1. Diabetes Care Tasks at School: What Key Personnel Need To Know
After-School Programs, Sports and Camps
The American Diabetes Association’s Diabetes Care Tasks at School: What Key Personnel Need to Know is a training curriculum that consists of PowerPoint modules with corresponding video segments, pre-/post-tests and other helpful resources.
This training is based on and should be used in conjunction with the 2016 “Helping the Student with Diabetes Succeed: A Guide for School Personnel”, a guide developed by the National Diabetes Education Program (NDEP), which is a federally sponsored partnership of the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention and over 200 partner organizations. Training participants should read the NDEP guide prior to this training in order to gain a full understanding of the requirements of appropriate school diabetes care. Participants should have a copy of the guide during this training and for future reference. The guide can be found on the web at
Some key points about the overall training:
Overall objective: The overall goal is to optimize both health and learning for students with diabetes by providing diabetes care training to school personnel about how and when to perform routine and emergency diabetes care tasks for students, under the supervision of a school nurse or another qualified health care professional. Completion of training will help prepare school personnel to perform diabetes care tasks, ensuring that health needs are addressed in times and locations when a nurse is not available.
Rationale: The school nurse, when available, is the most appropriate person in the school setting to provide care for a student with diabetes. However, many schools do not have full-time nurses. Even for schools that do, the nurse may not always be available during the school day, during school-sponsored extra-curricular activities or field trips to assist with routine care and emergency care. Trained school personnel must be available to perform and assist the student with diabetes care tasks.
August 2018

2. Goal: Optimal Student Health and Learning
All program staff members should have basic knowledge of diabetes and know who to contact for help.
This training component was created specifically for school nurses and other qualified health care professionals to train non-medical school personnel.
These components are:
• Diabetes Basics
• Diabetes Medical Management Plan
• Hypoglycemia
• Hyperglycemia
• Blood Glucose Monitoring
• Continuous Glucose Monitoring
• Glucagon Administration
• Insulin Basics
• Insulin by Syringe and Vial
• Insulin by Pen
• Insulin by Pump
• Ketones
• Nutrition and Physical Activity
• After-School Programs, Sports and Camps
• Before- and After- School Care
• Childcare
• Psychosocial Aspects
• Legal Considerations
This unit is After-School Programs, Sports and Camps.

3. Learning Objectives Participants will be able to understand:
Basic components of diabetes care at after-school programs, sports and camps
Hypoglycemia and hyperglycemia
Physical activity guidelines for students with diabetes
Participants will be able to understand:
Basic components of diabetes care at after-school programs, sports and camps
Hypoglycemia and hyperglycemia
Physical activity guidelines for students with diabetes

4. Caring for a Child or Youth with Diabetes at camp
Children, especially young children, are totally dependent on adults
With proper planning and glucose management, children and/or youth with diabetes can and should be allowed to participate in ANY activity
Diabetes Care Plans will vary depending on the after- school activity and the youth’s level of independence
Extra-curricular activities (band, choir, debate, etc.)
Sports
Day- or Overnight- camps
Children, especially young children, are totally dependent on adults. Depending on age and development, some have limited or no communication skills but with proper planning and glucose management, a child with diabetes can and should be allowed to participate in ANY activity. However, treat those with diabetes the same as other participants, except to meet their diabetes needs.
Prior to caring for a child or youth with diabetes, it is vital that the Caregiver has received training on:
Blood glucose management
Insulin administration
Recognizing symptoms of high and low glucose levels
Specific diabetes care plans, directly from the child’s guardians/parents

5. Diabetes Management Constant Juggling – 24/7 Glucose Raising
- Food - Not enough insulin or carbs don’t match insulin provided
- Illness, stress, injury - Side effects from other medications (steroids)
- Too much insulin - Carbohydrates don’t match insulin given or didn’t finish all carbohydrates after providing insulin
- Exercise or activity *
Glucose Raising
Glucose Lowering
Maintaining blood glucose control is a juggling act, 24 hours a day, 7 days a week.
Many variables affect blood glucose.
The key to optimal diabetes control is a careful balance or juggling of food, physical activity, and insulin and/or oral medication.
As a general rule:
Insulin/oral medication and physical activity makes blood glucose levels go down.
Food makes blood glucose levels go up.
Several other factors, such as stress, illness or injury, also can affect blood glucose levels.
* Physical activity generally lowers blood glucose. However, certain activities may raise blood glucose for some students.

6. Routine Diabetes Care Tasks
Before food intake and physical activity and when low or high blood glucose is suspected. Equipment includes blood glucose meter, lancet, lancing device, test strips, CGM (if used).
Blood glucose monitoring
Before or after food intake and to treat high blood glucose. Equipment includes insulin, delivery device (pump, pen, syringe).
Insulin administration
Snacks and meals provided and/or monitored to ensure food consumption is in accordance with insulin dosing. Equipment includes food, carbohydrate information.
Food intake scheduling and monitoring
Awareness that unusual behaviors after physical activity or insulin may signify hypoglycemia. Equipment includes quick-acting carbohydrates and glucagon.
Hypoglycemia treatment
Awareness that increased urination or drinking may signify hyperglycemia. Equipment includes water or other non-carbohydrate-containing liquid, insulin.
Hyperglycemia treatment
Check ketones if repeated blood glucose tests show above target range or if the child is ill. Equipment includes urine or blood ketone strips, ketone monitor.
Ketone monitoring
Diabetes care tasks prescribed by the DMMP include:
Blood glucose monitoring, including target glucose, the frequency and circumstances of checking and the use of CGM systems
Insulin administration, including doses, timing, insulin storage and the use of the prescribed insulin delivery device
Symptoms and treatment of hypoglycemia, including glucagon
Symptoms and treatment of hyperglycemia, including ketone checks
Training modules are available for each diabetes care task for further review.

7. Diabetes Management Routine Care: Emergency Care:
Many students will be able to handle all or almost all routine diabetes care by themselves
Some students will need staff to perform or assist with routine diabetes care
Care needs will be outlined in the DMMP for each student
Routine Care:
ALL students with diabetes will need help in the event of an emergency situation
Emergency Care:
The need for performance of or assistance with diabetes care tasks will vary from student to student.
Routine Care:
Many students will be able to handle all or almost all of their routine diabetes care by themselves – they can check their own blood glucose, and they can dose and give their own insulin or medication, keeping it in balance with physical activity and food intake.
Some students, because of age, developmental level, or inexperience, will need help from school staff, including performing tasks like insulin administration, blood glucose monitoring, or carbohydrate counting.
Emergency Care:
ALL students with diabetes will need help in the event of an emergency situation.
The level of care and assistance will be outlined in the Diabetes Medical Management Plan (DMMP) agreed upon by the health care provider, parent/guardian, school nurse and student.

8. After-School Diabetes Care
A school nurse is not always available and parental attendance cannot be required for the student’s participation
Non-medical staff can be trained to assist students:
For both routine and emergency care
Including insulin and glucagon administration
All staff members responsible for students with diabetes should be trained to know the warning signs of low and high blood glucose
The school nurse is the most appropriate person in the school setting to coordinate and provide care for a student with diabetes.
Many schools, however, do not have a full-time nurse; more often, school nurses cover a large number of schools. Moreover, even when a nurse is assigned to a school full time, he or she will not always be available during extracurricular activities, or other after-school programs. Yet, because diabetes management is needed 24 hours, 7 days a week -- and diabetes emergencies can happen at any time -- a student with diabetes will always need access to diabetes care at all other after-school activities or other programs.
The Diabetes Medical Management Plan (DMMP) details the specific conditions for all routine and emergency diabetes care tasks, including insulin and glucagon administration. Non-medical staff can be trained to assist students with these tasks. However, any and all clinical assessments are made by the child’s health care providers in the development of the DMMP; staff are simply following the plan as prescribed.

9. Mild to Moderate Symptoms
Hypoglycemia: Possible Signs and Symptoms
Mild to Moderate Symptoms
Hunger Sleepiness
Shakiness Changed behavior
Weakness Sweating
Paleness Anxiety
Dizzy or lightheaded Dilated pupils
Increased heart rate Restlessness
Yawning Confusion
Irritability/frustration Sudden crying
Extreme tiredness/fatigue
Severe Symptoms
Inability to eat or drink
Unconscious
Unresponsive
Seizure activity or convulsions
(jerking movements)
The symptoms of hypoglycemia vary from one individual to another. Also, they may vary for one individual, from one episode to another.
The symptoms of mild to moderate hypoglycemia are the first alert that the body is in a state of sugar deficiency. Symptoms may include the following:
Extreme hunger  Sleepiness
Shakiness  Changed behavior
Weakness  Sweating
Paleness  Anxiety
Dizzy or lightheaded  Dilated pupils
Increased heart rate  Restlessness
Yawning ▪ Confusion
Irritability/frustration ▪ Sudden crying
Extreme tiredness/fatigue
Mild to moderate hypoglycemia can usually be treated easily and effectively. Most episodes of hypoglycemia that will occur are of the “mild” type.
However, if not treated promptly a mild hypoglycemic reaction can quickly progress to a severe state or condition which may be characterized by severe cognitive impairment and will require assistance in treatment:
 Inability to swallow
Unconsciousness
Unresponsiveness
Seizure activity or convulsions (jerking movements)
Remember, onset and progression can happen very quickly. Each student will have his/her own set of symptoms that characterize hypoglycemia. These should be listed in the DMMP.
The important thing to remember is that early recognition and intervention is the best strategy to prevent progression to more severe symptoms.

10. Severe Low Blood Glucose
If a child should become unconscious, or can’t eat, drink or swallow…
1. Glucagon Emergency Kit should be given without delay
2. Parents should be immediately notified, call 911
Link to Glucagon

11. Hyperglycemia: Possible Signs and Symptoms
Mild Symptoms
Lack of concentration Thirst
Frequent urination Flushing of the skin
Sweet, fruity breath Blurred vision
Weight loss Increased hunger
Stomach pains Fatigue/sleepiness
Moderate Symptoms
Dry mouth Vomiting
Stomach cramps Nausea
Severe Symptoms
Labored breathing Confusion
Profound weakness Unconscious
High blood glucose can be caused by a number of things, including: too little insulin, too much food, not enough exercise, even illness and stress.
Refer to the care plan to determine what is the typical blood glucose range for the child and work with the parents to have a plan for handling a high blood glucose reading.
The important thing to remember is that intervention at any of these levels will prevent progression to more severe symptoms.
Link to Hyperglycemia module.

12. Goal Blood Glucose Range
Fasting blood glucose for people without diabetes is usually within the range of mg/dL
Students with diabetes have individual goal ranges based on their age and ability to feel low blood glucose
If above (hyperglycemia) or below (hypoglycemia) their target range, they may need an intervention or treatment to correct them back into a safe range to avoid serious acute complications
In general, a fasting blood glucose for people without diabetes is usually within the range of mg/dL. However, students with diabetes have individual goal ranges based on their age and ability to feel low blood glucose. These are determined by the student, parent/guardian and health care provider and will be identified in the DMMP.
Basic Steps to using glucose monitoring as a TOOL.
Know the target range. Each student’s target range should be clearly identified in the DMMP.
Check at times specified in DMMP. In general, students commonly check routinely before meals and snacks and before, during, and after physical activity. Most students use blood glucose but some students also use continuous glucose monitors (CGM). CGM can be a convenient way of monitoring glucose levels and provides more information than blood glucose alone for planning and treatment. See the student’s DMMP for glucose monitoring instructions.
Immediate Action – Treatment to get back within target range. If above or below their target range, they may need an intervention or treatment to correct them back into a safe range to avoid serious acute complications.

13. Insulin Dosing
Most students with diabetes need to take insulin several times per day
Insulin dosing varies for students and doses change over time
Insulin dosing and timing will be specified in the DMMP; these physicians orders may include provisions for the parent/ guardian and/or capable students to modify dosing themselves
How, where, and who may perform or assist with insulin administration should be documented
Years ago, few students with diabetes took insulin injections at school. But now many physicians prescribe intensive insulin therapy for children that requires multiple daily injections to enable students to maintain blood glucose levels within the target range. This is because studies have shown that intensive treatment can reduce risk or delay long-term complications of diabetes.
Today many students will take insulin at meals and snacks or when blood glucose levels are above target range.
Regardless of when they need to take insulin, many students will need accommodations to ensure timely, accurate insulin dosing. Most older or more experienced students are capable of self-administration although some may want a private place to inject. Others will need full assistance in drawing out, dosing, and injecting.
Insulin dosing and timing will be specified in the DMMP; these physician orders may include provisions for the parent/guardian and/or capable students to modify dosing.
How, where, and who may perform or assist with insulin administration is determined jointly by the parent/guardian, student, and school nurse and/or other appropriate program staff and should be documented in an Individualized Health Care Plan (IHP), and the student's 504 Plan, IEP, or other written accommodation plan.

14. Information for Coaches
Students with diabetes need the freedom to test their blood glucose and drink and eat as needed
Recognize hypoglycemia symptoms and be aware that students need immediate treatment if low
Individual targets but a glucose < 70 is low
Students with high blood glucose need to drink extra water
Individual targets but a glucose > 180 needs increased water
Exercise should be avoided if students have ketones
Know how to administer Glucagon and where it is kept
Physical activity is a critical part of diabetes management.
Everyone can benefit from regular activity, but it is especially important for a student with diabetes.
Students with diabetes should participate fully in physical education classes and team sports, unless indicated by another health care condition, hypoglycemia, or high ketones as per DMMP.
It’s important that coaches allow students with diabetes the freedom to test their blood glucose and drink and eat when needed.
In general, activity lowers blood glucose levels.
Students with diabetes may need to make adjustments to insulin/medications and food intake depending upon timing of activity to insulin peaks or meals and snacks.
A quick-acting source of glucose, glucose meter, and water should always be available. Be aware of hypoglycemia symptoms and when a student should assess their glucose (either by blood glucose meter or CGM, per DMMP). Each student has their individual target ranges but < 70 is considered low.
PE teachers and coaches must be familiar with symptoms of both high and low blood glucose and know what action they should take including how to get help.
If there is insufficient insulin, physical activity can raise also blood glucose levels. Follow DMMP for activity restrictions when ketones are present.

15. Physical activity for Students on Insulin Therapy
If no scheduled snack but the child is going to be active for at least 30 minutes:
Check glucose– and be prepared to check as needed if any symptoms during participation
If under 100 (or other value determined by the health care provider), give a 15g carbohydrate snack
If activity will exceed 2 hours, the child should check glucose half way through and at anytime signs or symptoms of hypoglycemia
Guidelines for activity and glucose monitoring:
Increased glucose monitoring is important for safe participation; some students use blood glucose and, increasingly, some also use CGM. CGM can be a convenient way of monitoring glucose levels during activity and provides more detailed information for planning and treatment. See the student’s DMMP for glucose monitoring instructions.
Check before, during, and after physical activity per DMMP.
Especially when trying a new activity or sport.
If blood glucose starts to fall, student should stop and have a snack. It’s commonly recommended to provide an uncovered (no insulin) snack when glucose values fall below 100 but each student’s plan is individualized.
Students with pumps may disconnect or adjust the basal rate downward temporarily, prior to physical activity (per DMMP). If students disconnect from the pump, they need to have a secure location to store the pump until reconnecting.
The effects of activity can last up to 12 hours. Glucoses can trend downward for hours after physical activity.

16. Parent/Guardian should be called if a child or youth has:
High Alert Situations
Parent/Guardian should be called if a child or youth has:
Severe low blood glucose
Vomiting, positive ketones
Refusing to eat
Refusing to check blood glucose
Low blood glucose has been treated but is not coming up
High blood glucose has been treated but is not coming down
Parent/guardian should be called during certain situations. These high alert circumstances include:
Severe low blood glucose
Vomiting, positive ketones
Refusing to eat
Refusing to check blood glucose
Refusing to take insulin
High blood glucose has been treated, but is not down
Low blood glucose has been treated but it is not going up.
Communication is an important piece of the Diabetes Care Plan. High alert situations are not anticipated frequently but routine communication with the parent/guardian is still important. Regularly communicate blood glucose results, insulin doses provided, symptoms and treatment of hypo- and hyper-glycemia, food intake, and physical acting using a logbook, electronic application or other method provided by the parent/guardian.

17. After-School Programs, Sports and Camps
Module 16 Pre – and Post – Tests:
After-School Programs, Sports and Camps
This tool may be freely duplicated and distributed for training purposes

18. Which of the following tasks are necessary for appropriate diabetes care?
Insulin administration
Blood glucose administration
Carbohydrate counting
Recognition and treatment of hypoglycemia (low blood glucose
All of the above
Parental attendance cannot be required in order for the student to receive diabetes care at after-school activities.
True
False
What should children with diabetes be allowed to do if they are playing sports?
Children with diabetes should not be allowed to play sports
Have access to water and snacks
Self-manage their diabetes if they are capable of doing so
b and c
None of the above

19. American Diabetes Association
Where to Get More Information
American Diabetes Association
DIABETES