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Commentaries on both new and classic studies of importance for the treatment of diabetes are posted here monthly.

School Management of Type 1 Diabetes in Children

Comment on:
Hellems MA, Clarke WL. Safe at school: a Virginia experience. Diabetes Care. 2007;30;1396-1398.

Background
In 1999 the state of Virginia passed legislation obliging public schools with pupils with Type 1 diabetes to have 2 non-medical staff members trained to support pupils in day-to-day diabetes management. The legislation also protected such staff from liability arising from this type of support. Additionally, a programme of training and appropriate guidelines were developed by the Virginia Board of Nursing, and treatment authorisation from parents and health care staff was required.

This survey examines the experiences of children with Type 1 diabetes attending public schools in central Virginia, USA, in 2005 as seen through the eyes of their parents. It sought to develop a picture of the current availability of school nurses and supporting non-medical staff and examine the frequency of hypoglycaemic events in the school-going population.

Methods and Key Results
This was an anonymous survey of parents whose children with Type 1 diabetes were attending university diabetes clinics and local public schools. Parents were asked about who took responsibility for their child’s care at school, including such tasks as glucose testing, insulin administration, and help with hypoglycaemic events. They were also asked about their child’s experience of hypoglycaemic events during the previous year. Parents of 185 children of all ages from kindergarten through twelfth grade attending 153 public schools responded.

Access to school nursing was substantial, with 95% of children attending schools with a nurse. Most of the remainder had a health clinic assistant employed at their school. However only 69% had a full-time nurse, and duties were also undertaken by teachers and administrators, as well as by cafeteria staff, bus drivers, gym teachers, secretaries, and parents, for a significant minority of students at least some of the time.

A total of 89% of parents reported that insulin needed to be administered during school time, and 79% of students injected their own insulin (41% in elementary grades and 74% in high school). Only 49% had permission to test blood glucose in the classroom.

Episodes of hypoglycaemia during school hours were common, reported by parents of 75% of students, with a median of 5 episodes per student per year. These episodes were treated by medical and other school personnel, but parents of 22% of students at all ages reported that they treated these episodes at school themselves. Around 9% of students have all their diabetes support at school provided by their parents. Only 1 student had a severe hypoglycaemic event requiring glucagon injection, but this was a senior student, and her school only had a part-time school nurse. The authors estimated that approximately 3% of school students with diabetes could experience severe hypoglycaemia in a year.

Conclusions
This study demonstrates that children with Type 1 diabetes can be safely managed at school by a variety of nursing and other school staff with appropriate training and support. It also shows that when this support is not available, parents are obliged to provide both routine and emergency care for their child in school, adding considerably to the burden of the condition on parents and the risks to the children.

The study also demonstrates that support in day-to-day management, and in the management of hypoglycaemic events, is frequently required, and when support is available, it is used at all stages in the child’s life at school, not only in the junior school years.

Virginia is in the happy position of having substantial numbers of school nurses, most of whom are full time, but even here, support from trained non-medical staff is frequently required and is provided without negative incident. Most of the world does not enjoy such luxury, and the advice of the American Diabetes Association’s Safe at School programme is relevant to everyone involved in the care of children with diabetes and can be supported by health care professionals and diabetes associations in every country. This includes:

• Encouraging positive attitudes to children with diabetes to prevent discrimination at school
• Encouraging the employment of school nurses at all levels in the education system
• Removal of legal barriers to the provision of care by non-medical personnel (eg, medical/nursing practitioner acts which forbid such intervention by unqualified personnel)
• Legislation to protect Good Samaritan care for children with diabetes
• Introducing effective training, guidelines, authorisation, and parental consent for non-nursing staff providing care
• Empowerment of children and their parents to reach independent self-management of diabetes at an appropriate age

Reference

American Diabetes Association. Diabetes care in the school and day care setting. Diabetes Care. 2007;30(suppl 1):S66-S73.

This Website Feature is funded by an unrestricted educational grant from Pfizer Inc.

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