Care of Children With Diabetes in the School and Day Care Setting
The child with diabetes
My 5-year-old son has had diabetes since he was 18 months and he is only 3′ 2″ (96 cm) tall. I have been told that he is very short for his age. The doctor says that poorly controlled diabetes could be slowing his growth. Is this true?
The average height for a 5-year -old boy is 3′ 6″ (108 cm), so your son is certainly short for his age. Having high glucose levels for several years could be the cause of this. If you now keep his dia-betes under control and make sure that he has plenty to eat, he should grow rapidly and may even catch up with his normal height. However, his short stature may be due to a growth disorder and may need further investigation.
I have been told not to expect my daughter to be as tall as she would have been had she not had diabetes. Is this true? If so, what can I do to help her reach her maximum height?
Unless your daughter’s diabetes control has been very poor, there is no reason why she should not reach her proper height without any special encouragement. We know of one 16-year-old boy who is 6′ 2″ (165.8 cm) tall and has had diabetes for 15 years. Diabetes does not have to stunt your growth.
My 6-year-old daughter has had diabetes for 4 years. She is on 12 units of Monotard insulin, once a day. Her urine test in the morning is always 2% and the teatime test 1%. My own doctor is satisfied with her tests and says that negative tests in a child of this age mean a risk of hypos. However, the school doctor says her diabetes is out of control and she should have two injections a day. What do you advice?
Until a few years ago most doctors did not try to achieve close control of diabetes in children. It was considered good enough if the child felt well and was not having a lot of hypos. The feeling nowadays is that good control is important to allow normal growth and prevent long-term complications. In the first place, you should start measuring your daughter’s blood glucose. This will tell you how serious her early morning high glucose actually is, and also whether she is running the risk of a hypo at any other time of the day. It is likely that she will need an evening injection to control her morning blood glucose. It is true that keeping her blood glucose down towards normal may make a hypo more likely. Mild hypos do not cause any harm and even severe reactions do no damage, except to the parent’s confidence! You must not worry about a few days or weeks of poor control and you will never achieve perfection in a little girl whose activities and lifestyle are changing daily.
My son, aged 10, started insulin last year and his dose has gradually dropped. Now he has come off insulin completely and is on diet alone. Will he now be off insulin permanently?
No. There is a 99.9% chance that he will have to go back on insulin. This so-called ‘honeymoon period’ can be very trying as it raises hopes that the diabetes has cleared up. Unfortunately, this very, very rarely happens in young people. Are there any special schools for children with diabetes?
There are no special schools for children with diabetes and they would not be a good idea. It is most important that young people with diabetes grow up in normal surroundings and are not encouraged to regard themselves as ‘different’. These children should go to normal schools and grow up in a normal family atmosphere.
I think my newly diagnosed son is using his insulin injections as a way of avoiding school. I can’t send him to school unless he has his insulin but it sometimes takes ages before I can get him to have his injection. I have two younger children and a husband whom I also have to help to get to school and work. How should I cope with my temperamental son?
You raise several related points. Firstly, you assume that he is using his insulin injections to avoid school. You may be right if he resisted going to school before developing diabetes. In this case you should try the same tactics that you used before. Alternatively, his dislike of school could be related to the diabetes, for example an overprotective attitude by sports instructors, frequent hypos or embarrassment about eating snacks between meals. If you suspect such difficulties, a talk to your son and his form teacher might clear the air. He may in fact be happy about school but actually frightened of his insulin injections so that things get off to a slow start in the morning. Problems with injections have been reduced with the introduction of insulin pens, but some children focus their dislike for diabetes as a whole on the unnatural process of injecting themselves.
Diabetes UK has produced an Information for Schools and Youth Organizations Pack to help parents communicate with the school. It contains information to be given to teachers and those responsible for children with diabetes. You can contact Diabetes UK for a copy of this publication.
When my son starts school, would it be better for him to return home for lunch or let him eat school dinners?
It depends largely on your son’s temperament and attitude to school. Some 4-year-olds skip happily off to their first day at school without a backward glance (much to their mother’s chagrin), while other perfectly normal children make a fuss and have tummy aches at the start of school. Diabetes will tend to add to these problems. You will have to talk to his teachers and it would be worth asking their advice and making sure that someone will take the responsibility of choosing suitable food for your son – you can’t leave that to a 4- or 5-year-old child.
My 10-year-old son has recently been diagnosed with diabetes. What is the best age for him to start doing his own injections?
The fear of injections may loom large in a child’s view of his own diabetes. Many children actually make less fuss if they do their own injections and most diabetes specialist nurses would encourage a 10-year-old to do his own injections right from day one. We know a girl who developed diabetes at the age of 6 and who gave herself her own first injection without any fuss – and has been doing so ever since. Insulin pens take a lot of the horror out of injections. If you do have an injection problem or if you want your son to have a good summer holiday, encourage him to go on a Diabetes UK holiday – you will find details in Balance or contact the care interventions team of Diabetes UK.
When I heard that I was to have a child with diabetes in my class (I am a junior school teacher), I read up all I could about diabetes. Most of my questions were answered but I cannot discover what to do if the child eats too much sugar. Will he go into a coma? If so, what do I do then?
Eating sugar or sweets may make his blood glucose rise in which case he may feel thirsty and generally off-colour. Coma from high blood glucose takes some time to develop and there is only cause for concern if he becomes very drowsy or starts vomiting. If this does happen, you should contact his parents. A child who is vomiting with poor diabetes control probably needs to go to hospital.
The most common sort of coma, which may occur over a matter of 10 minutes, is due to a hypo. In this case the blood glucose level is too low and he needs to be given sugar at once. The causes of hypo are delayed meals, missed snacks or extra exercise.
Can I apply for an allowance to look after my son who has frequent hypos and needs a lot of extra care?
Yes, as the parent of a child with unstable diabetes you can apply for a disability living allowance, which is a non-means-tested benefit. Many people in your position have successfully applied and feel that it provides some recognition of the burden of being responsible for a child with diabetes, especially if hypos are a major problem.
There is an opposing view that diabetes should not be regarded as a disability and that applying for an allowance fosters a feeling that the child is an invalid.
My little boy has diabetes and is always having coughs and colds. These make him very ill and he always becomes very sugary during each illness despite antibiotics from my doctor. Could you please give me some guidelines for coping with his diabetes during these infections?
Yes, of course.
I am headmaster of a school for deaf children and one of my pupils developed diabetes two years ago. Since then his learning ability has deteriorated and I wondered if this had any connection with his diabetes?
No. Diabetes in itself has no effect on learning ability and there are plenty of children with diabetes who excel academically. Poorly controlled diabetes with a very high blood glucose could reduce his powers of concentration. Hypoglycaemic attacks are usually short lasting but he could be missing a few key items while his blood glucose is low and be unable to catch up. At a psychological level, the double handicap of deafness and diabetes could be affecting his morale and self-confidence. Perhaps he would be helped by meeting other boys of his age who also have diabetes. This often helps children to realize that diabetes is compatible with normal life and activities. Contact Diabetes UK who can help you in this area.
My son was recently awarded a scholarship to a well-known public school but when they found he had diabetes, he was refused admission on medical grounds. They can give no positive reason for this and our consultant has tried very hard to make them change their minds. Why should he be so penalized?
This was a disgraceful decision based on old-fashioned prejudice. It looks as if nothing will make the school change its mind but, if Diabetes UK were told, they might have brought more pressure to bear. The Disability Discrimination Act will also cover access to education. You could also consider seeking legal advice.
Should my son tell his school friends about his diabetes?
It is very important that your son tells his close friends that he has diabetes. He should explain about hypos and tell them that, if he does behave in an odd way, they should make him take sugar and he should show them where he keeps his supplies. If your son shows his friends how he measures his blood glucose, they will almost certainly be interested in diabetes and be keen to help him with it. We know several young people who bring their closest friend to the hospital diabetes clinic with them. As he becomes older and spends more time away from home, your son will come to depend more on his friends.
My 10-year-old son moves on to a large comprehensive school in a few months time. Up until now he has been in a small junior school where all the staff knows about his diabetes. I worry that he will be swamped in the ‘big’ school where he will come across lots of different teachers who know nothing about his condition. Have you any advice on this problem?
Moving up to a big comprehensive school is always a daunting experience and is bound to cause the parents of a child with diabetes extra worry. The important thing is to go and talk to your son’s form teacher, preferably before the first day of term when he or she will have hundreds of new problems to cope with.
Assume that the teacher knows nothing about diabetes and try to get across the following points.
• Make sure that they know your child needs daily insulin injections.
• He may need to eat at certain unusual times.
• Describe how your son behaves when hypo and emphasize the importance of giving him sugar. If he is hypo do not send him to the school office or to home alone.
• Staggered lunch hours may be a problem as he may need to eat at a fixed time each day.
• If he needs a lunchtime injection, then you need to arrange with his teachers how he should store and have access to his insulin, syringe or insulin pen, and blood testing equipment.
• You will need to be told if he is going to be kept in late (e.g. for detention) as parents tend to worry if their children fail to show up.
• Ask the form teacher to make sure all your son’s other teachers know these facts.
Diabetes UK supplies a School Pack, which should help explain diabetes to his teachers and it is especially important to speak personally to his sports and swimming instructors. If there are problems with the school over such things as sports, outings or school meals, your diabetes clinic may have a diabetes specialist nurse or health visitor who could go to the school and explain things. You will probably have to repeat this exercise at the beginning of every school year.
What arrangements can I make with school about my 9-year-old daughter’s special requirements for school dinners?
It is important to go and see the head teacher and preferably the caterer to explain that your daughter must have her dinner on time. Explain that she needs a certain amount of carbohydrate in a form that she will eat and that she should avoid puddings containing sugar. If your diabetes clinic has a diabetes specialist nurse or health visitor, she may be able to go to the school and give advice.
Most parents of children with diabetes get round the whole problem by providing a packed lunch. This means that you have more control over what your daughter eats and you can supply the sort of food she likes and what is good for her. Point out to your daughter that it would be best for her to eat the contents of her own lunch box, and not to swap them with other children! When she goes on to secondary school she may be faced with a cafeteria system. This should allow her to choose suitable food but she may also choose unsuitable items and try to exist on jam doughnuts.
My son has diabetes. Can I allow him to go on school trips?
In general the answer is yes, but for your own peace of mind you would want to be satisfied that one of the staff on the trip would be prepared to take responsibility for your son. Day trips should be no problem as long as someone can be sure that he eats on time and has his second injection if necessary. At junior school level, long trips away from home, especially on the continent, could be more difficult and it really depends on you finding a member of staff that you can trust. They will need to keep an eye on your son and to know how to cope sensibly with problems like a bad hypo. Once in secondary school most children manage to go away on trips with the school, scouts or a youth group. Of course one of the adults in the party should be responsible, but as your son gets older he will be better able to look after himself.
Diabetes UK has the following check list for things to take on school trips and holidays:
• Identification necklace or bracelet
• Glucose
• Insulin, insulin pen (or syringe), needles
• Testing equipment for blood glucose
• Food to cover journeys with extra for unexpected delays
• Hypostop Gel.
My 10-year-old child has heard about Diabetes UK camps from the clinic. I am a bit worried about letting him go off on his own for two weeks. Do you not think that I shouldwait a few years before sending him to a camp?
No, he’s not too young to go. Diabetes UK has been organizing holidays for children since the 1930s and it has become an enormous enterprise. About 500 children take part in these holidays each year, so in one sense your son will not be on his own. Young children love going on group holidays, and the fact of being with other children with diabetes gives them a great sense of confidence – for once they are not the odd ones out. The children learn a great deal from each other and from the staff. Your son will have an exciting holiday and you will have a few weeks off from worrying about his diabetes.
Is it safe to let my little girl go on a Diabetes UK camp?
Perfectly safe. The care interventions team of Diabetes UK has had years of experience in running holidays for children. The average camp consists of 30–35 children who are supervised by the following staff:
• Warden, responsible for planning
• Senior Medical Officer, who is experienced in diabetes
• Junior Medical Officer
• 2–4 Nurses, usually with a special interest in diabetes and/or children
• 3 Dietitians
• 1–2 Deputy Wardens
• 8 Junior Leaders, young adults with diabetes themselves, who give up two weeks to help.
The staff/child ratio is about 1:2 and there is always close supervision on outings and all sports, especially swimming.
COPING WITH DIABETES DURING INFECTIONS
Insulin
• Never stop the insulin even if your son is vomiting. During feverish illnesses the body often needs more insulin, not less.
• During an illness it may be useful to use only clear (short-acting) insulin.
• You may have to give three or four injections a day as this is much more flexible and so you can respond more quickly to changes in the situation.
• Give one-third of the total daily insulin dose in the morning, as clear insulin only.
Food
• Stop solid food but give him sugary drinks, e.g. Lucozade 60 ml (10 g) or orange squash with two teaspoons of sugar (10 g).
• Milk drinks and yoghurt are an acceptable alternative for ill children.
• Aim to give 10–20 g of carbohydrate every hour.
Blood tests
• At midday, check his blood glucose and, if it is 13 mmol/litre or more, give the same dose of clear insulin as in the morning plus an extra 2 units.
• Repeat this process every 4–6 hours, increasing the dose of insulin if the blood glucose remains high.
• Once he is better, cut the insulin back to the original dose.
Ketones
• Check his urine for ketones twice daily. If these are +++, either your son needs more food or his diabetes is going badly out of control.
Vomiting
• Young children who vomit more than two or three times should always be seen by a doctor or specialist nurse to help supervise the illness.
They can become dehydrated in the space of a few hours and if vomiting continues they will need fluid dripped into a vein.
Unfortunately this means a hospital admission.
