feel they straddle a fine line between legal liability and giving a child with diabetes the same chances as other children.

“Some school officials have insisted that a parent or guardian come each day to help the child,” says Eugene Barrett, M.D., former president of the American Diabetes Association (ADA). “Likewise, there have been instances where children with diabetes are excluded from certain school activities such as field trips and other outings because there was no person willing to accept the responsibility for assisting the child.

“The ADA has taken a strong position that children with diabetes should have all the same opportunities as other healthy children within the schools,” he says.

Even though federal laws protect children with disabilities, some state laws limit what people without medical training can do to help with the medical care of children. The ADA is working with several states to pass laws to make sure someone within each school is trained to help children with diabetes.

(Next:Planning for Diabetes in School)

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