Sending a Child With Type 1 Diabetes to School: A Guide

On Monday, September 10, 2012, we sent my five year old son, Sacha, to his first day at his new school in Minneapolis. It was a big move; he was going on his own, and would be under the care of two wonderful Montessori teachers who had no previous experience with a child with type 1 diabetes. 

 

Last year, when Sacha was four, we lived for a year in Mexico City, and had decided to hire a full-time “shadow” to care for his diabetes. Although we didn’t want to make Sacha feel like he was being singled out for his diabetes, the long school bus rides (anywhere from 30 minutes to three hours), dense traffic, and generalized insecurity suggested that a shadow was safest. Type 1 diabetes, moreover, is relatively rare in Mexico, perhaps for genetic reasons, although there is likely a LOT of under-reporting, poor data collection, and undiagnosed mortality among children with type 1 diabetes. The Mexican school was very supportive, but the teachers were not in a position to test his blood or administer regular insulin shots. The school nurse said she could help, but her office was far from Sacha’s classroom. 

 

When Sacha was three, we’d been living in Ottawa, Canada. He was then on two daily shots of NPH + rapid acting insulin, however – morning and night, meaning that his teachers and caregivers only had to test his blood glucose every few hours, and make sure he ate. Although complicated and anxiety provoking, that task was far easier than what we were now asking his Minneapolis teachers to do: count his carbs, test his BG, and operate his insulin pump.  

 

I had a meeting with his teachers and the school principal shortly before the first day of school. As I walked them through the whole spiel – what type 1 diabetes was, along with carb counting, insulin trajectories, pump operation, glucagon, and the like – I realized, yet again, how complicated this all was to the novice. Three and a half years ago, my wife and I had been introduced to the disease through a two-day teaching session at our Canadian hospital. That had been so much simpler, as Sacha wasn’t then on the pump. Now, we had to somehow transfer all our knowledge about diabetes management to these two lovely teachers in only two hours! 

 

The teachers took it all in stride, although I could see that they were having a hard time internalizing it all. Over the weekend, the principal sent me a note, asking for a detailed sheet of instructions and “flow chart” instructing the teachers what to do at each stage of the process, including each button press on the pump and BG meter. She even asked for pictures of the screens at each stage, which I didn’t have. 

 

Sunday night, I sat down at the computer, and tried to pour all our knowledge into a comprehensible memo, reproduced below. If you had to tell someone who knew absolutely NOTHING about type 1 diabetes how to mange it, how would you do it? Now, imagine that it’s not for you, but for your five year old child, who still can’t alert adults if he’s low, and can’t fully articulate his needs and feelings. What a task. 

 

Thankfully, the first few days of school seemed to have gone quite well. On Monday, both of Sacha’s teachers called me at different times of the day, asking about dosing, testing, and eating. On Tuesday, they didn’t call at all; incredible. 

 

Thank you so much, teachers and staff at the Lake Country Montessori School in Minneapolis; you are wonderful. You have my little pancreas-impaired boy in your hands, and you are willing to jump right in and do it. I will always be grateful. 

 

Sacha Naughton-Ron’s School Diabetes Management Plan

September 9, 2012

 

General guidelines

1. Target Blood Glucose Range: Sacha’s target blood glucose (BG) is 120-180.
2. The basal/bolus system: Sacha’s insulin pump drips small doses of insulin into his body every hour (his “basal” dose). This basal dose is supplemented each time he eats, and when his BG is high, with an extra dose of insulin (his “bolus” dose).
3. Insulin pump: Sacha is using an Animas One Touch Ping insulin pump, with a Detach metal infusion set. There is a tech support number on the pump, along with the pump’s serial number. Animas tech support is excellent.
4. Pump devices: Sacha wears his pump on a belt; a plastic tube connects the pump to his body, and infuses him with insulin through a needle placed in his body (the infusion set).
5. BG Meter and Remote Control: We test Sacha’s blood, and administer insulin doses, though a device that doubles as BG meter and pump remote control. If this device is lost or malfunctions, doses can be administered directly from the pump. You will have a backup BG meter in the class with you.
6. Food/drink consumption: All food and drink with carbohydrates (“carbs”) must be counted prior to being consumed, and Sacha must receive an appropriate dose of insulin just prior to, or just after, eating/drinking.
   1. What has carbs? All food and drink except plain water, soda water (with no additives), cheese, meat, vegetables (not starches), fats, and nuts. 
   2. Carb counting: 90% of Sacha’s food/drink will be from home, and we will weigh and count all those items ahead of time. We will put a note in his lunch bag with the carb count for each food item. If he is going to eat an unplanned meal at school (eg birthday party), please weigh the food, calculate the total carbs, subtract the fiber, and dose him for the resulting number. For packaged foods, you can find the carb content on the label: look at the portion size and the carb count, subtract the fiber, make sure he eats the right portion, and dose him accordingly.
7. Blood testing is done at the following times:
   1. Before eating
   2. Three hours after eating
   3. Before exercise (eg, Phys. Ed)
   4. During a temper tantrum or other manifestation of extreme emotion
   5. If Sacha complains of being “very hungry”
   6. Whenever you have any concerns or doubts.

 

Blood Glucose (BG) Testing Procedure:

1. Wash your hands.
2. Wash Sacha’s hands, or clean his finger with an alcohol wipe.
3. Crack the lancing device open.
4. Place a lancet in the lancing device, and remove the plastic cap.
5. Close the lancing device, and cock it. (Wait to hear the “click).
6. Adjust the depth of the lancing device to the middle/upper range.
7. Open the BG test strip box, and take out one strip. Immediately thereafter, close the box, as the strips will otherwise spoil.
8. Place the strip in the BG meter, with the “piano keys” entering into the device.
9. Device will turn on.
10. Press the lancing device firmly against the pad of Sacha’s finger, towards one of the sides of the pad.
11. Press the lancing button.
12. Blood drop should appear. If hands are very cold, or if lancing was not deep enough, you may need to repeat. You can point the finger downwards, and gently “milk” the finger to get a small drop of blood.
13. Place the tip of the BG test strip against the drop of blood; the strip should “suck” the blood in.
14. Meter will count down five seconds, and beep when the BG test is completed.
15. If there was insufficient blood, or if you placed the test strip in incorrectly, you will receive an “error” message. Redo.
16. Meter will automatically record the number for future data collection.
17. For insulin-dosing purposes, meter will retain the BG number as “current BG” for 15 minutes.

 

Procedure for giving insulin at meals (giving a “bolus)

1. Calculate the carb count of the food portion he is about to eat. You may want to verify with him beforehand how much he intends to eat.
2. Test Sacha’s BG just prior to eating.
3. When BG number appears on screen, press “OK.”
4. Use arrow keys to place cursor on “ezCarb.” Press “OK.”
5. Cursor will be on the number “0,” under the rubric “Carbs.”
6. Using arrow keys, dial in the desired number of carbs. Press “OK.”
7. Cursor should jump to “add BG.” Press “OK.”
8. Cursor should be at the top of the screen, under the rubric “Actual.”
9. Latest BG number should appear at the top of the screen. Press “OK.” If there is no BG, retest, because it has been 15 minutes since last test.
10. Cursor should jump to “Show Result.” Press “OK.”
11. Cursor will jump to dosing number, which will show “0.00.”
12. Using arrow keys, dial in suggested insulin dose listed just above under the rubric, “Total.”
13. Verify that the number you dialed in matches the suggested dose under “Total.” (Have another adult check the number until you are comfortable.)
14. Press “OK.” Cursor should jump to “Go.” Press “OK” again.
15. Insulin pump should now deliver insulin. Sacha should feel a buzz. Verify that he says “feel it!”

 

How insulin works

The insulin begins working 10-15 minutes after being injected.

A dose of rapid-acting insulin (the only kind Sacha uses) disappears from his system within three hours.

The insulin peaks at 1.5 hours.

Sacha’s BG will begin to rise rapidly after eating, and will, under normal circumstances, continue to be elevated until three hours after eating.

If all goes well, his BG will be in the 120-180 range three hours after eating.

More often than not, however, the insulin dose is not perfect.

The only way to know if the bolus was correct is to wait three hours, and then test.

The dose is often “wrong” because of Sacha’s changing bodily patterns (hormones, growth spurts), exercise, heat, cold, excitement, and other factors that we cannot calculate.

We change his insulin-to-carb ratio quite frequently, in coordination with his doctors.

Given the inevitable lack of perfect fit between the current ratio and Sacha’s actual needs, he may have either high blood sugar (hyperglycemia) or low blood sugar (hypoglycemia) 1-5 hours after eating.

If Sacha’s BG is high, you will “correct” with an extra dose of insulin.

If Sacha’s BG is low, you will “correct” with extra food, typically a fast-acting sugar such as juice, or a glucose tablet.  

 

Treating low BG (hypoglycemia)

Low BG is more dangerous than high BG, because a low can quickly lead to seizure, shock, and, within 20-30 minutes, irreversible harm or death. Preventing low BGs, therefore, is your primary concern.

1. If Sacha’s BG is 80-120, monitor more frequently (eg, every hour).
2. If Sacha’s BG is below 80, treat with 13 carbs of juice (one juice box w/straw). Ensure he drinks the entire box. Re-test 15 minutes later to ensure that his BG has risen above 80 (and hopefully above 120). If it hasn’t, give anther box of juice, and retest again in 15 minutes.
3. If Sacha is very low (eg, under 50), and is no longer responding or able to drink juice, and/or is suffering from convulsions:
   1. One teacher calls 911, and says, “diabetic child in hypoglycemic shock,” and then calls parents
   2. Other teacher gives Glucagon injection in Sacha’s thigh muscle
   3. Can try to rub CakeMate into his gums as well.

 

Treating high BG:

High BGs over a prolonged period (months & years) will lead to organ damage and other health problems.

Very high BGs over multiple hours/days can lead to diabetic shock (ketoacidosis), a life threatening condition. This risk takes quite a few hours to develop, however, and is far slower than the risks posed by very low BGs.

When Sacha’s BG is high, you will give him a “correction” to bring it down.  As always, however, the risk is that the correction will “over-correct,” and cause a low. The insulin pump takes multiple factors into consideration, including “insulin on board,” and gives a suggested correction dose. However, the meter does not know if Sacha is about to engage in exercise. For exercise, see below.

1. When to correct: If Sacha’s BG is > 180 and he is NOT about to engage in recess/exercise, you will give an insulin correction as per the pump’s suggestion.
2. If Sacha is about to go to recess/exercise and his BG is 180-220, do NOT correct. His BG is likely to come down during exercise.
3. If Sacha is about to go to recess/exercise and his BG is >220, give him a correction, and then re-test after every hour of exercise.
4. 4.   How to give a correction:
5. You will have just tested his BG, so his “actual BG” number should be on the device’s screen. Press: “OK.”
6. Using arrow keys, place cursor on “Bolus.” Press “OK.”
7. Using arrow keys, place cursor on “ezBG.” Press “OK.”
8. Sacha’s most recent BG should appear in the window. If not, re-test, and start again.  
9. With cursor on actual BG number, press “OK.”
10. Cursor should jump to “Show Result.” Press “OK.”
11. Meter will offer a suggested dose under the “Total” rubric.
12. Using the arrow keys, dial in the suggested dose. (Double check with another adult until you feel comfortable with the procedure.) Press “OK.”
13. Cursor will jump to “Go.” Press “OK.”
14. Pump on Sacha’s belt will buzz; ensure that he says, “Feel it!”

 

If BG stays high

If you administer a correction, and BG does not come down after two hours, call parents. The pump may be malfunctioning.

 

Pump Problems:

If the infusion set is pulled out of Sacha’s body for some reason, call us; we will come and replace. 

If the infusion set starts to hurt, wait two minutes. If it is still hurting intensely, pull the needle out (you will have to peel back the transparent plastic, and then peel off the white sticky tape, and pull out the needle).

Call us; we will come immediately and replace the infusion set.

 

Suggested Daily Schedule

 

09:00: Sacha arrives at school, and is tested just prior to entering school. If he is low, parents will treat; if he is high, parents will perform a “correction” prior to him entering the school.

10:30: Snack time: If carbs are going to be consumed, test BG, and dose as per above. If no carbs, no need to test.

12:00: Lunch: test BG, and dose as per above. 

1:20: Test BG at end of recess. It should be elevated, because lunch was eaten a short time ago, and insulin hasn’t peaked yet. IF BG is <180, this may be a sign that his BG will be heading down more rapidly in the next hour; re-rest in an hour.

 3:00: This is three hours after lunch. Test BG, and correct if necessary.