1. Diabetes Education

2. 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.

3. 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.

4. 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.

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

6. 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

7. 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.”

8. 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

9. 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).

10. 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

11. 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

12. 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

13. 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.

14. Severe Hypoglycemia
Glucagon/Glucagen

15. 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

16. 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

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

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

19. 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

20. 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

21. 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 = 130
130/50= units (for whole unit syringes)
If you were using ½ unit syringes, then 2.6 would round to 2.5 units

22. The Math Method

23. 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 = 130/50= 2.6
Insulin dose: = 6.6 units
6.6 rounds to 7 units for whole unit syringes
6.6 rounds to 6.5 units for half unit syringes

24. A Few Rules…
Administer insulin approximately 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

25. 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

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

27. Insulin Pumps

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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.

34. The End