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CHILDREN WITH DIABETES
An Interview with Stephen W. Ponder, MD, FAAP, CDE
Source and Credit www.SchoolNurse.com

Dr. Ponder is a pediatric endocrinologist and Director of the Childrenís Diabetes and Endocrine Center of South Texas, located at Driscoll Childrenís Hospital in Corpus Christi, Texas. Dr. Ponder has directed the Texas Lions Camp for Children with Diabetes. He has produced diabetes educational videos for families and is developing PC-based diabetes educational tools for use in the Center and eventually in homes. As a certified diabetes educator, he emphasizes the power of knowledge in making sound self-care choices in his clinical practice. His own 36 years with type 1 diabetes, managed with an insulin pump, help him work with youth struggling to cope with diabetes.

SHA: What types of diabetes are of concern to the school age population?

SWP: Until recently, type 1 diabetes was the only form of diabetes most school personnel needed to be familiar with. However, the dramatic rise of type 2 diabetes (formerly called adult onset diabetes) in children and adolescents over the past decade has led to a new paradigm. Virtually any type of diabetes can affect the school age child or teen. Each type of diabetes carries slightly different considerations. For example, the child with type 1 diabetes (formerly termed juvenile onset diabetes) would be expected to require insulin by injection for the rest of his/her life. In addition, hypoglycemia (low blood sugar) is a constant concern and demands the vigilance of all personnel involved with the student with diabetes.

On the other hand, children with type 2 diabetes are typically overweight and are often treated with oral agents instead of insulin, although insulin may be used in the child with type 2 diabetes. Proper control of diabetes with an emphasis on exercise and changing nutritional habits are cornerstone therapies of type 2 diabetes of any age, but are even more relevant to the child with type 2 diabetes, who is often faced with significant excess weight and all its consequences on health and well being.

SHA: What is the latest research on the causes of diabetes in children and youth?

SWP: The various types of diabetes have different root causes. Type 1 diabetes is the end result of an autoimmune mediated destruction of insulin production at its source. For still poorly understood reasons, the immune system mistakenly recognizes insulin producing cells (called beta cells) as foreign. This precipitates a focused, chronic immunologic attack destroying the bodyís sole source of insulin. There is a genetic susceptibility which places a person at risk for developing autoimmunity, but a variety of environmental factors have been implicated in the initiation and maintenance of the autoimmune attack against the beta cells.

Without insulin to permit entry of glucose into body tissues, blood sugar levels rise to abnormally high levels and symptoms of diabetes appear. The absolute lack or deficiency of insulin underscores the fact that only insulin therapy by injection or a pump constitutes effective treatment. Oral medications do little or nothing to improve blood sugar control and are actually dangerous to a child for whom insulin is the only proper therapy.

Type 2 diabetes has a different pathophysiology. Insulin supply (from the pancreas) cannot keep up with insulin demand. The lack of effective insulin action results in increased glucose output from the liver and failure of skeletal muscle glucose uptake. The end result is high blood sugar. So the cause of type 2 diabetes is a combined effect of insulin resistance and insulin secretory failure. Insulin resistance has a genetic basis which can be worsened by obesity and relative inactivity. It remains a mystery why insulin secretory failure can strike at vastly different ages.

SHA: What are the key components of care for a child with type 1 diabetes?

SWP: The person with diabetes who knows the most, lives the longest. While the self care skills of exercise, proper nutrition and medication have been the tools to maintain adequate control of the blood sugar level, they ultimately rest on a foundation of diabetes self management education. The child with diabetes is the center of all efforts and ultimately determines their success or failure. The family and school play invaluable roles in any management plan. The student with diabetes constantly makes self care decisions each day. These choices can maintain or undermine overall control. One self care skill performed in the school is blood glucose monitoring. The student must be allowed to perform this vital task in order for proper self care choices to be made (e.g., insulin dosing). The information gathered is critical to long term control since it provides feedback to the studentís medical team to guide any necessary therapeutic adjustments.

SHA: What should a school care plan include and who should be involved?

SWP: Roles and responsibilities are the order of the day. These are defined by the age and maturity of the student, coupled with their level of day to day involvement in making management decisions at home. At a minimum, each secondary school teacher should be aware that a child with diabetes is in his/her classroom. Primary school teachers should be more familiar with the studentís individual needs and should meet with the parents and school nurse (if available). The rights of the student should be clear. These include the right to free access to water and a bathroom, the right to perform blood sugar testing in an appropriate location, the right to consume snacks at the appropriate times, and the right to treat low blood sugar whenever it occurs.

SHA: How can schools plan for safe care and involve the appropriate staff while maintaining student privacy and confidentiality of information?

SWP: This starts with a meeting with the family, teacher(s), school nurse and perhaps a member of the childís diabetes care team. The student may need a quiet, supervised location to perform his/her self care skills with no disruption. Some students may waive this right to privacy from time to time depending on circumstances. Nevertheless, if the child feels self conscious, he/she should have access to a setting conducive to proper self care.

SHA: What are the meal and snack guidelines during school and after- school programs?

SWP: Meals and snacks with proper timing are integral to optimal blood sugar control. The meal plan is determined by the physician in collaboration with a dietitian. The parents often convey this information to school personnel. The timing of snacks is intended to coincide with times of peak insulin activity. Furthermore, the childís insulin dose is "balanced" with a certain expectation in regards to food. The macronutrient most important to maintaining blood glucose levels is carbohydrate. Approximately 95-100% of ingested carbohydrate is converted into glucose by two hours post ingestion. The meal plan of the student with diabetes takes this into account and "prescribes" a specific quantity of carbohydrate to be consumed each day, apportioned between 3 meals and 2-3 snacks. Parents are encouraged to pack snacks for the student or guide the studentís selection of suitable snacks and meals. After-school program personnel should ensure the student consumes the afternoon snack. Failure to do so increases the risk of low blood sugar. "Time-released" insulin (by injection) demands certain adjustments with food intake in order to offset the surges of insulin action

Children using the insulin pump have a different paradigm. The timing of meals and snacks are determined by the pump user since insulin is delivered "on demand" by the pump. Children with type 2 diabetes (not on insulin therapy) often have meal plans that limits total fat and calorie intake and may not require between meal snacks.

SHA: What should school staff be expected to do to help young children whose insulin dose is based on counting carbohydrates eaten from the school menu?

SWP: The student should have a good knowledge of carbohydrate counting. Itís not the role of school personnel to assume this duty. However, some students need to properly count the carbohydrates to be eaten in order to administer an insulin dose (by injection or pump). School personnel can assist the student in this process and it should be discussed during the parent-teacher meeting. The school dietitian should be able to provide menus to parents with the estimated serving sizes and carbohydrate content. Providing the family access to school menus, which indicates the amounts of carbohydrates in food items served in the school cafeteria, is extremely useful.

SHA: Are there legal requirements for school food services to accommodate students with diabetes?

SWP: In regards to preparing special foods or meals for the student with diabetes, the answer is no. There are no "forbidden" foods in the meal plan of a person with diabetes. Virtually any food can be incorporated into a meal plan. However, this demands effective communication between school staff, the family and the childís health care provider.

SHA: How can a school handle field trips and class parties?

SWP: The student with diabetes is to be included in all school activities. Adjustments in menus may only require the inclusion of diet colas or access to some form of carbohydrate- free beverage. Even small portions of cake and ice cream can be worked into the meal plan. The key is to plan ahead and notify the parents of upcoming activities and what foods are anticipated. With this information the student and family can make adjustments to participate to the fullest.

For field trips, supplies (testing equipment, insulin and syringes, and a source of fast acting carbohydrate for treatment of low blood sugar) should be brought to allow the student to perform any self care tasks that might be necessary. Short trips of 1-2 hours may only need testing equipment and a source of fast-acting sugar to treat hypoglycemia.

SHA: Some parents want their child to check his/her blood glucose in the classroom but the teacher is uneasy about blood or doesnít want to "upset" classmates or principals think all health procedures belong in the nurses office. What should be considered?

SWP: Possible exposure to blood in the classroom is a concern for teachers, not only for themselves but also between students. The risk of blood borne pathogen exposure is minimal. Current blood sugar testing methods require minute amounts of blood (1-10 microliters) and can be performed on sites other than the fingers ("alternate site" testing). Nevertheless, this should be discussed at the parent-teacher meeting. The right to test is protected by law; the location where the testing is to be performed is subject to school district policy. Middle and high school students who may be required to go to the nurseís office for self care should receive a laminated "nurse hall pass" to avoid unnecessary confrontations with school personnel who are unfamiliar or unaware of the studentís diabetes.

SHA: Should students have to carry their glucometers to school every day? What are the pros and cons of using one school-owned glucometer on all students and staff with diabetes?

SWP: Pros: 1) School nurses can become more competent with one testing method compared to many. 2) There is the opportunity for consistent quality control. 3) If the student has only one meter, it reduces the risk of damage by transporting the meter to and from home and school. Cons: 1) Individual lancing devices are still needed. 2) The family needs to obtain additional sets of strips, perhaps two different types of strips (since each meter uses a different type of strip). 3) Parents might feel uncomfortable that others are "borrowing" from their childís equipment supply. 4) Some insurance companies may not cover the schoolís testing equipment. 5) There is a risk of cross contamination.

There are many brands of meters and each has specific features that make it appealing to the student or their family. Proper meter use requires that periodic quality control be performed with high and low control solutions. Furthermore, alternate site testing can only be performed with certain meters. These factors, plus the risk of blood borne infection, are reasons not to share use a school owned meter. Many children with diabetes have more than one meter at home. Typically, the child will have a dedicated meter for school. On occasion, the family may own only one meter device and may fear risking transporting it to and from school. Students should be individually assessed for the ability to carry their testing kits with them instead of having these items kept in the nurseís office. Current management of diabetes expects students to be able to test multiple times each day. Itís counterproductive to good diabetes management to separate the student from his/her testing equipment.

SHA: What is the minimum expectation for disposing sharps (lancets, needles)? Should students clean glucometers at school?

SWP: Parents should provide a proper sharps container for the school if this is not supplied by the school. A full sharps container should be closed, sealed and disposed of per state sanitation policy. Used test strips can be disposed of in the regular trash and should not be placed in a sharps container. Newer meters use strips which draw blood into the test chamber. Some older devices use optical readers which can become obscured by dried blood or strip holders which are reused. Proper care of these meters following manufacturer guidelines is crucial for accurate results. If the student is competent with this skill, it should be allowed. Otherwise, alternate arrangements for cleaning need to be made. This is another topic for the parent-teacher meeting.

SHA: What are some pointers for scheduling physical education and lunch times, especially in a small school where we donít have much flexibility? How do we minimize episodes of hypoglycemia (low blood sugar)?

SWP: Ideal blood sugar control in diabetes comes from daily balancing food intake with insulin. There is some leeway in the time that a meal must be consumed. It would be best to discuss this at the parent-teacher meeting and possibly include the school counselor, who might restructure the studentís schedule. However, insulin doses by injection are typically taken prior to a meal. This sets up the possibility of a mismatch of too much insulin action with too little food. The end result can be hypoglycemia. In most circumstances, exercise enhances the action of insulin. The duration and intensity of the exercise play key roles in determining the effect on blood sugar levels. Consistency in day-to-day scheduled activities is invaluable to optimal control. Snacks are sometime needed prior to PE, but if PE occurs after a meal adjustments may not be necessary. Diabetes experts recommend testing blood sugar prior to and after any strenuous activity to determine the impact on blood sugar levels. What's the bottom line? Eat on schedule, snack for exercise and monitor blood sugars to monitor overall effectiveness.

SHA: What is a basic plan (or algorithm) for managing low blood sugar- defined as less than 70 mg/dL?

Dr. Ponder: Low blood sugar is a fact of life of any person with type 1 diabetes and many with type 2 diabetes. Recognizing low blood sugar when it occurs is the real challenge for school personnel. Although any symptom can be associated with low blood sugar, signs and symptoms of hypoglycemia should be discussed during the parent-teacher meeting. Common symptoms include pallor, trembling (described as "shakiness"), rapid pulse, sweating. Behavior may change, including unusual sleepiness, slurring of speech, or frank confusion. If hypoglycemia is suspected by signs or symptoms, but no testing equipment is available, school personnel should treat for hypoglycemia. Treatment consists of providing 15 grams of rapidly absorbed carbohydrate. Examples of proper treatment include 4 ounces of fruit juice or 1/3 of a 12 ounce regular cola drink. Eight ounces of sport drink (e.g., Gatorade) is acceptable. Wait 15 minutes and test the childís blood sugar and retreat if blood sugar is below 70 mg/dL. Failure to treat can result in unconsciousness and frank seizure activity. Never send a child with suspected hypoglycemia alone to the school nurseís office. It could be disastrous. The student should be accompanied by an adult.

SHA: Whoís responsible for administering glucagon if a child is unconscious or vomiting? How is it administered and what else needs to happen?

SWP: Glucagon is a hormone preparation which induces the release of stored sugar into the circulation. It should only be used in cases of severe hypoglycemia when the person cannot safely take food or drink. Nursing staff should be able to prepare and administer this drug, typically by subcutaneous injection, like insulin. A glucagon kit is easy enough for anyone to administer and requires no specialized training. Ideally, the school should have at least 3 persons capable of administering the injection. None has to be a nurse-- parents do this care. Glucagon is safe; there is virtually no risk of allergic side effects.

Students receive 1 mg. Its effect may not be apparent for up to 10-15 minutes. During this interval, it is appropriate to call 911 or local EMS for severe hypoglycemia, since glucagon alone may not always raise blood sugar levels in some patients.

The child may vomit after a dose of glucagon. Position the child on his/her side to prevent aspiration. When the student regains consciousness and blood sugar is rising, begin feeding carbohydrate foods or beverages.

SHA: If a student has testing supplies at school to check for ketones, what is the typical action plan?

SWP: The current recommendation is to monitor urine (or now blood) for the presence of ketones during any illness or if blood sugar levels exceed 300 mg/dL. If high blood sugar and ketones are present, special guidelines known as "sick day" rules are to be implemented. These guidelines should be part of a studentís care plan and discussed in advance. Written and video materials about care are available.

Generally, children with high blood sugar and ketones need increased water and supplemental insulin with frequent monitoring. The exact amount of supplemental insulin will vary depending on the situation, but generally more, not less, insulin is required. Thus, if ketones are present, fluid intake should be increased and parents should be notified immediately to discuss the need for supplemental insulin. If blood sugar is high but ketones are negative in the urine or blood, then increase sugar-free fluid intake and recheck the blood sugar after two hours. Parents do not need to be notified in this situation. In either case, more frequent testing should be performed until blood sugar levels are back to desirable levels, and ketones are completely cleared from the childís system.

SHA: More students are getting insulin pumps. Who is a good candidate for a pump? What are school nurse responsibilities and campus staff duties? Can the student take full PE wearing a pump? What if the parent doesnít send supplies?

SWP: There has been a surge in the use of insulin pumps in school-age children with diabetes. Age is no longer a primary determinant, but rather attitude and interest in wearing and using the device properly. A supportive family is essential to good pump outcomes. An ability to problem solve is also invaluable. School personnel should have a basic understanding of the pump and how it works. For example, the pump cannot measure blood sugar levels. The pump delivers insulin which is either preprogrammed (the basal rate) or on demand (bolus) by the wearer. School personnel may need to assist a younger student in administering the proper insulin dose whereas the adolescent may be more independent. Pump use does not preclude contact sports. Either the pump or its infusion site can be protected, or the device can be temporarily removed with appropriate precautions. The diabetes care provider can assist in developing a plan for short periods of discontinuation without compromising control.

Failure to provide extra pump supplies for school use can become a major problem if the child begins to develop ketones, or if the infusion site becomes detached from the student. Since ketosis can develop after only a couple of hours off the pump, it will be necessary to call parents immediately so a new site can be inserted. This process takes only a few minutes to perform and can be done by older students but younger ones will need help. Pump issues should be discussed during the parent-teacher conference.

SHA: We hear about type 2 diabetes in younger ages, usually those who are obese. I thought that was the type that older people develop and take pills. What is happening that students are being diagnosed with type 2?

SWP: Type 2 diabetes has reached epidemic proportions in children compared to just 10 years ago. Much of this is associated with the steep increase in childhood obesity. Many children with type 2 diabetes can be managed with oral medications, but others may require insulin therapy to maintain effective control. Exercise and changes in eating habits are vital to improving control and perhaps even allowing temporary discontinuation of insulin therapy, but only with close medical supervision.

Many of the factors predisposing children to weight gain (fast foods, junk foods, less physical activity) all contribute to the rise in type 2 diabetes in children. There is no end in sight unless fundamental changes are made in the daily eating habits and activity schedules of at risk children. All persons can help by lobbying to keep physical education in schools at every level.

SHA: What is Acanthosis Nigricans (AN)? What should the school nurse know about AN?

SWP: Acanthosis nigricans is a dermatologic condition characterized by dark, thickened skin over body parts exposed to constant flexion or friction (e.g., the neck) Acanthosis has been associated with the presence of insulin resistance, the process that provides the foundation for the development of type 2 diabetes in adults and children. Most children with Acanthosis are overweight and AN is but another "risk factor" for the development of type 2 diabetes. Because it is easy to visualize, it is a screening marker in some Texas school districts for the possibility of diabetes. However, less than 1% of children with AN have diabetes at the time of screening. The rest are "at risk" and should be checked medically by their doctor annually for development of diabetes. Currently, there is no formal position statement on what, if any, interventions should be considered other than yearly testing for diabetes. However, many overweight children with AN are hypertensive (high blood pressure) and may have problems such as obstructive sleep apnea. Some adolescent girls with AN have symptoms of Polycystic Ovary Syndrome, including hirsutism, oligomenorrhea, acne, and a masculinized appearance. Any child with AN and obesity should be seen by the primary physician for a medical evaluation for the presence of type 2 diabetes, hypertension, dyslipidemias, liver abnormalities (steatohepatitis), and sleep disturbances ( obstructive sleep apnea).

SHA: What can reduce the risk of developing type 2 diabetes among youth and adults (such as parents and school staff)?

SWP: Weight maintenance and regular physical activity are the keys to type 2 diabetes prevention in any age group. A critical look at the foods served in the school cafeteria, sold at fund raisers and in vending machines can give an insight as to the nature of the problem we face. The nutritional "IQ" of the average student is nil. Schools should implement nutrition education in the curriculum. Given that over 20% of children are overweight, the need for programs that raise awareness and provide solutions should be apparent. School physical education programs which promote daily physical activity should also be encouraged for all students. Although a person inherits a risk for developing type 2 diabetes, but this does not necessarily mean it will be their destiny. If weight is maintained within acceptable norms for age, along with regular physical activity, then all is being done to manage this risk. Medical therapies to prevent type 2 diabetes are on the horizon, but are still under development and investigation.

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