1. Diabetes Care Tasks at School: What Key Personnel Need To Know
Before- and After- School Care
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 caregivers 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 Before- and After- School Care.

3. Learning Objectives Participants will be able to understand:
Basics of caring for a child with diabetes
Hypoglycemia and hyperglycemia
Diabetes care tools and resources
Participants will be able to understand:
Basics of caring for a child with diabetes
Hypoglycemia and hyperglycemia
Diabetes care tools and resources
In addition to this training, we highly recommend caregivers to take the following trainings, available online at
Introduction to Diabetes
Diabetes Basics
Hypoglycemia
Hyperglycemia
Blood Monitoring
Continuous Glucose Monitoring
Glucagon Administration
Insulin Basics
All of these can prepare you to learn more about diabetes, but the before- and after-school Diabetes Care Plan is determined by the parents/guardians of the child based on the individual child’s needs and Diabetes Medical Management Plan.

4. Special Considerations When Caring for a Child with Diabetes
Children, especially young children, are totally dependent on adults
Depending on age and development, some have limited or no communication skills
With proper planning and glucose management, a child with diabetes can and should be allowed to participate in ANY activity
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 children with diabetes the same as other children, except to meet their diabetes needs.
Prior to caring for a child 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.
The means to managing blood glucose is being prepared. Work with the family, in advance, to have meal and snack plans ready. Be sure to cover dietary preferences in greater detail if you will be caring for a child for a longer time frame.
* Physical activity generally lowers blood glucose. However, certain activities may raise blood glucose for some students.

6. Goal Blood Glucose Range
Fasting blood glucose for people without diabetes is usually within the range of mg/dL
Children with diabetes have individual goal ranges based on their age and ability to feel low blood glucose, see the Diabetes Care Plan for individual goals
If above (hyperglycemia) or below (hypoglycemia) their target range, they may need an intervention or treatment to correct glucose levels 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, children with diabetes have individual goal ranges based on their age and ability to feel low blood glucose. These are determined by the parent/guardian and health care provider and will be identified in the Diabetes Care Plan.
Basic Steps to using glucose monitoring as a TOOL.
Know the target range. Each child’s target range should be clearly identified in the care plan.
Check at times specified in care plan.
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. Refer to the Care Sheet provided by guardians for instructions and be sure to review with parents/guardians each time you provide care for the child.

7. Blood Glucose Monitoring
The parents must tell you when they want blood glucose checks to be done
Typical blood glucose checks often occur:
Before meals
Before bed
Before, during and after exercise
Whenever a child says they are feeling “low” or “high” or “not well”
Whenever a child is displaying signs and symptoms of a “low” or “high” blood sugar
After treatment for a “low” or “high” blood sugar
If a child is behaving in a manner that is not typical for them be sure to test their blood sugar
TALKING POINTS
In general, children commonly need glucose checks routinely before meals, before bed and before, during, and after physical activity. Most children use blood glucose but some 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. Glucose monitoring instructions should be outlined in the Diabetes Care Plan.
Change in behaviors may be related to the child’s personality, the child’s developmental stage or the child’s blood sugar. You need to check blood glucose whenever behavior is unusual for the child.
Refer to the Care Sheet provided by guardians for instructions and be sure to review with parents/guardians each time you provide care for the child.
Independence versus Assistance:
Children will begin taking ownership of their diabetes management in different ways and at varying ages. This is an important topic to review with parents, so you are comfortable with what the child is comfortable doing on their own, what they are learning with supervision, and/or what they will need direct assistance with. Either way, it is important to understand each step of diabetes management.
Ask the parents if you do not understand some part of the child’s diabetes management plan.

8. 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)
Preventing and treating low blood glucose is one of the biggest responsibilities as a caregiver.
When caring for children with diabetes you need to be familiar with both signs and treatment for hypoglycemia and hyperglycemia. Each individual shows signs of lows at different blood glucose levels. Discuss the typical signs of lows with the parents and review the treatment in their care plan carefully. When applicable, ask the child if they know their symptoms of low blood sugars.
Hypoglycemia requires immediate attention to prevent a severe low blood sugar reaction that can lead to the child passing out, having a seizure or death.
Hypoglycemia is usually easily treated with a fast acting carbohydrate such as juice.
It is important to treat immediately, so if you notice any changes, always check blood glucose to be sure.
The symptoms of mild to moderate hypoglycemia are the first alert that the body is in a state of sugar deficiency. 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:
The important thing to remember is that early recognition and intervention is the best strategy to prevent progression to more severe symptoms.
Link to Hypoglycemia module.

9. 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

10. 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.

11. Before- School Care
Many before care programs include having breakfast served
Insulin often needs to be given with breakfast
The carbohydrate amount needs to be calculated or the child will need help in choosing foods that fit their meal plan
Many children require rapid acting insulin before meals and snacks; timing should be included in the Diabetes Care Plan
Sometimes the Diabetes Care Plan will include dosing after meals for picky eaters and very young children
Note: Hypoglycemia can occur if meal or snack is delayed for more than 15 minutes after insulin injection or insulin pump bolus
If the child does not eat all of the food for which insulin was given, they are at risk of hypoglycemia
The child must finish their carbs after insulin dosing or needs to have the carbs replaced with another food or drink to prevent lows
If a child routinely eats less than planned, contact the parents to discuss
TALKING POINTS
Insulin dose will vary, depending upon:
blood glucose readings
food availability/preference
activity level
age and body weight
See the child's Diabetes Care Plan for specific instructions.
Link to Insulin Basics

12. After- Care Most after- care programs involve a snack
Generally, follow the same steps as if the child was having breakfast; see Diabetes Care Plan for individual details that usually include:
Identify the amount of carbohydrates
Divide total carbs by insulin to carb ratio or fixed dose
Check blood glucose
Determine if a correction dose is needed; sometimes insulin may be held or decreased to prevent lows with exercise
Prior to providing a snack:
Most after- care programs involve a snack. Before providing the snack you generally need to follow the same steps as if the child was having breakfast. This includes:
Identify the amount of carbohydrates
Calculate the insulin dose using the insulin to carb ratio, per Diabetes Care Plan
Check blood glucose, per Diabetes Care Plan
Determine the insulin dose; sometimes insulin may be held or decreased to prevent lows with exercise
See the child's Diabetes Care Plan for specific instructions.

13. After- Care Most after- care programs involve physical activity
Check glucose– and be prepared to check as needed if any symptoms during participation
If under 100 (or other value determined by the parent), 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
If no scheduled snack but the child is going to be active for at least 30 minutes:
Guidelines for activity and glucose monitoring:
Increased glucose monitoring is important for safe participation; some children 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 child’s Diabetes Care Plan 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, child 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 child’s plan is individualized.
Children with pumps may disconnect or adjust the basal rate downward temporarily, prior to physical activity (per DMMP). If the child disconnects 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.

14. Parent/Guardian should be called if a child has:
High Alert Situations
Parent/Guardian should be called if a child 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.

15. Caregiver follow up
Record and report the following to the next caregiver and parent/guardian:
Blood glucose readings
Any insulin doses given
Failure to complete prescribed meal plan
Symptoms and treatment provided for hypoglycemia or hyperglycemia
Communication is an important piece of the Diabetes Care Plan. 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.

16. Before- and After- School Care
Module 15 Pre – and Post – Tests:
Before- and After- School Care
This tool may be freely duplicated and distributed for training purposes

17. What might a child with diabetes need before she or he eats breakfast at school?
Whole grain toast
Insulin
Sugar-free beverage
None of the above
Which actions may after-school staff have to perform for a child with diabetes attending an after-school program?
A ride home
Insulin administration
Count carbohydrates
B and c above
What information should be recorded and reported by the caregiver and parent/guardian:
Blood glucose readings
Any insulin doses given
Failure to complete prescribed meal plan
Symptoms and treatment provided for hypoglycemia or hyperglycemia

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