DATE: _________________
SCHOOL: _________________________________________________ GRADE: _________________
STUDENT: ________________________________________________ BIRTHDATE: _________________
HOME ADDRESS: ___________________________________________________________________________
PARENT/GUARDIAN:________________________________________________________________________
PARENT'S PHONE: Home: _______________ Mom's work: _______________ Dad's work: _______________
EMERGENCY CONTACT (NAME, NUMBER AND RELATIONSHIP):
____________________________________________________________________________________
MEDICATION: Insulin:________________________________________________________________
ALLERGIES: ________________________________________________________________________
HEIGHT: _________________ WEIGHT: _________________

PHYSICIAN AND PHONE: ___________________________________________________________
HOSPITAL PREFERENCE: __________________________________________________________

1. GENERAL INFORMATION FOR SCHOOL PERSONNEL
Diabetes is not contagious. Type 1 diabetes is caused by the pancreas not producing enough insulin. The result is too much sugar in the blood. Treatment consists of daily shots of insulin, blood sugar tests, food management, and exercise. It is an entirely different condition from adult-onset diabetes, in which shots may not be required. The priority for a child with diabetes is to lead a normal life. Children with diabetes can participate in all school activities, including sports. They should not and do not want to be singled out. They should be treated in the same way as others. Although performance may be impaired during and after low blood sugars, schoolwork and grades should not be affected by diabetes.

2. FOODS AND SNACKS
In general, large amounts of high-sugar foods are avoided. The child with diabetes may need snacks in the morning and/or afternoon as these are often the times when insulin has its greatest effect and blood sugars are lowest. In general, the morning snack should be around 10:30 or 11:00 a.m., depending on the child. If not too disruptive to the class, most children do best just eating their snack at their desk. By doing this they will not miss as much school time. Others may prefer to eat their snack in the nurse's or school office. If gym class is in the last hour of the morning or afternoon (the parents should find out before the first day of school), a snack is usually needed before gym. If other children question why the child with diabetes is having a snack, the teacher should explain that it is because he/she has diabetes. It is usually then well-accepted.

3. BLOOD SUGAR TESTING
There may be times that blood sugar testing needs to be done at school. This may be at a set time (e.g., before lunch) or it may be when a low blood sugar is suspected. A form is included at the end of this chapter to use to keep records of blood sugars at school. This might be copied weekly or at some regular interval to send home to the parents. Children have their own testing equipment. This should be kept in their backpack or an extra set should be in their desk, the nurse's or the principal's office. When possible we prefer that the student be allowed to test their blood sugar at their desk. School personnel may need to be taught how to do blood sugar testing to help younger children.

4. LOW BLOOD SUGAR ("Insulin Reaction" or "Hypoglycemia")
This is the only emergency likely to occur at school.

• Onset: SUDDEN and, if not treated promptly, can be an emergency.
  
• Signs: Variable, but may be any of the following:
  
  • Hungry
    
  • Eyes appear glassy, dilated, or "big" pupils
    
  • Personality changes such as crying or stubbornness
    
  • Inattention, drowsiness, or sleepiness at unusual times
    
  • If not treated, loss of consciousness and/or seizure
    
  • Pale, sweating, shaking
    
  • Pale or flushed face
    
  • Headaches
    
  • Weak, irritable, or confused
    
  • Speech and coordination changes
    
• Student's usual symptoms are: ____________________________________________________________
  _______________________________________________________________________________________
  
• Most likely time to occur is before lunch or after gym class.
  
• Causes: Too much insulin, extra exercise, a missed snack, or less food at a meal than is usually eaten. Field days or trips with extra exercise and excitement may result in reactions. The parents should be aware of all field days or trips so that the insulin dose can be reduced and/or extra snacks provided.
  
• Treatment:
  
  1. Mild Reaction
     Symptoms: Hunger, shaking, personality changes, drowsiness, headache, paleness, confusion, or sweating.
     Blood sugar: If equipment is available to do a blood sugar test, this is ideal to do even if juice has been taken. We prefer this to be done by the student (if old enough) in the classroom so that extra energy is not spent going elsewhere. However, we realize that for some schools this is not possible (note G). It takes 10 minutes for the blood sugar to rise after the juice has been given. Doing the blood sugar tests will help to tell if the blood sugar was truly low and how low (70-120 mg/dl or 3.9-6.7 mmol/L is normal for a person without diabetes) or if the symptoms were just due to a rapid fall in blood sugar.
     Treatment: two or three sugar packets, cubes or tablets (can dissolve in warm water), or
     one small can (4-6 oz or 1/2 cup) of juice, or
     instant glucose, or
     any sugar-containing food or drink
     Liquids are absorbed in the stomach more rapidly than are solid foods. However, INSULIN REACTIONS TREATED WITH LIQUIDS INITIALLY SHOULD BE FOLLOWED IN 10 MINUTES WITH MORE SUBSTANTIAL FOOD (e.g., cheese and crackers or 1/2 sandwich, etc.).
     
  2. Moderate Reaction
     Symptoms: Combative behavior, disorientation, lethargy.
     Blood sugar: Do the same as in a Mild Reaction (see above).
     Treatment: Instant glucose immediately, then give sugar or juice. After the person is feeling better (10 minutes), give solid food as above.
     
  3. Severe Reaction
     Symptoms: Seizure or unconsciousness
     Treatment: CALL 911 IMMEDIATELY
     Give glucagon (0.5cc) subcutaneously or intramuscularly if nurse is available to administer
     
• IF YOU SEND THE CHILD TO THE OFFICE, HAVE SOMEONE ACCOMPANY HIM/HER. The child may become confused and not make it to the office, if he/she is alone.
  
• If you suspect that the child is having a low blood sugar reaction and it is not possible to do a blood sugar, do not hesitate to give the child something sweet to drink (such as juice or sugar pop).
  
• In general, it is helpful if the school will notify the parents whenever an insulin reaction occurs at school. This will allow for adjustment of the insulin dose the next day so that hopefully further reactions can be prevented. Children often forget to tell their parents that they had an insulin reaction.
  

5. HIGH BLOOD SUGAR
People with diabetes may have high blood sugars and spill extra sugar into the urine on some occasions. These occasions include periods of stress, illness, overeating, and/or lack of exercise. High sugars are generally NOT an emergency (unless accompanied by vomiting). When the blood sugar is above 300 mg/dl (16.65 mmol/L), the urine ketones also need to be checked (a urine dipstick). When the sugar is high, the child will have to drink more and urinate more frequently. It is essential to make bathroom privileges readily available. If the teacher notes that the child is going to the bathroom frequently over a period of several days, the parent should be notified. The diabetes care provider can then adjust the insulin dose. The student may also occasionally need to check the urine ketones at school. This may be because ketones were present earlier at home, because the blood sugar is above 300 mg/dl (16.65 mmol/L), or because the child is not feeling well. The parents should be notified if moderate or large urine ketones are present as extra insulin will be needed.

Extra insulin possibly needed at school by our child:
For blood sugar above: _______________ give: _______________
To be given by: child _____, parent _____, school RN _____, school staff _____
(If insulin is given by the child, it should be supervised.)
Physician's signature: ___________________________________________________

6. CLASS PARTIES
If the class is having a special snack, the child with diabetes should also be given a snack. Please notify the parents ahead of time so that they can decide whether the child may eat the same snack as the other students or they may want to provide an alternate food. Preferred types of snacks are: fruit (fresh or dried), trail mix, pretzels, diet soda, sorbitol candy, sugarless gum, etc.
Suggested treats for school parties: ____________________________________________________________
___________________________________________________________________________________________
If an alternate snack is not available, the student should be given the same snack as the other children.

7. BUS TRAVEL
Please allow ________________________ to take some food with him/her on the bus. It would also be helpful if the teacher checks with the bus driver to see what arrangements parents can make for allowing snacks on the way to or from school. At times, bus rides take longer than usual due to bad weather or stalls, and the child needs to have a snack available and permission from the bus driver to eat it if necessary.

8. SUBSTITUTE TEACHERS
Place a copy of this information sheet in either the substitute teacher's folder or mark the attendance register so that a substitute would know:

• there is a child with diabetes in the class
  
• when he/she usually eats a snack; and
  
• symptoms and treatment of an insulin reaction.

9. GYM (PHYSICAL EDUCATION) TEACHERS AND COACHES
It is particularly important for the gym teacher or coach to also have a copy of this information. Low blood sugars may occur during exercise, and a source of instant sugar should be nearby. Often a snack is recommended before gym and the child may be delayed in getting started. Exercise is even more important for children with diabetes than for other children. They should not be excluded from gym or sports activities.

10. AFTER SCHOOL DETENTION
Children with diabetes should not be singled out or treated differently from the rest of the class. However, if required to remain after school (at noon or in the afternoon) for a longer time than usual, an extra snack should be given. Most parents will have packets of cheese and crackers, peanut butter and crackers, or some such snack for the teacher to keep in the drawer. This is a common time of the day for the morning or afternoon insulins to be peaking. If a snack is not taken, an insulin reaction is likely to occur.

OTHER SPECIFIC INSTRUCTIONS
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

TO THE PARENT/GUARDIAN: If your child experiences a change in health condition (such as a change in medication or a hospitalization), contact the School Nurse so that this Health Care Plan can be revised.

I give permission for the staff at ________________________________ to carry out this Health Care Plan for _________________________________________ effective until revised.