Preparation, technology key to managing diabetes in schools during pandemic
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As the start of the new school year quickly approaches in the United States, parents of children with diabetes are trying to figure out how their child’s needs will be met when classes begin.
Anastasia Albanese-O’Neill, PhD, ARNP, CDE, assistant clinical professor and director of diabetes education and clinic operations in the division of pediatric endocrinology at the University of Florida, told Healio it is very difficult to predict how diabetes management will be handled as schools shift their reopening plans along with the ever-changing efforts to combat COVID-19.
“These are unprecedented times. The familiar rhythms and rituals that accompany the start of the school year have been disrupted. Change will be the only constant, and we will all need to have patience and make every effort to support each other,” Albanese-O’Neill, who is an Endocrine Today Editorial Board Member, said. “The schools aren’t going to do things perfectly in this context, no one is. This is not a perfect situation. We need to be flexible, communicate and work hard to find the best path forward on behalf of our children.”
Albanese-O’Neill discussed how parents can best prepare for the upcoming school year and how technology can make diabetes management easier both during and after the pandemic.
What are some ways COVID-19 could cause new challenges for the management of diabetes in schools?
Albanese-O’Neill: I see several challenges. For example, in the past, students with diabetes typically went to the school clinic to receive support for diabetes management. During the pandemic, students with fevers will need to be evaluated in the school clinic. Some may have COVID-19. Schools will need to find a way to separate students who are potentially ill with an infectious disease and children who need to come to the clinic for assistance with management of a chronic condition. This likely means two “clinic” locations.
This will be an additional resource and staffing burden on schools that are already dealing with tremendous uncertainty and are struggling to adapt to the pandemic on a tight timeline, including designing and providing multiple academic options for students, such as brick and mortar, synchronous online learning and asynchronous online learning. Schools will also have to increase cleaning and enforce social distancing guidelines. I worry that schools are under-resourced and underfunded and do not have adequate staffing to carry out all of these requirements on such short notice.
The second challenge is that some children with diabetes depend on resources at school, and specifically the support provided by the school nurse, to manage diabetes. Some children receive their basal insulin injection at school, and the school nurse is a central partner in other aspects of diabetes care. In these situation, the child would be best served in a traditional brick and mortar school setting. However, during the pandemic, on-site education might not be available in all districs, and students with diabetes may have to attend digitally or online. Their need for additional support will not disappear. This support could potentially be provided by the school nurse via telehealth. During these visits, the school nurse could address issues around diabetes care, food insecurity and other needs.
The American Diabetes Association has compiled a collection of resources, including recommendations on how parents can obtain a diabetes medical management plan in advance of the upcoming school year, as well as suggested accommodations for the student’s 504 plan in the era of coronavirus (www.diabetes.org/resources/know-your-rights/safe-at-school-state-laws/safe-school-coronavirus-resources). When deciding if a child should attend school in person or online, students and parents should review all the available evidence and talk with the diabetes care team about an individualized plan.
How can schools and families prepare now for some of the challenges they will face?
Albanese- O’Neill: Families of children and adolescents with diabetes should make sure they obtain a diabetes medical management plan (DMMP) or doctor’s orders in advance of the school year. In addition, the parents should request a 504 meeting in writing to establish accommodations for the student with diabetes.
The DMMP and 504 need to be in place before the school year starts — ideally at least a week before. The DMMP describes the student’s glucose monitoring and insulin administration requirements, as well as treatments of acute complications. From this document, the school nurse or the district-level nurse will create other plans specific to that child. The DMMP also serves as a foundation for the 504 plan.
The 504 plan takes on more significance because the child may need to take additional sick days to avoid a COVID-19 exposure or establish other accommodations, like a safe place to monitor glucose and administer insulin. If the child is learning virtually or through e-learning, they may need a school nurse to check in with them. For some students, the school nurse may need to check in every week to make sure they have the resources they need, that they have enough to eat, that they have sufficient supplies so they can continue to manage diabetes effectively and safely while they’re attending school virtually.
Can technology play a beneficial role in some of the challenges?
Albanese- O’Neill: Technology can certainly help mitigate some of the challenges students and schools will face. For example, use of CGM with share technology would reduce the need for the student to come to clinic to check glucose levels. Say there’s an 8-year-old student in elementary school. Instead of the child walking over to the clinic multiple times each day, the school nurse could instead monitor the child’s glucose levels remotely via iPad. An iPad that’s been provided by the school would allow the school nurse to follow multiple students, without the need to have contact with them, without having the children physically come to clinic. The iPad could have an app that alerts the nurse to risk for severe lows — hypoglycemia — and the nurse could contact the teacher via the school intercom to intervene. This would reduce the need for the student to come to clinic and risk exposure to coronavirus. Students using blood glucose meters can take advantage of meters with Bluetooth capability and link them to apps. These data can also be sent remotely to the school nurse, again reducing trips to the clinic where exposure to COVID may occur.
Will the way we address some of the challenges presented by COVID-19 benefit how diabetes is managed in schools after the pandemic?
Albanese-O’Neill: I think so. We piloted a program last year using direct-to-school telehealth. It was really cool because I could be on the video conference and so could the child and school nurse. We also invited the teacher, the district nurse and, of course, mom and dad. In cases where parents are separated and might not come to diabetes appointments together, this model improves communication. This way, we’re all on the Zoom call together, we can review and agree on the plan of care for the child. If this model of care can expand, it has the potential to improve communication and, ultimately, diabetes outcomes.
The other thing that would be helpful is increasing utilization of the patient portal. For example, if we mail the DMMP, it could go to an old address, it could get lost in the mail. You might receive it, but then put it into a pile with other documents, and not be able to locate it when the time comes to take it to school. If it’s available in the patient portal as an electronic document, it’s right there on your phone at your fingertips. All you do is click on the letters tab to access it.
Many school nurses have already adapted to following student’s CGM data remotely, but maybe we take it to the next level and reduce missed class times, because kids are no longer walking back and forth during instruction time to get their glucose levels checked. By leveraging technology, students with diabetes can miss less class time and spend more time learning or hanging out with friends instead.
For more information:
Anastasia Albanese-O’Neill, PhD, ARNP, CDE, can be reached at aalbanese@ufl.edu.
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