Diabetes Care in Schools

Preface

Diabetes can be challenging for everyone involved, but with your loving support, children with diabetes could enjoy school as much as others do! We do not aim to make you an expert in diabetes care, but we wish to equip you with the essential knowledge.

This booklet will provide you with the information you need to understand the condition to safeguard the children in your school. We hope you find it useful and will share it with the rest of your staff as appropriate. The information and guidance are for general reference only. Patient-specific details should ALWAYS be sought from the child, parents and the medical team.

Content

• Chapter 1: What is diabetes?
• Chapter 2: Types of diabetes
• Chapter 3: Self-monitoring of blood glucose: finger-prick blood glucose monitoring and continuous glucose monitoring system (CGMS)
• Chapter 4: Insulin therapy: multiple daily injections (MDI) and insulin pump
• Chapter 5: Hypoglycaemia (low blood glucose) and management
• Chapter 6: Hyperglycaemia (high blood glucose) and management
• Chapter 7: Exercise management
• Chapter 8: Psychological care of children and adolescents with diabetes
• Chapter 9: Living a normal school life
• Chapter 10: FAQs
• Chapter 11: Diabetes management plan

Chapter 1: What is diabetes?

Diabetes is a chronic condition that occurs when the pancreas does not produce enough insulin or there is a reduction in sensitivity of cells to insulin. Insulin is a hormone that regulates blood glucose. Uncontrolled diabetes leads to raised blood glucose (hyperglycaemia) and over time leads to damages to many of the body's systems, especially the kidneys, nerves and blood vessels.

Symptoms of diabetes include

• Frequent urination
• Increased thirst
• Fatigue
• Increased food intake
• Weight loss
• Slow wound healing
• Blurred vision

In severe cases, symptoms of diabetic ketoacidosis (DKA) may occur. These include abdominal pain, nausea, vomiting, rapid breathing, and fruity breath. Without appropriate interventions, this could result in severe complications.

Chapter 2: Types of diabetes

There are 2 main types of diabetes in children and some other less common forms.

Type 1 diabetes

Type 1 diabetes is the commonest form of diabetes in children and teenagers. It is an autoimmune condition where the body's immune system attacks the ‘beta cells' of the pancreas, affecting its ability in producing insulin.

There is nothing the child or their parents did or didn't do that could have prevented the condition. People with Type 1 diabetes need insulin treatment to stay alive.

Type 2 diabetes

Type 2 diabetes usually affects older people but is increasingly seen in younger people. It is often associated with sedentary lifestyle and obesity. In people with Type 2 diabetes, the pancreas can still produce some insulin but the body is less sensitive to insulin. Patients with Type 2 diabetes can often be managed by lifestyle changes and weight control, although some may need oral or injectable (insulin or other agents) treatment.

Other types of diabetes

Other types of diabetes occur less commonly. They are associated with different conditions such as damage to the pancreas or genetic conditions.

Chapter 3: Self-monitoring of blood glucose: finger-prick blood glucose

Self-monitoring of blood glucose is an important component of diabetes management. Children with Type 1 diabetes need to check their glucose levels regularly by performing finger-pricks and/or using continuous glucose monitoring system (CGMS).

Finger-prick blood glucose monitoring

A blood glucose meter is a small, portable machine that is used to measure glucose level in the blood. A finger-prick device is used to draw a drop of blood for the test.

Continuous glucose monitoring system (CGMS)

CGMS is a device inserted under the skin to measure interstitial glucose level continuously and gives information on glucose trends. Some models also have alarms to alert users on high or low sensor glucose levels.

When using a CGMS, finger-prick tests are still necessary under these situations:

• Symptoms of low or high blood glucose
• When symptoms and signs do not match the sensor glucose value
• When a treatment decision has to be made with low (<3.9mmol/L) or high (≥15mmol/L) sensor glucose readings, e.g., treatment of low blood glucose, adjusting insulin dosage before a meal, or giving a correction dose of insulin.

Students have different abilities in monitoring, interpreting and responding to their blood glucose levels according to their age and experience. Students who are younger, newly diagnosed with diabetes or with special needs require more assistance from school teachers and staff.

In general, students will need to check their glucose level:

• Before eating
• Before exercising
• When feeling unwell
• When having symptoms of hypoglycaemia (low) or
• hyperglycaemia (high)
• Other times as described in the diabetes management plan

Chapter 4: Insulin therapy: multiple daily injections (MDI) and insulin pump

Students with Type 1 diabetes depend on daily insulin therapy to replace the insulin that their body cannot produce. This has to be given by injection (injection pen or syringe) or insulin pump into the fat layer under the skin (subcutaneous). The level of support, supervision and assistance required varies for each student.

Multiple daily injections (MDI)

Multiple daily injections (MDI) typically consist of four or more injections per day. This includes one injection of long-acting insulin (basal) and injections of rapid- or short-acting insulin before each meal (bolus).

Long acting (basal) insulin:

• Slower onset and longer duration of action
• Usually given once daily at an approximate similar time every day to cover basic requirements of the body
• Examples：Glargine, Degludec

Short or rapid acting (bolus) insulin:

• Absorbed quickly into the body after the injection
• Usually given before each meal and used to correct high glucose levels
• Children need to eat within 10 minutes after insulin is administered
• Onset of action varies, for example: Aspart, Lispro: 15-30 mins, Actrapid: 30-60 mins
• Injection sites: abdomen, outer upper quadrant of buttock, arm, outer upper thigh

Insulin pump

Insulin pump is a small machine with pre-programmed insulin dose calculator. There is an insulin reservoir and infusion set that is connected to the user's body for delivery of insulin. Insulin pump gives rapid acting insulin continuously. Users need to enter the carbohydrate content to be consumed before each meal. The pump then calculates the insulin dose required and delivers the bolus after confirming with the user. Some pumps can automatically adjust basal and correction bolus according to the glucose levels from a connected CGMS.

Pump failure should be suspected if these signs and symptoms appear:

• Persistently high blood glucose, despite correction bolus
• Evidence of ketosis (e.g., urine ketone: moderate/large or blood ketone >0.6)
• Infusion set falling off

Actions to be taken:

• Inform parents
• Drink plenty of clear fluid
• Follow pump failure action plan and give correction bolus by insulin pen
• Check blood glucose (+/- ketone) every hour, and check urine for ketones with each urination

Chapter 5: Hypoglycaemia (low blood glucose) and management

Causes

• Too much insulin
• Missed or delayed meals
• Inadequate carbohydrate-containing food
• Doing extra, intense or unplanned physical activities
• Fallen sick, e.g., gastroenteritis with diarrhoea, decreased appetite or nausea/vomiting

Signs & symptoms of mild to moderate low blood glucose:

• Shaky hands
• Sweaty
• Pale
• Hungry
• Irritable or nervous
• Palpitation
• Unable to concentrate
• Weak
• Sleepy
• Dizzy
• Change in personality or behaviour
• Disorientated / Confused

Management of mild to moderate low blood glucose:

• Check blood glucose
• If blood glucose level < 3.9mmol/L: Take 5-15 grams quick-acting sugar (e.g. juice / candies)
• Recheck blood glucose level after 15 minutes
• If blood glucose level < 3.9mmol/L: Repeat 5-15 grams quick-acting sugar (e.g. juice / candies)
• If blood glucose level ≥ 3.9mmol/L: take 10 grams of complex carbohydrate (e.g. crackers / milk) to sustain the blood glucose level or take main meal instead if it is meal time and food is ready

Signs & symptoms of severe low blood glucose:

• Unresponsive
• Convulsions

Management of severe low blood glucose:

• Remain calm
• Position the student on the floor on his side to prevent choking, fall or injury
• Do not attempt to give food or drink
• Administer glucagon in the thigh
• Call 999
• Contact parents/guardian

Glucagon

Glucagon is an emergency medication used to treat severe low blood glucose. When a child is comatose or having seizures due to severe low blood glucose, stay calm and do not force-feed. Caregiver can inject glucagon for the patient or allow medical staff to do it.

How to inject Glucagon

Chapter 6: Hyperglycaemia (high blood glucose) and management

Causes

• Too little insulin
• Missing insulin dose
• Having a larger meal than usual
• Decreased physical activity
• Pump malfunction
• Stress
• Illness / Infection / Injury

Signs and symptoms of high blood glucose:

• Increased thirst sensation and/or dry mouth
• Frequent urination
• Blurry vision
• Fatigue

Management of high blood glucose:

• Check blood glucose level
• If blood glucose level ≥ 15mmol/L: Check urine or blood for ketones
• Drink extra water
• Do not engage in strenuous exercise
• Notify parents/guardian if ketones are present
• Call the ambulance if there are symptoms of diabetic ketoacidosis

Diabetic Ketoacidosis (DKA)

DKA occurs when there is severe lack of insulin which forces the body to break down fat tissue. This causes the release of by-products called ketones, which are dangerous when released at high levels. Ketones are poisonous to the body and are passed into the urine as they reach high levels in the blood. Students with diabetes are at higher risk of DKA when they are sick.

Signs and symptoms of DKA:

• Extreme thirst and dehydration
• Nausea and vomiting
• Severe abdominal pain
• Heavy breathing or shortness of breath
• Increasing sleepiness or lethargy

Management:

• Inform parents and call an ambulance to seek emergency medical care

Chapter 7: Exercise management

Children with diabetes can participate in all kinds of exercise. Some people with diabetes are in fact outstanding athletes!

Blood glucose response to exercise may vary depending on:

• Blood glucose level before starting activity
• Type of activity
• Intensity of activity
• Duration of activity
• Exercise habit

Blood glucose monitoring before exercise:

In general, if blood glucose level:

• < 3.9 mmol/L: Delay exercise and treat low glucose
• 3.9 ‒ 6.9 mmol/L: Give extra 10-20g carbohydrate
• 7 - 14.9 mmol/L: Proceed to exercise and monitor blood glucose regularly
• ≥ 15 mmol/L: Check urine/blood ketones, if positive: delay exercise If negative: drink extra water and proceed to exercise, monitor blood glucose regularly

During exercise:

May need to take 10-15g carbohydrate every 30 mins during moderate to vigorous exercise

Exercise tips for insulin pump user:

• May need to set to temporary target before exercise
• For contact sports/ water activities, insulin pump can be disconnected but for 1 hour at most only

Please refer to Chapter 11- the student's Diabetes Management Plan for more details

Chapter 8: Psychological care of children and adolescents with diabetes

Common psychological issues for children or adolescents with diabetes:

• Managing diabetes, family conflicts about diabetes management, and dealing with diabetes emotions are often a major source of stress for children and adolescents with diabetes.
• Youth with Type 1 Diabetes are about twice as likely to be diagnosed with psychiatric disorders, especially eating disorders, depression, anxiety, and behavioral disorders, compared with peers without diabetes.

A supportive school environment can help children and adolescents with diabetes gain confidence in managing their illness. Having diabetes shouldn't stop the child from fully participating in all academic, social and sporting activities. We encourage students and families affected by diabetes to let the school and other classmates know about their condition.

Sometimes other kids at school may tease about it. Hence it is important that teachers know what is going on and offer support and guidance when necessary. With close collaboration between the school and the medical team, children with diabetes can achieve their life goals and dreams as far as others do.

Chapter 9: Living a normal school life

What can the school do to support?

• Provide support and supervision to children with diabetes in school
• Receive basic diabetes education
• Provide a private and clean space for insulin injection (e.g., a corner in the classroom)
• Allow bathroom breaks or water drinking as needed
• Allow students to have access to glucose monitoring device, CGMS or insulin pump (receiver or smartphone) at all times
• Allow students to participate safely and fully in physical activities
• Implement student's individualised diabetes management plan and discuss with parents and medical team if in doubt
• Beware of peer influence, support students' psychological and social needs if necessary
• Encourage students to tell their peers about their health condition: it's part of them and there is nothing to be ashamed of! You could help too! E.g., organising a story telling session, drama, or workshop on diabetes topics

Chapter 10: FAQs

1. What should I do if the student missed a dose of rapid-acting insulin before a meal?

• Within 1 hour after eating: give half of the usual insulin dose and recheck blood glucose after 2 hours. If glucose level is still high, give a correction bolus according to the blood glucose level
• More than 1 hour after eating: give a correction bolus according to the blood glucose level
• Observe closely for any signs of high or low blood glucose levels
• Contact parents or medical team for advice if in doubt

2. What should I do if the student has accidentally given too much insulin?

• Contact parents or medical team for advice
• Take extra food with carbohydrates
• Monitor blood glucose closely for 3-5 hours and follow diabetes management plan for low glucose management if it occurs

3. Can we use cookies or milk to treat low glucose levels?

• No. For rapid treatment of low glucose, consuming fast acting carbohydrate e.g., juice/candies is recommended. It is because simple sugars help elevate the glucose levels much quicker than complex carbohydrate found in cookies and milk

4. When should the school contact parents?

• The school should contact parents when there is an emergency, e.g., severe low blood glucose, persistent high blood glucose (especially with presence of ketones), symptoms of DKA, pump failure etc
• At any time when there are concerns about psychological issues found at school

Chapter 11: Diabetes management plan

The medical team would formulate individualised diabetes management plan for each patient, please consult and follow up with your team.

Jointly produced

Endocrine and Diabetes Team, Hong Kong Children's Hospital
Youth Diabetes Action

Written by

Endocrine and Diabetes Team, Hong Kong Children's Hospital
Dr. Joanna Tung
Dr. Gloria Pang
Dr. Sarah Poon
Ms. Iris Poon
Ms. Candy Chan
Ms. Ir ne Lok
Dr. Jennie Wong (AHNH Endocrine Trainee)

Acknowledgement

Patients and families of Endocrine and Diabetes Team,
Hong Kong Children's Hospital

Spring 2025