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As more children adopt diabetes technology, schools must share best practices
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Children with diabetes and their families are seeing improved health outcomes and better quality of life as they adopt newer diabetes technologies. However, the schools in which these children spend a substantial portion of their day are often under-resourced and under-informed about technology.
Diabetes care providers must empower families by writing orders for them to share with schools and also help to educate and train school staffs to offer effective education in a safe environment.
“We need to accomplish this as a community-wide effort and locally,” Anastasia Albanese-O’Neill, PhD, APRN, CDE, director of diabetes education and clinic operations in the division of pediatric endocrinology at the University of Florida, told Endocrine Today. “Communication and working in partnership will be important because there will be a lot of change in diabetes technology over the next decade.”
Albanese-O’Neill, who is an Endocrine Today Editorial Board Member, discussed the diabetes technologies children are using and their benefits, as well as resources for schools serving these students.
A few years ago, we talked about how difficult it can be to provide and access good diabetes care in schools . Has that changed?
Albanese-O’Neill : A child with diabetes spends between 6 and 8 hours, or 25% to 33%, of their day in school. The American Diabetes Association recommends that you should spend 70% of your day with blood glucose in the range between 70 mg/dL and 180 mg/dL. To achieve that goal, diabetes has to be managed well at school.
If you look at data from the T1D Exchange going back 6 or 7 years, children and adolescents are not meeting glycemic targets. However, the people who are using diabetes technology, especially continuous glucose monitors, are achieving better results.
We’ve made a lot of progress in terms of partnerships with schools, but there remain some issues. We don’t have a nurse in every school in the United States, even though that’s the American Academy of Pediatrics’ recommendation. In some states, the ratio is as high as one nurse to 6,000 students, so there are staff members — a teacher, a paraprofessional, a front office staff member — who take care of kids with type 1 diabetes. As we simultaneously see a frankly striking increase in type 1 diabetes technology use, which we know improves outcomes, we also see a lot of school staff and school nurses who don’t have exposure to this technology. Our challenge is to make sure that A) there’s a written plan for these kids that describes what technology they’re using and how it should be used and B) we get training for school nurses and the staff so they can assist children at school in a meaningful way with their diabetes care.
How many children are using CGM ? How are their outcomes?
Albanese-O’Neill : According to data from the T1D Exchange, in 2010 to 2012, the first year they published data, CGM use among children under 6 years was 4%, and among children 6 to 12 years it was 3%. By 2016 to 2018 when they reran the numbers, in the group under 6 years, it had jumped to over 50%, and among the 6- to 12-year-olds it had jumped to 37%. Kids of all ages, from preschool to high school, are wearing the devices.
We know we get better outcomes if people wear a CGM at least 6 days a week. These devices also significantly reduce risks for severe hypoglycemia and improve overall diabetes outcomes. In addition, we see improvements in psychosocial outcomes or quality of life.
With automated insulin delivery systems, whether that’s with the Medtronic 670G hybrid closed-loop system or the t:slim X2 insulin pump predictive low-glucose suspend, we see a reduction in hypoglycemia. For many parents, fear of hypoglycemia is lessened because they can see a low coming overnight. There are always exceptions, of course, and some parents are overwhelmed with all the CGM data.
There are other benefits of diabetes technology as well. Not only is there a higher likelihood of preventing lows, but you can also see when they are overtreated. With hybrid closed-loop systems, we see very steady glucose levels overnight. Also, as long as you bolus before eating carbohydrates, even if you don’t get the carbohydrate count exactly right, the system’s algorithm can help out by giving additional insulin when it senses that you’re not coming to target. So, we’ve seen both a reduction in hypo- and hyperglycemia with these systems.
One of the challenges for schools is that all the CGMs are different. Now we have four: the Senseonics Eversense, an implanted CGM not approved for people younger than 18 years; the Abbott Freestyle Libre — also not indicated for people younger than 18 years — but sometimes prescribed off-label; the Medtronic Guardian or Guardian Connect; and the Dexcom G5 and G6. Some of these devices cannot be used if the child takes acetaminophen, some can. Some are disposable, some are not. If the device falls of at school and the school staff accidentally assume it is disposable, they could throw away a $500 piece of equipment that the family would be obligated to replace. These are important concerns.
Do you have any examples of schools that are addressing diabetes care really well?
Albanese-O’Neill : Remember that the technology landscape was completely different 5 years ago. You couldn’t calculate insulin doses or make treatment decisions based on continuous glucose monitors. We didn’t have hybrid closed-loop systems. We didn’t have share technology; we had very few diabetes apps; we didn’t have predictive low-glucose suspend. Students are using hybrid closed-loop system in schools, as well as do-it-yourself systems, like LOOP. It’s a completely different world, and school staffs and diabetes care teams are sprinting to keep up with all of these changes.
An example of a state that is trying to get ahead of the curve is Colorado. I want to give a shout out to Leah Wyckoff, MS, BSN, RN, NCSN, who led a program called Colorado Kids with Diabetes. What Leah and her team have tried to do is to create standard processes for diabetes care in the Colorado schools, including the use of diabetes technology. For example, for the hybrid closed-loop system, they’ve created a handout that is available online. You can edit it to add information tailored for a particular child. It has pictures of the device and additional information for school nurses. The American Diabetes Association has also created guidance for CGM use in schools and other resources.
Clinic by clinic, practice by practice, people are creating school orders in their electronic health record, and they’re providing in-services for schools. But really, we’re all addressing the same problem. I’m calling for a national approach — and frankly, it’s an international question because this technology is used globally. I would rather spend more time actually educating the school and the family than creating the materials necessary to do so. We should share these resources as a community, including best practices, processes and templates within the EHR, as well as patient-facing materials. Having a suite of resources at our fingertips will allow us to spend more time with patients and not on creating the same template over and over and over across clinical practices.
What are some of the hurdles to adopting diabetes technology for schoolchildren?
Albanese-O’Neill : A decade ago, the technologies were complicated from an end-user perspective. CGMs were hard to put in, they hurt and people bled, you had to calibrate them all the time and they weren’t always reliable. Most people didn’t perceive the work required to be worth the benefit they received. Now, we’ve come over the hump with regard to CGM, and it’s much easier to pop it in, in some cases you rarely have to prick your fingers, and you can share the data pretty easily. Adoption rates are skyrocketing. I anticipate we will see that same trajectory with automated insulin delivery systems, but we’re not there yet.
Access to technology is going to be the crucial issue. Barriers include cost, lack of coverage and other challenges. For example, share technology is a very powerful tool, but if parents can’t afford to buy a compatible phone for their child to use as the receiver, or can’t afford a data plan or have wireless at home, they can’t benefit from this important CGM feature. Clinically, I see families that A) don’t have a device that can be used for the child to share the data, or B) they don’t have a way to upload the data because they don’t have a computer at home. The child can’t share data with caregivers in real-time, and the family can’t share data with the diabetes care team between clinic visits, diminishing the utility of the device.
In addition, some insurance companies only cover specific devices. High out-of-pocket costs and high deductibles can box children and adults out of technology completely.
Medicaid may cover only an older version of the device, for example a Dexcom G5 and not a G6. They may not cover hybrid closed-loop at all. We don’t want to create haves and have-nots in terms of diabetes technology, so this needs to be a priority for all of us in the diabetes community. – by Jill Rollet
For more information:
Anastasia Albanese-O’Neill, PhD, ARNP, CDE, can be reached at aalbanese@ufl.edu.
Disclosure: Albanese-O’Neill reports no relevant financial disclosures.