1 DATA Program Diabetes Awareness, Training, and ActionTraining Curriculum North Carolina Public School System NC Session Law , Senate Bill 911 Care of School Children with Diabetes Update #1 August, 2005

2 Supported by: Blue Cross and Blue Shield of North Carolina FoundationCollaborating Organizations: NC Department of Health and Human Services NC Department of Public Instruction Special Thanks to the School Nurse Consultants NC Diabetes Advisory Council American Diabetes Association The Diabetes Care Center of Wake Forest University Baptist Medical Center Wake Area Health Education Center

3 Introduction Thank you for being a participant in the DATA Program!! Your participation demonstrates your interest in all students being successful in school. You may already have an interest in diabetes and this program will help you learn more. Not only are we seeing an increase in Type 1 diabetes but there is an alarming increase of Type 2 diabetes in our young population. We are very proud that the state of North Carolina is among the eleven states who have legislation to assure these young people a positive and supportive school experience. Teaching Notes: DATA stands for “Diabetes Awareness, Training, and Action.” This program has been developed in conjunction with multiple disciplines across the state. All have reviewed the program and are in agreement that going through this program will begin to prepare you to better assist students with diabetes. Students are in the school environment about 35 hours per week. Those involved in extracurricular activities and sports are there even longer. It is important that the school staff involved with that student be knowledgeable enough to assist the student when needed and also be familiar with the school protocol concerning handling special situations and emergencies.

4 Introduction continued…When a student with diabetes is part of the school system, the school staff automatically becomes a part of the student’s health care team. A student with diabetes can have special challenges for which teachers and staff must be prepared. This program is designed to train school personnel who are available every day at school in basic and emergency diabetes care. Other personnel need to know some basic diabetes care to allow the student to have a successful day at school. Teaching Notes: A seamless care environment flowing from the medical setting to home to school is vital for the child’s well-being and success with learning to self-manage diabetes. The next slide demonstrates the training process going on in the state.

5 DATA (Diabetes Awareness, Training and Action) ProgramMaster Training By: State partners and Certified Diabetes Educators Target of Training: Two from Each LEA; One from each Charter School From LEA: 504 Coordinator responsible for assuring implementation of general training plan And One RN or other Health Professional responsible for intensive training General Training for 504 Contacts By: 504 Coordinator Master Trainer Target: 504 Contact Person or Other Person from each school in the LEA who becomes the trainer responsible for providing general training to all staff in his/her school Teaching Notes: The Master Trainer sessions commenced in May, 2003. The General Training and Intensive Training sessions must be completed before the school year starts. Intensive Training By: RN Master Trainer or Certified Diabetes Educator Target: Diabetes Care Manager (DCM) providing care management in each school in the LEA Two per school General Training of All School Staff By: 504 Contact or Other Person Target: All school personnel within the specific school

6 Care of School Children With DiabetesPart 1 Overview of SB 911 Care of School Children With Diabetes

7 Part 1: Overview of SB 911: Care of School Children with DiabetesFederal & State Support and History of the Law: Diabetes is considered a disability and is covered under the following Federal Acts: Section 504 of the Rehabilitation Act of 1973 Individuals with Disabilities Education Act of 1991 Americans with Disabilities Act Teaching Notes: Although school and districts may vary in the level of available health care assistance, federal law requires that every public school provide adequate services for students with all chronic illnesses. Federal laws require public schools to provide disabled students with a free, appropriate education in the least restrictive environment. When a school’s administration is advised that a student has a chronic illness, personnel must evaluate the student’s special needs and develop a plan for satisfying any medical requirements. Many schools have done a excellent job in accommodating students with diabetes and facilitating their self-management. However, there are still occurrences happening in some schools. Examples are: making the child leave class to go to the office to test blood sugar, not allowing the child to eat a snack in the classroom or be excused to the bathroom when needed. Many schools have also required a parent to go on a field trip or the child cannot go. The next slide covers the current state policy.

8 Overview of SB 911 continued…State Board of Education Policy # 04A107 Special Health Care Services (1995) Shall make available a registered nurse for assessment, care planning, and on-going evaluation of students with special health care service needs in the school setting… Teaching Notes: 1. These services include procedures that are invasive and carry reasonable risk of harm if not performed correctly, may not have a predictable outcome, or may require additional action based on results of testing or monitoring. Care planning includes but is not limited to: ID of appropriate person to perform the procedure, teaching those persons to perform the procedure, and ID of mechanism for nurses to provide ongoing supervision to ensure the procedure is performed appropriately and response to care is evaluated in the school setting. To assure that these services are provided, LEAs have the flexibility to hire RN’s, to contract with individual RNs, or to contract with other agencies or other providers to implement these services.

9 Overview of SB 911 continued…The bill passed unanimously in the House and Senate in August, 2002 and on September 5, 2002, the bill was signed into law by Governor Easley.

10 Overview of SB 911 continued…Implications for NC Schools Guidelines adopted in every school in the state must meet or exceed American Diabetes Association recommendations. Teaching Notes: 1. Refer participants to the actual copy of SB 911 at the end of the manual and go through the sections. See next slides.

11 Overview of SB 911 continued…Section 1 of SB 911 Procedures for the development of a diabetes care plan if requested by parent Procedures for the regular review Included should be: Responsibilities and staff development for teachers and other school personnel Development of an emergency care plan Identification of allowable actions to be taken Extent of student’s participation in diabetes care

12 Overview of SB 911 continued…Section 2 of SB 911 Local Boards of Education must ensure that guidelines are implemented in schools in which students are enrolled. Local Boards of Education will make available necessary information and staff development in order to support care plan requirements for students with diabetes.

13 Overview of SB 911 continued…Section 3 of SB 911 The NC State Board of Education delivered a progress report in September, 2003. Section 4 of SB 911 The guidelines were implemented by the beginning of the school year. Guidelines were updated August, 2005. Teaching Notes: In order to disseminate this information to parents, guardians, etc. schools will place information on SB911 and development of IHPs in every report card going out at the end of this school year ( )

14 Overview of SB 911 continued…Please refer to your copy of the ADA Standards. An Individual Health Plan (IHP) should be developed by the parent/guardian, the student’s diabetes care team, and the school nurse. At least 2 school personnel in each school should be trained in diabetes care and emergencies. (Diabetes Care Managers/DCM) Teaching Notes: Once children in the school are identified, parents or guardians should be encouraged to arrange a meeting for the development of an IHP if they have not done so already. The parent can also initiate the IHP process or an IHP can be developed by the parent and the Medical Team. See the Parent Request Form at the end of the manual. Note that IHPs are not mandatory and are of choice by the parent. However, if the school is to take any responsibility for the child’s diabetes care, one must be in place. If the parent refuses an IHP and the child has severe problems, then emergency procedures, such as would be in place for any child, would be commenced. The child/parent can decide to test blood sugar and/or take insulin in the office for assistance or for privacy reasons. Also, diabetes is not specific to trustworthy and mature children and specific guidelines may have to be developed where the diabetes care can also be watched more closely. If an adolescent is managing diabetes without any assistance and is doing well, an IHP still should be in place stating that this student does not need any diabetes supervision. However, any person with diabetes can still have problems and the DCM needs to maintain contact.

15 Overview of SB 911 continued…Children should have immediate access to diabetes supplies and diabetes treatments as defined in the IHP. Roles and responsibilities of the parents/guardians and the schools are defined. DCM roles are also defined. Teaching Notes: Continue to review the roles in the ADA Standards. Refer the participants to their copy of the ADA Standards Position Statement to review responsibilities of parents and schools. Go through these. Responsibilities are also detailed in the sample Diabetes Care Plan provided in the Appendix.

16 G.S. 115C April 28, 2005 House Bill 496 states that local boards of education shall ensure that guidelines for the development and implementation of individual diabetes care plans are followed. Local boards are to make available necessary information and staff development in order to support and assist students with diabetes in accordance with their individual diabetes care plans. A new bill introduced and passed this year, House Bill 496, also ensures that guidelines for development and use of individual diabetes care plans are followed by local boards of education. The bill further stipulates that staff development be made available and that kids with diabetes who need support and assistance are accorded this when needed.

17 Forms to Facilitate Implementation of the LawDiabetes Care Plan Request Diabetes Care Plan Responsibilities of Parent & School Quick Reference Plan

18 Role of the Master Trainer (One RN and One 504 Coordinator from each LEA)Participate in regional intensive training sessions. Set up general information sessions for 504 Contact Person or other person from each LEA. Set up the intensive training session for the DCMs from each school in the LEA. Coordinate continuing education for the DCMs. Teaching Notes: Remember, the training of the DCMs does not take the place of information needed by the teacher, TA, and other school personnel in order to recognize and treat signs of mild to moderate low blood sugars. All personnel have to know emergency protocol if find a student in need.

19 Communication- Role of NurseWith student, parent & school staff SB-911 Diabetes School Act Provide forms Provide training Act as a resource Continuing Education for diabetes management

20 Communication With student and parent before school year beginsBy phone, meeting at the library, by mail Ask questions about self care Get to know the student

21 Communicate: Self CareProcedures done at school Equipment kept at school Diabetes care recommendations may change during the school year Whom to tell about having diabetes Determine student’s level of maturity Diet issues: Meals Snacks Emergency snacks

22 Communicate: Parent ResponsibilitiesPhone numbers Home, work, cell, pager Supplies Snacks School absences Care Plan request Care Plan Student’s self-care capabilities Medication forms Diet form Student photo Medic alert ID

23 Customize: Parent Request FormNo MD signature required Request for Care Plan to be implemented Consent for release of information Trained staff in place Require annual review

24 Communicate: Parent ResponsibilitiesStudent, parent or may have to assume responsibility for diabetes care until the Care Plan is signed and returned. A new Care Plan is needed annually. Communicate on regular basis with school staff and bus driver either verbally or written.

25 Role of the DCM Diabetes Care Managers in Each SchoolParticipate in the Intensive training session. Obtain certificates of course completion and maintain documentation as proof of completion. Participate in IHP conferences. Have ready access to the student’s IHP. Be readily reached in case of a diabetes emergency. Teaching Notes: Good communication is vital for this process to work effectively. Please schedule a meeting with your administrators to set up the process for your school. IHP conferences should be held to review the IHP at least yearly. Periodic changes that are made to the student’s insulin doses by the Health Care Team should be on a physician’s order form if the changes involve the school.

26 DCM Roles continued… Communicate with teachers/substitute teachers/student/parents/health care team as indicated or as necessary. Assist the student with diabetes care as indicated in the IHP. Be available to go with the student on field trips or to school-sponsored extracurricular activities as indicated. Attend continuing education sessions as needed. Teaching Notes: DCMs should also be aware that the student has a substitute teacher. Please communicate that the sub should contact the DCM if any problems arise. How to initiate the emergency process should also be communicated to the substitute.

27 Role of the 504 Contact in Each SchoolAttend general information session instructed by the 504 Coordinator Master Trainer for the LEA. Provide a general information session for all personnel within his/her school. Develop communication and emergency protocol with the school administration and the DCMs. Attend review sessions when organized by the 504 Coordinator for their LEA. Teaching Notes: If a 504 Contact is not available in your school, please designate another to take this role. Again, good communication is vital for success of this program. All school personnel includes: Administrators Front Office Staff Guidance Counselors Primary Teachers Medication Clerks Resource Teachers Cafeteria Staff Bus Drivers Crisis Team First Responders Student Service Team, and Resource Officers

28 Guidelines for PE Teacher and CoachEncourage exercise and participation in sports and physical activities for students with diabetes. Treat the student with diabetes the same as other students except to meet medical needs. Encourage the student to have blood glucose equipment and treatment for low blood sugar available. Understand and be aware that hypoglycemia can occur during and after physical activity. Recognize any changes in student’s behaviors which could be a symptom of a low blood sugar. Exercise is very important in maintaining blood sugar levels. It is very important for kids with Type 2 diabetes to have an hour or more of physical activity a day. The PE Teacher or Coach may want to keep a fast-acting form of glucose (3-4 glucose tablets or hard candies in the First Aid pack. The coach should provide information to the student’s school health team; especially if persistent episodes of low blood sugar occur.

29 Guidelines for Bus DriversAt the beginning of the school year, identify any students on the bus who have diabetes. Be familiar with their DCP. Be prepared to recognize and respond to the signs and symptoms of a low blood sugar. Parents should consider giving bus driver their daytime contact numbers. Student may carry monitor, insulin, glucagon and snacks on bus. The student, teacher & parent should communicate with bus driver. Bus driver may consider carrying extra snacks in case of bus breakdown, traffic jam, etc.

30 Actions for Food Service Staff or Lunchroom MonitorProvide a lunch menu and lunch schedule in advance to parents along with nutrition information including grams of carbohydrate and fat. Be aware of your students diabetes meal plans and snack plans. Treat the student with diabetes the same as other students except to respond to medical needs. Understand that hypoglycemia can occur before lunch. Students with diabetes have varying needs regarding amounts of carbohydrate they will need included in their lunches and snacks. If possible, obtain a copy of the student’s meal plan from the Diabetes Care Plan. Recognize that eating meals and snacks on time is a critical component to most students with diabetes.

31 Role of School AdministrationWork with the LEA Master Trainers to identify at least 2 school personnel to serve as the school’s DCMs. Provide support for DCMs to attend the intensive training session. Identify new DCMs as turnover occurs.

32 Role of School Administration continued…Notify the Master Trainers for the school when such turnovers occur during the school year so individual training can be planned. Set up communication and emergency protocols for access to DCMs. Support the general information sessions for staff and all school support personnel. Teaching Notes: 1. It is important to involve all school personnel who work with any level of school function and activity.

33 Liability Concerns and Issues for DCMsHow do I prevent liability situations from occurring? Be very familiar with the student’s IHP and refer to it often. If the student needs assistance with administering insulin, make sure the most recent dosage schedule is available for your use. Teaching Notes: Be aware that students may have varying insulin regimens such as: a fixed dose of insulin. a sliding scale of insulin to adjust according to blood sugar level. formulas (or algorithms) to adjust dose according to how many carbohydrates he/she is going to eat plus any correction for blood sugar.

34 Liability Concerns and IssuesRemember, a vial of insulin kept at room temperature is discarded 30 days after opening. An insulin pen is discarded 15 days after it is first opened even if insulin remains. Check expirations dates on insulin and glucagon to make sure they are in date. Triple check yourself when drawing up a dose of insulin. Double check the student’s dose if he/she is drawing up the insulin.

35 Liability Concerns and Issues continued…What happens if there is an occurrence? Most incidents occur when we are in a rush. Think carefully about what you are doing and if the situation doesn’t make sense, question it! If an incorrect dosage is given, document the procedure you take to keep the child safe. Teaching Notes: Documentation is so important. Make sure you do not use the words mistake or error. Instead use incident or occurrence. If your school does not have one, an Incident Form should be created for this documentation.

36 Liability Concerns and Issues continued…If you give too much insulin Notify the student’s health care team to let them know. They may have special instructions for this situation. Test blood sugar more frequently or according to the Individual Diabetes Care Plan for the rest of the school day. Notify the parent/guardian of the procedure you have taken. Make sure the child has extra food/juice to consume. Alert the teacher. Teaching Notes: If too much insulin is given, make sure the child eats more carbohydrates to cover the insulin. It is OK if the parent wants to pick up the child and take him/her home to watch more closely there. Make sure you have documented all the procedures you have taken to make sure the child is safe. Remember, even with the correct dose, the child can have a low blood sugar. Diabetes would be easy if the only thing involved was insulin dose and amount of food eaten.

37 Liability Concerns and Issues continued…If you give too little insulin, an additional shot can be given to make up the missed amount if you discover the mistake quickly. Document your actions. If the child refuses the extra shot, document the occurrence and notify the parent . Generally there is not much you can do if insulin leaks at the site. Blood sugars may run a little higher that day. If insulin leaks are a common problem, take a little more time with the injection and count 10 seconds before withdrawing the needle. Teaching notes: Leak backs of insulin look like some clear fluid coming out of the injection site. With little children, you can count 5 or 10 hippopotamuses to prevent leak backs. This makes it a game for them. Also, make sure they bend the joint nearest the injection to relax the muscle underneath to help prevent leaks.

38 Liability Concerns and Issues continued…But how am I protected from litigation? The State of NC now has SB911 in place with directives for adoption by all public schools in the state. Many State Agencies have organized this training program. You are now going through the training and will receive a certificate of completion once the training has satisfactorily been completed. You will maintain up to date knowledge through continuing education. You will have resources to call upon if questions or problems arise. Teaching notes: 1. In other words, you have been approved by the State of NC to perform this function for children with diabetes in your school.

39 Liability Concerns and Issues continued…Do I have any other protections? NC General Statute adopted in 1975: Provides immunity for rescuers. Provides immunity for acquirers and enablers. Encourages/requires CPR & AED training. This is the “Good Samaritan Law” Teaching Notes: CPR is not required for this program. However, please encourage those involved that this may be a good tool for them to have in place if the need ever arises. Anyone can receive basic CPR training through their local Red Cross Agency. AED is the automatic defibrillator that is now kept in malls, on airplanes, etc. This training is now also included in basic CPR classes.

40 Liability Concerns and Issues continued…So what needs to happen in my school? You as DCM, should be known by administration and staff throughout the school. Communication is essential. You should make sure an emergency communication protocol is set up and is followed. You should have easy access to the child’s IHP and be included in any IHP conferences or revisions. You should be notified when special events or conferences occur for the child in order to include this in your schedule. Teaching Notes: 1. Because of the law and support by the DPI , you should have total support for your efforts by school administration for the current training, continuing education, and availability to the child with diabetes for emergencies, conferences, and special events.

41 Liability Concerns and Issues continued…So what about sharps, blood, carrying medication around the school? Self-monitoring of blood sugar should be supported. The lancet should not be removed from the lancing device. Insulin pumps cannot be removed except to quick release in certain instances. Students injecting insulin with pens or syringes should be provided a safe place for injecting. Teaching Notes: A drop of blood well controlled is not an issue. The lancet should be left in the lancing device and not exposed to the outside. Insulin pumps should be on the student at all times unless reasons exist for disconnecting. Some students may quick-release for PE. Those injecting insulin with a pen or syringe should be provided a safe place for injection according to their IHP and the student’s preference. Sharps containers should be part of the school health room set up and provided by the school. Glucose tablets are not medications, they are simply sugar. Students with discipline problems or students that need assistance with diabetes care should be under supervision. All individual needs should be written up in the student’s IHP.

42 Continued Glucose Tabs are not medication.Some students with diabetes should be monitored at all times for safety of all involved. Other discipline problems should not interfere with the self-management rights of the student with diabetes.

43 Questions ?? Teaching Notes:Make sure the DCM and the School Nurse for that school also have easy access to one another. It should be documented in the child’s IHP who the DCM’s in the school are and how they are to be located. Remember, the DCMs should always handle situations with a child in a very positive, open and honest manner. Communication with parents is most always appreciated and the DCMs should not hesitate to do this. If parents do not cooperate or become a problem, the DCMs should notify the School Nurse or the child’s Health Care Team. Remember, the child always comes first.

44 Part 2: Diabetes OverviewDiabetes Defined: “Diabetes Mellitus is a group of metabolic diseases characterized by hyperglycemia (high blood sugar) resulting from defects in insulin secretion, insulin action, or both.” (Diabetes Care, Supplement 1, 26:1, January, , p. S5) Teaching Notes: Diabetes effects over 17 million people in the US, 6.2% of the population, and 151,000 people less that 20 years of age have diabetes (year 2000 estimates) (National Diabetes Fact Sheet, American Diabetes Association Web Site, 2. Diabetes costs the US an estimated $132 billion in medical expenditures and lost productivity. (Diabetes Care 26: , 2003)

45 Diabetes Overview continued…Insulin is a hormone produced in the beta or islet cells of the pancreas. In order for glucose or sugar to be used as energy, it must be transported by insulin. Glucose is necessary to keep the cells in the body healthy. Teaching Notes: Picture this: You have an empty gas tank in your car (the body cell). The gas or fuel is in a large tank in the ground (the glucose in the blood stream). How do you get move the gas from the ground tank into your car……..the gas pump (insulin). Now, every time you pump gas you will think of insulin.

46 Diabetes Overview continued…Type 1: *Has been called Juvenile-Onset or Insulin Dependent Diabetes in the past. *Results from the autoimmune destruction of the beta or islet cells of the pancreas which produce the hormone, insulin. *Insulin is required for glucose metabolism (using blood sugar for fuel in the cells). *A person cannot live without insulin. Teaching Notes: Insulin was discovered in 1921. Prior to 1921 a person with type 1 diabetes had about 18 months to live. He/She literally starved to death no matter how much was eaten. So, thank goodness we have insulin!

47 Diabetes Overview continued…Type 2: * Has been called Adult-Onset or Non-Insulin-Dependent Diabetes. * Characterized by insulin resistance that develops into relative insulin deficiency. *Central abdominal obesity is directly related to insulin resistance. *Type 2 diabetes is a fast-growing epidemic in our young population. *Type 2 diabetes is related to family history of diabetes, weight gain, and sedentary lifestyle. Teaching Notes: (Have the participants think about the young population they see in their schools. How many are overweight? These young people either have or are at risk for type 2 diabetes.) This population is nicknamed the “Nintendo™” Generation. The genes are generally there, especially in the minority populations. A darkening of the skin around the back of the neck or in the armpits is a significant sign of insulin resistance (called acanthosis nigricans). It looks like the student has not washed his/her neck.

48 Diabetes Overview continued…Insulin resistance means that insulin is produced, but the body is not using it correctly. This resistance causes the blood sugar to rise; thus, type 2 diabetes develops. Insulin resistance is also related to the shape of the body. An apple-shaped body is more resistant than a pear-shaped body.

49 Diabetes Overview continued…Reasons for Control: Diabetes is the 7th leading cause of death in the United States. the major cause of blindness, nontraumatic amputations, and kidney failure leading to dialysis and the need for a kidney transplant. a major cause of heart attacks and strokes. a possible cause of lack of normal growth and development if not controlled prior to puberty.

50 Diabetes Overview continued…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. Effective diabetes management is needed to prevent the immediate dangers of blood glucose levels that are too high or too low. The key to optimal blood glucose control is to carefully balance food, exercise, and insulin or medication. Knowing what is involved in 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.

51 Diabetes Overview continued…Diabetes management means monitoring or checking blood glucose levels throughout the day. Planning for events outside the usual school day is very important. Dealing with the emotional and social aspects of living with diabetes is a key element to effective management.

52 Diabetes Overview continued…The Good News: The “Diabetes Control And Complications Trial” (DCCT) of 1993, clearly demonstrated that good diabetes control with blood glucose readings close to normal, prevents and postpones diabetes complications. The results of this study changed the direction of diabetes treatment to more aggressive care for most everyone with diabetes. Teaching Notes: The DCCT was conducted among the Type 1 diabetes population and showed that fifty-six to seventy-six percent of microvascular (small vessel), kidney, eye and nerve complications can be prevented. The United Kingdom Prospective Diabetes Study (UKPDS) demonstrated the same results for the type 2 population. Further research studies are being conducted to determine the relationship between diabetes control and prevention of heart attacks and strokes (macrovascular complications / large vessel).

53 Treatment Foundations:Type 1 diabetes: Occurs in approximately 1:400 children (10% of the diabetes population.) Often presents as an acute illness and results in diabetic ketoacidosis (DKA) due to lack of insulin. Requires insulin either by injection into subcutaneous tissue or by IV. Other routes of insulin delivery are under development. Teaching Notes: 1. Every school can then expect at least 1-2 children with type 1 diabetes. The country in the world with the highest incidence of type 1 is Finland. It is more prevalent in the Caucasian population. It is growing in incidence and is typically diagnosed under age of 20, although it can be diagnosed at any age. These children are typically thin, but being overweight does not rule it out. Other methods of insulin delivery that are being developed are inhaled insulin (inhaling into the lungs like an asthma medication), a mouth or nose spray insulin, and an insulin patch. Researchers are trying to develop and insulin pill. A syringe is used to draw up insulin from a vial into an insulin needle. Pen devices make administration easier. The student simply screws on a disposable needle and dials in the dose to give. Insulin pumps help to reduce the amount of injections taken. The pump set (soft catheter placed under the skin with an introducer needle) is changed every 2-3 days. The pump is programed to deliver a small amount of insulin all through the day and night. The student pushes a few buttons to administer a bolus of insulin with food or to correct a high blood sugar. 4. You will learn more about all of these in the skills stations this afternoon.

54 Treatment Foundations:Currently, most students are taking insulin by syringe, pen device, or insulin pump. The insulin pump is a type of injection using a very small catheter under the skin. Teaching Notes; Again, you will learn more about this in the afternoon station.

55 Treatment Foundations:The amount of insulin taken has to be balanced with food intake (specifically carbohydrates) and physical activity. The outcome of all this is measured by self-monitoring of blood sugar and keeping a written log or computer program. Ketone testing is also necessary when the blood sugar is very high or if the child complains of a stomach ache. Teaching Notes: 1. Ketone testing is only necessary for those with type 1 diabetes. You will get more details on this in the Acute Complication section.

56 Treatment Foundations:Type 2 diabetes: Most often occurs in the adult population. Accounts for 90% of the diabetes population in the world. Is a rising epidemic in the young obese person. Can be present for months or years before diagnosis. Has as a goal to develop and maintain a healthy lifestyle involving physical activity and weight loss. Usually improves with weight loss which decreases insulin resistance. May require medication if diet and exercise don’t improve blood sugars. Teaching Notes: Consider lifestyles today: We have sedentary jobs, long hours, and buy fast food on the way home because there is no time to cook. Kids play with computer and electronic games. We have pizza, corn dogs, and french fries for school lunches. Vending machines have candy, chips, carbonated sodas and high calorie fruit juices. We drive around for 20 minutes to find the closest parking place at the mall. Think about all of our developing lifestyles. Treatment for the child with type 2 diabetes has to involve the whole family lifestyle issue. This is a challenge.

57 Necessary Tools for Diabetes ManagementSelf-Monitoring of Blood Sugar: Is important for anyone with diabetes. Currently is done by placing a very small drop of blood on a test strip in a blood glucose meter. Takes from 5-45 seconds, depending on the meter. Should be recorded in the child’s log book. Teaching Notes: Think of a blood sugar test as one snapshot of the day. It takes several snapshots to get a look at the bigger picture of how the day is going. Most children with type 1 diabetes test before each meal and at bedtime, this is 4 times a day. If the child is doing multiple injections or on a pump, he/she may be testing more often, like before snacks or middle of the morning and afternoon (6-8 times a day). All children should have monitoring equipment handy and test if they feel or act low and if they feel bad in any way; headache, stomach ache, etc. A type 2 child (if not on insulin) may not be required to test at school. Blood sugar data should be recorded in the child’s log book. This info should be communicated to the parent on a regular basis if the log book does not go home with the child. Guidelines for when to call the parent or health care team is individual and should be documented in the child’s IHP health plan. A high blood sugar does not necessarily indicate that the student should be sent home. Guidelines should be written in the IHP. Mild lows are a common occurrence and should be treated according to the IHP health plan and the child should complete the day. If a severe low occurs, after emergency treatment is started, the parent should be notified. You will receive more detail in the “Acute Complications” section of this course.

58 Necessary Tools continued… Blood Sugar MonitoringIf you need to assist a child with blood sugar monitoring, please follow these steps: Make sure the child’s hands are warm, clean, and dry. (Hand washing is fine, alcohol to prep the finger is not necessary.) Use exam gloves to cover your hands. (Universal Precautions.) Set up the meter with the test strip. (Most meters today turn on when you place the strip in.) Make sure the meter is coded for the test strip used. Insert the lancet into the lancing device and pull trigger back to cock. Teaching Notes: 1. Hand washing with warm water and soap is fine for the testing. The warm water promotes easier blood flow. 2. The child may also need to rub hands together to warm and hold them lower then heart level to get a good drop. Many lancing devices have a place to control the depth of the stick. Verify this position with the child. Dialing the depth down to a more shallow stick and holding the lancing device tighter against the finger makes the stick more comfortable.

59 Blood Sugar Monitoring continued…Prick the fleshy part on the side of the fingertip (may use any finger.) Gently squeeze to get a small drop of blood and add to the test strip. The meter will automatically begin counting down and then read the sample. If you did not get enough blood on the strip, often the meter will read “Error” and you will need to repeat the test. Carefully remove the lancet and place in a sharps container. Please note: One lancet can be used for the entire day as long as no one other than the student uses it or it becomes otherwise contaminated.. Teaching Notes: Most school age children can do this procedure with minimal to no help. What the child can and cannot do should be addressed in the IHP. Every child should evolve to doing this procedure without help, so encouraging him/her in this area is helpful.

60 Blood Sugar Monitoring continued…If the school has a meter that is kept in the office for various students to use, the following must be addressed: How often are control tests done to verify accuracy? Single-Use Only lancets must be available. Who takes care of replacing the sharps container when needed? Who is assigned to clean the meter and check supplies? The meter must be approved for multi- person use. Teaching Notes: Control tests with Control Solution from the meter company should be performed daily and documented. Control Solutions are usually good for 6 months at time of opening. More Control Solution may be obtained from the meter company. Toll free numbers for customer service are on the back of all meters. One time use only lancets must be used in accordance with Universal Precautions. Sharps containers must be disposed of in accordance with your county’s waste management policy. Most meters should be cleaned with a mild detergent only – no alcohol.

61 Necessary Tools continued…Carbohydrate Counting and the Meal Plan Students with Type 1 diabetes may practice carb counting in order to balance insulin with food and activity. Students with Type 2 diabetes may focus on weight management. Every person with diabetes should undergo Medical Nutrition Therapy (MNT) with a Registered Dietitian or receive Diabetes Self Management Education (DSME) with a Certified Diabetes Educator (CDE). “Learn to Make Healthy Food Choices” Teaching Notes: Young children are learning the concept of what carbs are and how they effect blood sugar. Older children and adolescents are actually learning to count carbs either by choices or grams. Lower fat is for everyone and this is always emphasized with learning to carb count. Most every child will have some sort of a meal plan developed by a dietitian. These have to be revised often to keep up with growth and development. The latest data suggests that over thirty percent of our kids are overweight. Seventy percent of adults are overweight. Intensive management is either doing multiple shots a day or using an insulin pump. Algebraic formulas are set up by the Health Care Team for the student to use to calculate dosages according to grams of carbs eaten and blood sugar. Again, you will get to experience carb counting with lunch today.

62 1. You will learn a lot more about insulin regimens as our day progresses and during the hands on experience later in this program.

63 Insulin Action and AdministrationMost students take at least two injections of insulin a day. Some students are on intensive insulin therapy or wear the insulin pump. A combination of different insulins is most often used. It is important to remember that insulins have different “peak” times. These are times when insulin is working hardest to lower blood sugar. Teaching Notes: Most students with type 1 diabetes take at least two injections of insulin a day. This is usually a combination of an intermediate or long-acting insulin with a rapid acting insulin.

64 A battery operated device about the size of a pagerWhat is an insulin pump? A battery operated device about the size of a pager

65 Insulin Action Insulin types are categorized as rapid-acting, fast-acting, intermediate-acting, long-acting or basal. Each type has a different onset, peak and duration.

66 Insulin Action Rapid -Acting Fast- Acting Intermediate-Acting BasalTeaching Notes: Rapid Acting insulin is the fastest acting insulin currently available. Generally, it begins half and hour to forty-five minutes after the injection and has a peak effect at ninety minutes to two hours. The usual duration is three to four hours. Fast-acting insulin, also known as Regular insulin, has an effect beginning approximately thirty to sixty minutes from the time it is injected and peaks two to four hours afterward. Typically, it is a five to seven hour insulin. Intermediate-acting insulin starts working one to two hours from injection and has the greatest effect six to fourteen hours from the injection. The effect lasts approximately 18 to 24 hours. Relatively new is “basal” insulin. This insulin was developed to behave more like the naturally occurring insulin in people without diabetes. The effect lasts for twenty-four hours and usually does not have a peak. Intermediate-Acting Basal

67 Insulin AdministrationAfter carefully drawing up the correct amount of insulin, cleanse the injection site with an alcohol swab and wait for it to dry. For most students, a short-needle syringe is used. Insulin should be administered in subcutaneous (or fatty) tissue under the skin. This tissue is approximately the depth of the short needle when injected at a ninety degree angle.

68 Insulin Administration-ContinuedAfter pushing the plunger on the syringe, count slowly to five and remove the needle. Do not massage the area of the injection. If the needle on the syringe is one of the longer needles, the angle of insertion should be approximately 45 degrees. Injection sites are the outer area of the upper arm, abdomen, outer aspect of the thigh, or upper outer quadrant of the buttock. Teaching Notes: Yu will learn more about insulin administration in the skills station this afternoon.

69 Carb Counting, Insulin to Carb RatiosMany students are now using an algorithm instead of a sliding scale for an elevated blood sugar. For example, a student with a blood sugar of 347 may have a correction algorithm of BG-120/55. To determine the correct amount for administration using this formula, subtract 120 (the target blood sugar) from 347 (BG) and divide the product by 55 (insulin sensitivity—one unit will lower the blood sugar by this amount) = 227 ÷ 55 = 4.1 units of insulin to correct the blood sugar to the target of 120. Children with diabetes are now more than ever attempting to gain better control over their diabetes through the use of intensive insulin therapy. This involves using an insulin (Lantus) as a basal insulin and covering the carbohydrate using a rapid acting insulin (Humalog, Novolog, Apidra). Blood sugar corrections are done using an algorithm or formula such as BG-120/55. BG is the current blood sugar; 120 is the target, or where we would like to have the blood sugar; and 55 is the amount of “drop” in blood sugar anticipated by one unit of insulin.

70 Insulin to Carb Ratio In an effort to match insulin to carbohydrate eaten, an insulin to carb ratio is developed. Example: Haley is planning to have 57 grams of carb at lunch. Her established ratio is one unit of insulin for every 8 grams. 57 ÷ 8 = 7.1 (If given by syringe, this amount would be rounded to 7 units.)

71 Combining the Two In order to correctly determine the amount of insulin needed before a meal, it is necessary to add the amount to cover the carbs to the amount to return the blood glucose to target. In our examples just given, the two amounts ( 4.1 units and 7 units) would be added for a total injection amount of 11 units of insulin.

72 Insulin to Carb Ratios and the Insulin PumpMost insulin pumps today are far more sophisticated than those of only three to four years ago. Pumps are able to calculate the amount of insulin needed by the student when the blood glucose and grams of carb are programmed into the pump. The ratios and correction algorithm are pre-programmed into the pump so that calculations are done by a mini computer contained in the pump. Counting grams of carbohydrate is very important for successful application of pump therapy. Dosages are capable of being given in micro amounts. 1. These features will be demonstrated in the pump hands-on experience in labs later today.

73 Oral Meds for Kids With Type 2 DiabetesThe preferred method of treating Type 2 diabetes in young people is exercise and weight management. Most often, Type 2 diabetes requires the child to eat a certain amount of carbohydrate at each meal. Oral medications would be an option if Type 2 diabetes is not controlled with the measures mentioned above. Teaching Notes: An alarming trend seen today is the significant number of children and teenagers who are developing Type 2 diabetes. This has been attributed to lifestyles that we as Americans have adopted. Kids with Type 2 diabetes are typically treated with medical nutrition therapy, meal planning and exercise. Most students who develop Type 2 diabetes are over their ideal body weight. Often weight management and exercise will prevent the onset of Type 2 diabetes. Several oral medications are available for general treatment of Type 2 diabetes. The medication most often prescribed for kids with Type 2 diabetes is Glucophage™ or metformin.

74 Oral Meds The most frequently used medication for increasing insulin sensitivity in Type 2 diabetes in kids is metformin or Glucophage™. Metformin works by preventing the liver from releasing glucose into the system and does not cause low blood sugars or promote weight gain. Teaching Notes: Although not an insulin, metformin enables the body to more efficiently use insulin that is produced by the pancreas. Other medications that are typically prescribed for adults with Type 2 diabetes are not used in children. The significance of metformin is that is does not promote low blood sugar.

75 Oral Meds It is important to note that some kids with Type 2 diabetes may at times require insulin. This does not indicate worsening of their diabetes. Taking insulin does not mean this student has Type 1 diabetes. The regimen will vary according to the needs of the child.

76 Part 3 Acute Complications of DiabetesHyperglycemia (High Blood Sugar) Hypoglycemia (Low Blood Sugar)

77 High Blood Sugar “Hyperglycemia”

78 Hyperglycemia High blood glucose (hyperglycemia) occurs when the body gets too little insulin, too much food, or too little exercise. Hyperglycemia may also occur when a child has an illness such as a cold. Hyperglycemia may occur when a child is under extreme stress. Teaching Notes: Hyperglycemia usually indicates a level of glucose in the blood that is greater than 240. Many situations can precipitate an episode of hyperglycemia. Hyperglycemia is usually a result of too little insulin, too much food, or too little exercise. High blood sugar levels can also occur if the child has an illness or is in the process of becoming ill. A simple infection such as a cold or yeast infection can elevate a student’s blood sugar level. Extremely stressful situations can also cause a high blood sugar level. EOG testing periods are a good example of a high level of stress. Typical hyperglycemia that is associated with short periods of stress is usually returned to target once the child has been given a correction dosage of insulin for the high blood sugar. Other examples of protracted stress could revolve around family situations or discord among groups of students.

79 Definition: High Blood SugarTarget Blood Sugar <6 years: mg/dL pre-meal and bedtime 6-12 years: mg/dL pre-meal and bedtime >12 years: mg/dL pre-meal; <160 mg/dL 2 hours after start of meal Teaching Notes: The medical term for high levels of sugar in the blood is “hyperglycemia.” The normal level of sugar in the blood for individuals without diabetes is Because of age variability, medical people often use a patient’s age as a guideline for determining what should be considered as a high blood sugar. For example, if your student is 8 years old, his target blood sugar before a meal is typically

80 Definition: High Blood SugarMost health professionals view a blood sugar greater than 240 as “hyperglycemia.” 240 Teaching Notes: Target levels for blood sugar vary depending on age of the student and other medical conditions which may co-exist with diabetes. If a child has severe hypoglycemia unawareness, his target level may be increased in an effort to prevent low blood sugars. In general, hyperglycemia means a level of blood sugar greater than 240.

81 Signs & Symptoms of HyperglycemiaFrequent Urination Extreme Hunger Extreme Fatigue Unusual Thirst Irritability Blurred Vision Teaching Notes: The most common symptoms of high blood sugar are frequent urination and unusual thirst. A child that usually wakes up may start wetting the bed. If the student has been in fairly good control, he may not notice blurring of vision or feeling tired until his blood sugar has been elevated for some time. A long-term consequence of high levels of sugar in the blood is weight loss. This weight loss “side effect” of high blood sugars is often figured out by teenage girls with diabetes who want to stay thin. It is extremely unhealthy and dangerous for them to lose weight this way. By working with their health care team, excess weight can be detected and/or monitored and diabetes control can be safely achieved.

82 High Blood Sugar “Hyperglycemia”For the school age child, a blood sugar greater than 240 mg/dL requires an additional check half an hour later. Two consecutive blood sugars greater than 240 mg/dL requires ketone testing. A single blood sugar greater than 300 mg/dL requires ketone testing. Insulin injections for high blood sugar should be given according to the student’s IHP or Diabetes Care Plan. Teaching Notes: Because of the consequences of high levels of sugar in the blood, every effort should be made to prevent these high blood sugars and prevent a hospitalization due to ketoacidosis. If a student has a blood glucose reading at or close to 240, another blood sugar check should be performed within half an hour. If the blood sugar has not decreased, a urine ketone check should be done. In the event of a single blood sugar of 300 or greater, an immediate ketone test should be performed. You may also be able to detect the odor of ketones on the student’s breath. This is the “fruity” breath typically referred to as acetone breath and has been compared to the smell of Juicy Fruit™ chewing gum. In the student’s IHP, a plan for management of ketones should be included. This may include contacting the parent or guardian for instructions, or be so specific as to detail when to call

83 Ketostix® Directions must be followed exactly.Dip reagent end of strip in FRESH urine and remove immediately. Draw the edge of strip against rim to remove excess urine. Exactly 15 seconds later, compare to color chart. Teaching Notes: Ketostix™ are used to check for ketones in the urine. The test is fairly simple and instructions are included on the box or vial of strips. A reading of “large” at any time indicates the necessity for medical intervention. If a student has a level of Trace or Small ketones, the typical IHP would include forcing non-caloric fluids such as water, diet sodas, etc. The important point is to help the child maintain a safe level of fluid hydration. Often a small amount of rapid acting insulin is included as part of the plan for handling ketones that are not greater than Moderate as measured on the Ketostix™. Blood ketone testing is now available through one meter—the MediSense Precision Xtra™. Below 0.6 mmol/l is normal to 1.5 indicates a problem and may require medical assistance. Above 1.5 indicates the student is at high risk of developing DKA. Negative Trace Small Moderate LARGE

84 If a student’s ketone level is greater than “trace” but less than “large”, refer to that student’s IHP for information on steps to take to prevent Diabetic Ketoacidosis. This plan usually requires administration of insulin and drinking lots of water. Teaching Notes: If the student has positive ketones, he/she should be excused from PE that day. The added stress of exercise on tops of an already stressed body, could make the blood sugar go even higher.

85 In the event of moderate to large ketones, treat as an emergency situation according to the student’s IHP. Teaching Notes: Since the production of ketones indicates a lack of insulin or presence of illness, a level of “large” ketones indicates a medical emergency. If nausea and vomiting are present, place the child on his side while awaiting EMT help to prevent aspiration. He may also have severe abdominal pain. These symptoms are all related to the changes occurring in his body because of the ketone buildup. Do not have the student attempt to drink fluids as these can be aspirated and exacerbate the ketotic situation.

86 In all cases of high blood sugar, if the student is able, he should drink calorie-free, caffeine-free liquids such as water. If the student is unable to drink liquids because of nausea or vomiting, you should seek medical attention immediately according to the student’s IHP. Teaching Notes: Because high blood sugars cause dehydration, it is extremely important that the student be allowed to drink calorie-free liquids such as water or sugar-free caffeine-free soda to help rehydrate him and prevent the development of ketones. If the student is vomiting, medical attention should be sought immediately. Vomiting can be related to ketosis but may also be a symptom of another illness such as the flu.

87 Diabetic Ketoacidosis-DKAIf untreated over a period of time, high blood sugar can cause a serious condition called “diabetic ketoacidosis” (DKA.) DKA is characterized by nausea, vomiting, and a high level of ketones in the blood and urine. Teaching Notes: Diabetic ketoacidosis (DKA) results from grossly deficient insulin availability. In Type 1 diabetes, DKA is commonly precipitated by a lapse in insulin treatment or by an acute infection or trauma that makes usual insulin treatment inadequate. In DKA, the marked hyperglycemia causes fluid shifts with excessive urinary losses of water, sodium and potassium. The initial symptoms are frequent urination, nausea, vomiting, and particularly in children, abdominal pain. Lethargy is a common later development. In untreated patients, DKA may progress to coma.

88 Diabetic KetoacidosisFor students using insulin infusion pumps, lack of insulin supply may lead to DKA more rapidly. Insulin infusion pumps use only rapid acting insulin. Lack of insulin causes the breakdown of body fat for energy which releases “ketones” into the bloodstream. Teaching Notes: Most insulin infusion pumps use rapid acting insulin. A lack of absorption of rapid acting insulin can result in development of ketones at a rapid pace. Students using the insulin pump are routinely taught to treat the high blood sugar first. The first line of treatment of a student who exhibits high blood sugars on two consecutive occasions is insulin by injection and then troubleshoot the pump. It has been shown that hyperglycemia in pump patients results primarily from infusion set problems. In that event, using the pump would not result in lowering of the high blood sugar. An injection would be necessary to bring the blood sugar back to target

89 Diabetic KetoacidosisKetones in the bloodstream cause the pH of the blood and body fluids to be lower and more acidic. DKA can be life-threatening and thus requires immediate medical attention. IV fluids and an insulin drip along with hospital admission are necessary in severe cases of DKA. Teaching Notes: Ketones are a by-product of fat metabolism and are very acidic. Release of ketones into the blood changes the pH which results in many kinds of metabolic sequela. DKA requires immediate medical attention. A student may be admitted to the ED for fluids and rehydration or be in such serious condition as to be admitted to the hospital. If ketoacidosis is caught in the early stages, hospital admission can be avoided. Monitoring blood sugar is essential to prevent ketoacidosis. Students may require permission to leave the classroom to visit the bathroom frequently or may need to have extra fluids to replace fluid volume.

90 Any Questions???

91 Low Blood Sugar “Hypoglycemia”

92 What Is Hypoglycemia or Low Blood Sugar?Sometimes called an insulin reaction Occurs when blood sugar is below the target range (under 70-80) Can be caused by too much insulin, unplanned increased activity, eating too few carbohydrates Happens when the body does not have enough sugar in the blood Teaching Notes: Keeping blood sugar in control is sometimes like playing “limbo”. The student is trying to balance between being too high and touching the stick or too low and ending up on the ground. In diabetes, however, being too low is no laughing matter. Low blood sugar or hypoglycemia has sometimes been called an insulin reaction. Hypoglycemia can come on quickly and must be treated immediately by the person, family, teacher or friends. Early treatment prevents a more serious reaction and possible hospitalization. Hypoglycemia is usually defined as any blood sugar below 70-80, but depends on the age of the person. Some very young or very elderly people may have different blood sugar levels for hypoglycemia which should be defined in the IHP. When the body does not have enough sugar to burn for energy the blood sugar drops too low. It is a challenge for the person with diabetes to keep their blood sugar in balance all of the time. Low blood sugars often occur when there is not a correct balance of insulin, activity and carbohydrates.

93 Lows happen when insulin and blood sugar are out of balance.People without diabetes do not usually get hypoglycemia. When we have enough insulin our body stops releasing insulin automatically. But, people with diabetes have to figure out how much insulin their bodies will need. Teaching Notes: Keeping the blood sugar and insulin in perfect balance is a big challenge for the person with diabetes. Once insulin is injected, it keeps working until it is gone—even if the person’s blood sugar goes too low. The student with diabetes has to figure out exactly how much insulin their body will need when the schedule may vary everyday. One day the person may have PE and the blood sugar will drop too low. The next day the person may be sitting for the day taking tests. One day the blood sugar may be too low and the next day too high when the amount of insulin and carbohydrates are the same.

94 Low blood glucose levels, which can be life-threatening, present the greatest immediate danger to people with diabetes. 1. Hypoglycemia usually can be treated easily and effectively. 2. If not treated promptly, it can lead to unconsciousness and convulsions and can be life threatening. Early recognition of its symptoms and prompt treatment, in accordance with the student’s Diabetes Medical Management Plan, are necessary for preventing severe symptoms that may place the student in danger.

95 Signs and Symptoms of Low Blood SugarHunger Shakiness Dizziness Sweatiness Fast heartbeat Drowsiness Feeling irritable, sad or angry Nervousness Pallor Teaching Notes: Each person reacts to hypoglycemia differently. The student’s most common symptom should be outlined in the IHP. Always encourage the student to let the teacher know if they feel low or different in any way.

96 More Signs and Symptoms of Low Blood SugarsFeeling sleepy Being stubborn Lack of coordination Tingling or numbness of the tongue Personality change Passing out Seizure Teaching Notes: If the reaction is not treated soon enough the student may actually become unconscious and a seizure or convulsion may occur. It is especially important to prevent severe lows in children age 7 or younger because the brain is still growing.

97 Recognizing Low Blood SugarIt is important to recognize a low blood sugar as soon as possible so that it does not progress to a severe reaction. Early signs are caused by the release of the hormone epinephrine. Our bodies make this hormone when we are excited or stressed. Teaching Notes: Early signs of low blood sugar are actually caused by epinephrine or adrenalin. This hormone is released when people are excited and it causes sweating, shakiness, dilated pupils and a rapid heartbeat. Some people are able to recognize symptoms of low blood sugar very early and may have only mild reactions. Others who have had diabetes for several years may have fewer early symptoms. This may be called hypoglycemia unawareness. Others may not be able to detect a small drop from 80 to 60 which occurs gradually , but are able to feel a drop from 180 to 60 which occurs rapidly. Younger children may have difficulty with detecting a low blood sugar and may need to be trained to recognize certain signs. For example, they may need to be reminded about how they felt when they were shaky and the need to tell an adult when they are feeling shaky again. Be sure to praise the child for letting you know if they feel shaky or low, or however they describe it.

98 Frequent Causes of Low Blood SugarMeals that are late or missed Extra exercise or activity An insulin dose which is too high Unplanned changes in school schedule Teaching Notes: Preventing low blood sugars is much better than having to treat the lows. Some frequent causes are related to late meals or snacks or meals too low in carbohydrate. Extra activity or exercise will burn more sugar than usual causing a possible low blood sugar or a need for an extra snack prior to the activity. The insulin dose which is too high for the balance of food and exercise may cause hypoglycemia. Unplanned changes in school schedule could include: Bomb Threats Fire Drills Gas Leaks Lock-down Assemblies Menu Changes 2 hr. Delay/Early Release No Resource Class In-school Detention Standardized Exams Class Treats

99 What To Do When Hypoglycemia OccursIf possible always do a blood sugar check first. If meter is unavailable and the child feels sick, treat as a low. Eat or drink about 15 grams of fast-acting carbohydrate. Wait 15 minutes and test blood sugar. If blood sugar remains lower than 70 or below target for individual child, treat again. Teaching Notes: When someone is having symptoms of hypoglycemia it is important for the child or responsible adult to treat right away. If it is possible and the person is not feeling too bad a blood sugar check should be done first. If the child feels very sick or does not have a meter available, go ahead and treat for hypoglycemia. Have the child eat or drink about 15 grams of carbohydrate. Wait about 15 minutes and test again. If the blood sugar remains below 70 or the target for individual child, treat again with 15 grams of carbohydrate. Once the child’s blood sugar begins returning to normal range, have them eat an extra snack of carbohydrate and protein, such as peanut butter and crackers. If the child is scheduled to eat a meal or snack within 30 minutes it would not be necessary to eat the extra protein and carbohydrate.

100 Hypoglycemia Busters 2-4 glucose tablets4 ounces of apple or orange juice 4-6 ounces of regular soda 2 tablespoons of raisins 3-4 teaspoons of sugar or syrup 1 cup of low fat milk 1 tube of cake gel Teaching Notes: A person with diabetes needs to have something containing sugar with them at all times to treat hypoglycemia. There are many options available which contain about grams of carbohydrate. Glucose tablets are available which each contain 4-5 grams of carbohydrate. Children younger than 5 may actually need 2 tablets while a child over 10 may need 4 tablets. It would be important to consult the IHP for further information for an individual child. A juice box of 4 ounces or a small box of raisins would be helpful when the child is away from home. About one-half of a can of regular soda would also be appropriate. Candy is also a possible choice but may be too tempting for the child or may be taken by other children. There are commercial products which come in containers similar to toothpaste and contain about 15 grams of carbohydrate. A tube of cake gel which is available at the grocery store is convenient and would also work well. After taking in the 15 grams of carbohydrate it is necessary to wait at least 10 before eating solid foods, such as peanut butter and crackers. This will allow the sugar to be absorbed more quickly.

101 Catch Low Blood Sugar EarlyBe alert for any symptoms and times when a low blood sugar is likely to occur. Test blood sugar if there is any doubt. Fast acting carbohydrate or sugar should always be available. Treat low blood sugar promptly or it can turn into severe hypoglycemia. Teaching Notes: The best way to avoid severe hypoglycemia is to catch low blood sugar early. The child may need to be reminded to check their blood sugar or may need assistance with the treatment. . Since each person reacts to hypoglycemia differently it is important to talk to the child or their parents to determine how this child usually responds. Sometimes another person may notice some symptoms, such as personality changes, before the child does. Testing the blood sugar is always necessary when there is any doubt. The child should always keep glucose tablets or carbohydrate containing foods with them at all times. There are certain times when hypoglycemia is more likely, such as during exercise. The longer the exercise the more important it is to watch for symptoms of low blood sugar. If the exercise is longer than an hour, it is necessary to take a short break to check blood sugar and to eat a snack. The blood sugar may be lower for up to 24 hours after strenuous exercise. Always have a responsible adult with the child and do not let the child leave the classroom alone either to check for a low or seek treatment for a low. .

102 Treating Severe HypoglycemiaWhen severe hypoglycemia occurs, not enough sugar is in the brain. The student may lose consciousness and/or have convulsions. At this time the student will need the assistance of someone else. Teaching Notes: Severe hypoglycemia is a medical emergency and occurs when the brain is lacking enough sugar to function. Glucose gel, cake gel, syrup, or honey may be used if the child is still conscious.

103 What Happens when the Child is Unconscious?Drinking soda or eating glucose tablets is not possible and would be dangerous when the child is unconscious . Glucagon injection may then be necessary. Glucagon is a substance or hormone that makes the liver release sugar into the blood stream. Teaching Notes: When someone is unconscious or having a seizure, it is not possible for them to swallow gel, soda, or glucose tablets. Swallowing at this time would be dangerous and could lead to choking or aspiration into the lungs. Never put anything in the mouth of a convulsing person. At this time the person should be placed on their side and glucagon should be administered if it is available for that student. Regardless, call Glucagon is a hormone made in the pancreas like insulin. While insulin makes the blood sugar go down, glucagon makes the liver release sugar into the bloodstream. You will learn more about glucagon in the skills station this afternoon.

104 Using Glucagon Glucagon should be administered promptly if the person is unable to swallow, loses consciousness or becomes combative. Call Glucagon can be stored at room temperature. Glucagon comes in a bottle and needs to be mixed with a diluting solution immediately before using. Glucagon is injected into the front of the thigh or upper arm muscle. Teaching Notes: If glucagon is available it should be administered promptly when the child loses consciousness. It can be stored at room temperature but should not reach temperatures greater than 90 degrees. Glucagon comes in a bottle and needs to mixed with diluting solution immediately before using. Glucagon should be injected into the muscle of the front of the leg or upper arm. If no glucagon is available or no one knows how to use it, an adult should call immediately. A prescription is required for a glucagon kit and the parents should discuss this with their health care provider. Not every student with diabetes will have glucagon available. Remember, the best way to prevent severe lows is to treat mild lows early.

105 In order for school staff to use Glucagon, orders for its use must be included on the child’s IHP or Diabetes Care Plan.

106 Any Questions??