It is strongly recommended that all Principals, Teachers, Aides and Office Staff who have contact with a child with diabetes read this information.

Diabetes mellitus (Type 1) is the most common endocrine disease in childhood. It occurs as a result of the body’s auto-immune system destroying the insulin-producing cells in the pancreas. A deficiency of insulin results in a chronic elevation of the blood glucose levels. The biochemical disturbance in the body results in an acidic build up.

Insulin is an essential hormone involved in the metabolism of principally carbohydrate, but it also affects the metabolism of fat and protein. 50% of individuals with Type 1 diabetes are diagnosed under the age of 16 years.

(Type 2 diabetes (non-insulin dependent diabetes generally occurs in adults (usually 40 years plus). It has a strong hereditary factor and may be accelerated by factors such as obesity, hypertension, inactivity, some medications and alcohol. It is treated by weight control, a balanced diet, exercise and maybe the inclusion of tablets or insulin injections. Unlike Type 1 diabetes, omission of insulin injections will not in the short term be fatal.)

Incidence of Type 1 diabetes

The two peak ages of onset are 10 - 12 years and 2 - 3 years.

Prevalence

Approximately 4 per 1000 children under the ages of 16.

There is no known cure for Type 1 diabetes. There is no risk of contracting diabetes from another person with the condition.

The onset of Type 1 diabetes is characterised by:

• weight loss
• excessive thirst
• excessive urination
• lethargy.

Without insulin treatment the disease is life-threatening and would lead to severe dehydration, a build up of acids in the body resulting in coma and death.

Treatment

Treatment of Type 1 diabetes:

• insulin injections may be given 2 – 4 times per day. Younger children usually have 2 injections, one before breakfast and the evening meal. Teenagers may have injections before each meal and bed, they may use an insulin pen to give the injection at school; they should be provided with an appropriate private area to do this if necessary.
• balanced food intake: the food plan is based on a healthy diet, which is low in sugar and fat. It is the same recommended for all children. Meals and snacks should contain a proportion of slowly absorbed carbohydrate such as bread, or grain-based foods, fruit, and yoghurt, and must not be late or missed. Extra food is usually required for extra physical activity. It may be necessary to have food before, during and following the activity if it is prolonged or strenuous. If meals are delayed or not eaten this can lead to an episode of hypoglycaemia
• blood glucose monitoring: children may need to test their blood glucose levels 2 – 6 times a day depending on the circumstances. This is usually done before main meals, or if the student is feeling the symptoms of hypoglycaemia. Often children will not have to test at school, but if they should, it is important to allow them an area for privacy to test if necessary. Monitoring may also be required before or during physical activity
• exercise: physical activity is recommended because it improves fitness and wellbeing, encourages a lifelong, healthy life-style, and should be a normal part of a child’s routine. During exercise, muscles use more glucose for energy and this may cause blood glucose levels to fall during, immediately after or several hours later in the case of prolonged intensive exercise. Therefore it is important to discuss with parents the timing of physical activity so that adjustments can be made to either the child’s insulin dosage or food intake. There are two options to prepare for exercise:
  • Slowly absorbed carbohydrate foods could be eaten half an hour before the activity, as they need time for absorption.
  • Rapidly absorbed foods can be given immediately before or during activity. Parents need to be notified well in advance if the children are doing cross country running or a special swimming program so that adequate preparation can be made.

If a child with diabetes is unwell or experiencing a period of high blood glucose levels, it is not advisable for them to be involved in physical activity as this may make their levels higher. Parents would advise the school if necessary.

Any sporting activity or even a lot of running around during school breaks can contribute to hypoglycaemia (a hypo).

Hypoglycaemia

In primary school,parents will usually provide the school/teacher with a Medical Alert form and poster, about diabetes and the appropriate food for treating a hypo.

In secondary school or college, often the student may not want people to know they have diabetes, and may not provide this information to the school. Posters and Alert Forms are available for all age groups.

A ‘hypo’ is a low blood glucose level. The child may experience the symptoms when their levels are below 3.5 mmol/s, however they may also experience this if their blood glucose levels drop rapidly and levels are higher. If a low blood sugar level is recorded then the child should be treated for a hypo even if they do not display symptoms of a low level.

Hypoglycaemia is the most frequent acute complication of Type 1 diabetes. All children treated with insulin are at risk of experiencing mild to moderate episodes of hypos. Severe episodes are infrequent but they are the most anxiety-promoting features of diabetes for both children and their parents.

Causes of hypos:

• a missed or delayed meal or snack, or a meal containing insufficient carbohydrate (starchy foods)
• extra physical activity without sufficient carbohydrate being eaten
• excessive quantity of insulin being injected
• other causes may be emotional or sometimes occur for no apparent reason.

How to recognise a hypo

The child who has been behaving normally may within 10 – 20 minutes present with any of the following symptoms:

• look pale
• sweaty/cold clammy skin
• weakness/shakiness
• dizziness
• headache/nausea
• hunger/ravenous
• mood changes
• lack of attention/concentration
• irritable/crying
• anxiety
• heart pounding
• visual disturbances
• slurred speech
• drowsiness
• coma.

If symptoms of hypoglycaemia are suspected but there is no meter available, it is important to treat the child as if they are having a hypoglycaemic incident.

Monitoring the blood glucose level is the only positive way to identify a hypo until you become familiar with the child’s symptoms. Children should be encouraged to bring their meter to school and monitor if symptoms of hypo are occurring regularly.

Procedure

If you suspect the child is experiencing a low blood sugar level (hypo) encourage them to test their blood sugar level and if the level is < 3.5 mmols or close to this level, then treat for a hypo.

Treat immediately with one of the following refined carbohydrate foods:

• 2 - 3 glucose tablets (BD or BM brand)
• 2 - 3 teaspoons of liquid glucose, honey or sugar
• 3 - 4 glucose jelly beans (large ones)
• 5 - 7 jelly beans or 2 - 3 barley sugars (do not give hard lollies to young children as they may choke)
• 125 ml of fruit juice/fruit box or half a can of ordinary cordial (not diet cordial).

Note: The smaller quantities of food are required for kindergarten child or small infant school child.

follow
with additional food such as a slice of bread, half a sandwich, or apple, orange, or banana, 5 - 6 Clix plain biscuits or 2 sweet biscuits. If close to a mealtime, give the meal immediately.

repeat
glucose treatment in 10 minutes if the child does not improve. Never leave the child by itself until the child improves. The child may require encouragement to take the food or drink if levels are very low.

Upon recovery from a mild to moderate hypo (which may take 10 - 15 minutes), the child should be able to return to their normal activity.

It is important that the teacher notifies the parents about the time of any hypo occurring so that preventative measures can be taken if appropriate ie an adjustment of food intake, activity or insulin dose.

However in the event that the hypo appears to progress and the child is responsive but uncooperative (i.e., behaving in an unusually uncooperative manner), be firm and encourage them to take the glucose or sugar-enriched food or fluids as per the instructions above.

If the child continues to refuse to take food or fluids and becomes more uncooperative, it may be necessary to call emergency assistance and treat for a severe episode of hypoglycaemia. A responsible adult must always stay with the child until their condition improves.

Severe hypoglycaemia

If the child is or becomes drowsy and unable to swallow, lie the child on their side and ensure they have a clear airway.

Do not continue to try to give food as the child may lapse into a coma and fit.

Immediately summon medical help, by contacting an ambulance, the child's medical practitioner or parents.

An injection of Glucagon is required. In normal situations, medical personnel should only administer this injection. In special circumstances a teacher or first aid officer who has been appropriately trained may give the injection (see Section 4).

Hyperglycaemia (high blood glucose level) related to sick days

The student may experience elevated blood glucose levels if they are experiencing a period of poor control, receiving insufficient insulin for their body’s requirements, or if they are unwell.

It is important that the student be allowed to go to the toilet or have extra drinks when necessary.

When a student is experiencing high blood glucose levels the teacher may notice these signs:

• the child constantly needs to go to the toilet and is excessively thirsty
• they may have flushed cheeks, experience abdominal pain and have rapid laboured breathing
• they may have a sweet acetone smell to their breath.

High blood glucose levels can be caused by:

• insufficient insulin
• too much inappropriate food
• common illness or infection eg cold, influenza or gastro-enteritis.

Students with diabetes should never be sent to sick bay alone, or left unattended when feeling unwell.

Vomiting is a danger signal and the child needs to see the medical practitioner urgently. The parents must be immediately notified regarding the child’s condition. If unable to contact them it would be advisable to contact their medical practitioner or the nearest diabetes unit.

If unable to contact the parents, and the child is repeatedly vomiting, a condition known as ketoacidosis may develop. The child can become severely dehydrated. Transfer them by ambulance to hospital if they are repeatedly vomiting.

Occasionally less severe illnesses may simply cause nausea and vomiting.

Food may not be absorbed and, instead of experiencing a high blood glucose level, the child could become hypoglycaemic particularly if they have not long been diagnosed with diabetes.

Cuts and abrasions incurred at school should be treated with mild antiseptic and a dressing if necessary as any infection can have an effect on blood glucose levels.

Normal first aid issues and immunisation

Unless the child with diabetes has some allergy to ointments, dressing tapes, etc. diabetes should not prevent the normal administration of basic first aid measures. There is also no reason for routine immunisation to be withheld.

School excursions

Children with diabetes should join in all school activities. It is important to plan ahead if they are going on a school excursion. If the child is young, it is helpful to ask the parent to accompany the group.

Follow these guidelines:

• timing of meals/snacks: always remember to consider the timing of meals if out of normal school routine
• blood glucose monitoring: ensure that if necessary the child takes their meter with them. This will depend on the nature of the planned activity
• ensure that the teacher or student is able to carry an adequate supply of hypo food or other foods in case of delays, or ensure that there is somewhere to buy food if necessary
• if the child complains of hunger, always allow them to eat, particularly if the excursion involves extra activity.

School camps

School camps enhance self-esteem, are fun, and promote confidence and independence.

It is important that the child with diabetes participates fully in the school curriculum, and attends camps if planned.

For a trouble-free camp ensure the child and their parents are notified in advance about the:

• proposed camp program
• proposed menu.

The student needs to be capable of caring for their diabetes with limited supervision. This will include:

• ability to self inject
• do their own blood glucose monitoring
• recognise and treat low blood glucose levels
• understand their own meal plan and be aware of the need to include extra food if necessary for activity.

If the student is unable to do all of the above then it is important for either a parent or guardian to be asked to accompany them on camp.

On camp, staff need to know about the student's:

• food plan, importance of regular meals and snacks. Ensure that adequate carbohydrate is available at all meals and snacks
• prevention of hypos
• blood glucose testing
• recognising and treating hypos (including the use of Glucagen injection for use in severe hypoglycaemia. See Section 4 about the ruling on the administration of injections)
• sick day management
• notify the nearest medical facility that a child with diabetes is on camp with them in case of emergency
• know when to call for help and have a plan for medical evacuation if necessary.

In general, all staff at camp should be able to identify the child with diabetes and have a basic understanding of treating hypoglycaemia.

The child should contact his/her diabetes team prior to camp to discuss reduction in the insulin dose to compensate for the planned extra physical activity.

The child should ensure that he has adequate supplies of hypo foods, insulin (plus spares in case of breakage), blood glucose monitor, urine testing strips and a Glucagen kit. If refrigeration is not available during the camp, there will need to be a means of keeping supplies cool.

Special events and rewards

Students with diabetes should be able to join in all special events such as birthday celebrations. They can have a small amount of birthday cake and other foods. Where possible, encourage the inclusion of savoury foods in planned festive occasions. The child with diabetes will need to provide low joule soft drinks if necessary.

If teachers use lollies as rewards it puts a lot of unnecessary pressure on a child with diabetes. However if this has been the practice, then giving the child a small lolly and suggesting that this be eaten following a meal would be acceptable. Notify the parents if this is happening regularly.

School examinations

It is usually not until a student is in high school or college that they are involved in examinations.

Due to stress, a student with diabetes may experience elevated levels when preparing for examinations, thus requiring them to urinate more frequently and be very thirsty. They may conversely experience low blood glucose levels.

For these reasons students are encouraged to monitor more frequently during times of stress.

During an exam the student should be able to monitor if necessary, take food into the classroom and be allowed to go to the toilet if required. If they experience extremes of blood glucose levels they should be allowed extra time to complete the examination paper. Extremes of blood glucose levels may also have an effect on their ability to concentrate.

If a mild hypoglycaemic episode is experienced during an exam the student should be allowed extra time. If a severe episode is experienced then the student should be given special consideration.

Note: Fluctuating blood glucose levels can have an effect on the student’s vision and at times, ability to concentrate. If the teacher notices this occurring on a regular basis, they should discuss these perceived difficulties with the student's parents to resolve the situation in an effective manner.