Diabetes in Day Care Settings
The American Diabetes Association (ADA) continues to publish position statements in regard to the care and management of diabetes. Most recently, Siminerio, Albanese-O’Neill, Chang, Hathaway, Jackson, Weissberg-Benchell, Wright, Yatvin, and Deeb published “Care of Young Children with Diabetes in the Child Care Setting: A Position Statement of the Amercian Diabetes Association,” Diabetes Care, October 2014, vol. 37 no.10, 2834-2842.
This position statement is immediately relevant to my patient population, and I have included key tables and resources from it in order to assist families caring for young children with diabetes. According to the authors, there is an annual increase of 2.3 percent in type 1 diabetes incidence with children under the age of 5 years. This age group is experiencing the greatest increase relative to all children. The goal of the paper is to “describe the diabetes management recommendations in the child care setting that includes day care, camp, and other programs where young children with diabetes are enrolled.” Of importance, the position statement is meant as a guide and is not to provide specific advice and treatment for these children. The authors of this position statement are my respected colleagues who represent the pediatric diabetes multidisciplinary team. As such, I have quoted and summarized the major packets of information from the publication.
The most important key points are about the management of food and activity, hypoglycemia, hyperglycemia, blood glucose monitoring (including continuous glucose monitors[CGM]), insulin administration, and glucagon. The ADA suggests utilizing a Diabetes Medical Management Plan (DMMP) that provides the medical orders necessary to provide the care in the appropriate setting. To view a sample plan, visit www.diabetes.org/childcare.
Keep in mind that the Americans with Disabilities Act “prohibits discrimination against people with disabilities by places of public accommodation, including camps and child care programs. This includes a home-based setting if the program is open to the public.” However, programs that are operated by religious groups, such as churches or synagogues, are not subject to these guidelines unless the program receives federal funding.
What are the staff requirements?
- Child care staff must have a basic comprehension of diabetes; know how to check blood glucose levels; be able to prevent, recognize, and treat hypoglycemia; and lastly, be able to handle diabetes emergencies and know how and who to contact for help.
- Child care staff needs to have an understanding of hyperglycemia.
- Blood glucose monitoring is essential and needs to be checked before meals or snacks, exercise, and when the child is exhibiting symptoms of highs or lows.
- CGM detailed management should not be expected of childcare providers.
- Staff must be trained to administer insulin and glucagon, if necessary.
Please review the following table: from Diabetes Care, October 2014, vol. 37 no.10, 2834-2842.
Diabetes care tasks prescribed by DMMP to be provided by child care staff:
Equipment/supplies (provided by parent/guardian)
Blood glucose monitoring
Before food intake and physical activity and when low or high blood glucose is suspected
Blood glucose meter, lancet, lancing device, test strips, CGM*
Before or after food intake and to treat high blood glucose
Insulin, delivery device (pump, pen, syringe)
Food intake scheduling and monitoring
Snacks and meals provided and/or monitored to ensure food consumption is in accordance with insulin dosing
Food, carbohydrate information
Awareness that unusual behaviors after physical activity or insulin administration may signify hypoglycemia
Quick-acting carbohydrate and glucagon
Awareness that increased urination or drinking may signify hyperglycemia
Noncarbohydrate-containing liquid, insulin
Check ketones if repeated blood glucose tests show elevation above target range or if the child is ill
Urine or blood ketone strips, ketone monitor
↵* This device may or may not be used by the child.
Keep in mind that there must be a written care plan with medical orders that must be provided to the day care provider and that all child care staff should receive basic training. Advanced training should be provided for a small number of child care staff, and according to the authors, there should be at least one trained staff member available to provide care at all times.
What are the parent responsibilities?
- Providing information about management of diabetes and training resources
- A detailed written care plan signed by the child’s healthcare provider or a DMMP
- Emergency contact information for the guardians and diabetes healthcare provider
- All necessary equipment and replacement
- Record keeping
- Basic and advanced diabetes training for care providers
- Information unique to the child that may impact blood sugars levels such as activity, certain foods, stress, etc
- Consent to release confidential information with the diabetes healthcare provider
In addition to the provider and parent requirements, the child’s healthcare provider has a role to ensure the child’s safety in the day care setting.
Diabetes care within the day care setting is fraught with much anxiety for the parent or guardian and the child. Therefore, please work together with all parties in an effort to keep your child safe within the confines of the day care setting. The following are resources provided by the ADA to assist in planning for childcare (provided in the same reference):
American Diabetes Association. Safe at School resources and information: www.diabetes.org/safeatschool.
American Diabetes Association. Diabetes Care Tasks at School: What Key Personnel Need to Know: www.diabetes.org/schooltraining.
National Diabetes Education Program. Helping the Student with Diabetes Succeed: A Guide for School Personnel (2010): http://ndep.nih.gov/media/Youth_NDEPSchoolGuide.pdf.