THIS GUIDELINE DESCRIBES THE MANAGEMENT OF DIABETES

Transcription

1 THIS GUIDELINE DESCRIBES THE MANAGEMENT OF DIABETES IN THE SCHOOL & EARLY YEARS SETTINGS INCLUDING THE ROLE OF COMMUNITY CHILD HEALTH MEDICAL AND NURSING SERVICES (NOT RELEVANT TO ARGYLL & BUTE see separate guideline) This guideline is designed to assist both health-care and non-health-care personnel involved in the care of children Lead Reviewer: Mairi Dunbar Version: 1 Authorised by: Mairi Dunbar Date: 10 April 2017 Distribution: Medicines in Schools Steering Group The Highland Council Health & Safety Hospital Paediatricians Committee Pharmacists Schools/Nurseries Public Health Nurses Community Paediatricians GP s Method CD Rom Paper Intranet Authorised by: Mairi Dunbar Page 1 of 11

2 Description of clinical condition & Support required Diabetes Mellitus The majority of children who have diabetes will have Type 1 diabetes which is when the body is unable to produce insulin in order to regulate blood sugar levels. This type of diabetes will require treatment with insulin. There may also be children in school with Type 2 diabetes which is when the body either doesn t produce enough insulin or is resistant to insulin. Treatment in this case may include dietary management strategies, tablets and/or insulin. A very small number of children will have other rarer forms of diabetes, e.g. Cystic Fibrosis related diabetes. In CF related diabetes there are different dietary requirements. Please see the Medicines in School Cystic Fibrosis Guidance document for further information. Support with insulin injections and pump therapy *Note Some children are using a Freestyle Libre device to determine their sugar levels (scanning over a sensor in their arm) as well as finger prick blood sugar testing. The Libre device measures the sugar in the tissues and not in the blood. Always use finger prick blood sugar readings when making decisions about hypo treatment, insulin or when the child is unwell. Children are on a variety of insulin regimes with some requiring lunchtime injections or snack/mealtime insulin pump boluses. Many children will be able to administer their mealtime insulin completely independently either via injection or by giving an insulin pump bolus. However some younger children may require supervision from education staff in order to ensure the insulin is administered safely. Others will require staff to administer the injection or give an insulin bolus via the pump. Some children will be comfortable to administer their insulin in front of their peers, while for others a private place to take the injection will be welcomed and should be made available. An injection or insulin pump bolus should be given no more than 15 minutes before the meal. Therefore issues such as lunch queuing need to be taken into account whilst ensuring that pupils are not separated unnecessarily from their peer group. Please speak to the School Nurse or the Diabetes Specialist Nurse about the safe disposal of sharps. Authorised by: Mairi Dunbar Page 2 of 11

3 Support with Blood sugar testing *Note Some children are using a Freestyle Libre device to determine their sugar levels (scanning over a sensor in their arm) as well as finger prick blood sugar testing. The Libre device measures the sugar in the tissues and not in the blood. Always use finger prick blood sugar readings when making decisions about hypo treatment, insulin or when the child is unwell. Complications at school Common Complication - Most children will test their blood glucose on a regular basis. Some children will need assistance with this, while others will manage independently. Blood sugar testing is a very quick procedure and should take less than a minute. The blood sugar target is mmol/l. Where children require assistance, parents/carers can advise on how often and when the child should do the test and negotiate a system of how to report results back to them. Please speak to the School Nurse or the Diabetes Specialist Nurse about the safe disposal of sharps. Children with diabetes are susceptible to episodes of low blood sugar (hypoglycaemia) or hypos, where the blood sugar drops below 4.0 mmol/l.* While aiming for optimal blood glucose control one or two hypos a week will be almost inevitable. *Note Some children are using a Freestyle Libre device to determine their sugar levels (scanning over a sensor in their arm) as well as finger prick blood sugar testing. The Libre device measures the sugar in the tissues and not in the blood. Always use finger prick blood sugar readings when making decisions about hypo treatment, insulin or when the child is unwell. Precipitating factors Preventative measures During or after exercise When a meal or snack is due, delayed or missed Too much insulin Stomach upset e.g. diarrhoea and vomiting Excitement or Stress Unknown cause (occasionally) Meals or snacks should not be delayed or food omitted Be aware of children if lunch money is lost Parents/Carers can provide a snack or sports drink for before or during PE/ extracurricular activities Adjustment to mealtime insulin doses (if relevant) to take account of planned exercise Be aware if child is detained in class for any reason that food requires to be made available Authorised by: Mairi Dunbar Page 3 of 11

4 Common signs & symptoms Treatment *Note Some children are using a Freestyle Libre device to determine their sugar levels (scanning over a sensor in their arm) as well as finger prick blood sugar testing. The Libre device measures the sugar in the tissues and not in the blood. Always use finger prick blood sugar readings when making decisions about hypo treatment, insulin or the child is unwell. Please be aware Lucozade and other fizzy sugary drinks are no longer advised as hypo treatments due to reductions in the sugar content. Any of the following: Pallor, sweating Shaking or unsteadiness/faint Funny feelings in the head or abdomen Hunger lack of concentration, glazed eyes Uncharacteristic behaviour either quiet (vague), confused, obstreperous or tearful Drowsy Other as advised by parent/carer If available try to confirm a hypo by checking the blood sugar first. If however blood sugar testing is not available and you are not sure whether it is a hypo or not, treat anyway, as no immediate harm will be done. Treatment should be immediate and with sugar, for example, Dextrose/Lucozade Tablets or Fresh fruit juice or Other as advised by parent Treatment should be given wherever the child is at the time, e.g. in class, as walking for example to the office, sick bay will worsen the hypo. Do not make an unnecessary fuss. Hypo treatment differs with age as follows: Nursery Pupils: 100mls fresh fruit juice or 3-4 Dextro/Lucozade Tablets or 4 Fruit Pastilles Glucose gel (1 tube) if uncooperative/confused Primary School Pupils: mls fresh fruit juice or 3-6 Dextro/Lucozade Tablets or 4-6 Fruit Pastilles Glucose gel (1 1½ tubes) if uncooperative/ confused Secondary school Pupils: mls fresh fruit juice or 5-8 Dextrose/Lucozade Tablets or 6-8 Fruit Pastilles Glucose gel (1½ - 2 tubes) if uncooperative/ confused Authorised by: Mairi Dunbar Page 4 of 11

5 Treatment (cont.) The treatment should be repeated after 10 minutes if the blood sugar has not risen above 4.0 mmols/l. Unless a meal or snack is due within the next hour or the child is on pump therapy follow this with some starchy carbohydrate as well e.g. a plain biscuit or a cereal bar. Parents are responsible for providing necessary supplies, both for the school bag and the spares for school to hold. Communication with Parents/Carers School Attendance Preparation & Support during School Trips If left untreated a hypo can cause a child to become very drowsy, unable to swallow and pass out completely or have a fit. If this happens give nothing by mouth, lay the child in recovery position (on their side) and dial 999 for an ambulance. Parents/Carers are the expert in their child s care. There should be appropriate arrangements in place to inform parents/carers when hypoglycaemia occurs in school. If hypos or indeed high sugars are occurring frequently and there are continuing concerns the Diabetes team should also be contacted for advice. Children with diabetes are expected to have attendance levels comparable to their peers who do not have diabetes. If there are concerns about attendance this should be discussed with parents/carers in the first instance but if there are continuing concerns the Diabetes team should be contacted for advice. This should not present a problem provided the following principles are followed: Day trips: Regular meals and the child may need a between meal snack dependent on their insulin regime (take some extra food in case of unforeseen delays) Extra snacks or sports drinks or sweets for vigorous or sustained physical activity Prompt treatment of hypoglycaemia should it occur If the child requires an insulin injection or insulin pump bolus during the trip the degree of supervision should be discussed with the parents/carers well in advance, so that additional support can be put in place as necessary. Authorised by: Mairi Dunbar Page 5 of 11

6 Preparation & Support during School Trips (cont.) Responsibilities of Organisations Health Overnight trips: Staff accompanying the trip and parents/carers should meet in advance to ensure that staff are fully aware of the child s diabetes regime including how to deal with any emergencies as might arise. Supplies taken on the trip should include blood ketone strips, fast acting insulin, glucose gel and glucagon. Staff should ensure that their insurance company is notified that there is a child in the party with diabetes. The Diabetes Specialist Nurse can be contacted in advance if additional advice or training is felt to be required. A detailed individualised care plan for the child s diabetes management during the trip can also be prepared on request if due notice is given. There will be a named Community Paediatrician for each school. There will be a named school nurse for each school. Provide relevant training to staff on how to support children with diabetes at school on request. Liaise in provision of relevant clinical guidance. Education Headteacher responsible for ensuring staff receive appropriate training. Ensure appropriate facilities and procedures are in place in education environments to support children with diabetes. Liaise with parents in relation to sharing information on health and medicine requirements for their children. Social Work Ensure relevant staff receive appropriate training. Ensure appropriate facilities and procedures are in place in education environments to support children with diabetes. Liaise with parents in relation to sharing information on health and medicine requirements for their children. Authorised by: Mairi Dunbar Page 6 of 11

7 Responsibilities of Personnel involved Lead Consultant Paediatrician or Diabetologist Dr Victoria Franklin (Paediatric Team) age 0-16 yrs Dr David MacFarlane (Young Adult Team) age over 16 years Transfer between teams is flexible and usually occurs between the ages of 15 and 17 years For paediatric patients, letters from the Diabetes clinics will be copied to the appropriate School Nurse/Health Visitor Diabetes Nurse Specialist(s) Highlands: Paediatric Diabetes Specialist Nurses Tel: Diabetes Specialist Nurse (Adults) Tel / The Diabetes Specialist Nurse is often the first point of contact for parents/carers and young people if specific information is required. The Diabetes Specialist Nurse will ensure that Head teachers receive an up to date list of pupils with diabetes once a year, including which children are having lunchtime injections or on an insulin pump. Note: Parents/carers will be responsible for informing the school at the time of diagnosis. In conjunction with the parents/carers the Diabetes Specialist Nurse will prepare the initial individual health care plan when a child is newly diagnosed as well as for specific situations where a child requires assistance from staff with insulin injections and in all cases of pump therapy. Please note: Pupils over the age of 16yrs attending the Young Adult Clinic and their parents/carers will be responsible for informing the school about the diagnosis of diabetes as NHS policies on privacy and consent prevent this information being shared by health care professionals. The Diabetes Specialist Nurse will aim to provide general awareness training to education staff every 3 years where it is requested. Training for staff who are assisting children to check blood sugars, administer insulin injections or give insulin pump boluses will be carried out on a pupil Authorised by: Mairi Dunbar Page 7 of 11

8 specific basis as required. The Diabetes Specialist Nurses will offer a general diabetes update session to School Nurses and Health Visitors every 3 yrs. Dieticians affiliated to the Diabetes Teams Advice is recorded and shared with relevant members of the diabetes team, health, education and social work colleagues as appropriate. Highland Council Area: Lochaber Tel Caithness & Sutherland Tel Skye & Lochalsh Tel All other Highland Council Areas: Children 0-16 yrs. Tel: Young Adult 16yrs+ Tel Community Paediatricians School Nurses & Health Visitors Parents/Carers The Dietician can provide advice to school nurses and school staff as required. Where necessary liaise with parents and members of the Diabetes Team to support children who experience difficulties managing their diabetes in school or where there are complex health or social concerns. Should ensure that Education staff in individual schools and nurseries are aware of pupils who have diabetes Teachers and support staff are aware of how to access assistance from the Diabetes Specialist Nurse to address training needs, in order for them to have the appropriate knowledge and skills to support pupils with diabetes Support is given to education staff when requested when individual health care plans are updated, referring to the Diabetes Specialist Nurse as necessary Any problems or concerns unable to be dealt with by the School Nurse or Health Visitor are referred to the Diabetes Specialist Nurse Inform the school of their child s condition, hypo signs, treatment in school and level of supervision required Keep school information current Authorised by: Mairi Dunbar Page 8 of 11

9 Parents/Carers (cont.) Education staff e.g. teachers, playgroup leaders, classroom assistants etc In conjunction with education staff update the child s individual health care plan on an annual basis and on transition to primary and secondary school. Note: Where a child requires assistance with insulin administration and in all cases of pump therapy the plan will be updated in conjunction with the Diabetes Specialist Nurse. Provide school with relevant snacks and emergency hypo supplies Responsible for ensuring all equipment held in school in relation to diabetes management is in date and working correctly e.g. blood sugar meters and insulin injection pens Meets with school/social care staff in advance of school trips to discuss the child s diabetes regime including how to deal with emergency situations including severe hypos and prevention of Diabetic Ketoacidosis. Raises any concerns or queries about their child s diabetes management in school with the Headteacher, School Nurse and/or the Diabetes Specialist Nurse as appropriate. Obtain relevant information about children with diabetes in their class. It is particularly important that supply or temporary staff are informed if they have a child in their class with diabetes. Take steps to enhance knowledge and skills in order to support children with diabetes, including attendance at relevant training Headteacher responsible for ensuring staff receive relevant training and maintaining records of such persons. Annual updating of individual health care plans in conjunction with parents as outlined on Medicines in Schools website. Note: Where a child requires assistance with insulin administration and in all cases of pump therapy the plan will be updated in conjunction with the Diabetes Specialist Nurse. Share information with health and social care staff as appropriate e.g. highlighting poor school attendance related to diabetes Raise any issues or concerns about diabetes management in school with the School Nurse/Health Visitor and/or Diabetes Specialist Nurse as appropriate. Authorised by: Mairi Dunbar Page 9 of 11

10 Requirements for implementation Training Continuing professional development Health staff Updates on diabetes for School Nurses and Health Visitors offered by the Diabetes Specialist Nurses every 3 years (unless new developments deemed significant by the Diabetes Team necessitate this to be sooner). Training School and Social Work staff Equipment/facilities Documentation Content of training to include prevalence, aetiology, treatment & complications, impact on lifestyle, issues for relevant age groups, planning for school trips and policies in place. General update on diabetes every 3 years for school staff conducted by the Diabetes Specialist Nurse upon request Content of update to include description of condition, treatment regimes, prevention/treatment strategies/triggers in relation to hypoglycaemia, dealing with emergencies at school, planning for school trips policies in place and when to refer. Specific training and annual updates by the Diabetes Specialist Nurse to support individual children in school/nursery such as those requiring assistance with insulin administration. Delivery of specific training for care staff for those children in local authority care delivered by the Diabetes Specialist Nurse as requested. Storage of supplies from parents and carers for treatment of hypos with easy access. Most children will be responsible for their own insulin and carry it on their person if it is required during the school day. Storage of insulin - If insulin requires to be kept at school, it should be labelled with the child s name with any appropriate directions and stored securely at room temperature. Only insulin pens/cartridges in use should be stored at school. Insulin expiry dates Parents/carers are responsible for ensuring insulin used at school is in date. Prefilled Insulin pens/cartridges in use should be disposed of by parents after 28 days. Communication of blood sugars and insulin doses (where appropriate) to parents/carers where this is requested by a mutually agreed method e.g. via blood sugar diary, homework diary Authorised by: Mairi Dunbar Page 10 of 11

11 Documentation (cont.) Individual Health Care Plans including where appropriate completion of Record of Training sheet for staff assisting a child to administer insulin. Incident Recording Organisation specific documentation Referrals and Liaisons Liaison with the diabetes team is particularly important at school entry and before transfer to secondary school from P7, and on any school transfer. For contact details refer to section on responsibilities of personnel involved. Exceptions School not advised by parent/carer of child s condition Staff member declines to provide treatment In these instances it would be appropriate to contact the child s parents or phone for an ambulance/medical assistance as appropriate. Resources referred to during the creation of this guideline: Childhood & Adolescent Diabetes Scotland (2014) Supporting Children & Young People in Type 1 Diabetes in Education Diabetes UK (2014) Type 1 Diabetes At School School & Parent Packs The Scottish Government (2014) Diabetes Improvement Plan Scottish Executive (2001) The Administration of Medicines in Schools Guidelines ISPAD (2014) Clinical Practice Consensus Guidelines: Assessment and management of hypoglycaemia in children and adolescents with diabetes Scottish Intercollegiate Guidelines Network (SIGN) (March 2010, updated May 2014). Management of diabetes: A national clinical guideline [online] Available at: < 29 January 2016] The National Institute for Health and Care Excellence (NICE) (August 2015). Diabetes (type 1 and type 2) in children and young people: diagnosis and management [online] Available at: [Accessed 29 January 2016] Authorised by: Mairi Dunbar Page 11 of 11