Diabetes in kindergarten and at school: What should be considered?

Type 1 diabetes results in a massive disruption in the child’s life and everyday family life. This makes it all the more important for children with diabetes to be allowed to live a life that is as normal as possible. This includes attending a normal kindergarten or normal school. It is important to include the educators and teaching staff in the diabetes care. The following measures can be helpful for educators and teachers as well as parents:

• Talk to the educators and teaching staff about your child’s diabetes. Provide educational staff with information material. 
• If your child wears a continuous glucose monitoring (CGM) device, explain to the educators or teachers what to do if alarms are triggered. Explain the necessity of reading the values with a smartphone or other receiving device.
• If your child wears an insulin pump or a closed-loop system, inform the nursery or school staff about the relevant handling steps.
• Emergencies, such as severely low blood sugar levels where a child needs help, have become rare thanks to modern diabetes technology. Nevertheless, explain to educators and teachers what they should do in the event of a diabetes emergency. Information on what to do in an emergency can be found here.
• Make sure to provide your telephone number and the number of the treating medical specialists as well as the nearest hospital.
• Ask your diabetes team to provide training for the educators or teaching staff. The more they know about the disease and how to manage it, the better they can support your child. If your diabetes team is unable to offer training in the clinic or in daycare/primary schools, contact national training organizations. For example, the Dianiño Foundation offers free training for teachers, educators and care staff (Link in German).
• Educators or teaching staff are not obligated to provide diabetes management. They are helping on a purely voluntary basis.

• Discuss special arrangements: Your child must be allowed to eat and drink, read the CGM system or measure blood sugar levels and/or administer insulin at any time, including classes and physical education. Your child must also be allowed to use a smartphone, for example to receive sensor data, use an insulin pump and consult with parents in the event of problems.
• In coordination with the diabetes team, determine how best to adapt treatment to enable participation in physical activities. Share this information with the person supervising your child.
• Before excursions or class trips, you should talk with your diabetes team and the person who will be supervising the children. This ensures that your child’s blood sugar levels will not go unnoticed during their trip.
• Find support. For example, an outpatient care service can help with blood sugar measurements and injecting insulin. If more support and continuous monitoring are required, for example with infants or young primary school children, one-to-one support (daycare or school support) is often necessary.

There are various options for support in kindergarten and school routines. For example, parents can hire an outpatient care service to support the child with the treatment of diabetes. The attending specialist will issue a corresponding prescription. The application for nursing care is made through the health insurance provider. If requirements are met, the health insurance provider will cover the costs. It should be noted that not all care services are familiar with the care of children with automated insulin pumps.

The parents can also apply for a kindergarten or school support assistant. This is known as integration assistance. Depending on the federal state, the cost bearer can be the health insurance provider, the social welfare office or the integration assistance, sometimes several bearers together. Recent rulings by the social courts indicate that the health insurance provider is increasingly being named as the responsible body in cases of primary diabetes. It is advisable to discuss the application with the diabetes team in advance. Some federal states also offer what are called “pool models.” The funding body (e.g., the federal state) provides the school with additional hours for the care of children with special support needs so that the school can employ appropriate staff. This staff looks after several children at the same time. This is a great advantage, as it means that absences due to illness can be compensated for.

The kindergarten or school assistant, also known as integration worker or pool worker, looks after the child for the approved number of hours during the kindergarten or school days: The assistant carries out the therapy, guides the young schoolchild step by step and, if possible, accompanies them on school trips.

Primary school children and pupils in grades 5 and 6 with type 1 diabetes need to be accompanied on school trips. Such trips are special highlights in the school day: From traveling by train or bus, staying in shared rooms and eating together in a youth hostel to activities such as climbing tours or mudflat hiking tours – all of these are exciting experiences for children with a healthy metabolism. For children with diabetes, on the other hand, the changed physical activity and eating habits pose a challenge for their therapy. They need support, for example when changing the sensor or the catheter of the insulin pump. They must therefore be accompanied by a parent or a trained caregiver. The corresponding costs can be partially covered by the health insurance provider or the integration assistance.

In practice, applications for assistance in a daycare center and at school are often delayed or rejected because the responsibilities between the health insurance companies and the integration assistance providers are not clearly defined. It is therefore very important that advice on these topics is provided by a pediatric diabetes team that is familiar with the conditions in the catchment area.

When children are jumping about in kindergarten or during school sport

Children with type 1 diabetes are just as resilient and physically capable as healthy children. However, due to the increased energy requirements, sport requires an adjustment of insulin therapy and, if necessary, the child must eat or drink foods containing carbohydrates.

• Children with type 1 diabetes can take part in physical education class, but beforehand they must eat food containing carbohydrates, such as juice or dextrose, at any time. They are instructed to check their glucose (sugar) level before going to physical education class and adjust their therapy accordingly. Sports instructors should therefore ask children with diabetes whether they have made these checks and adjustments before physical education. Parents should inform the teachers about this and support them in their preparations.
• When children of nursery age run around outside or jump on a trampoline, this corresponds to the activities during their physical education. The same rules apply to small children, but trained adults must adapt the therapy and, if necessary, give the child some juice or dextrose beforehand.
• Physical exertion or insufficient food intake can lead to low blood sugar levels. In this case, the child needs fast-acting carbohydrates (juice or dextrose) immediately. The child should therefore always keep a supply in the classroom and in the sports hall. In addition, children should carry fast-acting carbohydrates with them, but the teachers should also have some dextrose available if the children are doing sport outside school, for example.
• In very rare cases, severely low blood sugar levels may prevent the child from being able to help themselves. For these rare cases, (sports) teachers should have an emergency medication (glucagon as a nasal spray or emergency injection set) to hand for medical laypersons. Parents should show teachers how to administer this emergency medication.
• If a child with diabetes does not feel well or is nauseous, the parents must be informed and pick up the child. The child should never be sent home when it is not accompanied by an adult. It is therefore important that teachers can always reach parents by telephone.
• Parents should inform the teachers that the children must eat the food they have brought at the specific times. The child must be allowed to eat or drink at any time during class, read the glucose value on their CGM system or measure their blood sugar level and/or administer insulin. This also applies to physical education.
• Children should never swap the food they brought with other children. If sweets are distributed in the classroom, it is important to clarify whether the child is allowed to eat them, how much insulin is needed for this or whether the parents want to compensate for the increased sugar level later.

Primarily, the parents inform educators and teachers about what to look out for.

Practical courses given by diabetes specialists can provide educational professionals and teachers with basic information about type 1 diabetes. The information provides them with confidence in dealing with diabetic children. In Germany, there are currently no standardized courses of this type and their funding is uncertain.

To date, the courses have been given by diabetes specialists, diabetes self-help groups, public health professionals, or the parents of affected children. The courses are funded by health insurance providers, the public health department, the institution, donations from a society of friends, the parents themselves, or other funding bodies.

However, efforts are underway to include structured seminars in the standard training programs for educators and teaching staff, for example, in Rhineland-Palatinate.

There are also projects from self-help groups such as “Diabetes at School (Diabetes in der Schule)” (Link in German), which aim at training educators and teaching staff on how to manage children with diabetes.

Children with type 1 diabetes can take part in physical education class or sports events. They are just as physically capable as other children. However, physical activity does reduce blood sugar levels. These children therefore have to reduce their insulin dose in advance or eat additional carbohydrates. The parents should talk to the diabetes specialist about how best to adapt the treatment to physical activity. The supervising person must be aware of the child’s condition and should always have dextrose on hand for emergencies.

Children with type 1 diabetes can take a break from physical education class if they feel it is necessary. They must also be able to eat and drink during physical education class and be able to monitor their glucose levels.

If the physical education class is unexpectedly re-scheduled, the children with type 1 diabetes must be given the opportunity to eat something before. This helps prevent low blood sugar. During longer activities, such as hiking, short breaks to eat additional snacks may be needed. During these types of activities, it must be ensured that sufficient food is available, as well as rapidly absorbed foods containing sugar, such as dextrose.

You can find out what to do in an emergency here.

There are usually individual rules for physical education class for each child. Depending on the time of day, the blood sugar (glucose) level may be high before physical education class (for example, directly after breakfast or after a break meal), in the target range or too low.

The normal range for people with diabetes is 70 to 180 mg/dl (3.9 to 10.0 mmol/l). A glucose value of at least 140 to 160 mg/dl (7.8 to 8.9 mmol/l) should be aimed at before physical education class, and even higher levels should be reached for swimming lessons, around 200 mg/dl (11.1 mmol/l).

Modern insulin pump systems can adjust their insulin delivery during physical education class. However, the child may still need to eat additional carbohydrates. Some children prefer to disconnect the insulin pump from the body for physical education class, especially for contact sports. This is possible for up to 2 hours. Teachers should then have a plan for treatment without an insulin pump during the sports session. In this case, the children should also be able to store the pump safely in the sports hall or in the sports teacher’s room.

Children who use insulin pens usually need to eat something before physical education class. Only if the tissue glucose or blood glucose value is too high for several hours (over 250 mg/dl (13.9 mmol/l)) or if the child feels unwell, has abdominal pain and/or is nauseous, should the cause of the high sugar levels be investigated first. The values should then be corrected and the child should leave physical education class on that day.

A short-term increase in blood/tissue sugar after a meal and before physical education class does not require any further measures if the child feels well. Participation in physical education is possible.

Find out more about type 1 diabetes and physical activity here!