Chapter 21: Management of type 1 diabetes in school
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5/14/2018 at 8:18:25 AM GMT
Posts: 40
Chapter 21: Management of type 1 diabetes in school
Dear ISPAD member/friend,

Thank you for your continued interest in the 2018 ISPAD Clinical Practice Consensus Guidelines and in the previous drafts chapters we shared with you.

We are happy to announce that the Chapter 21: Management and support of children and adolescents with type 1 diabetes in school is now ready for you to read and comment on. We are looking forward to hearing your thoughts and input on this chapter. 

Kind regards,

David Maahs

ISPAD Secretary-General

Last edited Friday, July 13, 2018
5/14/2018 at 10:15:40 AM GMT
Posts: 5
Dear David and All, it is a pleasure to see the chapter on Diabetes in School finally announced. Hope that we can get interest in what has been written and many good comments, best gun

7/9/2018 at 9:01:24 AM GMT
Posts: 5

This is an important chapter but gaining consensus will be difficult across regions.  The executive summary and recommendations clearly state that they are almost all based on level E “evidence” (other than some of the epidemiology and impact of dysglycaemia on assessment performance), and it would be useful to point this out at the beginning.


The need for an individualized school plan is very appropriate, but then suggesting a solitary cut-off of 10 mmol/l (180mg/dL) appears to go against that concept, especially when it is suggested as a trigger point for additional insulin administration. This is potentially dangerous, if timing of previous insulin administration, exercise and other variables are not taken into account, which in most circumstances is beyond the expectations of staff at school. The references to maintaining BGL within normal limits at all times if possible, while an important goal, appear to come without the acknowledgement that variation outside of "normal limits" is common and caused by a multitude of normal life events. 


In general it is reasonable to expect school staff to administer prescribed medicines, once they have had training, but not to determine how to adjust them, as these guidelines imply or state directly. Elsewhere the guideline discusses school personnel being able to respond to “symptomatic hyperglycaemia” (page 22, first paragraph), so there appears to be inconsistency in advice. My main concerns centre around the strong messaging re: school staff being involved with insulin adjustment in relation to factoring in diabetes technologies, exercise, nutritional intake and even Insulin ON Board. A caveat such as “dependant on local circumstance, legal requirements” may be appropriate etc.


Page 3“Reasonable adjustments”(to facilitate prescribed medical care) include school personnel support with insulin administration, as well as understanding and knowledge of diabetes technologies (including CGM devices and advanced insulin pump settings).Suggest omit “advanced”


Page 6 2ndlast line” “ongoing ignorance”, this should be “lack of knowledge” or omit.


Page 8 - ‘School personnel responsible for supporting students with TID ideally also be trained to make insulin dose adjustments at school’

Use of Bolus advisor meter is fine but does not refer to these meters in the document


Page 9 –‘pre meal bolus to occur 10-20 minutes before eating’

 Potentially dangerous - fine in the care of parents and the home setting but not school


Page 13“for physical activity lasting less than 60 minutes, additional carbohydrate is only needed if the activity is of high intensity or …:this needs a reference


Page 16 – checking for ketones and giving a correction bolus- could be potentially dangerous and in my opinion is not the responsibility of school staff


Page 17/18 – Treatment of severe hypoglycaemia should include safe positioning, contact parents and call an ambulance. 


Page 24-25, Psychological adjustments. While all of this is true, it is not unique to the school environment and is something diabetes teams should be identifying. The capacity for schools to be involved in treating psychological issues in children with diabetes in many countries would be very limited – although identification of such problems would be a useful role for schools.


Page 32onwards, legal perspectives. This section appears problematic and it is unclear whether it has been written by someone with international legal expertise. Given that legal frameworks vary considerably between individual countries (or even between different states in the same country), it would appear to be an area where ISPAD should take great care in producing a guideline that discusses “complying with law” that is likely to vary considerably between different jurisdictions. This section in general appears at odds with the earlier statement guideline: “Currently, many countries do not have legal or statutory provisions in place that mandate that children with T1D receive prescribed health-care support at school“ (which makes much of the rest of this section redundant). Some of the statements in this section are also clearly at odds with the following section relating to resource-limited countries (eg the statement ‘medical treatment and management are not to be dictated by the resources currently available to the school”) and could in fact be used to prevent inclusion of children at school or reduce their participation. A collaborative approach with schools would appear to be more useful. This whole section should be removed. 


In Sydney we have made a local decision not to teach schools how to test for ketones, and not to administer glucagon admin (not unless overseas /or school camp event). Similarly testing BG before during, and after exercise is unrealistic. 


Page 32 – ‘…may also include glucagon administration, continuous glucose monitoring, understanding and intervention (including using predictive arrows) and use of advanced insulin pump settings…’ This is asking too much of school staff and could be potentially dangerous. The inclusion of a caveat such as “dependant on local circumstance, legal requirements” etc. may be helpful as we all know there are always exceptions to the rule. Would be better to omit as this is coveredelsewhere.

7/17/2018 at 7:55:13 AM GMT
Posts: 40
We want to thank all members who provided feedback on the Chapter 21: Management of type 1 diabetes in school.

Specific responses are provided in the attached PDF.

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