Diabetes Education

Diabetes Mellitus Facts Diabetes is one of the most common chronic diseases in childhood Approximately 215,000 youth under the age of 20 had diabetes- Type 1 or Type 2- in 2010 It is likely you have, or will soon encounter, a student with diabetes in your school system ADA Position Statement. Diabetes Care in the School and Day Care Setting. Diabetes Care, 2006; 29, S49-S55. Courtesy Animas Corporation.

Diabetes in Schools: Legislation Virginia Senate Bill 889 requires public schools with at least one student diagnosed with diabetes to ensure that at least two employees have been trained in the administration of insulin and glucagon. http://leg1.state.va.us/cgi-bin/legp504.exe?000+cod+22.1-274

Diabetes Medical Management Plan A medical management plan must be provided for each student with diabetes completed by the students’ medical management team and signed by both the health care provider and the student’s parent.

Diabetes Mellitus Chronic disease Pancreas Partial or complete inability to produce insulin Body unable to properly use and store carbohydrates, fats, and protein.

Diabetes Mellitus Type 1 Type 2 Insulin Dependent Diabetes Mellitus (IDDM) Children and Young Adults Pancreas produces little or no insulin – autoimmune related Treated with daily insulin injections + Diet and Exercise Non-Insulin Dependent Diabetes Mellitus (NIDDM) Adults and Children Pancreas produces insulin Insulin is not effective – insulin resistance Treated with diet, pills, and/or insulin +Exercise is important

Virginia Guidelines for Specialized Health Care Procedures “…when a licensed RN or licensed LPN are present in the school, the nurse will administer the insulin or glucagon when needed. Should the licensed nurse not be available, the principal must assume responsibility for arranging the administration of medication.”

HbA1c – a indicator of average blood sugar over a period of time Measured every 3 months It is the percentage of red blood cells that have glucose molecules attached to them RBCs recycle every 3 months Goal is <7.5% in pediatrics

Blood Glucose Monitoring All students with diabetes must check their blood sugar while at school. Plan will tell you target range – usually between 80 and 150 depending on student’s age. Check when symptomatic to determine hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Hypoglycemia or Low Blood Sugar Causes: not enough food, too much insulin, too much exercise Can be mild, moderate or severe Must be treated since very low blood sugar can be serious

Rule of 15 for Treating Low Blood Sugar Use this guideline to treat a BG <80 mg/dL Give 15 gm fast-acting carb and recheck BG in 15 min 4 oz juice or regular soda or 3-4 glucose tabs Repeat this process until BG comes above 80 mg/dL Once BG comes above 80 mg/dL, give a combination snack of 15 gm carb + protein Peanut butter and crackers If nauseated then give glucose gel or cake decorating gel and recheck in 15 min

Treating a low If classes/activities are some distance from classroom or health office, allow child to carry emergency glucose to treat hypoglycemia Parents should provide glucose tablets for teachers, PE teachers and coaches Glucose tablets are not controlled medication

A student who complains of feeling low or who you suspect may be low should never be sent to check blood glucose, to go the nurse’s office or anywhere else alone. The student could lose consciousness or become disoriented.

Severe Hypoglycemia Glucagon/Glucagen

Nutrition Same basic nutritional needs as other children: sufficient calories to balance daily expenditures for energy and for growth and development requirements More attention is given to carbohydrate content of meals. Insulin dose is based on number of grams of carbs School lunches in the usual portions are acceptable Fresh Fruit is allowed Desserts are not eliminated

Carbohydrate Counting to Determine Insulin Dose Nutrition Food Labels Carbohydrate Counting to Determine Insulin Dose Total number of grams of carbohydrates at each meal/snack Use a carb ratio: 1: 15 Add the carbs and divide by 15 Do not round dose yet

Carb Counting Foods that contain carbohydrates Fruit Vegetables Milk Grains Foods that contain little to no carbs Meat Cheese Eggs

Calculating Meal TimeDose of Insulin Carbohydrate ratio Correction factor based on blood sugar reading.

Carb Ratio for Insulin Dose Example Order: 1 unit of Humalog/Novolog for every 15 grams of carbohydrate before each meal. Lunch: 60 grams carbohydrate (CHO) 60 grams CHO/ 15 = 4 units of Humalog/Novolog before lunch

Scenarios What if a child does not eat all of the carbs that they were dosed for? Make sure that the child eats the carb containing foods first and then eats the fat/protein food Make up carbs with skim milk, applesauce, or yoghurt

Correction Dose Test the blood glucose before each meal Correction: 1 unit for every 50 mg/dl over 150: If BG is 280 mg/dL then subtract 280-150= 130 130/50= 2.6 3 units (for whole unit syringes) If you were using ½ unit syringes, then 2.6 would round to 2.5 units

The Math Method

Calculate the meal insulin dose Add the insulin dose for the carbs to be eaten PLUS the insulin dose for the blood glucose using the correction factor: Carb ratio: I unit for 15 grams of carbs: 60 carbs/ 15 = 4 Correction Factor: 1 unit for every 50 over 150: Blood glucose 280-150= 130/50= 2.6 Insulin dose: 4 + 2.6 = 6.6 units 6.6 rounds to 7 units for whole unit syringes 6.6 rounds to 6.5 units for half unit syringes

A Few Rules… Administer insulin approximately 10-15 minutes before meal if possible Carbs peak in 1.5 hours Rapid-acting insulin peaks 2 hours after it is given Optimal goal is for carbs and insulin to peak at the same time No correction dose sooner than every 3 hours Rapid acting insulin is in the body for 3 hours

Scenarios Child’s blood glucose is 90 mg/dL before lunch. Can he/she have their mealtime insulin? YES! They can be dosed for the carbs that they will consume. Child’s blood glucose is 65 mg/dL before lunch. What do I do? Treat the low BG using the Rule of 15 Once BG comes above 80 mg/dL then you can give insulin for carbs ONLY and then let child eat lunch Do NOT give a correction dose within 3 hours of treating a low

Insulin Three methods to administer insulin Vials and syringes 2) Insulin pens 3) Insulin pumps

Insulin Pumps

Pump Management If patient has high BG and ketones then a site change is needed Treating a low Suspend the pump if BG <60 mg/dL Keep it suspended for 30 min Continue to follow the Rule of 15 while pump is suspended

Continuous Glucose Monitor (CGM) Uses a sensor under the skin to read interstitial glucose readings (about one reading every 5 mins) The interstitial glucose readings are then transmitted to the receiver The receiver shows the readings and show arrows for up or down A finger stick is needed to verify the CGM reading before meals or if patient is high or low There can be a 20 minute delay between the CGM and a finger stick reading Calibrations make it more accurate

Continuous Glucose Monitor (CGM) Uses a sensor under the skin to read interstitial glucose about once every 5 minutes Interstitial reading is transmitted to receiver The receiver shows the readings and show arrows for up or down A finger stick is needed to verify the CGM reading before meals or if patient is high or low There can be a 20 minute delay between the CGM and a finger stick reading

Hyperglycemia or High Blood Sugar When blood sugar is high as determined by the plan, student may need to test urine for ketones using ketone dip sticks If urine contains ketones, student may not exercise Treatment is to drink water and rest until there are no more ketones in urine See plan for when to send student home for very high blood sugar

Exercise Special considerations: Extremely high blood sugars, +/- ketones Low blood sugars May need to carry fast-acting carbs such as glucose tablets, juice box or candy

Exercise, cont. Snack may be necessary prior to participating in strenuous exercise If PE is immediately before lunch, a snack may be necessary. Rule of thumb: 15 grams of Carbohydrate for each 30 minutes of strenuous exercise.

The End