What is diabetes and what are the symptoms?
Diabetes affects around 130 million people worldwide, and the World Health Organisation (WHO) estimates that this number will more than double by 2025. About one in 550 school-age children have diabetes, with the majority suffering from Type 1, although the number of children with Type 2 diabetes is on the increase – recognised as being linked to obesity.
Diabetes occurs when the body is unable to process glucose properly, either because of a lack of insulin (Type 1 diabetes); or because insufficient insulin is produced or the insulin available doesn’t work properly (Type 2 diabetes).
This leads to a raised level of glucose in the blood, which is unable to be converted – with the help of insulin – into energy.
The main symptoms of diabetes include:
- increased thirst,
- extreme fatigue,
- loss of weight,
- frequent trips to the toilet,
- blurred vision,
- itchiness in the genital area or repeated bouts of thrush.
Diabetes UK has additional helpful information on how to spot symptoms and what steps to take if you believe a child you know may have undiagnosed diabetes.
Including diabetes in your school medicines policy
General information about supporting pupils with diabetes should be included in the school medicines policy, and should reflect Department for Education (DfE) and NEU guidance on the subject.
This can be achieved simply by including this guidance, and/or that contained in the DfE publication Supporting Pupils at School with Medical Conditions.
Drawing up individual healthcare plans
Symptoms and treatment vary from one person to another, so it is vitally important that an individual health care plan is drawn up by the school for each child with diabetes, as with all chronic illnesses.
The main purpose of the individual health care plan is to identify the nature of support needed at school. This plan should be developed and updated as and when necessary with the full support and involvement of the child, his or her parents/carers, and the diabetes care team.
One particularly important member of this team is the diabetes specialist nurse (DSN) who will act as a central point of contact and be able to provide expert advice for the school.
Alongside the DSN, others who may be involved in devising the plan might include the head teacher, the parent or guardian, the child, the class teacher, support staff members, and the school health service or the GP.
Each plan should judge the pupil’s needs individually since each student with diabetes will have a different level of control.
The plan should identify:
- the management of the condition,
- individual symptoms and triggers,
- arrangements for daily care (including type of medication, blood glucose monitoring and access arrangements),
- arrangements for medical emergencies (including support from school staff),
- considerations relating to supervision, diet and exercise.
- Necessary contact details should include family details and paediatric diabetes clinic as well as the child’s GP.
Care plans will need to be reviewed on a regular basis to ensure that that they are still relevant to the needs of the child. The diabetes care team should be able to assist in determining the level of frequency with which the care plan might require revision.
The DfE guidance Supporting Pupils at School with Medical Conditions includes model forms for developing individual health care plans.
Remember that there is no legal or contractual duty on teaching staff to administer diabetes medication.
Although many school staff are willing to assist students by agreeing to administer medication or supervising the student taking them, this is nevertheless voluntary. Where staff require information or training in this regard, it should always be made available.
Supporting students with diabetes
Most children with Type 1 diabetes need:
- to have injections of insulin every day,
- check their blood glucose level and;
- eat at regular intervals according to their personal dietary plan.
The child's personal dietary plan will usually have been drawn up by a dietician at the hospital and the child’s parents or carers should be able to provide details of this to the relevant staff.
Type 2 diabetes is normally controlled by dietary changes and exercise, although some people with Type 2 diabetes require tablets or insulin injections as well.
Most children of junior school age receive insulin injections twice a day, at breakfast and teatime. Consequently they would not usually require injections during the school day unless they were taking part in school activities involving extended hours such as an educational visit.
However, older children who are able to inject themselves may choose to take their insulin three or four times a day, as this gives them greater control and flexibility in managing their condition. The child would have been trained by the paediatric diabetes team to calculate the amount of insulin to administer each time, depending on the amount of carbohydrate they have consumed. They may well need to test their blood sugar before meals as part of this routine.
Where children are following this type of regime, the insulin and injecting equipment would need to be brought in to school, and the pupil concerned should be provided with a suitably private and quiet area where their needs can be met. Adult supervision may be necessary.
All such arrangements should be clearly detailed in the child’s individual health care plan.
School staff will need to be aware of safe disposal of needles and syringes and the local policy for collection.
Blood glucose monitoring
It is important that blood glucose levels are well managed in the treatment of diabetes. Depending on how frequently their insulin requires adjustment, children with diabetes may need to check their blood glucose levels using a small monitoring device.
This is most likely to be necessary at:
- lunchtime and
- before periods of increased physical exertion such as a PE lesson.
As before, older children will often be able to manage this for themselves, given time and a suitable place for carrying out the checks. Younger pupils, however, may require the assistance of an adult in administering the test and comprehending its results.
No teacher can be compelled to help supervise or administer blood glucose tests or insulin injections. Where a member of staff has agreed to act in this capacity, they should receive full training from an appropriate health professional.
Care should be taken to ensure that:
- the times at which food is consumed are known and adhered to,
- where a school has a staggered lunch break, the child should attend the same sitting each day,
- in a canteen setting, it may be necessary to ensure the child can go to the front of the queue.
A child with diabetes will suffer a hypoglycaemic episode (a hypo) when blood glucose levels fall too low.
This can happen because of:
- too much insulin,
- too little food,
- physical exertion,
- cold weather
- or the child vomiting.
Staff should look out for signs such as
- glazed eyes,
- lack of concentration,
- shaking or trembling,
- headache or
- mood changes, especially involving angry or aggressive behaviour,
Any of these symptoms are indicative of a hypoglycaemic reaction (hypo) in a child with diabetes.
As symptoms will differ from one child to another, it is important to discuss individual patterns with parents/carers when drawing up the child’s individual health care plan and to keep a written record of what they will be.
It is vital that a hypo is treated quickly. If untreated, the blood glucose level will continue to drop and the child will become unconscious.
Staff should therefore be aware of the warning signs listed above, and ensure that prompt action is taken.
In some cases, the child will be able to recognise the symptoms of an impending hypo and take appropriate action themselves, for example by having a sugary drink or glucose tablets but it must be noted that often a child does not recognise their symptoms.
Teachers in charge of PE lessons, in particular, should be aware of the need to ensure that glucose tablets or a sugary drink are available nearby in case the need arises.
If the child is very drowsy, they may require assistance in treating the hypo. If they are unwilling or unable to eat or drink but still able to swallow, a glucose gel – or a suitable substitute such as honey or jam – should be massaged into the inside of their cheek.
If the child loses consciousness, they should not be given anything by mouth. They should be placed in the recovery position (lying on their side with the head tilted back) and an ambulance should be called. In some cases the child may have a seizure, but the above procedure should be followed in any case.
On recovery, the child should eat some starchy food – for example a cereal bar or a couple of biscuits – to prevent the levels of blood glucose falling again. Often children feel nauseous and may vomit following a hypo, so be prepared for this to occur.
The child’s individual care plan should indicate who will provide any adult intervention where it becomes necessary. Whether this responsibility falls to a member of non-teaching staff or a teacher who has volunteered to take it on, they should of course have received comprehensive training from an appropriately qualified health practitioner.
In cases of emergency:
- teachers must always be prepared to help as they and other school staff in charge of pupils have a general legal duty of care to act as any reasonably prudent parent would;
- however, teachers should do no more than is obviously necessary and appropriate to relieve extreme distress or prevent further and otherwise irreparable harm.
- Qualified medical treatment should be secured in emergencies at the earliest opportunity.
There is no reason why a child with diabetes should not be able to take an active part in physical activity. Indeed, one of the most well-known athletes with the condition is five-times Olympic gold medallist Steve Redgrave.
However, as any form of activity uses up glucose, it is important that a child with diabetes:
- has something to eat prior to the session,
- and maybe afterwards as well if, for example, the next meal is not imminent.
- has suitable sugary food should on hand during the activity in case of need.
Such arrangements should be clearly detailed in the child’s individual health care plan of which all staff should be aware.
A child who is undertaking a physical activity outside school grounds, such as a cross-country run, or a sports event at another location, must wear some form of appropriate ID so that if they become unwell and need medical assistance or first aid, other agencies can provide appropriate assistance.
Blood glucose levels can rise when a child with diabetes is unwell – even if they simply have a cold. Symptoms may include thirst and frequent visits to the toilet.
If teachers or support staff notice such signs, they should ensure that this is reported to the parents/carers in order that insulin doses can be appropriately adjusted.
In cases of vomiting the parents should be contacted immediately, as children become acutely ill more quickly than adults and it could easily become a diabetic emergency. The child should be taken to a hospital Accident and Emergency department if the vomiting persists.
Day trips are unlikely to involve different considerations from those applying to a normal school day.
The child should take:
- their insulin and their insulin injection kit
- any blood sugar testing equipment they would normally need (it is safer if an adult agrees to be responsible for these pieces of equipment in case of loss or damage.)
- their normal hypo treatment and;
- sufficient supplies of starchy foods they might need, for example, after an insulin injection.
- an emergency identity card or jewellery ID
- details of the child’s treatment regime (as well as carried by an accompanying adult)
Where any overnight stays are involved, even if the school staff are confident that the child is competent to administer their own injections, there should be a member of staff who is willing to take responsibility for assisting with injections and blood glucose testing if the child requests help.
Where a child is not able to look after their injections and tests for themselves, some parents may feel uncomfortable about their participation in such a trip, but this in itself is not a reason to refuse the child the opportunity of participation. It is therefore important that a member of staff is willing and able to take responsibility for assisting with or administering injections and blood glucose testing.
Should any medical equipment be lost or forgotten during the trip, the nearest hospital paediatric or Accident and Emergency department should be contacted for help.
For further advice on such considerations when planning a school visit, especially for trips abroad, Diabetes UK has helpful information and advice on travel and managing diabetes away from home.
It is also vital to check that pre-existing conditions such as diabetes are covered by the travel insurance for the trip, in case of medical emergency. Diabetes UK produces specific guidance on diabetes and insurance.
Legal protection for staff or pupils with diabetes in schools
Pupils or staff who suffer from diabetes may not consider themselves to be disabled, but in many cases they will meet the statutory definition of disability set out in the Equality Act 2010 and related legislation.
The Equality Act requires employers to make reasonable adjustments to the workplace in order that employees with disabilities are given specific forms of protection from employer discrimination or less favourable treatment.
The Equality Act also sets out the legal requirements of schools in relation to disabled pupils.They must not discriminate for a reason relating to a pupil’s disability and must make reasonable adjustments to ensure that disabled pupils are not at a ‘substantial disadvantage’ in comparison with their peers.
Since December 2006 there has been a duty on all schools to promote disability equality. This means in effect that schools have to show that they are complying with the principles of disability equality in everything they do – right from the planning stage onwards.
While there is no doubt that the majority of schools work hard to ensure the inclusion and welfare of pupils with diabetes, there may be rare examples of poor practice.
For instance, the school may well be acting unlawfully if any of the following occur, as the pupil with diabetes has received less favourable treatment compared to other pupils as a result of their condition:
- a school refuses to admit a pupil with diabetes because of their condition
- a head teacher excludes a child with diabetes from a school trip on account of their medical needs
- a pupil with diabetes fails to receive proper care because of poor or non-existent school policies for the effective management of the condition
- children with diabetes receive punishments for eating in lessons or examinations, despite feeling hypoglycaemic
- a school takes little or no action to prevent pupils from bullying a diabetic pupil, or fails to take reasonable steps to prevent theft or damage of essential medical equipment.
Employers in schools also have a responsibility under the Health and Safety at Work etc Act 1974 (HASAWA) – and related legislation – to secure the health, safety and welfare of people at work; and to protect pupils against risks to their health or safety arising out of the activities of people at work.
For example, where a pupil suffers as a result of being denied treatment – and this could include the consumption of a snack to relieve a hypo – the school could well be in breach of the HASAWA.