Children and Adolescents with Diabetes and the Role of the Nurse in the School Setting

1. Children and Adolescents with Diabetes and the Role of the Nurse in the School Setting Dr. Jane K. Kadohiro, DrPH, APRN, CDE Assistant Professor and Diabetes ConsultantUniversity of Hawaii at Manoa

2. Objectives Discuss the current practice recommendations for treatment and care of children and adolescents with diabetes State the role of the nurse in the school setting Formulate a care plan for a student with diabetes

3. The Burden of Diabetes in the U.S. Prevalence 18.2 million plus 44 million  with Pre-diabetes Mortality 6th leading cause of death Cost � $132 billion USD yearly � $13, 243 USD per person with diabetes  vs. $2,560 for those with no diabetes � 15 to 17 percent of all U.S.  health care costs due to diabetes 9% of the Medicare population use 27% of the Medicare budget

4. Diabetes Prevalence in Youth Type 1 One in every 400 to 500 youth;  approx 5% all persons with diabetes  have type 1 Type 2 Increasing significantly in youth,  particularly among American Indians,  African Americans, and Hispanic/Latinos Percent among all youth  Year with diabetes 1994 16% 1999 8 to 45% 2000 25 to 50%

5. Advances in Treatment of Type 1 Diabetes Past Present Very restricted diet Healthy eating with many options Restricted activity Regular activity and  sports are encouraged Urine testing Blood glucose testing One shot a day 3 to 5 shots a day or  insulin pump Dose constant Dose adjustments frequent, based on many factors

6. Standards of Care for Children and Adolescents with Type 1 Diabetes American Diabetes Association.Diabetes Care (2005). 28(1), 186-212.

7. Overview of Standards Diagnosing Initial Care (Survival Skills) Appropriate Management By Age Diabetes Care Glycemic Control Insulin Management Blood Glucose Monitoring Nutrition and Medical Nutrition Management Exercise

8. Overview of Standards (continued) Assessment of Child and Family Risk Factors at Diagnosis Psychosocial Issues Affecting the Diabetes Care Plan Acute Complications Immunizations Chronic Complications Associated Autoimmune Conditions Adjustment and Psychiatric Disorders Sick Days Adolescent-specific Issues

9. Diagnosing Diabetes Glucose values for diagnosis are similar to those for adults: casual plasma glucose > 200 mg/dl (11.1 mmol/l) OR fasting plasma glucose > 126 mg/dl (7.0 mmol/l) OR 2 hour plasma glucose > 200 mg/dl during OGTT, Differentiation between type 1 and type 2 is based on: patient characteristic presenting signs and symptoms History lab tests

10. Initial Care Evaluation by a diabetes team Diabetes education and self management training Diabetes identification

11. Diabetes Education: Survival Skills and Life Long Living Skills Covers basic diabetes management skills Presented within a context that addresses family dynamics and issues facing the entire family Includes sensitivity to child�s age and developmental stage Includes thorough assessment of readiness to learn and potential barriers Includes parents and other caregivers Is continuous� education is NOT a one time event!

12. Appropriate Self-Management by Age Infants (< 1 year) Toddlers (1-3 years) Pre-schoolers and early school aged children (3-7 years) School-aged children (8-11 years) Adolescents

13. Glycemic Control Values by age Before Meals Bedtime A1C Toddlers and 100-180 mg/dl 110-200 mg/dl <8.5 but >7.5%Preschoolers School age, 90-180 mg/dl 100-180 mg/dl <8% 6-12 years Adolescents, 90-130 mg/dl 90-150 mg/dl <7.5 13-19 years

14. Insulin Management Dosage usually based on body weight, age, and pubertal status May require diluted insulin for infants and toddlers Some insulin still recommended during honeymoon phase Many regimens Methods of insulin delivery

15. Blood Glucose Monitoring At least 4 to 5 tests for children with type 1 Both pre-prandial and postprandial are important Occasional nocturnal testing Additional testing for sick days, increased activity, travel, etc Newer, improved technologies are in development

16. Nutrition and Medical Nutrition Therapy Consultation with a dietitian for individualized meal planning Annual evaluation of height, weight, BMI, and nutrition plan Calories: adequate for growth and restricted if overweight

17. Exercise Minimum of 30 to 60 minutes of moderate activity daily Monitor blood glucose prior to exercise 10 to 15 g carbohydrate prior to exercise Hourly BG monitoring for prolonged exercise BG is still affected for 12 + hour post exercise period 

18. Assessment of Child and Family Risk Factors at Diagnosis Behavior patterns become established and are difficult to change Assess family strengths and risks at time of diagnosis Counsel family accordingly

19. Psychosocial Issues Affecting the Diabetes Care Plan Presence of other health, learning, or behavior problems Parental issues single parent home physical, mental, or emotional problems substance use employment, finances and insurance health/cultural/religious beliefs Sibling issues

20. Acute Complications Growth assessment DKA at diagnosis Recurrent DKA Hypoglycemia

21. Chronic Complications Nephropathy Hypertension Dyslipidemia Retinopathy Foot care

22. Associated Autoimmune Conditions Thyroid Disease Prevalence ~ 17% Alters glucose metabolism Celiac Disease Causes malabsorption Prevalence 1-16% (compared to .3-1%) Symptoms: weight loss/growth failure, abdominal pain, fatigue

23. Adjustment and Psychiatric Disorders Prevalence of major depression ~ 27% Prevalence of generalized anxiety disorder ~ 18.4% Suicide ideation ~ 26.4% Eating disorders including insulin omission

24. Special Situations Sick day management School issues

25. Adolescent-Specific Concerns Annual screening for depression Self-management and adherence issues Risk behaviors Driving Tobacco, alcohol, and substance use Sexual activity Continued involvement of parents is essential!

26. Diabetes: a Major Balancing-Act

27. Challenges for Youth with Type 1 Diabetes Poor public understanding Fear of others Attitudes of others Liability concerns Resulting restrictions placed on youth Discrimination Schools Sports Parties and Overnights Driving Employment Normality

28. Challenges for the Prevention and Control of Type 2 Diabetes in Youth Fast foods and convenience foods Super-sized meals Vending machines with unhealthy choices Television Computers Decreased physical activity requirements in schools Decreased after school programs that are activity focused Latch key kids Busy families

29. Common School Issues Facing Students with Diabetes Failure to have trained staff to assist Inadequate assistance in help with insulin No one trained to administer glucagon Lack of coverage during field trips, other activities Not permitted to check BG in classroom, etc. Pressure to send child to a special school, or Refusal to allow a student to attend school

30. Role of the Nurse in the School Setting Coordinate diabetes care at school Initiate or review students� Diabetes Medical Management Plan Facilitate the initial school health team meeting Assess student, develop additional plans, and periodically re-assess Obtain materials and medical supplies necessary for diabetes tasks Maintain accurate documentation Communicate with parents

31. Role of the Nurse in the School (continued) Act as a liaison between the school and the students health care provider Address safety issues Educate school personnel and others Develop a quick reference plan for those personnel who work closely with the child include brief info from the students diabetes medical management plan summarize how to recognize and treat hypoglycemia and hyperglycemia

32. Role of the Nurse in the School (continued) Assure that the child has easy access to food, glucagon, testing equipment, insulin, use of bathroom, etc. Advocate for school policies affecting the child with diabetes lunch choices and vending machines physical activity participation in sports and field trips Be knowledgeable about federal, state, and local laws and regulations Assist in fostering a healthy learning environment

33. The Diabetes Medical Management Plan A Diabetes Medical Management Plan (DMMP) should be implemented for every student with diabetes. DMMP is developed by the student�s personal health care team and family and signed by a member of student�s personal health care team implemented collaboratively by the school diabetes team, including: school nurse the student parents/guardians other school personnel

34. Elements of a DMMP Date of diagnosis Emergency contact information Student�s ability to perform self-management tasks at school List of diabetes equipment and supplies Specific medical orders for blood glucose monitoring, insulin, glucagon, and other medications to be given at school Meal and snack plan Exercise requirements Actions to be taken in response to hypoglycemia and hyperglycemia

35. What Takes Center Stage