1. Diabetes in the School University of Iowa Children’s Hospital, Iowa City, IA Revised January 2011

2. Type 1 Diabetes (Juvenile diabetes) Disorder in which the pancreas cannot make insulin When foods with carbohydrates are eaten they break down into sugar Insulin is the key that unlocks cell door & allows sugar in the bloodstream to enter the cell Sugar is the energy source for the body cells Without insulin the blood sugar level rises causing high blood sugar

3. Type 1 Diabetes Person must take insulin for rest of life No known cure Nothing could have prevented it from happening Typical age at onset is during school age years but can happen at anytime 1 in 400 school aged kids have type 1

4. Type 1 Diabetes—What it is NOT! NOT caused from eating too much sugar NOT contagious

5. What Happens? Genetic predisposition & environmental insult causes autoimmune process in body where the body’s immune system destroy the cells in the pancreas where insulin is produced Destruction of insulin making cells in pancreas occurs for weeks to months or longer When 80-90% of insulin making cells destroyed blood sugars rise higher than normal range & cause symptoms of high blood sugar signaling the onset of diabetes

6. Early Signs and Symptoms of Type 1 Diabetes Increased thirst Increased urination Fatigue Weight loss Increased hunger *important for teachers to let parents know if they notice a child having frequent thirst or urination *a simple finger-stick blood sugar can diagnose or rule out diabetes

7. Diagnosis of Diabetes Normal blood sugar is 70-120 Fasting blood sugar > 126 (normal is low end of normal range) Random blood sugar > 200 Hemoglobin A1c > 6.5% (normal 4-6%)

8. Normal Blood Sugar Children with diabetes, have much wider range of blood sugars, including low and high blood sugars It is impossible for someone with diabetes have completely normal blood sugars, but it is a goal to strive toward

9. Type 1 vs. Type 2 Diabetes Type 2 diabetes is increasing worldwide, including in the overweight, adolescent age group This type of diabetes very often runs in families and is passed on from generation to generation Typical age range: over 40 years of age, but is increasing in school-aged and adolescent overweight children More common in Hispanic, Asian, Polynesian Islanders, Native American & African American

10. Type 2 Diabetes High blood sugars due to insulin resistance not lack of insulin as in type 1 High incidence in other family members Metabolic Syndrome is precursor (central obesity, high BP & high lipids) Usually seen in overweight child or teen Higher incidence in Hispanic, African Americans, Native Americans, Pacific Islanders

11. Treatment of type 2 Diet Exercise Oral medication that help with insulin resistance Insulin

12. Treatment of Type 1 Diabetes: 4 Basic Steps 1) Insulin Injections – must replace what body no longer making 2) Carbohydrate Counting – carbs break down into sugar 3) Exercise – controls balance of insulin & carbs 4) Check blood sugar – gives us info to help adjust insulin, carbs, exercise

13. Blood Sugar Checking Student will provide his/her own meter What is a blood sugar check? Finger- poke blood sample to check blood sugar on meter with digital result When to check? –Before each meal, at bedtime, and anytime there are symptoms of low blood sugar –Before PE or sports best

14. Insulin Injections Injection of insulin into fatty tissue under skin on upper arm, thighs, abdomen, buttocks. 4 injections per day –Before breakfast –Before lunch –Before supper –Before bedtime

15. Injections Insulin syringes have very short thin needles Can use short thin pen needle on an insulin pen Nurse or designated adult must give or supervise the injection Usually by age 10, most kids can give their own injections but still need supervision

16. Insulin Pumps Small battery operated device containing 2- 3 days supply of insulin which slowly infuses small amounts of insulin 24 hours/day With meals & snacks push button to deliver amount of insulin needed to cover carbs Best if pumps not removed for sports or PE

17. Insulin—see graph 2 Main Types: –1) Rapid-acting: given before each meal (and large snacks) which acts as a bolus to cover carbs & allow sugar into cells to control BS Most common forms: Humalog or Novolog –2) Long-acting: given once per day at the same time every 24 hours to act as the “background” or basal insulin Most common form: Lantus

18. Humalog/Lantus Insulin LantusHumalog

19. Pre-meal Insulin Humalog or Novolog Insulin –Starts to work in 15 min. –Peaks in 1-2 hours –Duration: 4 hours –Most recent recommendation is to take insulin 15 minutes prior to eating to avoid high swing in BS after eating

20. Mealtime Routine Students with diabetes need to check blood sugar and get insulin before eating meals Blood sugar level and insulin dose need to be verified by an adult Students of all ages need positive reinforcement to stay on time with meal and snack times We cannot expect kids to always remember when and how to care for their diabetes regardless of age

21. Carbohydrate Counting Student will be on a set amount of carbs with meals & snacks and take a set amount of insulin or will eat amount of carbs desired & calculate dose of insulin accordingly Snacks best given mid-morning (only for younger kids) mid-afternoon, bedtime, & prior to exercise

22. Meticulous Carb Counting Label reading Use of measuring cups Use of food scale Measure to the gram of carbohydrate Kids often can still eat most of same foods they ate before diagnosis of diabetes Avoid or eat in moderation refined sugars such as candy, cakes, cookies, Pop Tarts—have only on special occasions

23. Exercise Important to help maintain good blood sugar control Extreme exercise lowers blood sugar up to 24 hours May need a snack to pre-treat exercise or PE (General Guideline: 10-15 grams of carbohydrate for every 1 hour of strenuous exercise)

24. Acute Complications (problems that may occur at school) 1) Hypoglycemia (Low Blood Sugar) 2) Hyperglycemia (High Blood Sugar) 3) Ketones in urine or blood

25. Hypoglycemia (Low Blood Sugar) Low Blood Sugar (less than 70) Urgent situation –Causes: Extra unplanned exercise Not eating enough carbs at a meal or snack Delay in eating after shot taken Too much insulin

26. Low Blood Sugar Symptoms Shaky Sweaty Hungry Weak Pale Quiet Irritable Tired Unable to concentrate Blurry vision Headache

27. Low Blood Sugar May experience one or more symptoms Usually show same symptoms May not always know when low since low blood sugar impairs ability to think Younger children may not be able to communicate their lows Watch for signs of a low and if in doubt, have the student check blood sugar

28. Low Blood Sugar Students with diabetes need to tell school staff immediately if they think they are low Lows need treatment immediately to prevent severe low (unable to help self) Check BS as soon as symptoms occur to determine if treatment is needed. All school staff need to be aware of students with diabetes so they can assist immediately if needed

29. Treating a Low Blood Sugar If blood sugar <70, treat immediately with 15 grams of quick-acting sugar (carbohydrate) –Examples: 4 oz. (1/2 cup) Juice—any flavor 4 oz. (1/2 cup) Sugar-sweetened soda (NOT DIET SODA) 4 glucose tablets 3 sugar packets

30. Preventing Low Blood Sugar Check BS before, during, after exercise For young kids check prior to bus or walk home Pre-treat exercise with extra carbs if needed If meal & insulin are due prior to practice or sport event may need less insulin Extra BS checks help to determine how much to adjust food & insulin

31. Rule of 15’s… After treating a low blood sugar with 15 grams of quick-acting carbohydrate….. If student feels fine, return to class If student still symptomatic, check blood sugar after 15 minutes If still <70, re-treat with 15 grams of quick- acting carbohydrate

32. Refer to Low Blood Sugar Chart

33. Severe Lows **If low blood sugar is not treated with quick-acting sugar, the student could progress to inability to swallow sugar or juice or unconsciousness or a seizure Glucagon injection required immediately!

34. Glucagon Emergency Kit Used for severe low blood sugar –Blood sugar so low cannot safely swallow juice without choking –Unconsciousness –Seizure –Glucagon may be given by any person trained in the administration of Glucagon—does not have to be medical personnel

35. Administering Glucagon Must be mixed before injecting Inject saline filled syringe into vial of white powder & swirl to mix Inject into thigh muscle Give ½ dose for student <44 pounds Give full dose for student >44 pounds Refer to Glucagon handout

36. Hyperglycemia (High Blood Sugar) Causes: –Not enough insulin –Eating too many carbs –Lack of exercise –Illness

37. Symptoms of High Blood Sugar Increased thirst Increased urination—do not limit bathroom privileges Dry mouth Tired

38. Treating High Blood Sugar Offer water to prevent dehydration—allow water bottles in classroom or drink 8 oz. every hour Check ketones if >240 If ketones present do not exercise Can participate in normal activities if negative for ketones Unnecessary to remove student from class to exercise to try to bring down blood sugar

39. Refer to High Blood Sugar Chart

40. Ketones Ketones occur when not enough insulin in body to open cell doors causing cells to starve for sugar. When cells starve they eat body fat resulting in acid build up in blood and urine. Common causes are: Illness such as infection, vomiting, fever Missing insulin shots Misuse of insulin pump or pump failure

41. What To Do If Student Has Ketones If positive for ketones, do not ignore Call parent(s) immediately Parent(s) will direct you to treat ketones immediately with: –1) extra rapid-acting insulin –2) lots of sugar-free fluids –3) Do not exercise if ketones present

42. Special Occasions Parties Allow student to participate May need to exchange usual snack for cake, etc… Try not to make child feel different Field Trips –BE PREPARED!! –Pack all supplies: meter, strips, juice, Glucagon

43. Living with Diabetes Living with diabetes presents many daily challenges with no vacation The attitude of those who care for kids with diabetes can help kids to better accept these challenges Thank you for all you do to help these kids live a healthy and happy life