Evidence based advocacy

Supporting  diabetes care in Canadian schools

Clinical Consensus Guidelines for School Care

posted Jun 6, 2012, 11:22 PM by admin user   [ updated Jun 6, 2012, 11:27 PM ]

ISPAD Clinical Practice Consensus Guidelines 2009 Compendium
The delivery of ambulatory diabetes care to children and adolescents with diabetes
Pediatric Diabetes 2009: 10 (Suppl. 12): 58–70.

(E) Expert consensus or clinical experience

Children spend 40–50% of their waking hours in school. Diabetes care in school is an important part of their diabetes management plan. The school should never discourage or alter a medical treatment plan that is regarded by the diabetes team to be optimal for the child. The child has the right to receive adult support for diabetes care from school personnel during school hours, outdoor school activities, when at school sponsored events away from school, and should natural disasters occur at school (E).

• School personnel must be trained to provide or supervise all diabetes care prescribed by the diabetes team (E)

• School personnel must be supportive of providing diabetes care and encourage diabetes management during school hours (E)

The treatment required may include 
• Insulin administration by injection or with an insulin pump.
• Testing BG in young children and older newly diagnosed children and adolescents until they are capable of performing the task independently.
• Identification and treatment for hypoglycemia, both mild–moderate and severe.

Evidence Letter - BC

posted Nov 4, 2011, 5:54 PM by admin user

November 2011 - in this review of medical evidence and legal precedents by Unsafe at School authors, and endorsed by BC medical professionals, the authors argue for the human rights of Canadian Children with Type 1 Diabetes (T1D).

Significantly better diabetes control and quality of life with training

posted Feb 22, 2011, 2:10 PM by admin user   [ updated Feb 22, 2011, 2:35 PM ]

Children whose parents reported that school personnel received diabetes training showed significantly better diabetes control than those who reported untrained school personnel. Children who reported their classmates received diabetes training had significantly better quality of life (QOL) than those who reported untrained classmates. Conclusions Students with diabetes continue to face challenges at school. Training staff and classmates and allowing students the maximum appropriate flexibility in diabetes care appears beneficial for disease control and QOL.

Can school personnel who do not receive training for insulin administration (injection, pump) be considered trained?

Hypoglycaemia in childhood onset type 1 diabetes–part villain, but not the only one

posted Feb 11, 2011, 11:32 AM by John Paul Morrison   [ updated Feb 11, 2011, 11:44 AM ]

A review of the paediatric and adolescent literature over the past 15 yrs reveals inconsistent findings concerning the relative neurotoxicity of hyperglycaemia and hypoglycaemia (9, 10, 23–25, 31–33, 38–46)–see Table 1. Earlier reports tended to support the role of hypoglycaemia in explaining neurocognitive deficits in youth with type 1 diabetes. The possible contribution of hyperglycaemia was either not considered, in the belief that youth are yet to experience the cerebrovascular complications evident in adults with long duration diabetes, or was tested using a very limited sampling of glycosylated haemoglobin (HbA1c) levels. Recent studies, using improved methodology, report positive associations between hyperglycaemia and neurocognitive deficit in youth with diabetes (10, 23, 31, 41, 46), with hypoglycaemia also implicated in some (10, 23, 46), but not all, of these reports.

Early educational, cognitive and behavior modifying interventions recommended for children with diabetes

posted Feb 11, 2011, 10:51 AM by John Paul Morrison   [ updated Feb 11, 2011, 10:59 AM ]

In this review of hyperglycemia and hypoglycemia in children with diabetes, physicians observe "There is, however, an increasing body of evidence that hyperglycemia may beget further hyperglycemia through neurobehavioral pathways, and that hyperglycemia can be associated with anatomic as well as cognitive alterations in central nervous system morphology and function." and recommend that "all children with diabetes have neuropsychologic testing shortly after diabetes diagnosis and engage in early initiation of educational, cognitive and behavior modifying interventions in order to address maladaptive behaviors."

Hyperglycemia not hypoglycemia alters neuronal dendrites and impairs spatial memory.

posted Feb 11, 2011, 10:25 AM by John Paul Morrison   [ updated Feb 11, 2011, 11:22 AM ]

In this basic science, original research involving an animal model of diabetes and brain development, researchers compared control, hyperglycemic and intermittent hypoglycemic groups. The hyperglycemic, diabetic group was treated with sufficient insulin to maintain proper growth, but with blood glucose levels consistently above 11.1 mmol/L (diagnostic level for diabetes), or the same level of hyperglycemia as observed in typical adolescent children who were reported with the same HbA1c levels. The hypoglycemic group had normal blood glucose levels, except for intermittent episodes of hypoglycemia (blood glucose < 3.3 mmol/L, average 2.5 ± 0.21 mmol/L) induced by insulin, for three hours/day, three times a week - the type of hypoglycemia that clinicians are typically concerned about because this is much more common than hypoglycemia-induced seizures. 

Conclusion: Hyperglycemia, but not hypoglycemia, was associated with adverse effects on the brain polyol pathway activity, neuronal structural changes, and impaired long-term spatial memory. This finding suggests that the hyperglycemic component of diabetes mellitus has a greater adverse effect on brain functioning than does intermittent hypoglycemia.

Malone, J. I., Hanna, S., Saporta, S., Mervis, R. F., Park, C. R., Chong, L. and Diamond, D. M. (2008), Hyperglycemia not hypoglycemia alters neuronal dendrites and impairs spatial memory. Pediatric Diabetes, 9: 531–539. doi: 10.1111/j.1399-5448.2008.00431.x

Verbal intelligence reduced with increased exposure to hyperglycemia, not hypoglycemia

posted Feb 11, 2011, 10:10 AM by John Paul Morrison

In this original research involving school aged youth aged 5-16 years old, the group with Type 1 Diabetes had lower estimated verbal intelligence compared to unaffected  siblings. Within Type 1  group, verbal intelligence was reduced with increased exposure to Hyper, not to Hypo. In contrast, spatial intelligence and delayed recall were reduced only with repeated Hypoglycemia

Conclusions: Hypo and Hyper have qualitatively different effects on cognitive function in T1DM that depend in part on the timing of exposure during development, independent of onset 
age. This information extends the known benefits of avoiding both Hypo and chronic Hyper during childhood to include preservation of specific cognitive skills.

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