Diabetes in SchoolsDONCASTER AND BASSETLAW PAEDIATRIC DIABETES TEAM

Housekeeping

Fire exits

Toilets

Water fountain

Please turn mobile phones on to silent

We are happy to email a copy of the presentation to you for your personal use

Welcome!

Agenda

Registration/Arrival

Diabetes in School Management presentation

Comfort break

Workshops

1. Blood glucose monitoring & freestyle Libre

2. Supervising and giving injection technique including insulin pumps

3. Carbohydrate counting

Questions, evalution and close

Aims of the sessions

Legislation – what is the responsibilities of the Schools

Diabetes – Type 1 & 2

Recognising signs of Diabetes

Managing Type 1 Diabetes in School1. Blood glucose levels- testing & monitoring

2. Food & Exercise

3. School trips & residential

4. Carbohydrate counting

5. Insulin administration – pens and pumps

6. Continuous Glucose Monitoring

Don’t panic!!!

TODAY IS AN INTRODUCTION TO DIABETES MANAGEMENT IN

SCHOOL

You will need to have practical experience to develop your confidence and skills

We suggest you work with people who have been responsible for Diabetes

management in School and allow them to supervise until all staff are confident

Legislation

Department of Education (2014)

‘Supporting pupils at school with medical conditions’

Statutory guidance for governing bodies of maintained schools and proprietors of academies in England.

‘Pupils in School with medical conditions should be properly supported so that they have full access to education, including School trips and physical education’

Why are we here?

There are about 31,500 children and young people with Diabetes in England

Our team cares for approximately 240 children and young people across

Doncaster and Bassetlaw

There has been a increase in the incidents of diabetes in children under 5

years old

This has significant implications for families, the early years settings and

Schools

Dr Anuja Natarajan

Consultant PaediatricianDr Razia Petkar

Consultant Paediatrician

Lisa Whinfrey

Paediatric Diabetes

Administrator

Debbie North

Paediatric Diabetes

Specialist Nurse

Debbie Davidson

Paediatric Diabetes

Nurse

Claire Dove

Paediatric Diabetes

Specialist Nurse

Sam Garbutt

Paediatric Diabetes

Specialist Nurse

Dr Nikki McCloud

Clinical Psychologist

Dr Sarah Banbury

Clinical PsychologistAnne Gilliead

Paediatric Health Care Assistant

Natalie Wilson

Paediatric Diabetes

Dietitian

Karen Darwin

Paediatric Diabetes

Nurse

What is Diabetes?

Diabetes is life-long condition – there is currently no cure

In diabetes the level of glucose (sugar) in your blood goes

too high because the body is unable to convert the glucose

into energy to be used in the body

There are two main types of diabetes – Type 1 and Type 2

There are also other rarer forms such as MODY and other

genetic forms

Type 2 Diabetes – the facts

Develops when the body makes insulin but cannot utilise it

properly

Is often linked to being overweight, but not exclusively

The prevalence of Type 2 diabetes is increasing in children

as it is in adults. It still only make up 4% of children with

diabetes.

1st line treatment is diet but often oral medications are

needed and in some case insulin is included

Blood glucose testing is needed whilst at School

Type 1 Diabetes – the facts

Typically developed as a child/young adult. 97% of children with diabetes

Type 1 is an auto-immune condition & NOT caused by eating too much

sugary or fatty food or an inactive lifestyle

Failure of insulin making cells in the pancreas to produce any Insulin

From diagnosis, the child or young person will need to give Insulin

Insulin will need to be replaced by injection or a Insulin pump for the rest of

the individual’s life.

What does Insulin do?

Insulin is an essential hormone that regulates the body’s blood glucose.

Without insulin, the glucose sits in the blood stream and builds up to

dangerous levels

It acts as a ‘key’, opening the doors of the body’s cells to allow the glucose to

move from the blood stream into the cells to be used as fuel for all our daily

activities

WHAT IS TYPE 1

DIABETESHTTPS://WWW.DIABETES.ORG.UK/DIABETES-THE-BASICS

Recognising Type 1 Diabetes – signs and

symptoms

Tired

Thirst

Toilet

Thinner

Other symptoms include poor concentration and blurred vision.

It is often School staff that pick up on these symptoms

If you have any concerns please contact parents

What is needed in schools

Blood Glucose Levels

Above 10.9 mmols

Action needed

High Blood Glucose levels

HYPERGLYCAEMIA (HYPER)

Normal Blood Glucose Level

Low Blood Glucose levels

HYPOGLYAEMIA (HYPO)

Between

4 -9 mmols

Below 4mmols

Action needed

Acceptable Blood Glucose Levels

Pre Meal – Blood glucose between 4 and 7mmols

- 7-8am, 12pm, 5-6pm

Post Meal – Blood glucose between 6 and 9mmols

- 10am, 2pm, 7-8pm

Bed time glucose range

- Between 5 and 7mmols

Hypoglycaemia – BG below 4 mmols

Signs and Symptoms

• Quiet

• Hungry

• Dark/sunken eyes

• Dizzy

• Pale

• Sweaty

• Shaky

• Uncoordinated

• Bad temper

• Tired

Hypoglycaemia can come on very quickly

Why monitor Blood Glucose in School?

Long-term effects of Hypoglycaemia’s (low BG’S)

Poor concentration

Reduced educational performance – hypos affect the areas

of the brain responsible for memory, language and attention

Hypoglycaemia leading to seizures can result in a lower IQ

Hypoglycaemia - causes

Meal or snack not completed or dropped on the floor!

Too much insulin

A missed or delayed meal or snack

Exercise

Very hot or very cold weather.

Illness

Alcohol

How to treat a Hypo

Step 1

Give 12-15g of quick-acting sugar e.g

• Glucotabs

• Glucojuice

• A spoonful of jam/honey or sugar

Step 2

Re-check blood glucose level after 15

minutes then;

If still below 4mmols – repeat step 1

If BG above 4mmols, consider

whether a snack is required

This will be documented in the child’s

school healthcare plan.

GluaGen Hypo Kit

When to use?

When the child is unresponsive/unconscious or is unsafe to swallow – they maybe having a seizure

Glucagon is a hormone that kicks starts the liver to release glucose.

Stored in the fridge prolongs the expiry date, once taken out of the fridge it must be used within 18 months.

Contents needs to be mixed. Instructions are inside the box. It is injected into thigh/buttock

Children over 8 years old need the entire mixed contents of the vial.

Children under 8 years need half the mixed contents of the vial.

Hyperglycaemia – BG above 11mmols

Signs and symptoms

Thirst

Frequently need the toilet

Nausea

Stomach ache

Headache

Laboured breathing

Hyperglycaemia - treatment

Treatment is extra insulin BUT this must be done safely:

If it is meal time a correction dose MUST be given as per meter or child’s care plan

A child MUST check for blood ketones (if 2nd consecutive high readings). If ketones

present (>0.6) ring parents for advice and follow sick day rules

Child should be encouraged to drink water / no added sugar squash ½ - 1 glass/hour

Child should be allowed to go to the toilet as needed

Discussion may be needed with a parent / carer over the phone or the child may need

to go home

Long-term impact of Hyperglycaemia

Poor cognitive function - more time on task

Reduced memory

Poor motor control

Diminished verbal intelligence

Reduced attention span

Impacts on planning, organisation, exams and independent thinking tasks (particularly in adolescence)

Insulin administration

Insulin Pen Devices

Insulin is given by injection, at least four

times per day. One injection of long acting

insulin and an injection of rapid acting

insulin with carbohydrates

Insulin Pump Therapy

Insulin is delivered continuously via the

pump through a 6mm fine plastic

cannula. Additional insulin is then

programmed to be given with

carbohydrates

Multiple Daily Dose – Pen Therapy

There are two types of insulin that the children need to take:

Long-acting insulin (given once a day)

E.G. Tresiba/Levemir/Lantus

Quick-acting insulin (given when eating carbohydrates)

E.G. Novorapid/Humalog/FIASP

Insulin Pump Therapy

• Small pager size device

• Continually delivers insulin through a small tube placed just

under the skin (cannula)

• Aim of the pump is to mimic the pancreas

BASAL Insulin• Pre-set rates

• Small, frequent pulses of

insulin

• To keep BG levels stable

when not eating

BOLUS Insulin• Covers all food eaten

• Check blood glucose before

eating

• Enter BG level and carb

amount into pump

Injection sites

Giving insulin in Schools

We suggest that two members of staff be present to check insulin dose

and supervise when insulin given

Ideally insulin should be given directly before food but this is not always

practical, see the child’s individual medical care plan

School staff CANNOT decide on the dose of insulin. Staff must follow the

child’s BG meter or as per care plan

Insulin in current use should be stored at room temperature as per the

Schools policy for storage of medicines (This will last 28 days).

School Healthcare Plans

Contain information such as:

o Contact information

o Info about diabetes

o Insulin type and dose

o Consent to administer medication

o Support the young person needs

o Emergency actions

Signed by parents (and young person when relevant), professionals and school staff

School must ensure this is updated with parents & young person at least annually

How much Insulin to give?

All our children and young people are taught to count carbs and

how much Insulin to give for the carbs

Insulin is worked out on a ratio of units per grams of carbs.

e.g. 1 unit of Insulin per 10 grams

Each child will have a different ratio and often will have a different

ratio at different times of the day

Don’t worry, most children have a meter that works the ratio out for

them!

Why is Carb Counting important?

• Without diabetes – blood glucose rises, insulin released by pancreas to match this.

• With type 1 diabetes – blood glucose rises, need to inject correct amount of insulin to cover this rise.

• Carb counting = predicting blood glucose to calculate insulin required

Foods containing carbohydrates

Carbs and Cals

• Given at diagnosis

• Selection of portion sizes with carb

values

• Select portion size most similar

• Available for smartphones – more portable

• Larger selection of foods, including brands

• Ability to save favourites

Label Reading

• If weighing foods – per 100g

• Per pack – e.g crisps, yoghurt pots

• Per serving – used in cereals, pasta etc.

• Serving sizes – be aware that this may be significantly different to actual

portion size

Carb-free Snacks

Vegetables – e.g. carrot, cucumber & pepper sticks, tomatoes, lettuce

Sugar free jelly

Cheese –hard cheese, cream cheese, cheese strings, Dairyleatriangles

Plain meat – e.g. chicken, ham, beef, pork

Plain fish – e.g. tuna, salmon, sardines

Nuts – NOT honey roasted nuts

Seeds – e.g. sunflower, pumpkin

Eggs – which can be made into omelettes using other carbohydrate free foods e.g. ham & cheese omelette

Sugar free ice pops

No added sugar squash

Diet fizzy drinks

Exercise

Activity may cause blood glucose to drop too low as:

Exercise makes muscles more sensitive to insulin

Longer lasting activity uses up carbohydrate stores

Activity may cause the blood glucose to rise if:

They don’t have enough insulin in their body

Short bursts of activity (adrenaline type effect for short time)

If Blood glucose high at start of activity

Exercise

Activity can affect glucose levels both during and after activity so manage by:

Planning with parents/diabetes nurse

Regular blood glucose checks

Insulin and snacks/meals can be adjusted to keep blood glucose stable

Ensure PE staff, swimming teacher is aware of diabetes and possibility of hypos

School/Residential trips

Named nurse will provide a plan for the parents/carers;

Arrival/departure times – transport type

Planned activities timetable

Meal Plans / catering arrangements

Sleeping arrangements

Consider risk assessment and take appropriate action

Key workers to support child/young person and parent/carer before and

during trip

Additional training for overnight care

Ensure you have emergency contact details

Psychological impact of diagnosis of Type 1

Diabetes

Type 1 diabetes can have a significant impact on the child/young person and their family. It is akin to the grieving process in the first year after

diagnosis.

Some of the issues that can arise are:

Low self esteem and anger outbursts

Difficulties with friendships/bullying

Eating disorders

Family conflict

Anxiety/Depression

Diabetes burnout

Difficulties with Academic abilities This list is not exhaustive

VIDEOHTTPS://WWW.YOUTUBE.COM/WATCH?V=VK8CQP76CEM

Continous Glucose Monitoring

• Continually monitors bloods glucose day and night

• Typically reads blood glucose every 5 minutes

• Tracks dropping or rising blood glucose levels

• Alarms can be set to highlight blood glucose levels when outside of

range

• Blood glucose readings with a meter still needed but CGM can give

additional information to improve diabetes control

• Can be linked with insulin pump and data can be sent to up to 5

different phones

Continous Glucose Monitoring (CGM)

DEXCOM G6 MEDTRONIC 640G

Alarms can be set to alert the user to blood

glucose fluctuations.

Can also be linked with the pump and can

suspend insulin when child is going

hypoglycaemic.

Small device worn in the stomach.

Takes glucose reading from fluid around

cells.

More accurate than the libre and can be

used to titrate insulin

Libre Freestyle scanner

Flash monitoring of interstitial glucose

Time lag

One second scan

Still need to blood test if hypoglycaemic or hyperglycaemic

Still need to blood test at lunchtime and input carbs into BG

meter

Retains 8 hours of data

NHS funded under strict supervision

All staff should be aware that they have young people in their classroom who have diabetes

Never send a young person out of the classroom when hypo, treat wherever they are

All staff carrying out diabetes care should have been trained by the diabetes team, keep your

hand in with blood tests and injections

Don’t single them out in class because of their diabetes

Ensure there is a plan for all PE and after school clubs

Young people should never be excluded from a school trip or sports event due to their diabetes

NB Blood glucose meters look like mobile phones, please ensure it is a phone before you

challenge them

Young people with diabetes are expected to attend clinic a minimum of 4 times a year with

additional sessions needed for education/poor control

Further reading

Digibete www.digibete.org

Diabetes UK www.diabetes.org.uk

JDRF https://jdrf.org.uk

Your diabetes team available Monday –Friday 9am -5pm

Thank you for listening!

Any questions