ISPAD Clinical Practice Consensus Guidelines 2022: Management and support of children and adolescents with diabetes in school

Developing Self-Management in Type 1 Diabetes at Secondary Schools: Who Is Responsible? A Qualitative Study

IMPORTANCE

Occupational therapists have the proven capacity to improve outcomes for young adults who are self-managing Type 1 diabetes (T1D). There is insufficient understanding of adolescents' experiences of developing responsibility for diabetes self-management (DSM).

OBJECTIVE

To investigate adolescents' perceptions of sharing responsibility for T1D management at school.

DESIGN

This study had a descriptive qualitative design and used semistructured interviews and thematic analysis. It is the second phase of a mixed-methods study with a sequential explanatory design that investigated mechanisms of responsibility-sharing at school.

SETTING

Secondary school in Australia.

PARTICIPANTS

Purposive sample of adolescents (age 15-16 yr) with T1D (N = 11).

RESULTS

Adolescents approached the complex occupation of school-based DSM primarily in partnership with their parents, with each adolescent having unique responsibilities while sharing others. Health care professionals and teachers reportedly had minimal involvement. Adolescents described owning most DSM tasks, with their perceptions of building independence limiting the sharing of this responsibility. A heightened sense of risk meant that adolescents were likely to communicate with others in cases of errant blood glucose readings. Current processes commonly resulted in reduced school participation.

CONCLUSIONS AND RELEVANCE

Adolescents valued working responsively and interdependently with their parents to manage T1D at school, which aligns with the occupational therapy model of co-occupation. Effective responsibility-sharing depends on clear, frequent, autonomy-supportive, team-based communications. Our results showed that patterns of communication for determining school-based DSM processes were fragmented and risk focused, with limited adolescent involvement, resulting in strategies that led to students at times being excluded from school activities. Plain-Language Summary: This is the first study to use an occupational lens to examine the way in which adolescents share their responsibility for diabetes care at school. Diabetes self-management in secondary schools occurs more often when adolescents work interdependently with their parents to manage their diabetes. Adolescent involvement in formal school processes and a clearer allocation of team roles and responsibilities would better support health-promoting habits and school participation.

Recommendations for recognizing, risk stratifying, treating, and managing children and adolescents with hypoglycemia

There has been continuous progress in diabetes management over the last few decades, not least due to the widespread dissemination of continuous glucose monitoring (CGM) and automated insulin delivery systems. These technological advances have radically changed the daily lives of people living with diabetes, improving the quality of life of both children and their families. Despite this, hypoglycemia remains the primary side-effect of insulin therapy. Based on a systematic review of the available scientific evidence, this paper aims to provide evidence-based recommendations for recognizing, risk stratifying, treating, and managing patients with hypoglycemia. The objective of these recommendations is to unify the behavior of pediatric diabetologists with respect to the timely recognition and prevention of hypoglycemic episodes and the correct treatment of hypoglycemia, especially in patients using CGM or advanced hybrid closed-loop systems. All authors have long experience in the specialty and are members of the Italian Society of Pediatric Endocrinology and Diabetology. The goal of treating hypoglycemia is to raise blood glucose above 70 mg/dL (3.9 mmol/L) and to prevent further decreases. Oral glucose at a dose of 0.3 g/kg (0.1 g/kg for children using "smart pumps" or hybrid closed loop systems in automated mode) is the preferred treatment for the conscious individual with blood glucose <70 mg/dL (3.9 mmol/L), although any form of carbohydrate (e.g., sucrose, which consists of glucose and fructose, or honey, sugary soft drinks, or fruit juice) containing glucose may be used. Using automatic insulin delivery systems, the oral glucose dose can be decreased to 0.1 g/kg. Practical flow charts are included to aid clinical decision-making. Although representing the official position of the Italian Society of Pediatric Endocrinology and Diabetology (ISPED), these guidelines are applicable to the global audience and are especially pertinent in the era of CGM and other advanced technologies.

Type 1 Diabetes in Ontario Schools: Policy and Practice

OBJECTIVES

Type 1 diabetes (T1D) is a challenging chronic condition. Young children with T1D require daily support to manage their condition while at school. In 2018, Ontario established a provincial policy to ensure safe and equitable school participation for children with diabetes. Despite this, children and parents describe very different school experiences. In this qualitative study we describe the interpretation and implementation of school board policy related to the care of children with T1D from the perspective of school educators (principals/teachers).

METHODS

Policy documents were reviewed employing a qualitative descriptive research design using directed qualitative content analysis. Semistructured interviews were conducted with 13 teachers and principals from 10 publicly funded elementary schools across the Hamilton and Toronto District School Boards in 2021.

RESULTS

There are major differences in how policies regarding T1D are being implemented in schools. This includes how school staff are educated about T1D, and how they interpret and act on blood glucose information. Although educators often play an active role in supporting children, many face barriers, including competing priorities, fear, lack of information, and lack of support. Facilitators include effective communication/collaboration, actionable information, time, and a diabetes "champion." In some instances, access to nursing support could help to resolve barriers or create care gaps.

CONCLUSIONS

School board policy provides high-level guidance on how to support children with T1D in school, but gaps remain. We provide specific recommendations regarding policy, staff education/training, roles and responsibilities, and future research.

Diabetes Management Support in Preschool and Primary School: A Qualitative Ideation Study Presenting Recommendations for Improved Communicative Practice

Diabetes care in institutional settings is a significant challenge that affects the whole family as well as care workers and teachers. The present study is the ideation part of a rigorous development process in the KIds with Diabetes in School (KIDS) project. We have previously conducted a thorough three-part needs assessment in which we explored the problem area from the viewpoints of (1) municipal administrative staff, (2) preschool and school staff and (3) families. Based on the identified needs and to a great extent on the contents and shortcomings of existing guidelines, the objective of the present study is to explore and develop possible solutions and recommendations for addressing the challenges and problems. To meet this objective, we held comprehensive multistakeholder participatory workshops in each of the five Danish regions. Five main themes with multiple subthemes were identified as areas to be addressed: (1) training and knowledge, (2) communication and collaboration, (3) the designated contact/support person, (4) national guidelines, and (5) the Diabetes Coordinator. Our findings demonstrate that communicative structures and dynamics are at the very heart of the identified problems and challenges and that the possible solutions should revolve around improving existing structures and highlighting the importance of constantly working on understanding and developing communication strategies. We propose a set of recommendations for practice based on these communicative needs.

Management of Type 1 Diabetes in a school setting: effectiveness of an online training program for school staff

Background and aims

Since Type 1 Diabetes (T1D) onset usually occurs at a young age, a relevant number of affected people attend school for most of their time; it is necessary that school personnel receive appropriate education and training. We aimed to evaluate the effectiveness of the online training program offered by IRCCS Istituto Giannina Gaslini during and after COVID-19 pandemic.

Methods

The Institute's Diabetes team offered an online training program to school staff of the Region during COVID-19 pandemic. A validated questionnaire was proposed to all the schools in which training meetings were held in the previous 2 years (2020-2021 and 2021-2022). The questionnaire consisted of four sections: Section 1 (Socio-demographical data), Section 2 (Theoretical knowledge on T1D), Section 3 (Confidence in handling T1D), and Section 4 (Practical skills and Glucagon Administration). To evaluate the effectiveness of the online training program, the answers between participants (Group A) and non-participants (Group B) were then compared.

Results

225 subjects from 19 schools participated in the survey. People who participated to the training (Group A, n = 53) demonstrated better T1D theoretical knowledge compared to non-participants (Group B, n = 154; p < 0.001). Group A revealed to feel more confident in the management of children with T1D during scholastic (p = 0.006) and extra-scholastic activities (p = 0.01), in supporting the children in the administration of insulin (p < 0.001) and in recognizing hypoglycaemia (p = 0.006). Moreover, results confirmed good levels of confidence among scholastic personnel who participated in the training of administration of glucagon in case of severe hypoglycaemia.

Conclusion

School staff who took part in the online training program on management of T1D showed better theoretical knowledge and better confidence in the management of daily needs and possible emergencies of students with T1D. It appears essential to offer educational programs on T1D for school staff by implementing the use of technological tools to reach a wider population. Moreover, it is advisable to offer a more practical approach, involving educational nurses.

Family Interviews Inform School-based Nursing for Children with Type 1 Diabetes and their Families

The purpose of this study was to better understand the burden(s) associated with type 1 diabetes mellitus (T1DM) on school-aged youth and families and subsequently identify strategies school nurses can adopt to reduce the impact of this disease. Family interviews (n = 5 families, comprised of 15 individual participants) were conducted using a semi-structured interview guide to further explore family members' experiences with T1DM. Directed content analysis was employed for theme identification. Themes reflect individual and family struggles, the importance of teamwork within families, navigating barriers, and facing uncertainty. Select themes provided the impetus for the development of a school-based program directed toward youth and families with T1DM. Plans include developing educational content plus therapeutic conversations with a focus on communication, care coordination, cognition, problem-solving, and strength-building. An emphasis will be placed on participant-directed program content with peer support for youth with T1DM and family members.