School-age children spend about half their waking hours at school, and children with diabetes are no different. Since your child can’t leave his diabetes at home when he goes to school, it is necessary to have a plan — preferably a written plan — for managing his diabetes while he is at school. Such a plan should be individualized and should cover your child’s daily diabetes care as well as provide instructions for handling problems, emergencies, and any unusual situations that may arise during the school day. Copies of the plan should be kept at school so that your child’s teachers and other school personnel such as the nurse can access it easily when it is needed.
Types of plans
One format for laying out your child’s diabetes management needs in school is the Diabetes Medical Management Plan (DMMP), which was developed by the American Diabetes Association. A DMMP includes such information as who is responsible for particular diabetes management duties, instructions for what to do in emergency situations, and guidelines for attending to the child’s needs. (For information on getting a sample plan, see “School Plan Resources.”) In many cases, putting together a DMMP and discussing it with teachers and other school staff is all that is needed to make sure a child’s diabetes-related needs are attended to at school.
However, if you feel that your child’s diabetes is not being cared for properly in school in spite of having a DMMP in place or if he is being discriminated against because of his diabetes (for example, if a gym teacher regularly prohibits him from participating in gym activities for fear he’ll develop hypoglycemia), you may ask for a 504 plan to be developed.
Section 504 of the Rehabilitation Act of 1973 is a civil rights law that prohibits disability-based discrimination in all programs that receive or benefit from federal financial assistance. While this law does not provide extra federal funding to schools, a program failing to comply with Section 504 can lose the funding that it currently receives.
A 504 plan is an agreement between a student and a school district that the student will have full access to all school activities and will have his medical needs met. This type of plan includes information similar to that contained in a DMMP but is legally binding, where a DMMP is not.
If a student with diabetes has special education needs, an Individualized Education Plan (IEP) may be developed, using the DMMP as a foundation for details on the student’s diabetes management routine. Rules and guidelines pertaining to IEPs are found in the Individuals with Disabilities Education Act (IDEA), which provides some extra federal funding to state and local education agencies to ensure the viability of special educational services. These services are implemented to provide a free and appropriate education to students with special needs, as IDEA establishes it is the right of these students to receive.
To qualify for an IEP, a child must have an impairment that affects his academic performance. A child who has had to miss many school days due to diabetes complications and is doing poorly in his classes as a result, for instance, might qualify for an IEP. Under the law, there is certain information that an IEP must contain, including the child’s current level of academic performance, the services that he is to receive, and an evaluation and revision schedule for the IEP. The plan should be created in collaboration with the child’s parents, health-care team, teachers, and perhaps the child himself, and it must be reviewed and revised yearly, although evaluations can be conducted more frequently if desired. If the parents are unhappy with the performance of the plan, or if it no longer reflects the student’s needs, they can initiate a process to adjust the plan at any time. If, after revision, the parents still do not feel that the plan is adequate, they can refuse to sign it and try to reach an agreement or facilitate a change with the help of an outside source.
Both a 504 plan and an IEP are formal, legal documents, which means the school is legally bound to implement the practices laid out by the plan. One or the other may be particularly useful in situations where there have been prior difficulties at school or when a student is taking timed, standardized tests or going through a transitional period such as a change of grades or teachers.
As stated earlier, however, many if not most students with diabetes do fine with just a DMMP, and putting together a DMMP is useful even if parents intend to pursue the option of a 504 plan or IEP.
What to include in a DMMP
A DMMP should outline the student’s plan for the daily management of his diabetes. This plan should be developed by the parents with help from the child’s diabetes health-care team and possibly with input from the student, depending on his age. It’s a good idea for the parents to plan an office visit with members of their child’s diabetes health-care team specifically to talk about the school diabetes management plan. Once the student’s parents and health-care providers have agreed on a plan, the parents should set up a meeting with the appropriate school staff to discuss how the plan will be put into effect. After the plan has been reviewed and accepted by all parties, copies should be made available to school staff.
The DMMP should include information on the following topics:
Contact information. Phone numbers for the student’s parents, other caregivers, and physician should be included on the DMMP.
Blood glucose monitoring. Blood glucose monitoring is a necessary part of maintaining blood glucose control. In addition to providing information about blood glucose levels under normal circumstances, monitoring can also let teachers, coaches, and the student himself know effects of exercise or sickness on blood glucose levels. Monitoring provides feedback about how well insulin is working and can be useful in seeing if an insulin dose has lowered a high blood glucose level or covered the carbohydrate eaten.
The plan should address the following questions:
- Who performs the blood glucose check?
- What type of meter is used?
- Where is the meter stored and used?
- Who writes down monitoring results, and where?
- How should parents be informed of blood glucose results and treatments?
- What are the blood glucose target ranges?
- What action is to be taken if the blood glucose level is outside the target?
- Are ketones to be checked?
- At what blood glucose level should ketones be checked?
- By whom should they be checked?
- What should be done with information on ketones?
Insulin. Whether insulin is given on a regular basis during the school day (such as at lunchtime every day) or just stored at school for particular situations (such as when the student’s blood glucose is greater than 300 mg/dl) is specific to each student’s needs. Very clear guidelines should be written in the diabetes plan with regard to usual and correction doses of insulin.
School staff should be informed of the following:
- What type(s) of insulin does the student take?
- Where is the insulin stored?
- How is the insulin dose determined?
- When is insulin administered?
- Who fills the syringe, dials up the dose, injects the insulin, or supervises the bolus from an insulin pump?
If the student is on an insulin pump, written directions for its operation are also necessary.
Meal planning. Information about food issues needs to be written in the diabetes plan. Teachers, the school nurse, and often cafeteria staff need to be aware of the student’s food requirements.
Information to record includes the following:
- What time does the student eat lunch?
- Does he eat a school lunch or bring lunch from home?
- Is there a plan if the student refuses to eat his lunch?
- Who is responsible for making sure the student eats a snack?
- Does the school restrict where food can be eaten?
- Can snacks be eaten in the classroom?
- If the whole class has a snack, how will the student with diabetes be accommodated?
- Are there classroom parties or special projects that involve food?
- If so, what are the guidelines and accommodations for the student with diabetes?
How the parents are kept informed of future or past parties or events must also be part of the written plan.
Over the past 10 years, dietary recommendations for people with diabetes have undergone enormous changes. There are therefore many misconceptions about what people with diabetes can and cannot eat. Parents should get the support of the child’s health-care team to let the school team know a kid with diabetes can eat anything that a kid without diabetes can eat. There are no “bad” foods that must be avoided completely; even moderate amounts of sugar can be safely consumed. Written instructions and good communication between parents and school are key to successfully fitting meals, snacks, special treats, and parties into the school routine of a student with diabetes.
Physical activity. Physical activity at school may include gym class, recess, and after-school sports. It is important to remember that while activity is a good thing for students with diabetes, planning is important. Depending on the intensity of the activity, as well as when and how long the student will be active, a change in insulin doses or an extra snack may be necessary to avoid low blood glucose.
The plan should address the following questions:
- Does the student add a snack or increase food at lunch prior to activity?
- Whose job is it to remember the extra food?
- Is the snack something that the student brings from home?
- Is there a set blood glucose level at which activity is restricted?
- What should be done if the child has very high or very low blood glucose levels before or after exercise?
Low blood glucose. A student may have obvious symptoms of low blood glucose, or his symptoms may be so subtle that they are easily overlooked. School staff must be aware of the student’s symptoms of low blood glucose, since these symptoms differ from person to person. Additionally, it is important for the staff to know what blood glucose level is considered “low” for the student; although the American Diabetes Association recommends treating most adults for low blood glucose at 70 mg/dl, some children’s diabetes teams may recommend treating at a slightly higher level to prevent hypoglycemia (low blood glucose).
The plan should address these concerns:
- At what blood glucose level should treatment be given?
- What should be used to treat low blood glucose and how much of it should be given?
- Who will treat low blood glucose?
- Where are the treatments kept?
- When should a teacher let the school nurse know that the student has or has had low blood glucose?
How near the nurse’s office is to the classroom, as well as how safely the student can get to the office, should determine whether the student is sent there. A student with low blood glucose should not be expected or allowed to walk alone to the school nurse’s or principal’s office.
When blood glucose levels drop so low that a student has lost consciousness, can no longer swallow, or is having a seizure, glucagon must be injected (glucagon is a hormone that causes the liver to release stored glucose). In case such an injection should become necessary, the diabetes plan must contain all the relevant information, including who will inject the glucagon, at what dose, and at what injection site. Once the student has been given glucagon, his parents or 911 should be called.
High blood glucose. High blood glucose levels do not cause the immediate threat that low blood glucose does. The signs of high blood glucose include being very thirsty, having to use the bathroom often, or becoming very tired. The child’s individual symptoms should be written on the diabetes plan. The plan should state that the student is allowed to go to the bathroom as well as to get water to drink. How and when blood or urine ketones are measured should also be recorded. It should be specified whether the parents and diabetes health-care team are to be notified when blood glucose or ketone levels are high.
Emergencies. Until recently, little attention was paid to the development of a disaster plan for the student with diabetes. A disaster might be a natural one, such as a blizzard, hurricane, or tornado, or a manmade one. A lockdown of the school building could be necessary. Many schools are now asking for a diabetes management plan that covers a span of 48–72 hours, including a supply of insulin to cover that time period, in the event that a child is unable to be reunited with a parent.
An emergency situation is not the only time that a child could be separated from his insulin and snack supply for an extended period of time. A fire drill could also keep him from his diabetes supplies, so a plan should be made for fire drills in the event that the student has low blood glucose during the time outside the school building.
Field trips. Students with diabetes should never be excluded from field trips, which are not just learning experiences but also social ones. Requiring a parent to go on a field trip is often not reasonable, possible, or age-appropriate for the student. A DMMP should specify what accommodations are necessary to allow a child with diabetes to participate in outings with the rest of the class while still receiving the medical care he needs. According to the specific circumstances of the child, a DMMP should state who, if anyone, needs to accompany him, and what guidelines, such as permission to eat snacks on the bus, need to be followed.
Letting kids be kids
All children deserve a level playing field. A DMMP, 504 plan, or IEP can help ensure just that. With the aid of the information and instructions laid out in one of these written plans, and the legal recourse provided by a 504 plan or IEP, neither parent nor child will have to worry about lost opportunities or unfair treatment. Which means there will be plenty of time for the excitement that accompanies just being a kid in school.