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Diabetes Management in the Childcare Setting
Children with diabetes are typical children with special health care needs. They usually are able to participate in planned activities throughout the day with a few adaptations to help them keep their blood sugar levels within a preset range.
Diabetes is a long term condition that blocks the body from using food properly, especially sugars. Sugar (glucose) builds up in the blood and then spills into the urine. If not treated properly, this sugar in the blood can cause damage to the kidneys, eyes, nerves, and circulation.
Most children with diabetes have Type 1 diabetes, previously called "Juvenile Diabetes." The child with Type 1 diabetes does not produce enough of the normal body hormone called insulin. This lack of insulin prevents the body from using food to give the body cells energy for healthy growth and development. Diabetes is not caused by eating too much sugar. It is not contagious. There is no cure for diabetes and children will not "outgrow" it. Type 1 diabetes is managed with daily shots of insulin.
Type 2 diabetes is usually the result of the body's inability to use insulin properly. Although Type 2 diabetes is more often seen in adults, an increasing number of children with Type 2 are being identified. Type 2 diabetes is treated with diet, exercise, pills and sometimes insulin shots.
An Individualized Health Care Plan (HCP) If a child with diabetes is part of your childcare program, it is important to obtain information about the child's needs. This information is a part of an individualized health care plan (HCP), a written communication between the parent, health care professionals, and the childcare staff. It allows everyone involved to be informed on the steps to take for managing the child's condition and enables the child to participate in and benefit from everyday activities. In this case, the child's HCP may involve blood sugar monitoring, diet and nutrition, insulin requirements, and modified activities for the child.
To develop the HCP, ask parents to help create a daily schedule that includes the daily needs of the child. These needs may include diet restrictions, times for snacks, modified activity periods, and special procedures such as blood glucose testing, urine testing, and the administration of insulin injections. The HCP also identifies steps to take in an emergency.
Diet and Nutrition Everything that the child eats or drinks (except water or non-caloric drinks) raises the amount of sugar (glucose) that goes into the blood stream. Generally speaking, the child with diabetes should eat the same nutritious foods that all children should eat. However, the childcare staff should work with parents and health care professionals to create a food plan which meets the energy and growth needs of the child. The food plan should be strictly followed to help the child maintain an appropriate blood sugar level. Usually, menus and food service timetables can be easily adapted to meet the child's needs.
When special activities such as parties are scheduled, plan meals and snacks ahead of time. Be sure the child with diabetes is included in celebrations with appropriate food and drink selections. Discuss changes in the day's food plan with the parent. Sometimes the adjustment may be as easy as having sugar-free cookies and diet soda available instead of cake and fruit punch.
Exercise and Activity Like their classmates, children with diabetes enjoy activities such as running, jumping, playing ball, and using outdoor equipment. Activity and exercise play an important part in the control of blood sugar. Exercise lowers blood sugar. The timing of exercise may affect a child's meal plan and need for insulin. Children may need a snack before strenuous exercise to keep their blood sugar in balance. Notify parents in advance if a game, sports event or outing will change the child's routine and delay snack and meal times.
Blood Sugar Monitoring Children with diabetes may require routine monitoring of blood glucose levels while they are in childcare. Testing is done by taking a drop of blood, usually from a finger, and placing it on a special test strip in a glucose meter. A glucose meter is easy to use, but will take some practice to feel comfortable using it. Childcare directors should identify who will perform the testing of the blood, and arrange for training by a physician, registered nurse, certified diabetes educator, or other health care professional who has expertise in performing the test. In programs with multiple staff, more than one person should receive training. Testing should be periodically monitored by the health care provider to assure it is being done safely and correctly.
The HCP outlines the actions to be taken based on the results of the blood glucose test. For example, "give 8 oz. of orange juice for low blood sugar level" or "call Grandma to come and give insulin if the blood sugar is high."
Childcare programs should check with their licensing/certifying authority regarding any rules and regulations that may limit their ability to provide blood sugar (glucose) monitoring. Regulatory issues may include the need to obtain a certificate of waiver from the health department and compliance with the Occupational Health and Safety Administration's (OHSA) blood borne pathogens standards, and state and local solid waste disposal rules.
Keeping Track Each Day It is important to maintain a system that assures caregivers and parents share information each day. The adult who brings the child to the program should write down the child's blood sugar level when last checked, at what time it was checked, what the child has eaten that day, when he or she last ate, and other information that might relate to blood sugar levels.
Information to be logged during the day includes the meal and snack time and foods actually eaten (not what was served), time and results of glucose testing, and actions taken based on blood glucose testing, such as "gave 8 oz. orange juice." Log other important information such as signs and symptoms of high or low blood sugar noted during the day, action taken, and steps taken for emergency situations.
Emergencies If the child's HCP is updated regularly and followed closely, emergencies will be uncommon. However, emergencies do occur, and most are related to low blood sugar. The names, phone numbers, and individuals authorized by the parent to make decisions regarding the child's urgent health care needs should be clear. Parents should be told that where time is a critical factor, the emergency medical system (this may be 911 in your area) will be called.
Special Supplies Some childcare providers, such as Head Start, may provide needed supplies, like the glucose monitoring tool. If the child requires special foods, be clear as to who provides them. If the parent provides foods and supplies, develop a system to alert parents when supplies need to be replenished. It is essential that you have all supplies included in the child's HCP.
Psychological Issues Some children take blood glucose testing, food intake requirements, and injections in stride; others may react negatively, making their diabetes management more difficult. Most children are somewhere in between. There may be times when children, who normally are well-adjusted to these routines, resist testing, cry, refuse to eat, and resent their diabetes.
With planning and preparation, and by seeking sound information from the family and the child's physician, the child with diabetes can enjoy everyday events and activities with all the enthusiasm of childhood.
by Kathleen M. Ford, BSN, RN, C, Early Childhood Nurse Consultant, Pima County Health Dept.
& Karen Liberante, BSN, RN, C, Early Childhood Nurse Consultant, Maricopa County Dept. Of Public Health
& Paula Marshall, RN, CDE, CCM, Case Manager, APIPA, an AZ Medicaid HMO
Ford and Marshall also work with the AZ Dept. Of Health Services, Office of Women's and Children's Health
Additional Information
Low blood sugar is usually the result of too little food, too much insulin or delayed meals and snacks, and it can quickly cause an emergency situation. All caregivers should be alert for the signs of low blood sugar, for instance when the child seems or complains of being:
- Hungry or weak
- Shaky or sweaty
- Inattentive or sleepy
- Pal.
- Nauseous or suffering from a headache
- Fussy or cranky
If the child with diabetes does not seem well, give juice, sugared soda, glucose tablets, or another source of sugar right away as instructed by the child's HCP.
High blood sugar usually is caused by too much food, missing an insulin injection, illness, or stress. Look for signs and symptoms such as:
- Upset stomach or stomach pain.
- Drowsiness.
- Hunger and thirst.
- Dry, flushed skin.
- Frequent urination.
- Nausea and vomiting.
- Difficult breathing and/or testing higher than the preset range with a blood glucose meter.
High blood sugar is usually managed by encouraging the child to drink sugar-free beverages, increasing physical activity, or providing additional insulin. Follow instructions in the child's HCP, including contacting the parent or designated individual if insulin is required.
If the child's condition requires insulin injections while in the care of the provider, check your state licensing requirements and other regulations, and work with the child's parent/guardian and health care provider to determine who will give the injections and what training is required. Training should be provided by qualified personnel, such as a physician, registered nurse, or certified diabetes educator.
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