Helping all children become happy learners
Diabetes
Introduction
Diabetes (Diabetes Mellitus) is a condition affecting an individual's ability to regulate the amount of sugar in their blood. When blood sugar is too low our bodies no longer have the energy it needs to function properly. If blood sugar levels continue to drop then then the brain begins to shut down. Ultimately, if no action is taken to address the low blood sugar this can lead to coma and death. The opposite is having too much sugar in our blood. If left unmanaged over a period of 24 hours or more this too can be fatal. However, this is very rare and the main aim of managing high blood sugar levels is to reduce the risk of long term health conditions and reduced life expectancy.
There are two types of diabetes: Type 1 and Type 2. In Type 1 the body fails to produce any insulin, a hormone necessary for the transmission of sugars from the blood to the cells of the body. In Type 2, the body produces insulin but either not enough or for some reason it doesn't work properly.
Management of diabetes depends of the severity of the condition. For some diabetics dietary and lifestyle changes are enough but for others it can include regular monitoring of blood sugar levels and injections of insulin throughout the day.
What is the normal blood sugar range?
A healthy individual will usually have a blood sugar level of between 4 and 6 mmol/L (milimoles per litre) before eating. After eating blood sugar can rise rapidly as the body absorbs carbohydrates and other foods. A healthy individual's blood sugar should then gradually fall and be below 7.8 mmol/L about 2 hours after eating. Because diabetes is a condition of having too much blood sugar the optimum range for a diabetic is 4 to 7 mmol/L before meals and between 5 and 9 mmol/L 2 hours after meals.
It is important to follow professional medical advice and guidance regarding the exact range for any specific individual.
How do you get diabetes?
Type 1 diabetes is caused by a fault in the autoimmune system. For reasons still unknown, the cells in the pancreas responsible for making insulin are attacked and destroyed. Type 1 is a comparatively rare form of diabetes in the general population.
The majority of children have Type 1 diabetes
About 90% of adult diabetics have Type 2. Anyone can develop Type 2 diabetes but some people are more genetically likely to develop the condition than others. Risk also increases with age particularly beyond the age of 50. Other important risk factors are weight and lifestyle. There is a correlation between increasing rates of obesity and rises in those diagnosed with Type 2 diabetes.
Type 2 diabetes is rare in children but incidence rates are increasing
It is also worth noting that there is a correlation between eating disorders such as anorexia nervosa and diabetes.
What is a 'low' or 'hypo'?
'Low' and 'hypo' are everyday terms for hypoglycemia, the medical name for low blood sugar. Someone is usually considered hypoglycemic when their blood sugar level falls below 4 mmol/L (72mg/dL). A person with low blood sugar may start to experience a range of symptoms. These usually include:
difficulty concentrating
fatigue
feeling dizzy
sweating
Hypoglycemia may also cause:
being pale
feeling weak
being hungry
a faster heart rate
blurred vision
confusion
If hypoglycemia is untreated:
convulsions
loss of consciousness
coma and eventually death
It should be noted that it is extremely rare for hypoglycemia to be fatal. Blood sugar levels take time to be exhausted before becoming critically dangerous. However, convulsions and loss of consciousness represent a real emergency with a real possibility of death.
The diabetes plan for the student should assess this risk and have clear procedures for dealing with it. This should involve both emergency services and any actions that staff should take such as the use of glucose gels rubbed into the inside of the mouth.
What is hyperglycemia?
Hyperglycemia is the medical name for having high levels of sugar in the blood. It is usally defined as being greater than 7 mmol/L (126 mg/dl) when fasting or over 11mmol/L (200mg/dl) two hours after eating.
Schools often worry about their students having a 'hypo' because of the rare risk of coma and fatality. Of course, they are right to. However, it is the opposite, having hyperglycemia, that their doctors are concerned about; as this leads to long term health issues and a reduced life expectancy.
When the blood sugar level is above 7 mmol/L for extended periods of time there is a risk of damage to internal organs. When blood sugar levels reach 11 mmol/L (200mg/dl) the individual may start to experience any of the following symptoms:
feeling thirsty
needing to urinate more often
feeling tired
blurred vision
If the blood sugar level continue to rise then there is the risk of acute and potentially fatal symptoms including Diabetic Ketoacidosis. This is a dangerous complication that occurs when the blood glucose levels rise above 15 mmol/l (270 mg/dl). This usually occurs because the body has run out of insulin. The body can no longer get any energy from blood sugar and starts to burn fats. This in turn produces acidic ketone bodies that build up in the blood and can cause the following symptoms:
vomiting
dehydration
rapid heartrate
rapid breathing
confusion
strange smell on breath (like pear drops)
coma
The symptoms of Diabetic Ketoacidosis develop over a period of about 24 hours. With regular monitoring and access to medication these symtoms should rarely occur in school. However, immediate action is needed as soon as blood sugar levels rise above 15 mmol/l (270 mg/dl). Treatment is generally to give additional insulin or other prescribed medication. This should only be done in accordance with the diabetic plan agreed with parents. Exercising and drinking water can also help reduce blood sugar levels.
How do you manage the medical needs of diabetics in school?
It is important to have an agreed plan with parents and where possible medical professionals such as the diabetes nurse. This plan should indicate the frequency of scheduled blood sugar monitoring and the optimum range that it should be for the student. It should then state what action should be taken by the school when the level is too low and when it is too high.
Nearly all students with diabetes have Type 1 and therefore require injections of insulin to maintain the correct level of blood sugar. Injections are usually necessary at lunchtime to counter the rise in blood sugar that follows eating lunch. The exact dose of insulin required can vary from day to day depending on the blood sugar level before lunch and how much food has been consumed at lunchtime. Other factors such as sports lessons and minor illnesses like coughs and colds can also affect the blood sugar level. All but the youngest children will be able to self-inject under supervision. Some students may alternatively be fitted with an insulin auto-injector that adminsters their dosage gradually.
Dealing with a low or 'hypo' (hypoglycemia)
Too high a dose of insulin can often be the trigger for hypoglycemia. Getting the dosage right, on any given day, can be very tricky. There are a number of variables that affect blood sugar levels such as: activity levels, food intake, exercise, stress and illness.
In the classroom the student will not always recognise the signs of low blood sugar. Some may be able to let you know that they are feeling 'low' but research suggests, that over time, diabetics often become worse at recognising these signs. At this stage it is not possible to know whether their blood sugar level has dropped below 4 mmol/L (unless the student has been fitted with some automated monitoring device). They will therefore need to go and be tested.
Testing is usually done in the school welfare room. Rarely, trained staff may come to the classroom and take the student to a nearby quiet and private space. Students are usually able to perform the test themselves under supervision. It is extremely important that the hands are cleaned with soap and water or hand wipes before testing to avoid contaminants affecting the result.
If testing reveals a low, below 4 mmol/L (72mg/dl) then the student may require some food. This could be a biscuit, a piece of fruit or a glucose tablet. This should be in accordance with the previously agreed plan with parents. When the level is still above 3.8 mmol/L (68.4 mg/dl) and after they have eating something, if the student feels OK then they may be able to return to class. It takes a little time for the blood sugar level to rise and re-testing usually needs to be done after 30 minutes. So, as long as the student feels OK and the lesson is not too energetic, they can benefit from being back in class. Again this needs to be part of the agreed plan with parents and classroom staff, who will need to monitor. If below 3.8 mmol/L (68.4mg/dl) the student should sit quietly under supervision until re-test.
If testing reveals an extreme low of less than 2.2 mmol/L (<40 mg/dl) then the student should remain under very close supervision in the medical room and given food and/or glucose as part of the agreed diabetes plan. Some diabetics can be prone to severe drops in blood sugar and will bounce back quickly with glucose. However, at or below this level is a significant cause for concern and it will be usual to be in consultation with parents as to next steps. Calling emergency services should be considered if unable to talk to parents or the student's condition deterioates. It is usually appropriate to re-test blood sugar levels every 15 minutes.
Dealing with hyperglycemia
High blood sugar levels are most likely detected during routine blood glucose testing. When only slightly raised it can be simply managed by extra exercise and drinking water. When more significantly raised additional doses of insulin or other medication may be required. This needs to be in consultation with parents who need to keep track on insulin dosage during the day. It also important so that a 'hypo' is not inadvertently triggered.
With hyperglycemia above 15 mmol/L (270mg/dl) there is increasing risk of developing Diabetic Ketoacidosis. Above 17 mmol/L (300mg/dl) it is usually appropriate to test for keytones. Some glucose monitors have this function for testing the blood or sometimes this is done by placing a test strip in urine. It is important that the diabetes management plan includes agreement on how any testing for keytones is to be undertaken.
Hyperglycemia is more likely during illness. When glucose levels remain high above 17 mmol/L (300 dg/dl) it may be appropriate for the student to go home.
Can diabetic students go on residential trips?
There is no reason why a diabetic student should not enjoy all opportunities provided by the school including residential trips. The individual medical needs should be integrated into the full risk assessment for the trip. This should include the storage and accessibility of medication and how potential incidents can be managed by available staff. Risk assessment should also include whether any monitoring through the night is required. If foreign travel is involved it may be useful to have a translated copy of the students diabetes management plan.
Some residential trip may involve a lot of physical activity. It is important to consider access to snacks and water during demanding days. As diabetics often have the need to urinate more often consider the availabilty of toilets when out and about and also finding private space to test or inject.
A designated member of staff should have responsibility for monitoring the diabetic student. This should be done sensitively and unobtrusively particularly with older children and adolescents. However, it is important to recognise that students can easily become absorbed in activities etc and be less focussed on their own self-management of their diabetes.
How does diabetes affect learning?
Diabetes can affect a student's learning directly as the sugar levels fluctuate in the body. The brain is the biggest consumer of blood sugar and if the level drops it becomes increasingly difficult to concentrate and focus. This decline in cognitive processing efficiency will often occur before the diabetic begins to feel 'low' and is aware of their low blood sugar. Unfortunately, high blood sugar levels can also affect concentration and other symptoms such as headaches and blurring of vision also impact. Students who have more difficulty maintaining optimum blood levels will more frequently experience times of poor attention and focus and may be more at risk of underperformance. In spite of this difficulty many diabetics are unaffected in their learning and make good academic progress. However, where students have other behavioural, social or learning needs the diabetes adds another challenge.
Diabetes may also affect a student's learning indirectly as a result of absences during lessons. Though monitoring and insulin injections can be timetabled to minimise disruption to learning, most diabetic children will feel 'low' at least occasionally and need to leave the classroom for help. Equally, high blood sugar levels increase the frequency of urination needed and students may need in lesson toilet breaks. Again it is those whose condition is more difficult to manage that are more likely to experience disruption to lessons. This can lead to gaps in learning and can undermine confidence in the subject matter. It is important to have a some form of pre-planned support to enable the diabetic student to quickly and quietly rejoin the lesson and continue with their learning without any embarrassment in front of their peers. This is crucial for older children and teenagers.
How does diabetes affect behaviour?
There are many different factors that influence a person's behaviour. Having diabetes just adds another thing into the 'melting pot' of forces that shape behaviour. Many manage their diabetes without much impact on their day to day behaviour and their mental well-being. For others their diabetes may have greater influence. However, as blood sugar levels fluctuate below and above 'normal' it is quite common for diabetics to be prone to mood swings and irritability and they can often experience headaches and fatigue that can make them less motivated and sociable. For those most affected this can increase the probability of friction with peers and staff. At times of distractability some may exhibit low-level off task behaviour. Like all vulnerable children and adolescents diabetic students have an increased risk of being bullied.
A minority of diabetic students may use their condition to control situations they do not like. They may use the 'I'm feeling low' and the need to go immediately and check their blood sugar; as a way of avoiding activities they don't like or find challenging. There is no choice but to allow the student to go. However, it is worth being vigilant for any pattern and work with the student and parents etc to manage this.
Teenagers
No teenage student likes to feel different from their peers and diabetics may be more vulnerable during this time. Research suggests that diabetics have an increased risk of depression and self-harming behaviours. This can take the form of the student not taking their insulin to deliberately make themselves ill. These students require support from mental health workers.
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Important
This article is written for schools and other educational and child-care contexts. It is designed to give an introduction to the medical, learning and behavioural needs of diabetic students and provide advice on how this may be managed. However, in all cases, the advice of professional medical practitioners should be sought to ensure that the management plan meets the individual needs of each student.
