Diabetes Treatments

his guide was produced by the National Diabetes Education Program (NDEP) American Diabetes Association’s Position Statement: “Care of Children with …

Helping the Student with Diabetes Succeed
A Guide for School Personnel

US Department of Health and Human Services
April 2003 Draft: Not for attribution or distribution

A Joint Program of the National Institutes of Health and the Centers for Disease Control and Prevention

Helping the Student with Diabetes Succeed
A Guide for School Personnel

US Department of Health and Human Services
June 2003

A Joint Program of the National Institutes of Health and the Centers for Disease Control and Prevention

T

his guide was produced by the National Diabetes Education Program NDEP, a federally sponsored partnership of the National Institutes of Health, the Centers for Disease Control and Prevention, and more than 200 partner organizations The following organizations support its use by school personnel: American Academy of Pediatrics American Association for Health Education American Association of Diabetes Educators American Diabetes Association American Dietetic Association American Medical Association Barbara Davis Center for Childhood Diabetes Centers for Disease Control and Prevention Indian Health Service Juvenile Diabetes Research Foundation International Lawson Wilkins
Pediatric Endocrine Society National Association of Elementary School Principals National Association of School Nurses National Association of Secondary School Principals National Association of State Boards of Education National Diabetes Education Program National Education Association Health Information Network National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health US Department of Education

ii Helping the Student with Diabetes Succeed

Table of Contents
Acknowledgments iv Foreword v Introduction 1 Section 1 Diabetes Primer for School Personnel 5 Section 2 Actions for School Personnel, Parents, and Students 31 Section 3 Tools for Effective Diabetes Management in Schools 47 Sample Diabetes Medical Management Plan 49 Sample Quick Reference Emergency Plan Hypoglycemia 53 Sample Quick Reference Emergency Plan Hyperglycemia
54 Section 4 School Responsibilities Under Federal Laws 55 Appendices Resource List: Help for Students with Diabetes 61 Glossary of Diabetes Terms 69 American Diabetes Associations Position Statement: Care of Children with Diabetes in the School and Day Care Setting 73

Helping the Student with Diabetes Succeed iii

Acknowledgments

M

any National Diabetes Education Program partners contributed to the development of this guide A core writing and review team helped research, write, and refine drafts of the manuscript and enlisted the involvement of school personnel and parents in reviewing the guide Their dedication and assistance were invaluable their names appear below Guides developed by state departments of health and education in New York, Rhode Island, Vermont, Virginia, and Washington to address the issue of diabetes in schools and materials from the National Association of State Boards of Education provided additional background information and direction for developing this document American Academy of Pediatrics Janet Silverstein,
MD American Association of Diabetes Educators Jean Betschart Roemer, CPNP, CDE American Diabetes Association Shereen Arent, JD Crystal Jackson Francine Kaufman, MD Regan Minners American Dietetic Association Alison Evert, RD, CDE Hager Sharp Inc Rachel Greenberg, MA National Association of School Nurses Nichole Bobo, MSN, RN, ANP National Diabetes Education Program Joanne Gallivan, MS, RD Jane Kelly, MD National Institute of Diabetes and Digestive and Kidney Diseases Barbara Linder, MD, PhD University of Illinois, College of Medicine, Department of Pediatrics Rodney Lorenz, MD US Department of Education Eileen Hanrahan, JD Anne Hoogstraten, JD Bobbi Stettner-Eaton, PhD

iv Helping the Student with Diabetes Succeed

Foreword

M

ajor research advances have been made in diabetes management and control during the past decade Several landmark research studies have proved conclusively that aggressive treatment to lower blood glucose sugar levels can help prevent or delay diabetes-related complications affecting the eyes, kidneys, nerves, and cardiovascular system In addition, advances in medical research and technology have produced an array of treatment and management tools that have
made it easier for people with diabetes to check their blood glucose levels and to control them For young people with diabetes, these advances mean a brighter and healthier future Blood glucose levels that are well managed have the potential to help young people not only to stave off the long-term complications of diabetes but also to feel better and to be happier and more productive at school and at play Accordingly, students with diabetes need a supportive environment to help them take care of their diabetes throughout the school day and at school-sponsored activities The National Diabetes Education Program NDEP developed this guide to educate and inform school personnel about diabetes, how it is managed, and how each member of the school staff can help meet the needs of students with the disease School principals, administrators, nurses, teachers, coaches, bus drivers, health care, and lunchroom staff all play a role in making the school experience safe and sound for students with diabetes The NDEP convened an expert panel comprised of health care professionals, federal agency staff, and representatives from key diabetes, pediatric medicine, and educational organizations to
develop this comprehensive guide and to help disseminate it throughout the country We hope that schools will take advantage of the important information contained in this guide, share it with school staff, parents, and students, and use it to ensure that all students with diabetes are educated in a medically safe environment and have the same access to educational opportunities as their peers Sincerely,

James R Gavin III, MD, PhD Chair, National Diabetes Education Program May 2003

Helping the Student with Diabetes Succeed v

vi Helping the Student with Diabetes Succeed

Introduction

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ore than 17 million Americans have diabetes In your work with children and youth in the school setting, it is likely that you already have, or will have, a student with diabetes in your care Diabetes is one of the most common chronic diseases in school-aged children, affecting about 151,000 young people in the United States, or about 1 in every 400 to 500 young people under 20 years of age Each year, more than 13,000 youths are diagnosed with type 1 diabetes In addition, health care providers are finding more and more children and teens with type 2 diabetes, even though the disease is usually
diagnosed in adults over age 40 Diabetes is a serious chronic disease that impairs the bodys ability to use food for energy It is the sixth-leading cause of death by disease in the United States Long-term complications include heart disease, stroke, blindness, kidney disease, and amputation of the foot or leg Although there is no cure, the disease can be managed and complications delayed or prevented Diabetes must be managed 24 hours a day, 7 days a week For students with type 1 diabetes, and for some with type 2 diabetes, that means careful monitoring of their blood glucose sugar levels throughout the school day and administering multiple doses of insulin therapy–now prescribed for most young people with diabetes As a result, the school health team, which includes the school nurse, teachers, office personnel, and other school staff members, plays an important role in helping students manage their diabetes Effective diabetes management is crucial

The school nurse, teachers, office personnel, and other school staff members play an important role in helping students manage their diabetes

for the immediate safety of students with diabetes for the long-term health of students
with diabetes to ensure that students with diabetes are ready to learn and to participate fully in school activities and to minimize the possibility that diabetes-related emergencies will disrupt classroom activities

Helping the Student with Diabetes Succeed 1

The purpose of this guide is to educate school personnel about diabetes and to share a set of practices that enable schools to ensure a safe learning environment for students with diabetes

The purpose of this guide is to educate school personnel about diabetes and to share a set of practices that enable schools to ensure a safe learning environment for students with diabetes, particularly the student who uses insulin to control the disease all students with type 1 and some with type 2 diabetes The team approach to school-based diabetes management presented in this guide builds on what schools already are doing for children with other chronic diseases Current practices and use of existing resources have been adapted for the student with diabetes The practices shared in this guide are not necessarily required by the federal laws enforced by the US Department of Education for each student with diabetes This guide can be
used, however, in determining how to address the needs of students with diabetes The individual situation of any particular student with diabetes will affect what is legally required for that particular student Additionally, the guide does not address state and local laws, as the requirements of these laws may vary from state to state and school district to school district This guide should be used in conjunction with federal as well as state and local laws At its core, effective school-based diabetes management requires two things:

All school staff members who have responsibility for a student with diabetes should receive training that provides a basic understanding of the disease and the students needs, how to identify medical emergencies, and which school staff members to contact with questions in case of an emergency A small group of school staff members should receive training from a qualified health care professional such as a physician or a nurse in student-specific routine and emergency care so that a staff member is always available for younger or less-experienced students who require assistance with their diabetes management eg, administering insulin, checking their
blood glucose, or choosing an appropriate snack and for all students with diabetes in case of an emergency This group may be comprised of the school nurse and other school staff who are not health care professionals The non-medical personnel are called trained diabetes personnel in this guide Other terminology may be used in your school

2 Helping the Student with Diabetes Succeed

introduction
Organized in four sections, the guide includes background information and tools for school personnel to help students manage diabetes effectively

This guide may be reproduced without permission and shared with all school personnel, parents, and students

Section 1, Diabetes Primer for School Personnel, provides
overview information about diabetes, describes how the disease is managed, and reviews the components for planning and implementing effective diabetes management in school The Primer should be copied and distributed to all school personnel who may be responsible for the safety of students with diabetes School nurses are the likely leaders in distributing this information and providing the background and education that other school personnel will need This leadership may vary,
however, from one school system to another because of state laws, staffing levels, and other considerations

Section 2, Actions for School Personnel, Parents, and
Students, lays out the roles and responsibilities of individual school personnel, parents, and students The pages in this section should be copied and distributed to school staff members, parents, and students with diabetes so that they understand their respective roles in diabetes management

Section 3, Tools for Effective Diabetes Management,
contains two important tools for helping schools implement effective diabetes management, a sample Diabetes Medical Management Plan and a sample Quick Reference Emergency Plan for a student with diabetes The Quick Reference Emergency Plan should be distributed to all personnel who have responsibility for the student with diabetes during the school day and during school-sponsored activities

Section 4, School Responsibilities Under Law, was developed by the US Department of Education This section provides an overview of federal laws that address schools responsibilities to students with diabetes, including confidentiality requirements In applying the laws, schools must consider each
student on an individualized basis; what is appropriate for one student may not be appropriate for another student

Helping the Student with Diabetes Succeed 3

The Appendices contain additional resources and information for diabetes management in the school setting The Resources section lists government, professional, and voluntary organizations that can be contacted for more information about diabetes and youth The Glossary provides additional explanations of the medical and technical terms used in this guide The American Diabetes Associations position statement on Care for Children with Diabetes in the School and Day Care Setting lays out the diabetes medical communitys recommendations that are the basis for this guide School personnel are encouraged to visit the National Diabetes Education Programs website, wwwndepnihgov, to download a comprehensive online resource directory on Diabetes in Children and Adolescents

wwwndepnihgov
To obtain additional copies of this guide and other diabetes information, please call the National Diabetes Education Program at 1-800-438-5383 or visit the programs website at wwwndepnihgov to download copies

4 Helping the Student with Diabetes
Succeed

Section 1 Diabetes Primer
primer

Section 1 Diabetes Primer
Copy and distribute this section to all school personnel who may be responsible for the safety of students with diabetes
What is diabetes? Page 6 What are the types of diabetes? Page 7
Type 1 Diabetes Page 7 Type 2 Diabetes Page 8

What is effective diabetes management? Page 9 How can a school plan and implement effective diabetes management? Page 11
Diabetes Medical Management Plan Page 12 Quick Reference Emergency Plan Page 13 Education Plans Page 14

What are the Elements of Effective Diabetes Management in School? Page 15
Monitoring Blood Glucose Page 15 Advantages of Checking Blood Glucose Levels Any Time and Any Place Page 16 Understanding Hypoglycemia low blood glucose Page 17 Understanding Hyperglycemia high blood glucose Page 19 Administering Insulin Page 21 Following an Individualized Meal Plan Page 23 Getting Regular Physical Activity Page 24 Planning for Special Events, Field Trips, and Extracurricular Activities Page 25 Planning for Disasters and Emergencies Page 26 Dealing with Emotional and Social Issues Page 26

Why is diabetes self-management important? Page 27 Why is diabetes management training
essential for school personnel? Page 28 Where can I learn more about diabetes? Page 29

Section 1 Diabetes Primer
for

S

chool Personnel
What is diabetes?
Diabetes is a chronic disease in which the body does not make or properly use insulin, a hormone needed to convert sugar, starches, and other food into energy People with diabetes have increased blood glucose sugar levels because they lack insulin, have insufficient insulin, or are resistant to insulins effects High levels of glucose build up in the blood and spill into the urine; as a result, the body loses its main source of fuel When insulin is no longer made, it must be obtained from another source–insulin shots or an insulin pump When the body does not use insulin properly, oral medications may be taken instead of, or in addition to, insulin shots Neither insulin nor other medications, however, are cures for diabetes: they only help control the disease Taking care of diabetes is important If not treated, diabetes can lead to serious health problems The disease can affect the blood vessels, eyes, kidneys, nerves, gums, and teeth, and it is the leading cause of adult blindness, lower limb amputations, and kidney failure
People with diabetes also have a higher risk of heart disease and stroke Some of these problems can occur in teens and young adults who develop diabetes during childhood The good news is that research shows that these problems can be greatly reduced or delayed by keeping blood glucose levels near normal

Taking care of diabetes is important If not treated, diabetes can lead to serious health problems

?

6 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer

What are the types of diabetes?
There are two main types of diabetes: type 1 and type 2 are described below A third type–gestational diabetes–occurs only during pregnancy and ends after delivery Women who have had gestational diabetes, however, are more likely to develop type 2 diabetes later in life

Type 1 Diabetes
Type 1 diabetes is a disease of the immune system, the bodys system for fighting infection In people with type 1 diabetes, the immune system attacks the beta cells the insulin-producing cells of the pancreas and destroys them Because the pancreas can no longer produce insulin, people with type 1 diabetes need to take insulin daily to live Type 1 diabetes can occur at any age, but it
occurs most often in children and young adults

Type 1 Diabetes

info
Symptoms:

Increased thirst
and urination

Symptoms The symptoms of type 1 diabetes usually develop
over a short period of time They include increased thirst and urination, constant hunger, weight loss, and blurred vision Affected children also may feel very tired all the time If not diagnosed and treated with insulin, the child with type 1 diabetes can lapse into a life-threatening condition known as diabetic ketoacidosis KEY-toe-asi-DOE-sis, or DKA

Constant hunger Weight loss Blurred vision Fatigue
Risk Factors:

Risk factors Although scientists have made much progress in
predicting who is at risk for type 1 diabetes, they do not yet know what triggers the immune systems attack on beta cells They believe that type 1 diabetes is due to a combination of genetic and environmental factors Researchers are working to identify these factors and to stop the autoimmune process that leads to type 1 diabetes

Genetics Environment

Helping the Student with Diabetes Succeed 7

Type 2 Diabetes

Type 2 Diabetes
The first step in the development of type 2 diabetes is often a problem with the bodys response to
insulin, or insulin resistance For reasons scientists do not completely understand, the body cannot use its insulin very well This means that the body needs increasing amounts of insulin to control blood glucose The pancreas tries to make more insulin, but after several years, insulin production may drop off Type 2 diabetes used to be found mainly in overweight adults ages 40 or older Now, as more children and adolescents in the United States become overweight and inactive, type 2 diabetes occurs more often in young people To control their diabetes, children with type 2 diabetes may need to take oral medication, insulin, or both

info
Symptoms:

Fatigue Increased thirst
and urination

Nausea Rapid weight
loss

Blurred vision Frequent
infections

Symptoms Type 2 diabetes develops slowly in some children,
but quickly in others Symptoms may be similar to those of type 1 diabetes A child or teen can feel very tired, thirsty, or nauseated and have to urinate often Other symptoms include rapid weight loss, blurred vision, frequent infections, yeast infections, and slow healing of wounds or sores High blood pressure may be a sign of insulin resistance In addition, physical signs of
insulin resistance, such as acanthosis nigricans A-can-tho-sis NIG-reh-cans, may appear; here the skin around the neck or in the armpits or groin appears dark, thick, and velvety On the other hand, some children or adolescents with type 2 diabetes show no symptoms at all when they are diagnosed For that reason, it is important for parents and caregivers to talk to their health care providers about screening children or teens at high risk for diabetes

Slow healing of
Risk Factors:

wounds or sores

Being

overweight member who has type 2 diabetes

Having a family Being African

American, Hispanic/Latino American, American Indian, Asian American or Pacific Islander American

Risk factors Being overweight and having a family member
who has type 2 diabetes are the key risk factors for type 2 diabetes In addition, type 2 diabetes is more common in certain racial or ethnic groups, such as African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Pacific Islander Americans For children and teens at risk, health care providers can encourage, support, and educate the entire family to make lifestyle changes that may delay–or prevent–the onset of
type 2 diabetes Such changes may include reaching a healthy weight and then maintaining it and engaging in regular physical activity

8 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer

?

What is effective diabetes management?
The goal of effective diabetes management is to control blood glucose levels by keeping them within a target range that is determined for each child Optimal blood glucose control helps to promote normal growth and development and allows for optimal learning Effective diabetes management is needed to prevent the immediate dangers of blood glucose levels that are too high or too low As noted earlier, research has shown that maintaining blood glucose levels within the target range can prevent or delay the long-term complications of diabetes, such as heart attack, stroke, blindness, kidney failure, nerve disease, and amputations of the foot or leg The key to optimal blood glucose control is to carefully balance food, exercise, and insulin or medication As a general rule, food makes blood glucose levels go up, and exercise and insulin make blood glucose levels go down Several other factors, such as growth and puberty, mental stress,
illness, or injury also can affect blood glucose levels With all of these factors coming into play, maintaining good blood glucose control is a constant juggling act–24 hours a day, 7 days a week

The key to optimal blood glucose control is to carefully balance food, exercise, and insulin or medication

Students with diabetes must check or test their blood glucose levels throughout the day by using a blood glucose meter The meter gives a reading of the level of glucose in the blood at the time it is being checked If blood glucose levels are too low hypoglycemia or too high hyperglycemia, students can then take corrective action, such as eating, modifying their activity level, or administering insulin Low blood glucose levels, which can be life-threatening, present the greatest immediate danger to people with diabetes see hypoglycemia, pages 1719 Many students will be able to handle all or almost all of their diabetes care by themselves Others, because of age, developmental level, or inexperience, will need help from school staff
Helping the Student with Diabetes Succeed 9

The school nurse is the most appropriate person in the school setting to provide care for a student with
diabetes

The school nurse is the most appropriate person in the school setting to provide care for a student with diabetes Many schools, however, do not have a full-time nurse, and sometimes a single nurse must cover a large number of schools Moreover, even when a nurse is assigned to a school full time, this staff member may not always be available during the school day, during extracurricular activities, or on field trips Yet, because diabetes management is needed 24 hours a day, 7 days a week–and diabetes emergencies can happen at any time–school personnel should be prepared to provide diabetes care at school and at all school-sponsored activities in which a student with diabetes participates In this case, the school nurse or another qualified health professional should be involved with training of appropriate staff and providing professional supervision and consultation regarding routine and emergency care of the student All students with diabetes will need help with emergency medical care

Effective school-based diabetes management requires two things: 1 All school staff members who have responsibility for students with diabetes should receive training that provides a
basic understanding of the disease and the students needs, how to identify medical emergencies, and whom to contact in case of an emergency 2 A few school staff members should receive training from a qualified health care professional in student-specific routine and emergency diabetes care tasks so that at least one staff member is always available for younger, less experienced students and for any student with diabetes in case of an emergency The diabetes medical community has found that nonmedical personnel called trained diabetes personnel in this guide can be trained and supervised to safely provide and assist with diabetes care tasks in the school setting, including blood glucose monitoring, insulin and glucagon administration, and urine ketone testing These nonmedical school staff members should be trained and monitored by the school nurse or a qualified health professional Assignment of diabetes care tasks must take into account state laws that may be relevant in determining what tasks may be performed by nonmedical personnel

10 Helping the Student with Diabetes Succeed

?

Section 1 Diabetes Primer
primer

How can a school plan and implement effective diabetes
management?
Collaboration, cooperation, and planning are key elements in developing and implementing successful diabetes management at school As is true for children with other chronic diseases, students with diabetes are more likely to succeed in school when students, parents, school nurses, principals, teachers, other school personnel, and the students health care providers or personal health care team work together to ensure effective diabetes management Your school probably has similar plans and systems in place for children with other health considerations To work collaboratively, a school health team should be assembled that includes people who are knowledgeable about diabetes, the school environment, and federal and state education and nursing laws Team members could include the student, parents/guardian, the school nurse and other health personnel, administrators, the principal, the students teachers and guidance counselor, and other relevant staff The school health team works together to implement the Diabetes Medical Management Plan see pages 49-52 developed by the students personal health care team and family The team decides who needs to receive appropriate medical
information about the child, who will be the trained diabetes personnel and who will monitor them, and what tasks will be delegated In addition, the school health team should be part of the group that develops and implements the students Section 504 Plan, Individualized Education Program IEP, or other education plan that addresses the students developmental and educational needs so that diabetes can be managed safely and effectively in school Three federal laws address the schools responsibilities to help students with diabetes: Section 504 of the Rehabilitation Act of 1973 Section 504 Americans with Disabilities Act of 1990 ADA Individuals with Disabilities Education Act IDEA

School Health

Team
Student with
diabetes

Parents/guardian School nurse Other school
health personnel

Principal Office staff Students
teachers counselor staff

Guidance

Other relevant

These federal laws provide a framework for planning and implementing effective diabetes management in the school setting School administrators and nursing personnel also should determine whether there are applicable state and local
Helping the Student with Diabetes Succeed 11

laws that should be factored into
helping the student with diabetes see pages 1415 and Section 4 for additional information on these federal laws Written plans outlining each students diabetes management help students, their families, school staff, and the students health care providers know what is expected of them These expectations should be laid out in writing in the following documents:

Diabetes Medical Management Plan, developed by the
students personal health care team and family, contains the prescribed diabetes health care regimen, tailored for each student

The Diabetes Medical Management Plan describes the diabetes regimen developed by the students personal health care team and family

Quick Reference Emergency Plan, based on the
information provided in the students Diabetes Medical Management Plan, describes how to recognize hypoglycemia and hyperglycemia and what to do as soon as signs or symptoms of these conditions are observed

Education plans, such as the Section 504 Plan or Individualized Education Program IEP, explain what
accommodations, education aids, and services are needed for each student with diabetes

Other documents may be generated when a school nurse is involved, such as a
nursing care plan and instructions to staff
see page 36

Diabetes Medical Management Plan
The Diabetes Medical Management Plan describes the diabetes care regimen developed by the students personal health care team and family and should be signed by the students physician or other member of the health care team see Section 3 for a sample plan Although this guide uses the term Diabetes Medical Management Plan, school districts may use other terms for this document While this plan is not required by Section 504, the ADA, or the IDEA, the information in it can be useful in addressing the requirements of these federal laws Information in the Diabetes Medical Management Plan may include the following:

Date of diagnosis Current health status

12 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer

Emergency contact information Students willingness and ability to perform self-management tasks at school List of diabetes equipment and supplies Specific medical orders Blood glucose monitoring Insulin, glucagon, and other medications to be given at school Meal and snack plan Exercise requirements Additional monitoring Typical signs, symptoms, and prescribed
treatment for hypoglycemia Typical signs, symptoms, and prescribed treatment for hyperglycemia

The Quick Reference Emergency Plan summarizes how to recognize and treat hypoglycemia and hyperglycemia

The Diabetes Medical Management Plan should be reviewed and updated each school year or upon a change in the students prescribed regimen, level of self-management, school circumstances eg, a change in schedule, or at the request of the student or parents/guardian Information from this plan is used by the school nurse to develop the students nursing care plan and may be incorporated into the 504, IEP, or other education plan

Quick Reference Emergency Plan
The Quick Reference Emergency Plan is based on the information provided in the students Diabetes Medical Management Plan; the school nurse will usually coordinate its development The plan summarizes how to recognize and treat hypoglycemia and hyperglycemia and should be distributed to all personnel who have responsibility for students with diabetes see Section 3 for a sample plan Although this guide uses Quick Reference Emergency Plan, school districts might use other names

Helping the Student with Diabetes Succeed 13

Education
Plans
The school health team, including the student and parents/ guardian, must agree on how the Diabetes Medical Management Plan will be implemented and what medical accommodations, educational aids, and services may be needed for the student This information might be included in a Section 504 Plan, an IEP, or other education plan A 504 Plan is the commonly used term for a plan of services developed under Section 504 of the Rehabilitation Act An IEP is required for students who receive special education and related services under the Individuals with Disabilities Education Act IDEA The information in the Diabetes Medical Management Plan can be used in developing either a Section 504 Plan or an IEP, but should not be a substitute for these plans The 504 Plan, IEP, or other education plan lays out what medical accommodations, educational aids, and services the student may need

Each student with diabetes has different needs, but the education-related plans developed for such students are likely to address the following common elements: Where and when blood glucose monitoring and treatment will take place Identity of trained diabetes personnel who are trained to conduct
blood glucose checking, insulin and glucagon administration, and treatment of hypoglycemia and hyperglycemia Location of the students diabetes management supplies Free access to the restroom and water fountain Nutritional needs, including provisions for meals and snacks Full participation in all school-sponsored activities and field trips, with coverage provided by trained diabetes personnel Alternative times for academic exams if the student is experiencing hypoglycemia or hyperglycemia Permission for absences, without penalty, for doctors appointments and diabetes-related illness Maintenance of confidentiality and the students right to privacy

14 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer
It is strongly recommended that this information be agreed upon before each school year begins or upon diagnosis of diabetes and that it be written down and signed by a representative of the school and the parents/guardian This assures that school staff members, parents, and students know their responsibilities Parents must be notified in a timely manner of any proposed changes in the provision of services and be included in related discussions This approach to
planning and implementing effective diabetes management in school can promote a better understanding of schools responsibilities and can prepare staff members to act in the best interest of students with diabetes

Elements of Effective Diabetes Management
Monitoring
blood glucose hypoglycemia

What are the elements of effective diabetes management in school?
Diabetes management means monitoring or checking blood glucose levels throughout the day, following an individualized meal plan, getting regular physical activity, and administering insulin and/or medications to help keep blood glucose levels in the target range and to help prevent the onset of hypoglycemia or hyperglycemia Additional elements of diabetes management in school include planning for events outside the usual school day, planning for appropriate disposal of materials that come in contact with blood, and dealing with the emotional and social aspects of living with diabetes

Understanding Understanding Following an
individualized meal plan physical activity insulin hyperglycemia

Getting regular Administering Planning for Planning for
special events disasters and emergencies emotional and social
issues

Monitoring Blood Glucose
One of the most important parts of diabetes management is regular monitoring or checking of blood glucose levels Monitoring involves pricking the skin with a lancet at the fingertip, forearm, or other test site to obtain a drop of blood and placing the drop on a special test strip that is inserted in a glucose meter The meter gives the current blood glucose level Physicians generally recommend that students check their blood glucose during the school day, usually before eating snacks or lunch, before physical activity, or when there are symptoms of hypoglycemia or hyperglycemia In young children, symptoms may be subtle; blood glucose should be checked whenever symptoms are suspected Many students can check their own

Dealing with

Helping the Student with Diabetes Succeed 15

Students Usually Check Their

Blood Glucose
Before eating
activity snacks or meals

Before physical When they have
symptoms of high or low blood glucose

blood glucose level; others will need supervision; and others will need to have this task performed by a school nurse or trained diabetes personnel It is extremely important for students to be able to check their blood
glucose levels and respond to levels that are too high or too low as quickly as possible Accordingly, if recommended by the students physician, it is medically preferable to permit students to check their blood glucose level and respond to the results in the classroom, at any other campus location, or at any school activity Taking immediate action is important so that the symptoms dont get worse and the student doesnt miss time in the classroom Blood glucose monitoring does not present a danger to other students or staff members when there is a plan for proper disposal of lancets and other materials that come into contact with blood The family and the school should agree on the plan, which should be consistent with standard Universal Precautions and local wastedisposal laws Disposal may be in a container kept at school or in the students personal container, a heavy-duty plastic or metal container with a tight-fitting lid Check with the students personal health care team about health and safety requirements in your area

Advantages of Checking Blood Glucose Levels Any Time and Any Place

The student can achieve better blood glucose control to prevent long-term complications of high
blood glucose and acute complications of high and low blood glucose It is safer for students because less time is lost between recognizing symptoms, confirming low blood glucose, and obtaining treatment with a fast-acting sugar source followed by a snack or meal The student gains independence in diabetes management when the blood glucose meter is easily accessible and checks can be conducted as needed The student experiences less stigma as blood glucose monitoring loses its mystery when handled as a regular occurrence The student spends less time out of class

16 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer

Understanding Hypoglycemia Low Blood Glucose
HYPOglycemia means LOW blood glucose
Hypoglycemia, also called low blood glucose or low blood sugar, is one of the most frequent complications of diabetes and can happen very suddenly Hypoglycemia occurs when a students blood glucose level falls too low, usually as a result of administering too much insulin, skipping or delaying meals or snacks, not eating enough food as prescribed in the meal plan, exercising too long or too intensely, or a combination of two or more of these factors It is more
likely to occur before lunch, at the end of the school day, or during or after physical education classes Hypoglycemia, which often cannot be prevented, is the greatest immediate danger to students with diabetes

Hypoglycemia occurs when a students blood glucose level falls too low, usually as a result of
Administering

Hypoglycemia usually can be treated easily and effectively If it is not treated promptly, however, hypoglycemia can lead to unconsciousness and convulsions and can be life threatening Early recognition of its symptoms and prompt treatment, in accordance with the students Diabetes Medical Management Plan, are necessary for preventing severe symptoms that may place the student in danger This information, contained in the Quick Reference Emergency Plan, should be provided to all school personnel who have responsibility for the student with diabetes see sample plan on page 53 Hypoglycemia is not always completely preventable, and not all students, especially young children, will recognize its symptoms with every episode Therefore, school personnel should be familiar with the symptoms and treatment so that an urgent problem can be handled appropriately Hypoglycemia
can impair thinking abilities and sometimes can be mistaken for misbehavior If a student has a sudden change in behavior, becomes lethargic, combative, or unconscious, or is having a seizure or convulsion, presume that the student has hypoglycemia Treat the situation as a hypoglycemic emergency and check the students blood glucose level immediately If a blood glucose meter

too much insulin
Skipping or

delaying meals or snacks
Not eating

enough food as prescribed in the meal plan
Exercising

longer and more intensely
Or a combina-

tion of these factors

Helping the Student with Diabetes Succeed 17

is not available in the immediate area, or if the blood glucose level is otherwise unknown, treat the student for hypoglycemia

How to Treat Hypoglycemia
Mild/Moderate Symptoms: As soon as symptoms are observed, give the student a quick-acting sugar product, such as:
3 or 4 glucose

The student should never be left alone or sent anywhere alone when experiencing hypoglycemia

As soon as symptoms of hypoglycemia are observed, give the student a quick-acting sugar product equivalent to 15 grams of carbohydrate, as specified in the Quick Reference Emergency Plan This may include:
3 or 4 glucose tablets, 3 teaspoons or threefourths of a tube of glucose gel, 4 ounces of juice, or 6 ounces half a can of non-diet soda Recheck the students blood glucose level 10 to 15 minutes after treatment Repeat treatment if the blood glucose level still falls below the students target range Symptoms of hypoglycemia, which are different for each student and may vary from episode to episode, can include: Mild/Moderate Symptoms shaky sleepy changed personality sweaty dizzy inability to hungry confused concentrate pale disoriented weak headache uncoordinated lethargic blurry vision irritable or nervous changed behavior Severe Symptoms inability to having a seizure or unconscious swallow convulsions Severe hypoglycemia is rare at school and generally can be prevented with prompt treatment when the early signs of low blood glucose are recognized When hypoglycemia is severe, the school nurse or trained diabetes personnel must respond immediately Symptoms may include inability to swallow, unconsciousness, unresponsiveness, seizure activity, convulsions, or jerking movements At this point, never attempt to give the student food or a drink or to put anything in the
mouth because it could cause choking If students become unconscious or experience convulsions or seizures, position them on their side to prevent choking Immediately contact the school nurse or trained diabetes personnel, who will administer an injection of glucagon see next page, if

tablets
3 teaspoons of

glucose gel
4 ounces of

juice
6 ounces of

non-diet soda Severe Symptoms: Position the student on his/her side
Contact the

school nurse or trained diabetes personnel
Administer

glucagon, as prescribed
Call 911 Call students

parents

18 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer
indicated in the students Diabetes Medical Management Plan While the glucagon is being administered, another school staff member should call for emergency medical assistance and then notify the parents/guardian If glucagon is not authorized, staff should call 911 immediately Glucagon is a hormone that raises blood glucose levels by causing the release of glycogen a form of stored carbohydrate from the liver It is administered when the students blood glucose level gets so low that the student passes out, experiences seizures, or cannot swallow Although it may
cause nausea and vomiting when the student regains consciousness, glucagon can be a lifesaving treatment that cannot harm a student The students parents/guardian should supply the school with a glucagon emergency kit This kit usually contains a bottle vial of glucagon in powder form and a pre-filled syringe with special liquid; the two are mixed just before a glucagon injection is given Glucagon may be stored at room temperature The school nurse and trained diabetes personnel must have ready access to the glucagon emergency kit at all times

Understanding Hyperglycemia High Blood Glucose
HYPERglycemia means HIGH blood glucose
Hyperglycemia, also called high blood glucose, is a serious manifestation of diabetes that may be caused by too little insulin, illness, infection, injury, stress or emotional upset, ingestion of food that has not been covered by the appropriate amount of insulin, or decreased exercise or activity High blood glucose symptoms include increased thirst, frequent urination, nausea, blurry vision, and fatigue Over a long period of time, even moderately high blood glucose levels can lead to serious complications, such as heart disease, blindness, kidney failure, and
amputations In the short term, hyperglycemia can impair cognitive abilities and adversely affect academic performance Hyperglycemia does not usually result in acute problems If, however, the student fails to take insulin, if a pump malfunctions and delivers less insulin, or if either physical or emotional stress

Hyperglycemia

info
Symptoms:
Increased

thirst Frequent urination Nausea Blurry vision Fatigue

Helping the Student with Diabetes Succeed 19

How to Treat Hyperglycemia
Drink extra

water or diet drinks Administer supplemental insulin Monitor blood glucose levels closely

causes the insulin not to work effectively, there will be a breakdown of fat, causing ketones to form see below At first, ketones will be cleared by the kidneys into the urine, but if there are more than the kidneys can handle, they will build up in the blood and may result in diabetic ketoacidosis DKA This complication will cause a fruity breath odor, nausea, vomiting, stomach pain, and, if untreated, deep breathing and increasing sleepiness Students who use insulin pumps can go into DKA within hours if their pumps stop delivering insulin appropriately DKA can be prevented if the students urine
is checked for ketones during times of illness, especially if vomiting occurs, or whenever the blood glucose level exceeds the target range provided in the Diabetes Medical Management Plan The test involves dipping a special strip into the urine and comparing the resulting color to a color chart Treatment of hyperglycemia may involve drinking extra water or diet drinks or administering supplemental insulin in accordance with the Diabetes Medical Management Plan

Free and unrestricted access to liquids and the restroom must be provided, as high blood glucose levels increase urination and may lead to dehydration if the student cannot replace the fluids

The students blood glucose level should be monitored closely until it returns to the target range, as outlined in the Diabetes Medical Management Plan If treatment does not lower blood glucose levels and clear the ketones, if vomiting occurs, or if the student is lethargic or experiences breathing difficulties, call the parents/guardian or call for medical assistance if they cannot be reached Treatment guidelines for ketones and when to call parents should be listed in the students Diabetes Medical Management Plan Information about
the symptoms and treatment of hyperglycemia, contained in the Quick Reference Emergency Plan, should be provided to all school personnel who have responsibility for the student with diabetes see sample plan on page 54

20 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer

Administering Insulin
Students with type 1 diabetes, and some students with type 2 diabetes, require insulin to be given at regular times each day Some students may need additional or corrective dosages of insulin to treat hyperglycemia or to cover a rise in blood glucose levels The Diabetes Medical Management Plan specifies the dosage, delivery system, and schedule for insulin administration, which will differ for each student The nursing care plan, 504, IEP, or other education plan, which are based on the Diabetes Medical Management Plan, specify who will administer prescribed insulin and under what circumstances Today, new types of insulin and new delivery systems help keep blood glucose levels within the target range These options may require closer monitoring and possibly more assistance for the student with diabetes Insulin has three characteristics: Onset is the length of time
before insulin reaches the bloodstream and begins lowering blood glucose Peak time is the time during which insulin is at its maximum strength in terms of lowering blood glucose Duration is the number of hours insulin continues to lower blood glucose levels There are several types of insulin that are used in combination to treat people with diabetes These different types of insulin have been manufactured either to have immediate rapid-acting or shortacting insulin, intermediate, or long basal insulin onset of action and duration of action in the body A coordinated combination of insulins is used to allow for adequate treatment of diabetes at meals, snacks, during periods of physical activity, and through the night Opened vials of insulin may be left at room temperature for 30 days after opening, but will keep for 3 months if refrigerated Unopened vials should be stored in the refrigerator and are good until the expiration date The three most common ways to administer insulin are with a syringe, an insulin pen, or an insulin pump Insulin syringes available today make it easier to draw up the proper dosage, and shorter, smaller needles make injections easier and relatively
painless

Insulin has three characteristics:
Onset Peak time Duration

Helping the Student with Diabetes Succeed 21

The three most common ways to deliver insulin:
Insulin syringe Insulin pen Insulin pump

An insulin pen looks like a fountain pen The pen holds a cartridge of insulin, and a needle is screwed onto its tip just before use Insulin pens are convenient and most appropriate when children need a single type of insulin An insulin pump is a computerized device that looks like a pager and is usually worn on the students waistband or belt The pump is programmed to deliver small, steady doses of insulin throughout the day; additional doses are given to cover food or high blood glucose levels The pump holds a reservoir of insulin that is attached to a system of tubing called an infusion set Most infusion sets are started with a guide needle, then the plastic cannula a tiny, flexible plastic tube is left in place, taped with dressing, and the needle is removed The cannula is usually changed every 2 or 3 days or when blood glucose levels remain above target range More students are opting for insulin pump therapy as a means to keep blood glucose levels in better control
Some students who need insulin during the school day are able to administer it on their own; others will need supervision; and others will need someone to administer the insulin for them The school nurse and/or trained diabetes personnel should provide this help in accordance with the Diabetes Medical Management Plan and the nursing care plan School personnel who are responsible for the students care should be knowledgeable about the use and operation of that students insulin delivery system Information about insulin administration should appear in the students Diabetes Medical Management Plan, nursing care plan, and education plan 504, IEP, or other education plan In the event a school nurse is not available to administer insulin, a nurse or another qualified health care professional should teach, monitor, and supervise trained diabetes personnel to administer insulin Further, when the school nurse is not available to administer insulin and insulin is administered by other trained diabetes personnel, additional safety precautions may be taken, such as verification of the dose by two trained diabetes personnel before administration

22 Helping the Student with Diabetes
Succeed

Section 1 Diabetes Primer
primer

Following an Individualized Meal Plan
The nutritional needs of a student with diabetes do not differ from the needs of a student without diabetes Both should eat a variety of foods to maintain normal growth and development The major difference is that the timing, amount, and content of the food that the student with diabetes eats are carefully matched to the action of the insulin The students meal plan is designed to balance nutritional needs with the insulin regimen and physical activity level There are usually no forbidden foods for people with diabetes The family and personal health care team create an individualized meal plan based upon carbohydrate counting or an exchange system Carbohydrate counting involves calculating the number of grams of carbohydrate or choices of carbohydrate the student eats This information, which can be obtained from nutrition information on food labels, is used to determine the amount of insulin the student needs to control blood glucose for any given meal or snack The exchange system groups foods in six different lists, each with a set nutritional value A meal plan is prepared that recommends several
exchanges or servings from each food group for each meal and snack The exchange list ensures that the meal plan is consistent in portion size and nutrient content while offering a wide variety of foods from each group Students using this approach consume a prescribed number of exchanges at meal and snack times The exchange lists include the following food groups:

The students meal plan is designed to balance the students nutritional needs with his or her insulin routine and physical activity level

Bread/starch Fruit Milk Vegetables Meat/protein foods Fats

With some insulin regimens, it is important to maintain consistency in the timing and content of meals and snacks The student should eat lunch at the same time each day Snacks are often necessary for a child with diabetes and must be eaten to balance the peak times of insulin action A missed or delayed snack could result in hypoglycemia The student also must have immediate access to a quick-acting form of glucose, such as juice, glucose
Helping the Student with Diabetes Succeed 23

tablets or gel, or regular soda to treat hypoglycemia The students nursing care plan or education plan 504, IEP, or other education plan
should show the timing of meals and snacks and an alternative plan for unusual or unforeseen circumstances

Getting Regular Physical Activity
Exercise and physical activity are critical parts of diabetes management Everyone can benefit from regular exercise, but it is even more important for a student with diabetes In addition to maintaining cardiovascular fitness and controlling weight, physical activity can help to lower blood glucose levels Students with diabetes should participate fully in physical education classes and team sports To maintain blood glucose levels within their target ranges during extra physical activity, students will make adjustments in their insulin and food intake To prevent hypoglycemia, they also may need to check their blood glucose levels more frequently while engaging in physical activity Students with diabetes should participate fully in physical education classes and team sports

Physical education instructors and sports coaches must be able to recognize and assist with the treatment of hypoglycemia A quick-acting source of glucose and the students glucose meter should always be available, along with plenty of water Students using pumps may
disconnect from the pump for sports activities If they keep the pump on, they may set a temporary, reduced rate of insulin while they are playing School personnel should provide the student with a safe location for storing the pump when the student does not wear it The students Diabetes Medical Management Plan, nursing care plan, 504 Plan, IEP, or other education plan should include specific instructions

24 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer

Planning for Special Events, Field Trips, and Extracurricular Activities
Meeting the needs of students with diabetes requires advance planning for special events, such as classroom parties, field trips, and school-sponsored extracurricular activities held before or after school With proper planning for coverage by trained diabetes personnel and possible adjustments to their insulin regimen and meal plan, students with diabetes can participate fully in all schoolrelated activities While there are usually no forbidden foods in a meal plan for children or teens with diabetes, school parties often include foods high in carbohydrates and fats Providing more nutritious snacks will be healthier for all
students and encourage good eating habits The parents/guardian should decide whether the student with diabetes should be given the same food as other students or food the parents provide Parents should be given advance notice of parties to incorporate special foods in the meal plan or to adjust the insulin regimen Students often view a field trip as one of the most interesting and exciting activities of the school year, and students with diabetes must be allowed to have these school-related experiences Although it is not unusual to invite parents to chaperone field trips, parental attendance is not a prerequisite for participation by the student with diabetes Trained diabetes personnel should accompany the student with diabetes and ensure that all the students supplies are brought along with the student and that there are snacks and supplies to treat hypoglycemia The plan for coverage and care during extracurricular activities sponsored by the school that take place outside of school hours should be carefully set out in the students 504, IEP, or other education plan As with field trips, trained diabetes personnel must be available at these activities

With proper planning,
students with diabetes can participate fully in all school-related activities

Helping the Student with Diabetes Succeed 25

Planning for Disasters and Emergencies
To be prepared in the event of natural disasters or emergencies when students need to stay at school, the parents/guardian must provide an emergency supply kit This kit should contain enough supplies for 72 hours, including the following items as appropriate:

Blood glucose meter, testing strips, lancets, and batteries for the meter Urine ketone strips Insulin and supplies Insulin pump and supplies, including syringes Other medications Antiseptic wipes or wet wipes Fast-acting source of glucose Carbohydrate-containing snacks Hypoglycemia food supplies enough for 3 episodes: quick-acting sugar and carbohydrate/protein snacks Glucagon emergency kit

Dealing with Emotional and Social Issues
Students with diabetes must deal not only with the usual developmental issues of growing up but also with learning to manage this complex disease Diabetes can affect every facet of life, complicating the task of mastering normal developmental challenges For the most part, children do not want to be singled out or made to feel
different from their peers Diabetes care tasks, however, can set them apart and make them feel angry or resentful about their disease Sometimes, children and teens feel pressured to please caretakers and yet cannot consistently comply with their requests To appease concerned parents or health care providers, some children report fictitious glucose levels or do not take all their insulin 26 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer
Children react differently to having diabetes They may be accepting, resentful, open to discussing it, or attempt to hide it Often, the same child will experience all of these feelings over time School personnel should be aware of the students feelings about having diabetes and identify ways to ensure the student is treated the same as others Diabetes can be a focal point for conflict within families One of the biggest tasks for children and adolescents is to become increasingly independent from their parents, but diabetes may compromise independence because parents are concerned about their childrens ability to perform self-care and take responsibility for it Parents, who are ultimately responsible for their childrens
well-being, may be reluctant to allow normal independence in children or teens who have not been able to take care of themselves properly This parental concern can lead to increasing struggles with dependence, oppositional behavior, and rebellion Some adolescent girls, for example, may rebel by not following their insulin regimen because they want to lose weight or avoid gaining weight Increasingly, depression is being recognized as quite common among children and teens generally, and even more so in those with diabetes Health care providers and school personnel must be aware of emotional and behavioral issues and refer students with diabetes and their families for counseling and support as needed

Diabetes care tasks can set children and teens apart from their peers and make them feel resentful or angry about their disease

?

Why is diabetes self-management important?
While it is very important to provide students with assistance and supervision of their diabetes care as needed, it is equally important to enable students to take on the responsibility of learning diabetes self-management and control The age for transfer of responsibility from caregiver to child varies from child
to child and from task to task because children develop and mature at different rates Students ability to participate in selfcare also depends upon their willingness to do so As students are ready, they can assume more responsibility for their care

Helping the Student with Diabetes Succeed 27

Students competence and capability for performing diabetesrelated tasks are determined by the school health care team and the parents/guardian Diabetes care depends upon self-management Ultimately, each person with diabetes becomes responsible for all aspects of self-care, including blood glucose monitoring and insulin administration Regardless of their level of self-management, however, all students with diabetes may require assistance when blood glucose levels are out of the target range

Why is diabetes management training essential for school personnel?
Diabetes management training teaches school nurses and staff members how to provide necessary care for students with diabetes during the school day and school-sponsored extracurricular activities Training should occur before the beginning of the school year, when a student is diagnosed with diabetes, when a student with diabetes is
enrolled in the school, or when appropriate There also should be regular refresher sessions There are two levels of training appropriate for school personnel The first level of training is for school staff members who have primary responsibility for students with diabetes eg, teachers and coaches, but who dont perform diabetes care tasks such as blood glucose monitoring or insulin or glucagon administration This training should include:

General overview of diabetes and typical health care needs of a student with diabetes Recognition of hypoglycemia and hyperglycemia Identity of school nurses and/or trained diabetes personnel and how to contact them for help

The second level of training is for school personnel who will perform routine and emergency care school nurses and trained diabetes personnel and should include the following content based on current standards of care for children and youth with diabetes recommended by the American Diabetes Association:

General overview of typical health care needs of a student with diabetes and how these needs are addressed in the students written care plans

28 Helping the Student with Diabetes Succeed

Section 1 Diabetes Primer
primer

Explanation/overview of type 1 and type 2 diabetes The effect of balancing insulin, food, and exercise upon a students blood glucose levels Procedures for routine care of individual students, including blood glucose monitoring, insulin administration, urine ketone testing, and recording results Signs and symptoms of hypoglycemia and hyperglycemia and the short- and long-term risks of these conditions Treatment of hypoglycemia and hyperglycemia Glucagon administration Managing nutrition and exercise in the school setting Tools, supplies, and equipment required for diabetes care and their storage Legal rights and responsibilities of schools and parents/guardian

More information on diabetes can be found in the Resource List beginning on page 61

Where can I learn more about diabetes?
The Resource List beginning on page 61 includes a list of the major organizations and their websites that offer related information, resources, and training

Helping the Student with Diabetes Succeed 29

30 Helping the Student with Diabetes Succeed

Section 2 Actions
Actions for the School District Administrator Page 33 Actions for the Principal, School Administrator, or Designee Page 34
Actions for the School Nurse Page 36 Actions for Trained Diabetes Personnel Page 38 Actions for the Teacher Page 40 Actions for the Coach and Physical Education Instructor Page 41 Actions for the Food Service Manager, Lunchroom Staff, or Lunchroom Monitor Page 42 Actions for the Bus Driver Page 43 Actions for the Guidance Counselor or School Psychologist Page 44 Actions for the Parent or Guardian Page 45 Actions for the Student with Diabetes Page 46

actions

Section 2 actions
for

The following pages should be copied and distributed to everyone involved along with the students Quick Reference Emergency Plan see pages 5354 All substitute and appropriate after-school personnel should receive information relevant to their position

S

chool Personnel, Parents, and Students
The health, safety, and educational progress of a student with diabetes depend on cooperation and collaboration between the family and school staff members Working together, they form the school health team that implements the provisions of the students written plans and provides the necessary assistance in the school environment see Diabetes Primer, page 11 When available, the school nurse is the most appropriate
person to plan diabetes care in the school and oversee implementation of the students written plans When a school nurse is not available, the diabetes medical community has found that nonmedical personnel trained diabetes personnel can be trained and supervised to safely provide and assist with diabetes care tasks in the school setting, including blood glucose monitoring, insulin and glucagon administration, and urine ketone testing Assignment of diabetes care tasks must take into account state and local laws addressing what tasks may be performed by nonmedical school personnel The responsibilities of each key school staff member are described in the pages that follow, along with those of the parents/guardian and the student One person may fill more than one role For example, a teacher or a coach also may be one of the trained diabetes personnel The recommended actions on the following pages do not represent legal checklists of what people must do to comply with relevant federal, state, and local laws Rather, they are steps that school personnel, parents, and students should take to ensure effective diabetes management

32 Helping the Student with Diabetes Succeed

Please copy and
distribute to the School District Administrator

Section 2 ACTIONS

ACTIONS for the School District Administrator
Superintendent, 504 coordinator, or other school administrator responsible for coordinating student services

actions

Provide leadership in developing district
policy related to all aspects of diabetes management at school that is consistent with the standards of care recommended for children with diabetes, including delegation of responsibilities, required staff training, medication administration policy, and blood glucose monitoring Obtain input from local or regional experts

Allocate sufficient resources to manage
students with diabetes

Monitor schools attended by students
with diabetes for compliance with district policy

Meet with members of the school
health team as needed Address issues of concern about the provision of diabetes care by the school district, as appropriate

Support implementation of district
policy Support school district health professionals and other school administrators regarding: 1 development, coordination, and implementation of diabetes management training; 2 ongoing quality control and improvement of these training programs; and 3
development and implementation of a program to monitor the performance of those who receive training

Respect the students confidentiality
and right to privacy

Learn about diabetes by reviewing the
materials contained in this guide

Understand and implement the federal
and state laws that may apply to students with diabetes, including Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act, and the Individuals with Disabilities Education Act see Section 4

Arrange for training of school
personnel Arrange for a health care professional, such as the school nurse or a diabetes-trained public health nurse, to provide training and ongoing monitoring for trained diabetes personnel

The American Diabetes Association ADA publishes Standards of Care for Diabetes Management annually in the journal Diabetes Care These standards also appear on the associations website, wwwdiabetesorg See the ADAs position statement on Care of Children with Diabetes in the School and Day Care Setting on pages 7377 Helping the Student with Diabetes Succeed 33

Please copy and distribute to the Principal, School Administrator, or Designee

ACTIONS for the Principal,
School
Administrator, or Designee
Participate in developing and
implementing school policy related to diabetes management at school and implement school district policy

Arrange for diabetes management

Allocate sufficient resources to manage
students with diabetes

Develop and implement a system to
inform school health services of the pending enrollment of a student with diabetes

Promote a supportive learning environment for students with diabetes Treat these students the same as other students except to respond to medical needs

training for the school nurse, trained diabetes personnel, and other staff members with responsibility for students with diabetes Inform staff members about how and when they should contact trained diabetes personnel Ensure that trained diabetes personnel are available at all times when the student is on or off campus for school-sponsored activities and events

Alert all school-related staff members
who teach or supervise a student with diabetes Ensure that they, including the bus driver, are familiar with the accommodations and emergency procedures contained in the students Diabetes Medical Management Plan, 504 Plan, IEP, or other education plan

Meet
annually with the school health
team Arrange and attend a meeting of the school health team members student, family, school nurse, 504/IEP coordinator, teachers, and other staff members who have primary responsibility for the student before the school year starts, or when the child is newly diagnosed, to discuss medical accommodations and educational aids and related services the student needs

Alert all substitute personnel Ensure
that they are aware of the needs and emergency procedures for students with diabetes

Work with the school health team to
implement the students written plans, including the Diabetes Medical Management Plan, and monitor compliance
Continued on next page

Identify all staff members who have
responsibility for the student with diabetes

34 Helping the Student with Diabetes Succeed

Section 2 ACTIONS

ACTIONS for the Principal,
School Administrator, or Designee
Implement school policy on availability
of trained staff The school nurse or at least one of the schools trained diabetes personnel must be available when the student with diabetes is on campus or is a participant in off-campus school-sponsored activities and events Continued

Learn about
diabetes by reviewing the
materials contained in this guide

Be able to recognize and respond to
signs and symptoms of hypoglycemia and hyperglycemia in accordance with the students Quick Reference Emergency Plan, which includes knowing when and how to contact the school nurse or trained diabetes personnel

actions

Respect the students confidentiality
and right to privacy

Help develop and implement oncampus as well as off-campus emergency protocols

Understand the federal and state laws
that may apply to students with diabetes, including Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act, and the Individuals with Disabilities Education Act; understand procedures for implementation see Section 4

Include diabetes awareness as part of
health or cultural education

Support and facilitate ongoing communication between parents/guardian of students with diabetes and school staff

Helping the Student with Diabetes Succeed 35

Please copy and distribute to the School Nurse

ACTIONS for the School Nurse

Coordinate development of the
students Quick Reference Emergency Plan and provide copies to staff members who have responsibility for the student
throughout the school day eg, teachers, coach, PE instructor, lunchroom staff, and bus driver

When a school nurse is assigned to the school or school district, that person is the key school staff member who coordinates provision of health care services for a student with diabetes at school and at school-related activities When notified that a student with diabetes is enrolled in the school, annually or more often as necessary, the school nurse will:

Obtain and review the students current
Diabetes Medical Management Plan from the personal health care provider and pertinent information from the family

Facilitate the initial school health team
meeting to discuss implementing the students Diabetes Medical Management Plan and participate in the development and implementation of the students 504 Plan, IEP, or other education plan Monitor compliance with these plans and facilitate follow-up meetings of the school health team to discuss concerns, receive updates, and evaluate the need for changes to the students plans, as appropriate

Obtain materials and medical supplies
necessary for diabetes care tasks from the parents/guardian and arrange a system for notifying the student or
parents/guardian when supplies need to be replenished

Plan and implement diabetes management training for the trained diabetes personnel and any other staff members with responsibility for the student with diabetes who require such training Ensure that all those mentioned in the 504 Plan, IEP, or other education plan know their roles in carrying out the plan, how their roles relate to each other, and when and where to seek help

Conduct a nursing assessment of the
student and develop a nursing care plan Many school nurses already have systems set up to develop nursing care plans for students with chronic diseases The plan for students with diabetes is based on assessment of the student, input from the parents/guardian and the student, and the Diabetes Medical Management Plan For example, the nursing care plan will identify specific functional problems, establish a goal to overcome each problem, and delineate tasks or interventions to help reach the goals

Participate in diabetes management
training provided by health care professionals with expertise in diabetes and attend other continuing education offerings to attain and/or maintain knowledge about current standards of care
for children with diabetes
Continued on next page

Conduct ongoing, periodic assessments
of students with diabetes and update the nursing care plans 36 Helping the Student with Diabetes Succeed

Section 2 ACTIONS

ACTIONS for the School Nurse Continued
Review the information about diabetes
in this guide

With parental permission, act as
liaison between the school and the students health care provider regarding the students self-management at school

Distribute the Diabetes Primer in this
guide to all school personnel who have responsibility for students with diabetes

actions

Train or oversee training of, assess
competence, and monitor trained diabetes personnel in carrying out the health care procedures defined in the Diabetes Medical Management Plan, 504 Plan, IEP, or other education plan

Communicate to parents/guardian any
concerns about the students diabetes management or health, such as acute hypoglycemia episodes, hyperglycemia, general attitude, and emotional issues

Perform routine and emergency
diabetes care tasks, including blood glucose monitoring, urine ketone testing, insulin administration, and glucagon administration

Promote and encourage independence
and
self-care consistent with the students ability, skill, maturity, and developmental level

Respect the students confidentiality
and right to privacy

Practice universal precautions and
infection control procedures during all student encounters

Act as an advocate for students to help
them meet their diabetes health care needs

Maintain accurate documentation of
contacts with students and family members; communications with the students health care provider; any direct care given, including medication administration; and the training and monitoring of trained diabetes personnel

Provide education and act as a
resource on managing diabetes at school to the student, family, and school staff Establish and maintain an up-todate resource file of pamphlets, brochures, and other publications for school personnel

Collaborate with other co-workers
eg, food service and agencies eg, outside nursing agencies, school bus transportation services as necessary to provide health care services

Assist the classroom teacher with
developing a plan for substitute teachers

Assist the PE instructor with managing
the students exercise program at school

Be knowledgeable about federal, state,
and
local laws and regulations that pertain to managing diabetes at school see Section 4
Helping the Student with Diabetes Succeed 37

Please copy and distribute to Trained Diabetes Personnel

ACTIONS for Trained Diabetes Personnel

With proper supervision and training, and where state laws do not prohibit it, nonmedical personnel can help students manage their diabetes safely at school This guide uses the term trained diabetes personnel, but some schools use other names Trained diabetes personnel may include school staff members, health aides, and licensed practical nurses Depending on the size of the school, at least two people should be trained to perform diabetes care tasks and be trained diabetes personnel If a school has a nurse, the nurse takes the lead in providing diabetes care Either the school nurse or at least one of the trained diabetes personnel should be on site throughout the school day and during school-sponsored activities that take place before or after school in which a student with diabetes participates

Understand the students Diabetes
Medical Management Plan, 504 Plan, IEP, or other education plan

Practice universal precautions and
infection control
procedures in all student encounters

Understand the students Quick
Reference Emergency Plan

Participate in planned evaluations of
care

Attend the students school health
team meetings to gain understanding of the overall goal of care

Document care provided according to
standards and requirements outlined by school policy

Participate in diabetes management
training

Observe and record student health
and behavior, noting any changes over time

Learn about diabetes by reviewing
materials contained in this guide

Perform routine and emergency
diabetes care tasks, including blood glucose monitoring, urine ketone testing, insulin administration, and glucagon administration after receiving training under the direction of the school nurse or other assigned health care professional

Communicate directly and regularly
with the school nurse or the supervising health care professional

Consult with appropriate members of
the students school health team when questions arise or the students health status changes
Continued on next page

38 Helping the Student with Diabetes Succeed

Section 2 ACTIONS

ACTIONS for Trained Diabetes Personnel Continued
Respect the students
confidentiality
and right to privacy

Provide support and encouragement
to the student

Be available on campus during regular
school hours and when the student participates in school-sponsored extracurricular activities held before or after school

Help ensure that the student has a
supportive learning environment and is treated the same as students without diabetes, except to respond to medical needs

actions

Accompany the student on field trips
or off-campus school-sponsored sports events and activities, as determined by the 504 Plan, IEP, or other education plan

Helping the Student with Diabetes Succeed 39

Please copy and distribute to the Teacher

ACTIONS for the Teacher
Participate in the school health team
meetings The teachers who has primary responsibility for the student participates in the school health team meetings when the Diabetes Medical Management Plan, 504 Plan, IEP, or other education plans are discussed

Provide classroom accommodations

for the student with diabetes, as indicated in the students 504 Plan, IEP, or other education plan

Provide instruction to the student if it
is missed because of absence for diabetes-related care

Work with the
school health team to
implement written care plans, including the Diabetes Medical Management Plan, 504 Plan, IEP, or other education plan

Provide information for substitute
teachers that communicates the day-today needs of the student and the Quick Reference Emergency Plan

Recognize that a change in the
students behavior could be a symptom of blood glucose changes Be aware that a student who has low blood sugar, even mildly low, may briefly have some cognitive impairment If changes occur, respond in accordance with the students Quick Reference Emergency Plan

Notify the parents/guardian in
advance of changes in school schedule, such as class parties, field trips, and other special events

Communicate with the school nurse,
trained diabetes personnel, or parents regarding any concerns about the student

Be prepared to recognize and respond
to the signs and symptoms of hypoglycemia and hyperglycemia in accordance with the students Quick Reference Emergency Plan, which specifies when and how to contact the school nurse or trained diabetes personnel

Attend diabetes management training,
if designated as trained diabetes personnel

Learn about diabetes by reviewing
the
materials contained in this guide

Treat the student with diabetes the
same as other students, except to meet medical needs

Provide a supportive environment for
the student to manage diabetes effectively and safely at school, which includes eating snacks for routine diabetes management and to treat low blood glucose levels, having bathroom privileges and access to drinking water, monitoring blood glucose, and administering insulin and other medications 40 Helping the Student with Diabetes Succeed

Respect the students confidentiality
and right to privacy

Please copy and distribute to the Coach and Physical Education Instructor

Section 2 ACTIONS

ACTIONS for the Coach and
Physical Education Instructor
Encourage exercise and participation
in physical activities and sports for students with diabetes as well as for other students

To treat hypoglycemia, provide the

actions

student with immediate access to a fast-acting form of glucose, as outlined in the Quick Reference Emergency Plan

Treat the student with diabetes the
same as other students, except to meet medical needs

Consider taping a fast-acting form of
glucose eg, 3 or 4 glucose tablets or hard candies to a
clipboard or include it in the First Aid pack that goes out to physical education activities, practices, and games

Encourage the student to have
personal supplies readily accessible Make sure blood glucose monitoring equipment is available at all activity sites

Allow the student to check blood
glucose levels as outlined in the 504 Plan, IEP, or other education plan

Learn about diabetes by reviewing
materials contained in this guide

Provide input to the students school
health team as needed

Understand and be aware that hypoglycemia can occur during and after physical activity

Communicate with the school nurse
and/or trained diabetes personnel regarding any observations or concerns about the student

Recognize that a change in the
students behavior could be a symptom of blood glucose changes

Provide information for the substitute
PE instructor that communicates the daily needs of the student and the Quick Reference Emergency Plan

Be prepared to recognize and respond
to the signs and symptoms of hypoglycemia and hyperglycemia and take initial actions in accordance with the students Quick Reference Emergency Plan, which specifies when and how to contact the school
nurse or trained diabetes personnel

Respect the students confidentiality
and right to privacy

If appropriate, please distribute this information to the playground/campus supervisor Helping the Student with Diabetes Succeed 41

Please copy and distribute to the Food Service Manager, Lunchroom Staff, or Lunchroom Monitor

ACTIONS for the Food Service Manager,
Lunchroom Staff, or Lunchroom Monitor
Obtain a copy of the students written
meal plan from the Diabetes Medical Management Plan

Recognize that eating meals and

Obtain a copy of the students Quick
Reference Emergency Plan and keep it in a known, yet secure, place in the lunchroom

Provide a lunch menu and lunch
schedule in advance to parents along with the nutrition content of menu selections, including grams of carbohydrate and fat

snacks on time is a critical component of diabetes management Failure to eat lunch on time could result in low blood glucose, especially if a student has missed a morning snack or has had a physically strenuous or otherwise active morning at school

Ensure that the student has timely
access to food and sufficient time to finish

Understand and be aware that hypoglycemia can occur before
lunch Supervisory lunch personnel may need to encourage the student to eat appropriate foods

Know where supplies to treat
hypoglycemia are kept eg, with the student or another place

Treat the student with diabetes the
same as other students, except to respond to medical needs

Be prepared to recognize and respond
to the signs and symptoms of hypoglycemia and hyperglycemia and take actions in accordance with the students Quick Reference Emergency Plan

Provide input to the students school
health team when requested

Communicate with the school nurse
and/or trained diabetes personnel regarding any concerns about the student

Recognize that a students behavior
change could be a symptom of blood glucose changes

Respect the students confidentiality
and right to privacy

Learn about the various kinds of
diabetes meal and snack plans Know which type of meal plan the student follows

42 Helping the Student with Diabetes Succeed

Please copy and distribute to the Bus Driver

Section 2 ACTIONS

ACTIONS for the Bus Driver
At the beginning of the school year,
identify any students on the bus who have diabetes

Keep supplies to treat low blood

actions

Obtain a copy of the
students Quick
Reference Emergency Plan and keep it on the bus in a known, yet secure, place Leave the plan readily available for substitute drivers

glucose on the bus and be aware of where the students with diabetes normally keep their supplies

Treat the student with diabetes the
same as other students, except to respond to medical needs

Understand and be aware that
although hypoglycemia normally occurs at the end of the day, it may happen at the beginning of the day if the student has not eaten breakfast

Allow the student to eat snacks on the
bus

Provide input to the students school
health team when requested

Communicate with the school nurse
and/or trained diabetes personnel regarding any concerns about the student

Recognize that a students behavior
change could be a symptom of blood glucose changes

Be prepared to recognize and respond
to the signs and symptoms of hypoglycemia and hyperglycemia and take initial actions in accordance with the students Quick Reference Emergency Plan, which specifies when and how to contact trained diabetes and emergency personnel

Respect the students confidentiality
and right to privacy

Helping the Student with Diabetes Succeed
43

Please copy and distribute to the Guidance Counselor or School Psychologist

ACTIONS for the Guidance Counselor or
School Psychologist
Work with school staff to promote a
supportive learning environment

Be aware that some students may not

Ensure that the student with diabetes
is treated the same as students without diabetes, except to respond to medical needs

wish to share information about their diabetes with other students or school staff, particularly if it makes them feel different from others

Be aware of and be prepared to
respond to the emotional needs of the student Children react differently to having diabetes Some are accepting and open to discussing it; others are resentful and may attempt to hide it Often, a single child will experience both kinds of feelings Be aware of the students feelings about having diabetes and identify ways to ensure the student is treated the same as other students

Promote and encourage independence
and self-care that are consistent with the students ability, skill, maturity, and development

Provide input to the students school
health team when requested

Communicate with the school nurse
and/or trained diabetes personnel
regarding any concerns about the student

Respect the students confidentiality
and right to privacy

Recognize that students with chronic
illnesses such as diabetes may rebel by discontinuing all or part of their medical regimen Adolescent girls, for example, may not follow their insulin regimen because they want to lose weight or to avoid gaining weight

44 Helping the Student with Diabetes Succeed

Please copy and distribute to the Parents or Guardian

Section 2 ACTIONS

ACTIONS for the Parents or Guardian
Inform the school principal that your
child has diabetes when the student enrolls in school or is newly diagnosed with the disease

Inform school staff of any changes in
the students health status

actions

Provide all supplies and equipment
necessary for implementing your childs Diabetes Medical Management Plan, 504 Plan, IEP, or other education plan, including blood glucose monitoring equipment, supplies for insulin administration and urine ketone testing, snacks, fast-acting glucose, and a glucagon emergency kit As appropriate, provide these supplies to school personnel Replenish supplies as needed

Provide accurate and current
emergency contact information

Provide
the signed Diabetes Medical
Management Plan to the school nurse or other member of the school health team

Attend and participate in the initial
and annual meetings of the school health team includes student, parents, school nurse, principal, 504 coordinator, teachers, and other school personnel who have responsibility for the student with diabetes to discuss implementing the students Diabetes Medical Management Plan, to review medical accommodations and educational aids the student may need, and to develop a 504 Plan, IEP, or other education plan

Provide and maintain all supplies and
equipment necessary to accommodate the students long-term needs 72 hours in case of an emergency

Inform appropriate school staff
principal, teachers, coaches, and others when the student plans to participate in school-sponsored activities that take place before or after school so that health care coverage can be coordinated to ensure the health and safety of the student with diabetes

Provide specific information about
your childs diabetes and performance of diabetes-related tasks at home to the school health team

Permit sharing of medical information
necessary for the students safety between
the school and the students personal health care providers

Understand the federal, state, and
local laws that address the schools responsibilities to students with diabetes

Helping the Student with Diabetes Succeed 45

Please copy and distribute to Students with Diabetes who are able to take responsibility for their self-management

ACTIONS for the Student with Diabetes
Participate in the school meeting to
discuss your Diabetes Medical Management Plan, 504 Plan, IEP, or other education plan, as appropriate

Things You Need to Know: 1 What your written school plans say
to help you manage your diabetes, which person at school will help you, and what is expected of you

Always wear a medical alert ID and
carry a fast-acting source of glucose

Tell teachers and other school staff
members if you feel symptoms of low or high blood glucose, especially if you need help

2 Who to contact and what to do when
you are having a low blood sugar reaction

Work with school staff members if you
need help checking your blood glucose, getting insulin, or eating the right amount of food at the right time during the school day

3 When you should check your blood
glucose levels, give yourself
insulin, have a snack, and eat lunch

Take charge of your diabetes care at
school if your written school plans allow you to This may include:

4 Where your diabetes supplies are
stored, if you dont carry them, and who to contact when you need to use them

checking and writing down blood glucose levels figuring out the right insulin doses giving yourself insulin throwing away needles, lancets, and other supplies you have used in the right place eating meals and snacks as planned treating low blood sugar carrying diabetes equipment and supplies with you at all times

46 Helping the Student with Diabetes Succeed

Section 3 Tools
Sample Diabetes Medical Management Plan Page 49 Sample Quick Reference Emergency Plan Page 53

Tools

Section 3 tools
for

E

ffective Diabetes Management in Schools
This section contains examples of two important tools to help the school health team in managing the student with diabetes:

The Sample Diabetes Medical Management Plan is completed by the students parents/guardian and personal health care team and can be used as the basis for developing education plans and nursing care plans for students with diabetes The Sample Quick Reference Emergency
Plan addresses management of hypoglycemia and hyperglycemia emergencies This plan should be completed for each student with diabetes and both pages should be copied and distributed to all relevant personnel, in accordance with the students Diabetes Medical Management Plan, 504 Plan, IEP, or other education plan

48 Helping the Student with Diabetes Succeed

Date of Plan:

Diabetes Medical Management Plan
Effective Dates:
This plan should be completed by the students personal health care team and parents/guardian It should be reviewed with relevant school staff and copies should be kept in a place that is easily accessed by the school nurse, trained diabetes personnel, and other authorized personnel Students Name: Date of Birth: Date of Diabetes Diagnosis:

Grade: Homeroom Teacher: Physical Condition: Diabetes type 1 Diabetes type 2 Contact Information Mother/Guardian: Address: Telephone: Home Father/Guardian: Address: Telephone: Home Students Doctor/Health Care Provider: Name: Address: Telephone: Other Emergency Contacts: Name: Relationship: Telephone: Home Work Cell Emergency Number: Work Cell Work Cell

Tools

Notify parents/guardian or emergency contact in the following
situations:

Helping the Student with Diabetes Succeed 49

Diabetes Medical Management Plan Continued
Blood Glucose Monitoring Target range for blood glucose is 70-150 70-180 Other Usual times to check blood glucose Times to do extra blood glucose checks check all that apply before exercise after exercise when student exhibits symptoms of hyperglycemia when student exhibits symptoms of hypoglycemia other explain: Can student perform own blood glucose checks? Yes No Exceptions: Type of blood glucose meter student uses: Insulin Usual Lunchtime Dose Base dose of Humalog/Novolog /Regular insulin at lunch circle type of rapid-/short-acting insulin used is _____ units or does flexible dosing using _____ units/ _____ grams carbohydrate Use of other insulin at lunch: circle type of insulin used: intermediate/NPH/lente _____ units or basal/Lantus/Ultralente _____ units Insulin Correction Doses Parental authorization should be obtained before administering a correction dose for high blood glucose levels Yes No _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl _____ units
if blood glucose is _____ to _____ mg/dl _____ units if blood glucose is _____ to _____ mg/dl Can student give own injections? Yes No Can student determine correct amount of insulin? Yes No Can student draw correct dose of insulin? Yes No _____ Parents are authorized to adjust the insulin dosage under the following circumstances:______________

For Students With Insulin Pumps Type of pump:

Basal rates: _____ 12 am to _____ _____ _____ to _____ _____ _____ to _____

Type of insulin in pump: Type of infusion set: Insulin/carbohydrate ratio:

Correction factor:

50 Helping the Student with Diabetes Succeed

Diabetes Medical Management Plan Continued
Student Pump Abilities/Skills: Count carbohydrates Bolus correct amount for carbohydrates consumed Calculate and administer corrective bolus Calculate and set basal profiles Calculate and set temporary basal rate Disconnect pump Reconnect pump at infusion set Prepare reservoir and tubing Insert infusion set Troubleshoot alarms and malfunctions For Students Taking Oral Diabetes Medications Type of medication: Other medications: Needs Assistance Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes
No

Timing: Timing:

Meals and Snacks Eaten at School Is student independent in carbohydrate calculations and management? Yes No Meal/Snack Time Food content/amount

Breakfast Mid-morning snack Lunch Mid-afternoon snack Dinner Snack before exercise? Yes No Snack after exercise? Yes No Other times to give snacks and content/amount: Preferred snack foods: Foods to avoid, if any: Instructions for when food is provided to the class eg, as part of a class party or food sampling event:

Tools

Exercise and Sports A fast-acting carbohydrate such as available at the site of exercise or sports Restrictions on activity, if any: Student should not exercise if blood glucose level is below or if moderate to large urine ketones are present

should be

mg/dl or above

mg/dl

Helping the Student with Diabetes Succeed 51

Diabetes Medical Management Plan Continued
Hypoglycemia Low Blood Sugar Usual symptoms of hypoglycemia: Treatment of hypoglycemia: Glucagon should be given if the student is unconscious, having a seizure convulsion, or unable to swallow Route_______, Dosage_______, site for glucagon injection: _______arm, _______thigh, _______other If glucagon is required, administer it
promptly Then, call 911 or other emergency assistance and the parents/guardian Hyperglycemia High Blood Sugar Usual symptoms of hyperglycemia: Treatment of hyperglycemia: Urine should be checked for ketones when blood glucose levels are above _________ mg/dl Treatment for ketones: Supplies to be Kept at School _______Blood glucose meter, blood glucose test strips, batteries for meter _______Lancet device, lancets, gloves, etc _______Urine ketone strips _______Insulin vials and syringes

_______Insulin pump and supplies _______Insulin pen, pen needles, insulin cartridges _______Fast-acting source of glucose _______Carbohydrate containing snack _______Glucagon emergency kit

Signatures This Diabetes Medical Management Plan has been approved by: Students Physician/Health Care Provider Date

I give permission to the school nurse, trained diabetes personnel, and other designated staff members of ______________________________ school to perform and carry out the diabetes care tasks as outlined by ________________s Diabetes Medical Management Plan I also consent to the release of the information contained in this Diabetes Medical Management Plan to all staff members and other adults who
have custodial care of my child and who may need to know this information to maintain my childs health and safety Acknowledged and received by: Students Parent/Guardian Students Parent/Guardian Date Date

52 Helping the Student with Diabetes Succeed

Quick Reference Emergency Plan
for a Student with Diabetes Hypoglycemia Low Blood Sugar
Students Name Grade/Teacher Emergency Contact Information: Mother/Guardian Home phone Work phone Cell Father/Guardian Home phone Contact Numbers Work phone Cell Date of Plan Photo

School Nurse/Trained Diabetes Personnel

Never send a child with suspected low blood sugar anywhere alone

Causes of Hypoglycemia Too much insulin Missed food Delayed food Too much or too intense exercise Unscheduled exercise Symptoms Mild Sweating Drowsiness Personality change Inability to concentrate Other: ___________
__________________
Circle students usual symptoms

Onset Sudden

Hunger Shakiness Weakness Paleness Anxiety Irritability Dizziness

Moderate Headache Blurry vision Behavior Weakness change Slurred Speech Poor Confusion coordination Other ___________
_________________

Severe Loss of consciousness Seizure Inability to
swallow

Tools

Circle students usual symptoms

Circle students usual symptoms

Actions Needed Notify School Nurse or Trained Diabetes Personnel If possible, check blood sugar, per Diabetes Medical Management Plan When in doubt, always TREAT FOR HYPOGLYCEMIA Mild Student may/may not treat self Provide quick-sugar source 3-4 glucose tablets 4 oz juice 6 oz regular soda 3 teaspoons of glucose gel Wait 10 to 15 minutes Recheck blood glucose Repeat food if symptoms persist or blood glucose is less than ______ Follow with a snack of carbohydrate and protein eg, cheese and crackers
or or or

Moderate Someone assists Give student quick-sugar source per MILD guidelines Wait 10 to 15 minutes Recheck blood glucose Repeat food if symptoms persist or blood glucose is less than ______ Follow with a snack of carbohydrate and protein eg, cheese and crackers

Severe Dont attempt to give anything by mouth Position on side, if possible Contact school nurse or trained diabetes personnel Administer glucagon, as prescribed Call 911 Contact parents/guardian Stay with student

Helping the Student with Diabetes Succeed 53

Quick Reference Emergency Plan
for a Student with Diabetes
Hyperglycemia High Blood Sugar
Students Name Grade/Teacher Emergency Contact Information: Mother/Guardian Home phone Work phone Cell Father/Guardian Home phone Contact Numbers Work phone Cell Date of Plan Photo

School Nurse/Trained Diabetes Personnel

Causes of Hyperglycemia Too much food Illness Too little insulin Infection Decreased activity Stress

Onset Over time–several hours or days

Symptoms

Mild Thirst Frequent urination Fatigue/sleepiness Increased hunger Blurred vision Weight loss Stomach pains Flushing of skin Lack of concentration Sweet, fruity breath Other: __________________
Circle students usual symptoms

Moderate Mild symptoms plus: Dry mouth Nausea Stomach cramps Vomiting Other:_______________

Severe Mild and moderate symptoms plus: Labored breathing Very weak Confused Unconscious

Circle students usual symptoms

Circle students usual symptoms

Actions Needed Allow free use of the bathroom Encourage student to drink water or sugar-free drinks Contact the school nurse or trained diabetes personnel to check urine or administer insulin, per students Diabetes Medical Management Plan If student is nauseous, vomiting, or lethargic,
____ call the parents/guardian or ____ call for medical assistance if parent cannot be reached

54 Helping the Student with Diabetes Succeed

Section 4 Laws

The federal laws described in this section apply to a schools responsibility to help students manage diabetes, including confidentiality requirements A particular student with diabetes could be covered under only one law or more than one law For information on getting copies of the laws, see page 57 Section 504 of the Rehabilitation Act of 1973 Section 504 and Americans with Disabilities Act of 1990 ADA Section 504 prohibits recipients of federal funds from discriminating against people on the basis of disability Title II of the ADA prohibits discrimination on the basis of disability by public entities, regardless of whether the public entities receive federal funds Public school districts that receive federal funds are covered by both Title II and Section 504 and the obligations of public schools to students with disabilities under each law are generally the same For schools, these laws are enforced by the Office for Civil Rights OCR in the US Department of Education Section 504 outlines a process for schools to use in
determining whether a student has a disability and in determining what services a student with a disability needs This evaluation process must be tailored individually, since each student is different and his or her needs will vary Historically, students with diabetes have been covered by Section 504 and the ADA Under Section 504, students with disabilities must be given an equal opportunity to participate in academic, nonacademic, and extracurricular activities The regulations also require school districts to identify all students with disabilities and to provide them with a free appropriate public education FAPE Under Section 504, FAPE is the provision of regular or special education and related aids and services designed to meet the individual educational needs of students with disabilities as adequately as the needs of nondisabled students are met However, a student does not have to receive special education services in order to receive related aids and services under Section 504 Administering insulin or glucagon, providing assistance in checking blood glucose levels, and allowing the student to eat snacks in school are a few examples of related aids and services that schools
may have to provide for a particular student with diabetes The most common practice is to include these related aids
Helping the Student with Diabetes Succeed 55

S

chool Responsibilities Under Federal Law

Laws

and services as well as any needed special education services in a written document, sometimes called a Section 504 Plan Private schools that receive federal funds may not exclude an individual student with a disability if the school can, with minor adjustments, provide an appropriate education to that student Private, nonreligious schools are covered by Title III of the ADA Individuals with Disabilities Education Act IDEA IDEA provides federal funds to assist state educational agencies and, through them, local educational agencies in making special education and related services available to eligible children with disabilities IDEA is administered by the Office of Special Education Programs OSEP in the Office of Special Education and Rehabilitative Services OSERS in the US Department of Education A child with a disability must meet the criteria of one or more of 13 disability categories and need special education and related services The IDEA category of other health
impairment includes diabetes as one of the health conditions listed To qualify under IDEA, the students diabetes also must adversely affect educational performance to the point that the student requires special education and related services, as defined by state law An example of a child with diabetes who may qualify under IDEA is a student who may have difficulty paying attention or concentrating in the learning environment because of recurring high or low blood glucose levels that adversely affect the students educational performance IDEA requires school districts to find and identify children with disabilities and to provide them a free appropriate public education FAPE Under IDEA, FAPE means special education and related services that meet state standards and are provided in conformity with an individualized education program IEP The IDEA regulations specify how school personnel and parents, working together, develop and implement an IEP Each childs IEP must include the supplementary aids and services to be provided for, or on behalf of, the child and a statement of the program modifications or supports for school personnel that will be provided for the child to make progress
and be involved in the general curriculum Administering insulin or glucagon, providing assistance in checking blood glucose levels, and allowing the student to eat snacks in school are a few examples of related services, supplementary aids and services, or program modifications or supports that schools could provide for a particular student with diabetes who is eligible under IDEA Generally, if a child with diabetes needs only a related service and not special education services as defined by state law, that child is not a child with a disability under IDEA and therefore is not eligible for any services under IDEA Such a child might still be eligible for services under Section 504

56 Helping the Student with Diabetes Succeed

Section 4 Laws
Family Education Rights and Privacy Act FERPA FERPA generally prohibits schools from disclosing personally identifiable information in a students education record, unless the school obtains the consent of the students parent or the eligible student a student who is 18 years old or older or who attends an institution of postsecondary education FERPA does allow schools to disclose this information, without obtaining consent, to school officials,
including teachers, who have legitimate educational interests in the information, including the educational interests of the child Schools that do this must include in their annual notification to parents and eligible students the criteria for determining who constitutes a school official and what constitutes a legitimate educational interest Additionally, under FERPA, schools may not prevent the parents of students, or eligible students themselves, from inspecting and reviewing the students education records How can I get copies of the federal laws? The statutes are found in the United States Code USC The regulations implementing the statutes are found in the Code of Federal Regulations CFR

Section 504 of the Rehabilitation Act of 1973, 29 USC 794, implementing regulations at 34 CFR Part 104 Available at wwwedgov/ocr/disabilityhtml Title II of the Americans with Disabilities Act of 1990, 42 USC 12134 et seq, implementing regulations at 28 CFR Part 35 Available at wwwedgov/ocr/disabilityhtml To obtain copies of the Section 504 and Title II regulations, you also may contact the Customer Service Team of the Office for Civil Rights, US Department of Education, at 202 2055413 or
toll-free at 18004213481 For TTY, call 18775212172 Individuals With Disabilities Education Act, 20 USC 111 et seq, implementing regulations at 34 CFR Part 300 Available at wwwedgov/offices/OSERS/OSEP For copies of the IDEA regulations, you also may contact EdPubs at 18774337827 Family Education Rights and Privacy Act FERPA, 20 USC1232g, implementing regulations at 34 CFR Part 99 Available at wwwedgov/offices/OM/fpco

Laws

How can I get more information? The Office for Civil Rights OCR and the Office of Special Education Programs OSEP in the US Department of Education can answer questions and provide technical assistance For more information from OCR, contact OCRs Customer Service Team at 202 2055413 or toll-free at 18004213481 For TTY, call 18775212172 Information is also available on the OCR website, wwwedgov/ocr You may also contact one of OCRs 12 Enforcement Offices around the country Contact information is available from the OCR Customer Service Team and from the OCR website For more information from OSEP, call 202 2055507 or 202 2055637 for TTY More information about FERPA is available at wwwedgov/offices/OM/fpco
Helping the Student with Diabetes Succeed 57

58 Helping
the Student with Diabetes Succeed

Appendices
Resource List: Help for Students with Diabetes Page 61 Glossary of Diabetes Terms Page 69 American Diabetes Associations Position Statement: Care of Children with Diabetes in the School and Day Care Setting Page 73

Appendices

60 Helping the Student with Diabetes Succeed

Appendices

resource list
Help for Students with Diabetes
American Academy of Family Physicians AAFP The AAFP is the national member organization of family doctors Its website includes articles about the link between obesity and diabetes in young people and how to help children lose weight 11400 Tomahawk Creek Parkway Leawood, KS 66211 Phone: 913 9066000 wwwaafporg American Academy of Pediatrics AAP The AAP is a professional membership organization committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults 141 Northwest Point Boulevard Elk Grove Village, IL 600071098 Phone: 847 4344000 wwwaaporg American Association for Health Education AAHE The AAHE serves health educators and other professionals who promote the health of all people through education and other systematic
strategies Programming focuses on health promotion in schools K-12, health care, public and community agencies, business/industry, and professional preparation AAHE is one of six national associations within the American Alliance for Health, Physical Education, Recreation and Dance 1900 Association Drive Reston, VA 20191 Toll-free: 18002137193, Ext 437 wwwaahperdorg/aahe American Association of Diabetes Educators AADE The AADE is a multidisciplinary organization for health professionals who provide diabetes education and care The AADE website provides diabetes links, including information about diabetes in children and adolescents 100 West Monroe Street, Suite 400 Chicago, IL 60603 Toll-free: 1800TEAMUP4 18008326874 wwwaadenetorg

Appendices
Helping the Student with Diabetes Succeed 61

American Council on Exercise ACE The ACE is a nonprofit organization that promotes active, healthy lifestyles and their positive effects on the mind, body, and spirit Its programs are directed to youths as well as adults 4851 Paramount Drive San Diego, CA 92123 Phone: 858 5358227 wwwacefitnessorg American Diabetes Association ADA The ADAs mission is to prevent and cure diabetes and improve the lives
of people with diabetes Founded in 1940, the association conducts programs in all 50 states and the District of Columbia, reaching hundreds of communities across the country The ADA is a nonprofit organization that provides diabetes research, information and advocacy The association offers a variety of programs focused on young people with diabetes 1701 North Beauregard Street Alexandria, VA 22311 Toll-free: 1800DIABETES 18003422383 wwwdiabetesorg For information about ADAs training curriculum for school personnel: wwwdiabetesorg/schooltraining

American Dietetic Association ADA The ADA is a member organization for registered dietitians and registered technicians representing special interests, including public health, sports nutrition, medical nutrition therapy, diet counseling for weight control, cholesterol reduction, and diabetes More than 5,000 dietitians now belong to the ADAs specialty group on Diabetes Care and Education 120 South Riverside Plaza, Suite 2000 Chicago, IL 606066995 Toll-free: 18008771600 Consumer referral: 18003661655 wwweatrightorg American Medical Association AMA The AMA is the nations leader in promoting professionalism in medicine and setting standards
for medical education, practice, and ethics As the largest physician membership organization in the United States, the AMA is at the forefront of every major development in medicine and is a steadfast and influential advocate for physicians and their patients The AMA works tirelessly to promote the art and science of medicine and the betterment of public health American Medical Association Science, Quality and Public Health Group 515 N State Street Chicago, IL 60610 Phone: 312 4644908

62 Helping the Student with Diabetes Succeed

Appendices
American School Health Association ASHA The mission of the ASHA is to promote and improve the well-being of children and youth by supporting comprehensive school health programs In addition to a journal, the association produces a book for school nurses and families on managing school-age children with chronic health conditions Route 43, PO Box 708 Kent, OH 44240 Phone: 330 6781601 wwwashaweborg Barbara Davis Center for Childhood Diabetes The Barbara Davis Center for Childhood Diabetes is the largest diabetes and endocrine care program in Colorado with unique facilities and resources for clinicians, clinical researchers, and basic biomedical
scientists working to help patients with type 1 diabetes The center provides stateof-the-art clinical diabetes care to a majority of children and many adults within the Rocky Mountain Region 4200 East Ninth Avenue Box B -140 Denver, Colorado 80262 Phone: 303 3158796 wwwbarbaradaviscenterorg Centers for Disease Control and Prevention CDC The CDC serves as the national focus for developing and applying disease prevention and control, environmental health, and health promotion and education activities designed to improve the health of the people of the United States CDC divisions with special relevance to diabetes in students are the Division of Diabetes Translation, the Division of Nutrition and Physical Activity, and the Division of Adolescent and School Health 4770 Buford Highway, NE Atlanta, GA 30341 Toll-free: 1800-3113435 wwwcdcgov Division of Diabetes Translation Toll-free: 1877CDCDIAB 18772323422 wwwcdcgov/diabetes Division of Nutrition and Physical Activity wwwcdcgov/nccdphp/dnpa Division of Adolescent and School Health wwwcdcgov/nccdphp/dash Disability Rights Education and Defense Fund DREDF DREDF is a national law and policy center dedicated to protecting and advancing the
civil rights of people with disabilities through legislation, litigation, advocacy, technical assistance, and education and training of attorneys, advocates, persons with disabilities, and parents and children with disabilities

Appendices

2212 Sixth Street Berkeley, CA 94710 Phone: 510 6442555 wwwdredforg
Helping the Student with Diabetes Succeed 63

Diabetes Exercise and Sports Association This nonprofit service organization is dedicated to enhancing the quality of life for people with diabetes through exercise 1647-B West Bethany Home Road Phoenix, AZ 85015 Toll-free: 18008984322 wwwdiabetes-exerciseorg Educational Resources Information Center ERIC The ERIC is a federally funded, nonprofit information network designed to provide ready access to education literature for teachers and parents 1307 New York Avenue, NW, Suite 300 Washington, DC 200054701 Toll-free: 18008229229 wwwericedgov Indian Health Service IHS IHS National Diabetes Program The mission of the IHS is to develop, document, and sustain a public health effort to prevent and control diabetes in American Indian and Alaskan Native communities 5300 Homestead Road, NE Albuquerque, NM 87110 Phone: 505 2484182
wwwihsgov

Joslin Diabetes Center The Joslin Diabetes Center and its affiliates offer a full range of services for children and adults with diabetes, including programs to help youngsters with diabetes and their families to better manage the disease 1 Joslin Place Boston, MA 02215 Toll-free: 1800JOSLIN1 18005675461 wwwjoslinharvardedu Juvenile Diabetes Research Foundation International JDRF The mission of JDRF is to find a cure for diabetes and its complications through the support of research 120 Wall Street New York, NY 100054001 Toll-free: 1800533CURE 18005332873 wwwjdrforg Lawson Wilkins Pediatric Endocrine Society LWPES The LWPES is a membership organization that promotes the acquisition and dissemination of knowledge of endocrine and metabolic disorders from conception through adolescence The LWPES website provides links with information about diabetes in children and adolescents 867 Allardice Way Stanford, CA 94305 Phone: 650 4943133 wwwlwpesorg

64 Helping the Student with Diabetes Succeed

Appendices
National Association of Elementary School Principals NAESP The NAESP promotes advocacy and support for elementary and middle level principals and other education leaders in
their commitment to all children Linkages to Learning 1615 Duke Street Alexandria, VA 22314 Toll-free: 180038NAESP 18003862377 wwwnaesporg National Association of School Nurses NASN The NASN is a nonprofit organization that represents school nurses; it offers continuing education, issues briefs, holds an annual conference, provides legislative updates and position statements, and other materials 1416 Park Street, Suite A Castle Rock, CO 80109 Toll-free: 1866NASNSNS 18666276767 wwwnasnorg For information about the National Association of School Nurses and the Pediatric Adolescent Diabetes Research Foundations PEDS Pediatric Education for Diabetes in Schools training workshop and manual, contact NASN National Association of Secondary School Principals NASSP The NASSP is a membership organization of middle level and high school principals, assistant principals, and aspiring school leaders from across the United States and around the world NASSPs motto is promoting excellence in school leadership, and the association provides members with various programs and services to guide them in administration, supervision, curriculum planning, and staff development to achieve that goal 1904
Association Drive Reston, VA 20191 703 8600200 wwwprincipalsorg National Association of State Boards of Education NASBE The NASBE is a nonprofit association that represents state and territorial boards of education NASBEs principal objectives include strengthening state leadership in educational policymaking, promoting excellence in the education of all students, advocating equality of access to educational opportunity, and assuring continued citizen support for public education 277 South Washington Street, Suite 100 Alexandria, VA 22314 Phone 703 6844000 wwwnasbeorg

Appendices
Helping the Student with Diabetes Succeed 65

National Center on Physical Activity and Disability NCPAD The NCPAD provides information about current research, local programs, adapted equipment, recreation and leisure facilities, and many other aspects of physical activity for persons with disabilities, including children and adolescents with diabetes 1640 West Roosevelt Road Chicago, IL 60608 Toll-free: 18009008086 wwwncpadorg National Education Association NEA Health Information Network The NEA Health Information Network is the nonprofit health affiliate of the National Education Association, the nations
largest labor organization representing 23 million public school employees The mission of the NEA Health Information Network is to ensure that all public school employees, students, and their communities have the health information and skills to achieve excellence in education 1201 16th Street, NW Suite 521 Washington, DC 200363290 Phone: 202 8334000 wwwneahinorg

National Information Center for Children and Youth with Disabilities This national information and referral clearinghouse on special education and disability-related issues provides information about local, state, or national disability groups and gives technical assistance to parents and professionals PO Box 1492 Washington, DC 200131492 Toll-free: 18006950285 wwwnichcyorg National Institute of Child Health and Human Development NICHD, National Institutes of Health The NICHD conducts and supports laboratory, clinical, and epidemiologic research on the reproductive, neurobiologic, developmental, and behavioral processes that determine and maintain the health of children, adults, families, and populations 31 Center Drive, MSC 2425 Bethesda, MD 208922425 Phone: 301 4965133 wwwnichdnihgov

66 Helping the Student with
Diabetes Succeed

Appendices
National Institute of Diabetes and Digestive and Kidney Diseases NIDDK, National Institutes of Health The NIDDK conducts and supports research on many of the most serious diseases affecting public health The Institute supports much of the clinical research on the diseases of internal medicine and related subspecialty fields as well as many basic science disciplines National Diabetes Education Program NDEP The NDEP is a federally sponsored program of the National Institutes of Health and the Centers for Disease Control and Prevention, involving over 200 public and private partners to improve diabetes treatment and outcomes for people with diabetes, promote early diagnosis, and prevent diabetes 1 Diabetes Way Bethesda, MD 208923600 Toll-free: 18004385383 wwwndepnihgov National Diabetes Information Clearinghouse NDIC The NDIC is a service of the National Institute of Diabetes and Digestive and Kidney Diseases that provides information about diabetes to people with diabetes, their families, health care professionals, and the public 1 Information Way Bethesda, MD 208923560 Toll-free: 18008608747 wwwniddknihgov Pediatric Endocrinology Nursing Society PENS The
PENS is a nonprofit professional nursing organization with the goal of advancing pediatric endocrine nursing Its website features articles about diabetes-related topics, including insulin pump therapy, obesity in children, and development of a pediatric diabetes education program for home health nurses PO Box 2933 Gaithersburg, MD 208862933 Phone: Not available All contact is through mail or email Email: Through website under Contact PENS wwwpensorg U S Department of Agriculture USDA The USDA supports several programs of importance to students with diabetes: the Center for Nutrition Policy and Promotion, the Food and Nutrition Information Center, and the Food and Nutrition Service Center for Nutrition Policy and Promotion wwwusdagov/cnpp Food and Nutrition Information Center wwwnalusdagov/fnic Food and Nutrition Service wwwfnsusdagov/fns

Appendices
Helping the Student with Diabetes Succeed 67

US Department of Education The mission of the Department of Education is to ensure equal access to education and to promote educational excellence throughout the nation 400 Maryland Avenue, SW Washington, DC 20202 Office for Civil Rights OCR Toll-free: 18004213481 TTY: 18775212172
wwwedgov/ocr Office of Special Education Programs OSEP Phone: 202 2055507 TTY: 202 2055637 wwwedgov/offices/OSERS/OSEP

A detailed listing of organizations and programs related to children and adolescents with diabetes and related conditions may be found in

Resource Directory: Diabetes in Children and Adolescents
The directory is available on the NDEP website:

wwwndepnihgov

Resources, including websites, are mentioned in this guide as examples and are only a few of the many appropriate resource materials available Other materials mentioned are provided as resources and examples for the readers convenience Listing of materials and resources in this guide should not be construed or interpreted as an endorsement by the US Department of Education of any private organization or business listed herein

68 Helping the Student with Diabetes Succeed

Appendices

glossary
of Diabetes Terms

Americans with Disabilities Act A federal law enacted in 1990 to protect people with disabilities from discrimination Under this law, diabetes can be considered a disability Autoimmune disease A disorder in which the immune system mistakenly attacks and destroys body tissue that it believes to be
foreign In type 1 diabetes, an autoimmune disease, the immune system attacks and destroys the insulin-producing beta cells

A

Carbohydrates One of the three main classes of foods and a source of energy for the body Carbohydrates are mainly sugars and starches that the body breaks down into glucose Foods high in carbohydrates raise blood glucose levels Carbohydrate foods include: breads, crackers, and cereals; pasta, rice, and grains; vegetables; milk and yogurt; fruit, juice, and sweetened sodas; and table sugar, honey, syrup, and molasses Complications of diabetes Harmful effects that may happen when a person has diabetes Short-term complications resulting from poorly controlled or uncontrolled diabetes include hypoglycemia low blood glucose and hyperglycemia high blood glucose Long-term complications, which may develop when a person has had diabetes for a long time, include blindness, amputation of feet or legs, kidney disease, heart disease, stroke, and nerve damage

C

Blood glucose level The amount of glucose in the blood The recommended blood glucose levels for most people with diabetes are from about 80 to 120 before a meal, 180 or less after a meal, and between 100 and 140
at bedtime Blood glucose meter A device that measures how much glucose is in the blood A specially coated test strip containing a fresh sample of blood obtained by pricking the skin, usually the finger, with a lancet is inserted in the meter, which then measures the amount of glucose in the blood Blood glucose monitoring The act of checking the amount of glucose in the blood Also called self-monitoring of blood glucose

B

Diabetes Medical Management Plan Describes the medical orders or diabetes regimen developed by the students health care provider and family Diabetic Coma A severe emergency in which a person is not conscious because his or her blood glucose is too low or too high See also hyperglycemia; hypoglycemia; and diabetic ketoacidosis Helping the Student with Diabetes Succeed 69

D

Appendices

Diabetic ketoacidosis DKA A condition that occurs due to insufficient insulin in the body This can be due to illness, incorrect doses of insulin, or omitting insulin injections The acidic state that follows causes fruity smelling breath, deep and rapid breathing, stomach pain, nausea, vomiting, and sleepiness DKA can lead to coma and death if not treated promptly

Hyperglycemia A
high level of glucose in the blood High blood glucose can be due to a mismatch in insulin, food, and exercise Symptoms include thirst, frequent urination, blurred vision, and fatigue Hypoglycemia A low level of glucose in the blood Low blood glucose is most likely to occur during or after exercise, if too much insulin is present, or not enough food is consumed Symptoms include feeling shaky, having a headache, or being sweaty, pale, hungry, or tired

Fast-acting glucose Foods containing simple sugar that are used to raise blood glucose levels quickly during a hypoglycemic episode

F

Glucagon A hormone that raises the level of glucose in the blood Glucagon, given by injection, is used to treat severe hypoglycemia Glucose A simple sugar found in the blood It is the bodys main source of energy Glucose tablets or gel Special products that deliver a pre-measured amount of pure glucose They are a fast-acting form of glucose used to counteract hypoglycemia

G

Individualized Education Program IEP A program designed for students covered by the Individuals with Disabilities Education Act IDEA Individuals with Disabilities Education Act IDEA A federal law that provides funds to states to
support special education and related services for children with disabilities, administered by the Office of Special Education Programs in the US Department of Education To be eligible for services under IDEA, a students diabetes must impair his or her educational performance so that he or she requires special education and related services Insulin A hormone produced by the pancreas that helps the body use glucose for growth and energy There are several types of insulin that are used in combination to treat people with diabetes These different types of insulin have been manufactured either to have immediate rapid-acting or short-acting insulin, intermediate, or long

I

Hormone A chemical produced by an organ that travels in the blood to affect other organs

H

70 Helping the Student with Diabetes Succeed

Appendices
basal insulin onset of action and duration of action in the body A coordinated combination of insulins is used to allow for adequate treatment of diabetes at meals, snacks, during periods of physical activity, and through the night Insulin injections The process of putting insulin into the body with a needle and syringe or an insulin pen Insulin pen A pen-like device
used to put insulin into the body Insulin pump A device that delivers a continuous supply of insulin The insulin is delivered in a steady, measured dose through a system of plastic tubing infusion set Most infusion sets are started with a guide needle, then the plastic cannula a tiny, flexible plastic tube is left in place, taped with dressing, and the needle is removed Insulin resistance A condition in which the body does not respond normally to the action of insulin Many people with type 2 diabetes have insulin resistance a long time lead to serious illness and coma See also: Diabetic ketoacidosis

Lancet A fine, sharp-pointed needle used by people with diabetes for pricking their skin to obtain a sample of blood for blood glucose monitoring

L

Metabolism The term for the way cells chemically change food so that it can be used to keep the body alive Medical alert identification An identification card and necklace or bracelet indicating the student has diabetes and giving an emergency number to call Mg/dL Milligrams per deciliter This term is used in blood glucose monitoring to describe how much glucose is in a specific amount of blood

M

Ketoacidosis See Diabetic ketoacidosis
Ketones ketone bodies Chemicals that the body makes when there is not enough insulin in the blood and the body must break down fat for its energy Ketones can poison and even kill body cells When the body does not have the help of insulin, ketones build up in the blood and spill over into the urine so that the body can get rid of them Ketones that build up in the body for

K

Nursing Care Plan A plan developed by the school nurse used to implement the students diabetes medical management plan The plan describes functional problem areas, sets goals for overcoming problems, and lists tasks/interventions to meet the goals

N

Appendices
Helping the Student with Diabetes Succeed 71

Pallor Abnormal paleness of the skin Palpitations Abnormally rapid or violent beating of the heart Pancreas The organ behind the lower part of the stomach that makes insulin Peak effect time Time when insulin has its major impact on reducing blood glucose levels See also Insulin

P

Target range A selected level for blood glucose values that the person with diabetes tries to maintain The target range is usually determined by the physician in consultation with the patient or parents, if the patient is a child
See also blood glucose levels Test strips Specially designed strips used in blood glucose meters or in urine testing Trained Diabetes Personnel Nonmedical personnel who have basic diabetes knowledge and have received training in diabetes care, including the performance of blood glucose monitoring, insulin and glucagon administration, recognition and treatment of hypoglycemia and hyperglycemia, and performance of urine ketone testing

T

Quick Reference Emergency Plan This plan provides school personnel with essential information on how to recognize and treat hypoglycemia or hyperglycemia

Q S

Section 504 of the Rehabilitation Act A federal law that prohibits recipients of federal funds from discriminating against people on the basis of disability Syringe A device used to inject medications such as insulin into body tissue

Urine ketone testing A procedure for measuring the level of ketones in the urine

U

72 Helping the Student with Diabetes Succeed

POSITION

STATEMENT

Care of Children With Diabetes in the School and Day Care Setting
AMERICAN DIABETES ASSOCIATION

D

iabetes is one of the most common chronic diseases of childhood, with a prevalence of 17 affected individuals
per 1,000 people aged 20 years 1 4 In the US, 13,000 new cases are diagnosed annually in children 4 7 There are about 125,000 individuals 19 years of age with diabetes in the US 8 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 9 12 Both parents and the health care team should work together to provide school systems and day care providers with the information necessary to allow children with diabetes to participate fully and safely in the school experience DIABETES AND THE LAW — Federal laws that protect children with diabetes include Section 504 of the Rehabilitation Act of 1973, 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 disabilities 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 childs usual school setting

with as little disruption to the schools and the childs 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 1315 Diabetes care in schools Appropriate diabetes care in the school and day care setting is necessary for the childs immediate safety, 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
To achieve glycemic control, a child must monitor blood glucose frequently, follow a meal plan, and take medications Insulin is usually taken in multiple daily injections or through an infusion pump Crucial to achieving glycemic control is an understanding of the effects of physical activity, nutrition therapy, and insulin on blood glucose levels To facilitate the appropriate care of the student with diabetes, school and day care personnel must have an understand-

ing of diabetes and must be trained in its management and in the treatment of diabetes emergencies Knowledgeable trained personnel are essential if the student is to avoid the immediate health risks of low blood glucose and to achieve the metabolic control required to decrease 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 12,18,19 Consequently, diabetes education must be targeted toward 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 GENERAL GUIDELINES FOR THE CARE OF THE CHILD IN THE SCHOOL AND DAY CARE SETTING I Diabetes Health Care Plan An individualized Diabetes Health Care Plan should be developed by the parent/ guardian, the students diabetes care team, and the school or day care provider Inherent in this process are delineated responsibilities assumed by all parties, including the parent/guardian, the school personnel, and the student These responsibilities are outlined in this position statement The Diabetes Health Care Plan should address the specific needs of the child and provide specific instructions for each of the following:

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 on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med 329:977986, 1993; and
Diabetes Control and Complications Trial 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 125:177188, 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, 2000

Appendices

1 Blood glucose monitoring, including the frequency and circumstances requiring testing
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Helping the Student with Diabetes Succeed 73

Position Statement

2 Insulin administration if necessary, including doses/injection times prescribed for specific blood glucose values and the storage of insulin 3 Meals and snacks, including food content, amounts, and timing 4 Symptoms and treatment of hypoglycemia low blood glucose, including the administration of glucagon if recommended by the students treating physician 5 Symptoms and treatment of hyperglycemia high blood
glucose 6 Testing for ketones and appropriate actions to take for abnormal ketone levels, if requested by the students health care provider Figure 1 includes a sample Diabetes Health Care Plan For detailed information on the symptoms and treatment of hypoglycemia and hyperglycemia, refer to the Medical Management of Type 1 Diabetes 20 A brief description of diabetes targeted to school and day care personnel is included in the APPENDIX; it may be helpful to include this information as an introduction to the Diabetes Health Care Plan II Responsibilities of the various care providers A The parent/guardian should provide the school or day care provider with the following: 1 All materials and equipment necessary for diabetes care tasks, including blood glucose testing, insulin administration if needed, and urine or blood ketone testing The parent/ guardian is responsible for the maintenance of the blood glucose testing equipment ie, cleaning and performing controlled testing per the manufacturers 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 results; blood glucose values should be transmitted to the parent/guardian for review as often as requested 2 Supplies to treat hypoglycemia, including a source of glucose and a glucagon emergency kit, if indicated in the Diabetes Health Care Plan 3 Information about diabetes and the performance of diabetes-related tasks
S132

4 Emergency phone numbers for the parent/guardian and the diabetes care team so that the school can contact these individuals with diabetes-related questions and/or during emergencies 5 Information about the students meal/ snack schedule The parent should work with the school to coordinate this schedule with that of the other students as closely as possible For young children, instructions should be given for when food is provided during school parties and other activities B The school or day care provider should provide the following: 1 Training to all adults who provide education/care for the student on the symptoms and treatment of hypoglycemia and hyperglycemia and other emergency procedures An adult and back-up adults trained 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 students Diabetes Health Care Plan; and 3 test the urine or blood for ketones, when necessary, and respond to the results of this test 2 Immediate accessibility to the treatment of hypoglycemia by a knowledgeable adult The student should remain supervised until appropriate treatment has been administered, and the treatment should be available as close to where the student is as possible 3 If indicated by the childs developmental capabilities and the Diabetes Health Care Plan, an adult and back-up adults trained in insulin administration 4 An adult and back-up adults trained to administer glucagon, in accordance with the students Diabetes Health Care Plan 5 A location in the school to provide privacy during testing and insulin administration, if desired by the student and family, or permission for the student to check his or her blood glucose level and to take appropriate action to treat hypoglycemia in the classroom or anywhere the student is in conjunction with a school activity,

6

7 8

9

10 11

if indicated in the students Diabetes Health Care Plan An adult and back-up adults responsible for the student who will know the
schedule of the students meals and snacks and work with the parent/guardian to coordinate this schedule with that of the other students as closely as possible This individual also will notify the parent/ guardian in advance of any expected changes in the school schedule that affect the students meal times or exercise routine Young children should be reminded of snack times Permission for the student to see school medical personnel upon request Permission for the student to eat a snack anywhere, including the classroom or the school bus, if necessary to prevent or treat hypoglycemia Permission to miss school without consequences for required medical appointments to monitor the students diabetes management This should be an excused absence with a doctors note, if required by usual school policy Permission for the student to use the restroom and have access to fluids ie, water as necessary An appropriate location for insulin and/or glucagon storage, if necessary

An adequate number of school personnel should be trained in the necessary diabetes procedures eg, blood glucose monitoring, insulin and glucagon administration and in the appropriate response to high and low blood glucose
levels to ensure that at least one adult is present to perform these procedures in a timely manner while the student is at school, on field trips, and during extracurricular activities or other school-sponsored events These school personnel need not be health care professionals The student 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, other school-sponsored events, and on transportation provided by the school or day care facility to enable full participation in school activities It is the schools legal responsibility to provide appropriate training to school

DIABETES CARE, VOLUME 26, SUPPLEMENT 1, JANUARY 2003

74 Helping the Student with Diabetes Succeed

Diabetes in School and Day Care

Appendices

Figure 1–Diabetes Health Care Plan

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Helping the Student with Diabetes Succeed 75

Position Statement

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 wwwdiabetesorg/ ada/teacherasp Your School Your Rights: Protecting Children with Diabetes Against Discrimination in Schools and Day Care Centers, Alexandria, VA, American Diabetes Association, 2000 brochure; available online at http://wwwdiabetesorg/main/type1/parents_kids/away/scrightsjsp Your Child Has Type 1 Diabetes: What You Should Know, Alexandria, VA, American Diabetes Association, 1999 brochure; available online at http://wwwdiabetesorg/main/community /advocacy/type1jsp Treating Diabetes Emergencies: What You Need to Know, Alexandria, VA, American Diabetes Association, 1995 video; 1-800-232-6733 Complete Guide to Diabetes, Alexandria, VA, American Diabetes Association, 1999; 1-800232-6733 Raising a Child with Diabetes: A Guide for Parents, Alexandria, VA, American Diabetes Association, 2000; 1-800-232-6733 Clarke W: Advocating for the child with diabetes Diabetes Spectrum 12:230236, 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 at wwwdiabetesorg/wizdom The Care of Children with Diabetes in Child Care and School Setting video; available from, Managed Design, Inc, PO Box 3067, Lawrence, KS 66046, 785 842-9088 Fredrickson L, Griff M: Pumper in the School, Insulin Pump Guide for School Nurses, School Personnel and Parents MiniMed Professional Education, Your Clinical Coach First Edition, May 2000 MiniMed, Inc, 1-800-440-7867 Tappon D Parker M, Bailey W: Easy As ABC, What You Need to Know About Children Using Insulin Pumps in School Disetronic Medical Systems, Inc, 1-800-280-7801
These documents are available in the American Diabetes Associations Education Discrimination Packet by calling 1-800-DIABETES

insulin with supervision and perform self-monitoring of blood glucose under usual circumstances when not experiencing a low blood glucose level 4 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, adolescents should be able to administer insulin without 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 and the blood glucose value has returned to the normal range MONITORING BLOOD GLUCOSE IN THE CLASSROOM — It is best for a student with diabetes to obtain a blood glucose level and to respond to the results as quickly and conveniently as possible This is important to avoid medical problems being worsened by a delay in testing/ treatment and to minimize educational problems caused by missing instruction in the classroom Accordingly, as stated earlier, a student should be permitted to monitor his or her blood glucose level and take appropriate action to treat hypoglycemia in the classroom or anywhere the student is in conjunction with a school activity, if preferred by the student and indicated in the students Diabetes Health Care Plan However, some students desire privacy during testing and this preference should also be accommodated In summary, with proper planning and the education and training of school personnel, children and youth with diabetes can fully
participate in the school experience To this end, the family, the health care team, and the school should work together to ensure a safe learning environment APPENDIX: BACKGROUND INFORMATION ON DIABETES FOR SCHOOL PERSONNEL — Diabetes is a serious, chronic disease that impairs the bodys ability to use food Insulin, a hormone produced by the pancreas, helps the body

staff on diabetes-related tasks and in the treatment of diabetes emergencies This training should be provided by health care professionals with expertise in diabetes unless the students health care provider determines that the parent/guardian is able to provide the school personnel with sufficient oral and written information to allow the school to have a safe and appropriate environment for the child If appropriate, members of the health care team should provide instruction and materials to the parent/guardian to facilitate the education of school staff Educational materials from the American Diabetes Association and other sources targeted to school personnel and/or parents are available Table 1 includes a listing of appropriate resources III Expectations of the student in diabetes care Children and youths should be
able to implement their diabetes care at school with parental consent to the extent that is appropriate for the students developS134

ment and his or her experience with diabetes The extent of the students ability to participate in diabetes care should be agreed upon by the school personnel, the parent/guardian, and the health care team, as necessary The ages at which children are able to perform self-care tasks are very individual and variable, and a childs capabilities and willingness to provide self-care should be respected 1 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 2 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 By age 10, some children can administer insulin with supervision 3 Middle school or junior high school The student should be able to administer

DIABETES CARE, VOLUME 26, SUPPLEMENT 1, JANUARY 2003

76 Helping the Student with Diabetes Succeed

Diabetes in School and Day
Care

convert food into energy In people with diabetes, either the pancreas does not make insulin or the body cannot use insulin properly Without insulin, the bodys main energy source– glucose– cannot be used as fuel Rather, glucose builds up in the blood Over many years, high blood glucose levels can cause damage to the eyes, kidneys, nerves, heart, and blood vessels The majority of school-aged youth with diabetes have type 1 diabetes People with type 1 diabetes do not produce insulin and must receive insulin through either injections or an insulin pump Insulin taken in this manner does not cure diabetes and may cause the students blood glucose level to become dangerously low Type 2 diabetes, the most common form of the disease typically afflicting obese adults, has been shown to be increasing in youth 21 This may be due to the increase in obesity and decrease in physical activity in young people Students with type 2 diabetes may be able to control their disease through diet and exercise alone or may require oral medications and/or insulin injections All people with type 1 and type 2 diabetes must carefully balance food, medications, and activity level to keep blood glucose
levels as close to normal as possible Low blood glucose hypoglycemia is the most common immediate health problem for students with diabetes It occurs when the body gets too much insulin, too little food, a delayed meal, or more than the usual amount of exercise Symptoms of mild to moderate hypoglycemia include tremors, sweating, lightheadedness, irritability, confusion, and drowsiness A student with this degree of hypoglycemia will need to ingest carbohydrates promptly and may require assistance Severe hypoglycemia, which is rare, may lead to unconsciousness and convulsions and can be life-threatening if not treated promptly High blood glucose hyperglycemia occurs when the body gets too little insulin, too much food, or too little exercise; it may also be caused by stress or an illness

such as a cold The most common symptoms of hyperglycemia are thirst, frequent urination, and blurry vision If untreated over a period of days, hyperglycemia can cause a serious condition called diabetic ketoacidosis DKA, which is characterized by nausea, vomiting, and a high level of ketones in the blood and urine For students using insulin infusion pumps, lack of insulin supply may lead to DKA more
rapidly DKA can be life-threatening and thus requires immediate medical attention
References 1 LaPorte RE, Tajima N, Dorman JS, Cruick-shanks 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 US have IDDM? Diabetes Care 16:841 842, 1993 3 Lipman TH: The epidemiology of type 1 diabetes in children 0 14 yr of age in Philadelphia Diabetes Care 16:922925, 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 1320 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 Rewers M: The changing face of epidemiology of insulin-dependent diabetes
mellitus IDDM: research designs and models of disease causation Ann Med 23: 419 426, 1991 8 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

9

10

11 12

13 14 15

16

17

18 19 20 21

Washington, DC, US Govt Printing Office, 1995, p 37 45 NIH publ no 951468 Diabetes Epidemiology Research International Group: Secular trends in incidence of childhood IDDM in 10 countries Diabetes 39:858 864, 1990 Kostraba JN, Gay EC, Cai Y, Cruickshanks KJ, Rewers MJ, Klingensmith GJ, Chase HP, Hamman RF: Incidence of insulin-dependent diabetes mellitus in Colorado Epidemiology 3:232238, 1992 Kyllo CJ, Nuttall FQ: Prevalence of diabetes mellitus in school-age children in Minnesota Diabetes 27:57 60, 1978 Wysocki T, Meinhold P, Cox DJ, Clarke WL: Survey of diabetes professionals regarding developmental charges in diabetes self-care Diabetes Care 13:65 68, 1990 Jesi Stuthard and ADA v Kindercare Learning Centers, Inc, Case no C2-960185 USCD South Ohio 8/96 Calvin Davis and ADA v LaPetite Academy, Inc, Case no CIV97-0083-PHXSMM USCD Arizona 1997 Agreement,
Loudoun County Public Schools and Office of Civil Rights, United States Department of Education Complaints nos 11-99-1003, 11-99-1064, 11-99-1069, 1999 Diabetes Control and Complications Trial 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 329:977986, 1993 Diabetes Control and Complications Trial Research Group: Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus J Pediatr 125:177188, 1994 Hodges L, Parker J: Concerns of parents with diabetic children Pediatr Nurse 13: 2224, 1987 Lindsey R, Jarrett L, Hillman K: Elementary schoolteachers understanding of diabetes Diabetes Educ 13:312314, 1987 Skyler JS Ed: Medical Management of Type 1 Diabetes 3rd ed Alexandria, VA, American Diabetes Association, 1998 American Diabetes Association: Type 2 diabetes in children and adolescents Consensus Statement Diabetes Care 23: 381389, 2000

Appendices

DIABETES CARE, VOLUME 26, SUPPLEMENT 1, JANUARY 2003

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Helping the Student with Diabetes Succeed 77

T

he
following organizations have contributed generously to the printing and dissemination of this guide Aventis Pharmaceuticals Eli Lilly and Company Indian Health Service Medtronic MiniMed Novo Nordisk Pharmaceuticals, Inc Pfizer Inc

US Department of Health and Human Services

A Joint Program of the National Institutes of Health and the Centers for Disease Control and Prevention

NIH Publication No 03-5217 June 2003

Source:uic.edu