Angie Middlehurst, Paediatric Diabetes Educator (CDE)
Melinda Morrison, Paediatric Diabetes Dietitian (APD/CDE)
Diabetes Australia-NSW

As the incidence of type 1 diabetes increases in children and young people, it is inevitable that more schools will encounter children with diabetes. Previously children with type 1 diabetes have been managed with 2-3 injections per day with only a small number of children having to give an injection at school. In the last 5 years, recommendations have changed with treatment being multiple injections per day (including injections at school) or insulin being giving by an insulin pump. There is strong evidence that this intensive form of management leads to fewer long-term complications of diabetes. However, with intensive management also comes additional diabetes related tasks, many of which must be performed in the school setting.

The Student with Diabetes
The student with type 1 diabetes has the right to attend school without discrimination, to participate in the same activities as their peers and be provided with a safe environment while at school. However, they also have additional needs with special consideration for blood glucose testing, insulin administration, treatment of hypoglycaemia, regular meal times, provisions for examinations and sick day management. A lack of support at school can impact on a child’s attendance, participation, as well as their physical and emotional development.

Younger children in particular require additional assistance and supervision in the school setting as they face a range of tasks and problems that are beyond their level of cognitive development. When a child with diabetes starts school, parental anxiety may be more pronounced than for other children, as parents must trust the school to attend to their child’s diabetes needs. Young people spend the greater part of their day at school; therefore it is imperative that schools have the resources and proficiency needed to assist with the daily care of children with diabetes and any unforeseen diabetes related emergencies.    

Support at School
Schools have a responsibility to provide a safe environment and adequate supervision. However, the degree of responsibility of school staff for diabetes related tasks may vary with individual school policies.

The Role of Parents
Parents have a responsibility to advise the school of their child’s medical condition and particular requirements for the management of their child’s diabetes. The school should be consulted on the development of a written individual diabetes health care plan. Problems can sometimes arise at school if there is a lack of understanding of diabetes and its management, poor communication between parents and staff or unrealistic expectations on all sides.  

School Visits
In NSW, diabetes education in schools is presently conducted on an ad hoc basis, requested either by parent or school. A diabetes educator from a diabetes service or Diabetes Australia-NSW attends the school to provide information on the management of type 1 diabetes.

Evaluation of the Diabetes Australia-NSW School Visit program has shown improvements in the school’s confidence in managing diabetes, attitude to the seriousness of the disease, understanding of management and improved parental perceptions in the school’s management of their child following a diabetes educator facilitated information session.

Diabetes at School Survey
In most cases schools are supportive of children with diabetes and their families. However, with the increase in number of children diagnosed with diabetes and changes to management, Diabetes Australia-NSW is aware of a number of cases where issues surrounding diabetes management have arisen at school.

With limited data available on the management of diabetes at school and issues faced by parents, further information was deemed necessary to be able to better advocate for children with diabetes at school.

To obtain this information, DA-NSW administered a survey of parents of school / pre-school aged children with the aims of describing diabetes management practices in the NSW childcare, pre-school and primary school settings, determining parental perceptions of the adequacy of the current level of care and ascertaining the types of resources parents believe would improve the care of their child at school.

A written postal survey was administered to 544 parents/carers of children with type 1 diabetes aged 0-12 years living in NSW with 231 responses.

The results of the survey indicated that diabetes management practices in the school setting and parental perceptions of adequacy of care are variable across NSW schools, pre-schools and child care services.

Insulin administration at school was required by almost half of the children on injections and 98% of those on insulin pumps. The responsibility for injections was on the child in 70% of cases, predominantly in the upper primary school age. While in many cases children of this age may be able to give their own injections, close supervision is paramount.

More than one quarter of parents of children needing insulin injections, were required to attend the school to administer the injection, which may place additional financial and time pressure on families. Parents of children on insulin pumps were less likely to attend the school to give the bolus.  Interestingly, teachers were more likely to give an insulin bolus via a pump than give an injection, despite the fact that the same medication was being administered.

Just over half of all children were currently BG testing in the classroom as is recommended for safety. This is of some concern due to the risk of severe hypoglycaemia if recognition and treatment is delayed. Over one quarter of teachers were reported to be performing BG testing, which is of particular importance in managing younger children in the school setting. 

The majority of parents reported that the school was well equipped to deal with hypoglycaemia, believing the teachers were aware of symptoms and appropriate treatment.  Hypo kits were available in 94% of cases, in a variety of locations around the school. Appropriate action in the event of severe hypoglycaemia was also reported by the majority of respondents.

Mixed results were reported regarding other aspects of management such as dietary management, sports days and sick days suggesting that these issues may need to be addressed in some cases.

In most cases, respondents (87%) stated that their child was able to participate in all school activities, however there were some exclusions reported including school camp, sport and excursions. Although very few children were excluded the psychosocial impact on those affected individuals cannot be underestimated.

Reassuringly the majority of students had individual health care plans in place at school. However not all schools or parents were accessing all available resources, such as the International Diabetes Federation School Pack or the www.diabeteskidsandteens.com.au website.

Diabetes education was conducted in the majority of cases by a qualified diabetes educator, however parents indicated the need for increased school staff training, with some believing this should be mandatory or conducted on an annual basis.

While for the most part, parents reported that they had not encountered any problems with diabetes management at school, approximately one third had issues at school relating to hypoglycaemia, staff awareness and diabetes management tasks. However parents reported that they generally felt supported by the school, with 84% describing their child’s school as supportive or very supportive. 

Overall, the results of this survey suggest that many schools are accommodating to the needs of children with type 1 diabetes. However there were a number of inconsistencies reported by parents in diabetes management that are not in line with recommendations for optimal care in the school setting.

DA-NSW has sent a copy of the full report to the NSW Department of Education and Training, as well as the State Ministers for Health and Education. We will continue to advocate for state wide policies and training of school staff for optimal management of children with diabetes in NSW schools.