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Children are not pawns

What we know about diabetes: Children are Not Pawns
By Francine R. Kaufman, MD

“Imagine you have a life-threatening medical condition that requires a critical procedure for you to survive.” So began Dale Parent’s explanation of why only a medical professional is able to safely administer insulin to a student with diabetes (“Judge rightly stopped health outrage” Dec. 10, 2008, LA Daily News). Ms. Parent, president of the California School Nurses Organization, goes on to provide horror stories of what might happen if someone without a medical degree were to administer insulin, a procedure that she makes sound very ominous.

As a pediatric endocrinologist for 30 years, my one word response was “balderdash”. In the time it took me to read Ms. Parent’s article I knew that tens of thousands of doses of insulin were administered across the country and only a very tiny percentage were given by health care professionals. Rather, they were being administered by people with diabetes, parents, friends, and babysitters of children with diabetes and even many children. Yet, Ms. Parent seems unaware that the foundation of modern diabetes management is lay people not medical professionals administering insulin.

So Ms. Parent is thrilled that a Superior Court judge struck down an agreement between the American Diabetes Association and the California Department of Education that would have allowed trained non-medical school personnel to administer insulin at school and school-related activities when a school nurse isn’t present.

While Ms. Parent was thrilled, I, my colleagues (who are doctors, nurses, and diabetes educators who specialize in diabetes care) and the families of children with diabetes were appalled. And we were frightened.

We know that when children with diabetes are able to successfully manage their disease they can hope to avoid the potentially deadly short term complications, as well as long term complications of diabetes including heart disease, amputation and blindness. This requires having immediate access to insulin before meals and at unpredictable times when blood sugar levels are higher than what is acceptable.

We know that school nurses are important to the health of all students and, like Ms. Parent, we would like to see more nurses in our schools.  But we also know that we have but one school nurse for every 2700 California students, one of the worst ratios in the country. Weathering the current financial crisis, school districts in our state are cutting positions, not adding them. Even in those rare schools lucky enough to have a full-time nurse, the nurse isn’t there during field trips and extra-curricular activities. But the child’s need for insulin is still there and this need simply cannot wait for a phantom nurse to show up.

We know that insulin is given in school by many different kinds of people other than the school nurse. Parents or their designees all unlicensed can administer insulin in school. Babysitters, aunts, uncles and grandmas even siblings show up to give injections with no assurance they have been properly trained. The nurse organizations that brought this lawsuit do not object to this, yet they will not let school staff members, many of whom have diabetes themselves, volunteer to give an injection after they have been trained. And worse yet is the insinuation that Ms. Parent made that we are asking unlicensed people to determine how much insulin to give. Nothing is farther from the truth.  Each child with diabetes has the dosage pre-calculated, and the parent or the child’s diabetes team are always available even for the school nurse to call to double check prior to giving the dose of insulin.

In short, we know that if only a nurse is allowed to administer insulin then students with diabetes will not be safe at school. Some will face long delays in getting insulin or will go without insulin altogether during school, putting them at increased risk of severe complications.  Sometimes they will be in school sick when they should be thriving. Some parents will be forced to quit their jobs to be on call to administer insulin; I’ve had parents of patients end up on welfare after they lost their jobs because they had to leave work to give their child an injection.

We know this is needless hardship when a safe and financially reasonable alternative is readily available. The American Diabetes Association (ADA) has supported training non-medical school personnel for years as have other leading organizations of people with diabetes and diabetes healthcare professionals. It happens today in over 30 states.

We know about families whose children got sick waiting for a school nurse. What we don’t know are where the horror stories Ms. Parent relates came from. The lawyers representing the ADA assured me none of Ms. Parent’s stories made it into facts alleged on the record in court.  They also told me that the judge in the case said he agreed with the ADA as a policy matter, but that it was a matter for the legislature to decide.

Parents of children with diabetes and health care professionals who have devoted their lives to caring for children with diabetes are not, as Ms.  Parent implies, mistaken about what is in the best interests of children with diabetes. We are not mistaken when we say that they are vulnerable children not pawns.

Dr. Kaufman is the Director of the Comprehensive Childhood Diabetes Center and the Head of the Center for Endocrinology, Diabetes and Metabolism at Childrens Hospital Los Angeles and the former president of the American Diabetes Association.


(Note: the California Court of Appeals stayed the lower court ruling in 2009, and until a final decision, the entire original Legal Advisory remains in effect, and California school districts are permitted to train unlicensed personnel to administer insulin. http://www.dredf.org/diabetes/July-09-Diabetes-in-CA-Schools.pdf)

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