Recently, our Safe at School Director, Crystal Jackson, got the chance to chat with Fran Cogen, MD, CDE, Director of Diabetes Services and Interim Co-Chief of Pediatric Endocrinology at Children’s Hospital. Dr. Cogen’s practice serves approximately 1,800 patients in the DC/Maryland/Virginia metro area, with 85 percent of those patients living with type 1 diabetes. Dr. Cogen has been working with diabetes patients since 2002 and is also a member of the ADA’s Safe at School Working Group. Crystal and Dr. Cogen spoke about the Safe at School program, diabetes management in schools and how parents can work with schools as a team—check out part one of this interview series that will be helpful to parents, diabetes providers and school staff.
Crystal Jackson: Most of [your patients] are school age. What are some common school diabetes care complaints that you hear from parents?
Fran Cogen, MD, CDE: Let’s start with insulin—sometimes, private schools may refuse to give insulin at school (but that’s happening less and less). Another concern is independence of the student. Many school nurses insist that students go to the clinic to check blood glucose or to receive other diabetes care. Students then often miss class time. That also goes for insulin pumps—some of the nurses feel that the students are not capable of bolusing on their own. In addition, some schools refuse to give glucagon…even if (in some cases) a child is seizing, they call 911 and give glucose gel. Other schools insist that every time the healthcare provider OR the parent/caregiver makes an insulin dose adjustment, we have to send new orders, which is impractical and can result in delaying an insulin dose and the child being able to eat lunch with classmates. Many school nurses take the position that they will not accept parental permission for insulin dose adjustment and require written orders from the student’s provider. This is unnecessary. Parents and self-managing students adjust insulin doses all of the time without input from the child’s provider.
CJ: What is your feeling about the need for provider authorization to make changes? What do you base that change on; for example, do you know what the child has been up to that day?
FC: I don’t personally know the latest insulin adjustments made by the family, but what we do (at least on the Maryland school form) is give permission to adjust the insulin-to-carb ratio at a certain range, and we give them permission to adjust the correction factor to a certain range…a responsible parent is best positioned to make these adjustments.
CJ: Going back to insulin, you mentioned that some of the private schools don’t have anybody to give insulin?
FC: Some schools don’t have nurses. [In those cases,] We ask that they delegate and train a school employee to give insulin—we haven’t seen many problems with that as of late. Of course, with some day care situations, that may be an issue.
CJ: What about public schools in the D.C. area?
FC: I haven’t heard any issues with the public schools in the area giving shots or using pens—what I am hearing are issues with the insulin pumps. They’re not comfortable letting the children manage them. For example, I recently got a call from one family whose child is perfectly capable of adjusting pump settings, and the child was low and knew what to do, but the nurse was trying to change the basal rates which she had no experienced in how to change. The father was very angry and ended up meeting with the principal.
CJ: What do you think could help to address a situation like that?
FC: It is my personal belief that we want someone trained and experienced to handle insulin pumps. Many school nurses—unless they’re insulin pump nurses—usually do not have that experience. I can understand if there’s a problem and [the school] wants to go over it with the parents on the phone, but I don’t feel it’s appropriate for a nurse to be changing pump basal rates, or changing infusion sites if they fall out in school unless they have training, experience and are comfortable with doing so. I don’t want someone who has little experience changing basal rates and replacing infusion sets basal rates in school, especially with the back-up option of giving insulin injections by pen or syringe.
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