Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDCES

: What are the take home messages for school staff regarding children with diabetes? First, make sure that they understand that they do not need to know everything about diabetes. They need to know how to safely manage the child that's in their classroom that has diabetes and the individualization that goes with every child with diabetes. One other thing that we have to understand is that children are children, and again, there is no such thing as perfection. So again, making sure that there's a dialogue between the school nurse and the family members because frequent medication changes are needed in growing children; we want to make sure that this is a team effort. The teachers themselves are the ones that are with these children the most. If they're seeing any particular idiosyncrasies that don't seem to fly very well in the classroom, again, it's highly likely that that child is going to need some frequent adjustments with their health care provider. Also, the school staff should rest assured that emergency situations are rare. Knowing how to use some of the newer glucagon methods is going to help them feel confident in the event that something happens in their classroom. The whole thing is about safety and about letting the school staff do their jobs, teach children, and allow them to make the most of the time that they have within the school setting.

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Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDCES shares clinical pearls for the management of school aged children with diabetes.

Key Takeaways for the Management of School Aged Children with Diabetes

: School staff, school nurses, and anyone that's involved with the student during the school day should be trained on how to use glucagon on an annual basis. Those are training recommendations from the Safe School Improvement Acts throughout the states. Now, what is going to be the best method of treatment? I'm a hands-on kind of girl. So again, making sure that even demonstration options are available for the staff to be able to just play around with is great, but there are plenty of videos as well as print materials that can be read to get that kind of training. However, when we think of glucagon, it is something that is a little more fearful in the minds of staff. Making sure that they're a little more comfortable with using it but also understanding how easy some of the newer methods are to use so that they don't have to really worry so much when they're actually delivering it is important.

One other thing about the glucagon types that are available: if using the traditional glucagon emergency kit, that’s going to have to be reconstituted. Children who are under 12 and under 100 pounds are going to require about half the typical dose. The prefilled injectables are available in either the half amounts or the full amount. So again, if you have a child that's over 100 pounds, they're going to need the full amount like an adult. So making sure that those are definitely delineated. And then the nasal is one of those that has the same amount regardless of the weight of the child. But again, definitely making sure that for that student with diabetes, that you have the correct formulation for their weight.

When I think of some of the challenges that are inherent with using glucagon itself, in the past, it was really because the only version that we had available was really hard to use. That alone has deterred a lot of people from actually using it or even getting prescriptions for it. So now that we're having newer formulations that have much simpler ways to deliver, we're going to be seeing that some of those challenges go away. Still, the challenge does include the prescription itself. We do know the number of people who are on insulin; it's nowhere near 100% of those that are getting glucagon. So we know that we need to increase the prescriptions. So again, those glucose—those rescue medications are available—and be sure that the child does have multiples throughout the school. Again, have one in the nurses' station or the front office, one in the classroom, one in their backpack just in case, or their emergency go-bag. We want to make sure that by making sure that they have multiples, and having easier modalities, that we're going to be minimizing those challenges. As I mentioned, the challenge still is whether the family can afford having this rescue medication itself. And so making sure that they're talking with their health care provider or finding methods to make sure that they're getting the most affordable cost, because this is one of the most important rescue medications that we can have for children with diabetes.

An expert in diabetes education provides an overview of dosing requirements and appropriate administration requirements necessary for the administration of hypoglycemia rescue therapies. 

Hypoglycemia Rescue Treatment Administration Considerations

Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDCES: 

When it comes to severe hypoglycemia, we need to talk about glucagon, and there are 3 different formulations on the market today. The first is the original that’s been around since its inception. It’s a traditional glucagon emergency kit that has saline and a dry powder that has to be reconstituted. That’s the first that is available. The second are prefilled shelf-stable injectables. Then the third is a nasal version. All 3 can be used in a multitude of situations.

The choice of which glucagon to use is going to be dictated by the child’s insurance and what is available to them. But also we want to take into consideration the school setting. If a nurse is not available every day, having easier methods to use may be a much better option. We do know in the past that the traditional glucagon emergency kit was a fearful conversation to have with staff who are not health care professionals. So using the prefilled injectable or even the nasal version is going to be a better option for those school staff who may have to do this in the classroom. I want to be very clear of course that severe hypoglycemia and glucagon is not something that’s used on a daily basis. These are again emergent situations where we want people to be prepared just in case it’s going to happen. We want to have the easiest method available that’s able to be used and going to be effective. We will know that the child is going to have an increase in their glucose level because of the glucagon that’s being delivered.

Glucagon itself is going to take about 15 minutes to have an impact on glucose levels. It’s important that people understand that. Also we want to keep in mind that this is one of the safest medications that somebody can give, but also that it’s not going to cause the blood sugar to rise incredibly high. We’re talking anywhere from 120 to 170 points. I want people to rest assured that we’re not talking about these poor children having blood sugar levels in the upper 300 mg/dL range and they’re going to feel awful all day. This is a rescue medication that’s just going to raise the blood sugar enough by dumping all of the glucose from the liver to keep the child safe.

Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDCES reviews the currently available rescue modalities for use in pediatric patients with diabetes experiencing severe hypoglycemia or very low blood sugar.

Available Therapies for the Management of Severe Hypoglycemia in Pediatric Patients with Diabetes

There are many places that individual school staff and school nurses can obtain resources to get them prepared for the student coming in with diabetes. There are 4 major places I tend to recommend. Of course, the CDC has a great website on some school-based training, education, and literature for someone to read. The American Diabetes Association [ADA] is usually my go-to because it has one of the best booklets that can be downloaded by anyone, and it’s called 

Helping the Student With Diabetes Succeed

. That was done in conjunction with the National Diabetes Education Program. We also have the Juvenile Diabetes Research Foundation, which also has a webpage that’s dedicated to school and diabetes. Then finally the diabetes educator group, the Association for Diabetes Care and Education Specialists, also has a website that has some nice handouts that can be downloaded and used for the schools. One other thing that I forgot to mention about the ADA is that there are videos and modules that school staff can watch to gain their annual competency. Now, I wish I could say that all 4 of these particular resources are something that’s very common knowledge, but they’re not. I do strongly encourage that anyone who’s working with children with diabetes, that you’re shouting about them from the rooftops, because these are some great resources that can be really useful, especially if the schools do not have access to in-person or virtual training.

The Safe at School state laws dictate that any student with diabetes is allowed to have staff on site all the time who can help them to stay safe at school. [It could be] a school nurse, which we would love to have a school nurse on staff on an ongoing basis, but there are some schools that don’t have that luxury, where the school nurse is kind of spread thin over several schools. So one or multiple staff members need to understand and be able to handle the emergency types of situations that can come with diabetes. In the event that someone needs to take insulin or needs to be given glucagon, someone has to be on site at all times who knows how to do that, whether it’s a nurse or not. That is what the state laws have stipulated, and that’s federal. So again, we want to make sure that there’s someone who can do that. If we can have a school nurse on staff all the time, I would love that greatly, but we know that may not be possible.

One thing we also have to have in place in all of these schools is something called a diabetes medical management plan. It’s basically the nuts and bolts of what that child with diabetes has to do throughout the day. It stipulates where the glucose levels need to be, when they need to take medicines, how much they need to take, and that should be done and signed off by the prescriber on an annual basis. That should also be disseminated to the school staff as well, specifically what kind of symptoms does this child have when it comes to hypoglycemia, how does their insulin affect them, and will that impact the school day at any particular time they’re in the classroom.

A certified diabetes educator comments on the some of the available resources for patients, their families, and school staff surrounding the management of diabetes in a school setting.

Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDCES

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