Management and Safety of students with Diabetes

1. Management and Safety of students with Diabetes Kanika Ghai MD Division Director Pediatric Endocrinology Advocate Children’s Hospital April 9, 2019

2. A world wide problem…

3. That continues to increase (Ann NY Acad Sci. 2008 December; 1150:1-13)

4. About 200,000 Americans under age 20 are estimated to have diagnosed diabetes • approximately 0.25% of those under age 20 have diagnosed diabetes

5. What is Diabetes ? • Diabetes is a chronic disease in which blood sugars are high • People develop Diabetes because pancreas produce little or no insulin or the cells in the muscles, liver and fat do not use insulin properly • High Blood Sugars ( Hyperglycemia) over the years can cause Serious Health Problems • There is no Cure for Type 1 Diabetes

6. What is Diabetes ?

7. Classification of Diabetes • Type -1 diabetes( cell destruction, usually leading to absolute insulin deficiency) • Immune mediated • Idiopathic: ADM • Type-2 diabetes( predominately insulin resistance with relative insulin deficiency) • Other specific types(MODY, Genetic defects of insulin, diseases of pancreas, endocrinopathies, drug induced, infections, genetic syndromes.) • Gestational Diabetes

8. T1DM vs T2DM • Type 1 diabetes mellitus • Autoimmune in nature • Requires insulin administration from time of diagnosis • Type 2 diabetes mellitus • Typically related to obesity • May be treated with diet, oral medications or insulin therapy

9. Presentation of Diabetes • Extremely variable • May be asymptomatic found on routine screening • May be critically ill • requiring intensive care • May initially present as diabetic ketoacidosis • results from a lack of insulin • body switches to burning fatty acids and producing acidic ketone bodies • Vomiting, dehydration, deep gasping breathing and mental status changes are typical symptoms.

10. Signs & Symptoms of Diabetes • Increased thirst • Increased urination • “accidents” – daytime or nighttime • Weight loss • Abdominal pain • Nausea / emesis • Headaches • Blurry vision

11. Diagnosing Diabetes • Fasting Plasma Glucose (FPG) • Glucose level after not having food or drink for at least 8 hours • Result • Normal - <100 mg/dl • Prediabetes - 100 – 125 mg/dl • Diabetes - >126 mg/dl

12. Diagnosing diabetes • Random Plasma Glucose • Glucose level at any time of the day when severe diabetes symptoms are present. • Result • Diabetes - > 200 mg/dl

13. Diagnosing Diabetes • HgbA1c • test measures average blood glucose for the past 2 to 3 months. • Result • Normal - less than 5.7% • Prediabetes - 5.7% to 6.4% • Diabetes - 6.5% or higher

14. Diagnosing Diabetes • Oral Glucose Tolerance Test • a two-hour test that checks your blood glucose levels before and 2 hours after consuming a high sugar drink • Result • Normal - less than 140 mg/dl • Prediabetes - 140 mg/dl to 199 mg/dl • Diabetes - >200 mg/dl

15. Treatment • Insulin therapy : Most important • Nutrition: High fiber, Less Free Sugar • Active Lifestyle • Frequent monitoring :Adjustments to correct high and low Blood sugars • Prevention of High and Low blood sugars. Anticipate high or low Blood sugars from Blood sugar trends and intervene before they get abnormal

16. Blood glucose monitoring • Allows one to determine the concentration of glucose in blood • Helps guide management • When to be done • Before meals or snacks • Before bedtime • With changes in insulin doses • Before activity • When symptomatic • Should be performed on finger-tip

19. CONVENTIONAL THEARPY EVE NIGHT AM AN D HS B Insulin Effect B L Meals

20. MULTIPLE DOSE INSULIN REGIMENS Short acting insulin analog/regular + NPH AM AN EVE NIGHT Insulin Effect B B D HS L Meals

21. AM AN EVE NIGHT Insulin Effect B D HS B L Meals Multiple Dose Insulin Regimens Novolog/Humalog/Apidra/Reg + Lantus/ Levemir/UL

22. Insulin dosing plans • Typical insulin plan at meal or snack • Step 1: Assess carbohydrate intake • Step 2: Check Blood sugar • Step 3: Calculate Food Dose/Carbohydrate dose. • Step 4: Calculate Correction dose • Step 5: Calculate Total Insulin Dose : Food dose + Correction dose • Food intake: Ham sandwich, apple, glass of milk, Blood sugar: 262 • Carbohydrate Intake =(15gms x 2+15gms+15 grams) = 60 grams • Dose = 60/15 (4 units)+ 262-130/60 (2.2 units) • Dose given = 6 units

24. Insulin Pumps – Cont’d

25. Insulin Pumps

27. Glucose sensors – 3 parts: 1. Sensor 2. Transmitter 3. Receiver

28. Three Day Continuous Glucose Monitor

30. Caring for a child with diabetes • A lot of a child’s diabetes cares will take place at school • Illinois has in place the Care of Students with Diabetes Act • Provides requirements school must meet in regards to care of diabetes • Difficult for many schools to have required training and personnel available • A partnership between nurse, students, parents and medical home

31. Effective Diabetes Management at School • Goal: Keep Blood sugar levels within target range determined by health care team • Assist Student in performing Diabetes care tasks • Designating Trained Diabetes Personnel

32. How to plan Effective management in School Setting • Assemble health care team • Review Federal Laws • Assemble Student’s health care plan • Diabetes Management plan (health care team) • Individualized health care plan ( school nurse) • Emergency care plans(school nurse) • Prepare Student’s education plan • Train School Personnel • Diabetes Management Training resources

33. Review Federal Laws • Section 504 of the Rehabilitation act of 1973 (section 504) • American with Disabilities Act of 1990 (ADA) • Individuals with Disabilities Education act (IDEA)

34. Diabetes Care Plan • Also known as a diabetes medical management plan (DMMP) • Provides direction for diabetes cares at school • Per Diabetes Care Act a DMMP is required: • “upon enrollment, as soon as practical following a student's diagnosis; or when a student's care needs change during the school year. Parents shall be responsible for informing the school in a timely manner of any changes to the diabetes care plan and their emergency contact numbers.”

35. Diabetes Care Plan • Provides information on: • Monitoring of blood glucose • Dosing of insulin • Authorization for insulin use • Treatment of hypoglycemia • Authorization for glucagon use • Treatment of hyperglycemia • Use of insulin pump • Physical activity and sports • Nutrition

36. Train School Personnel • Level 1Training: All school personnel • Level 2 Training: school personnel who have responsibility for the student • Level 3: School staff designated as trained Diabetes personnel

37. Help students lmplement Effective Diabetes management • Check BG • Plan Disposal of sharps • Recognize and Rx low BG • Recognize and Rx high BG • Administer insulin and/or other Diabetes medication • Plan for emergency • Plan Individualized meal plan • Plan for special events, field trips • Promote Regular physical activity • Deal with emotional and social issues

38. Hypoglycemia • Too much Insulin • Missing or delaying meals or snacks • Not eating enough food (carbohydrates) • Getting additional, intense, unplanned physical activity • Being ill particularly with gastrointestinal illness • Hypoglycemia is not always preventable • Not every student can recognize hypoglycemia

39. Checklist for Hypoglycemia • Mild/moderate : Oral glucose and recheck BG • Student should not be left alone or sent anywhere alone or with another student • Severe: Glucagon use • Position child to side • Do not feed orally • Call 911 • Administer Glucagon • Call parents /guardian • Stay with student

40. Checklist for Hyperglycemia • Check BG and repeat every 2 hours • Check urine ketones • Give insulin correction dose • Give Extra fluids (sugar free) • Allow unrestricted access to restroom • Restrict participation in physical activity per DMPP • Notify parents • Pump: Check if pump is connected properly • For suspected pump failure give insulin via injection

41. Thank You …

42. Classification of Diabetes Mellitus Nelson Essentials of Pediatrics, 7th Edition