UNIQUE CHALLENGES FOR THE YOUNG CHILD Diabetes Care Volume 37, October 2014 POSITION STATEMENT

Transcription

1 2834 Diabetes Care Volume 37, Otober 2014 Care of Young Children With Diabetes in the Child Care Setting: A Position Statement of the Amerian Diabetes Assoiation Diabetes Care 2014;37: DOI: /d Linda M. Siminerio, 1 Anastasia Albanese-O Neill, 2 Jane L. Chiang, 3 Katie Hathaway, 3 Crystal C. Jakson, 3 Jill Weissberg-Benhell, 4 Janel L. Wright, 5 Alan L. Yatvin, 6 and Larry C. Deeb 7 POSITION STATEMENT Diabetes is a relatively ommon hroni disease of hildhood (1); however, apturing prevalene data in hildren with type 1 and type 2 diabetes has been hallenging. The omprehensive SEARCH for Diabetes in Youth (SEARCH) study has made signifiant strides in better understanding disease prevalene in the pediatri population. A reent SEARCH study found that 1.93 per 1,000 youth (aged,20 years) were diagnosed with type 1 diabetes (2), an inrease of 21.1% from 2001 to 2009, with inreases seen in all ethni groups but with non-hispani whites disproportionately affeted (3). For type 2 diabetes, the SEARCH study reported a prevalene of 0.46 per 1,000 youth (aged years), an inrease of 30.5% from 2001 to 2009 in all ethniities (3). As youth rarely die of diabetes, the inrease in prevalene is most likely attributed to inreased inidene. An annual inrease of 2.3% in type 1 diabetes inidene has been reported in hildren, with hildren aged,5 years experiening the greatest inrease relative to all hildren (4). As type 2 diabetes is rarely seen in hildren younger than 10 years of age (3), this Position Statement will primarily fous on type 1 diabetes. The primary objetive of this Position Statement is to explain that young hildren (aged #5 years) are a vulnerable population and have unique diabetes management needs. Our goal is to desribe the diabetes management reommendations in the hild are setting. The hild are setting inludes day are, amp, and other programs where young hildren with diabetes are enrolled. This Position Statement is meant to guide hild are providers in aring for young hildren with diabetes and is not intended to provide speifi advie on the medial management for this population. While Position Statements ontain evidene-based reommendations, all of the information that pertains to young hildren is expert opinion only. For more detailed information on the medial management of type 1 diabetes in hildren, please refer to the Amerian Diabetes Assoiation s (ADA s) Standards of Medial Care in Diabetesd2014 (5) and Type 1 Diabetes Through the Life Span: A Position Statement of the Amerian Diabetes Assoiation (6). UNIQUE CHALLENGES FOR THE YOUNG CHILD Infants, toddlers, and preshool-age hildren (#5 years of age) are enrolled in the more than 330,000 hild are programs aross the ountry (7). These hildren wholly depend on adults for most, if not all, aspets of their are. Pediatri health are providers, parents/guardians, and hild are staff must work together to ensure that young hildren with diabetes are provided with the safest possible hild are environment. This ollaboration is essential to ahieve a seamless transition in are from home to the hild are setting. Managing type 1 diabetes in young hildren in hild are programs presents unique hallenges due to the young hild s developmental level. The limited ommuniation and motor skills, ognitive abilities, and emotional maturity of young hildren an hallenge even the most experiened hild are provider. For example, young hildren with hypo- or hyperglyemia may or may not exhibit abnormal behavior or irritability. As errati behavior is typial in this age-group, the hild are provider may not reognize hypo- or hyperglyemi symptoms and may miss 1 University of Pittsburgh Diabetes Institute, Pittsburgh, PA 2 Department of Pediatris, University of Florida College of Mediine, Gainesville, FL 3 Amerian Diabetes Assoiation, Alexandria, VA 4 Northwestern University Feinberg Shool of Mediine, Ann and Robert H. Lurie Children s Hospital of Chiago, Chiago, IL 5 Alaska Department of Labor, Anhorage, AK 6 Popper & Yatvin, Philadelphia, PA 7 Florida State University College of Mediine, Tallahassee, FL Corresponding author: Jane L. Chiang, jhiang@ diabetes.org. This Position Statement was reviewed and approved by the Professional Pratie Committee in July 2014 and approved by the Exeutive Committee of the Board of Diretors in July by the Amerian Diabetes Assoiation. Readers may use this artile as long as the work is properly ited, the use is eduational and not for profit, and the work is not altered.

2 are.diabetesjournals.org Siminerio and Assoiates 2835 the fat that the behavior is aused by low or high blood gluose levels that may require treatment. The diabetes regimen must be adapted quikly to the hild s dynami growth and development. As the hild develops and desires greater autonomy, hild are providers and parents/guardians may fae hallenges with the toddler s refusal to ooperate with his or her diabetes are regimen (8). One the hild enters the prekindergarten years, he or she may begin to be able to partiipate in his or her own are by indiating food preferenes, heking blood gluose, and hoosing a finger-prik or injetion site. With further ognitive and physial development, he or she may verbalize symptoms and beome more ooperative, but the hild still needs onstant supervision and blood gluose monitoring to detet hypo- or hyperglyemia. The age at whih hildren are able to perform self-are tasks is variable and depends on the individual hild s apabilities, but self-are is not expeted from the young hild and the parent/guardian or other aregiver must provide diabetes management and perform assoiated diabetes are tasks suh as blood gluose monitoring and insulin administration (5,8) (Table 1). Language barriers, ethni and ultural praties, limited resoures and support, geography (rural vs. urban setting), and health literay and apabilities must also be onsidered in developing the are plan. Another hallenge in the hild are setting may be staff turnover and ensuring that trained staff members remain available. Regardless, the hild are program must be prepared to provide needed are to the hild, and parents and health are providers play a pivotal role in partnering with the hild are staff. The safety, health, and well-being of the hild as he or she transitions from home to the hild are setting are ahieved through effetive ollaboration between the diabetes health are provider, parents/guardians, and hild are staff. Adults must provide most, if not all, of the diabetes are to young hildren beause of their limited motor, ognitive, and ommuniation skills as well as other abilities that are neessary to partiipate in self-management. As the hild grows older and beomes loser to shool age, he or she may partiipate in are tasks as appropriate for the individual hild, but adult supervision must always be present. Challenges in the hild are setting inlude staff turnover, language barriers, ethni and ultural praties, limited resoures and support, geography (rural vs. urban setting), and health literay and apabilities. DIABETES CARE The Diabetes Control and Compliations Trial (DCCT) showed a signifiant link between blood gluose ontrol and a slower onset and progression of diabetes ompliations in adults and adolesents, with improved glyemi ontrol dereasing the risk of miro- and marovasular ompliations (5,9,10). Although the DCCT did not inlude young hildren (the lower age limit at enrollment was 13 years), the general messaged optimize blood gluose ontrol while avoiding hypoglyemiadhas been linially applied to young hildren. Furthermore, reent data from ross-setional neuroimaging studies in young hildren appear to reinfore the importane of aiming for blood gluose levels in range and avoiding hypo- and hyperglyemia (11). Nutrition and Physial Ativities The parent/guardian remains primarily responsible for determining and providing healthy food hoies for the hild. The parent/guardian should eduate the staff on general information on the arbohydrate ontent of the food, regardless of whether it is provided by the parent/guardian or hild are program. If a hild are program provides the meals and snaks, the parent/guardian and the hild are provider should work together to determine appropriate food hoies and portion sizes for the hild. The hild are program should ensure that the hild eats the appropriate amount of food that is being overed by insulin in aordane with the diabetes medial management plan (DMMP). See the setion on DMMP for further details. For hildren who regularly attend hild are programs for longer durations or where meals or snaks and physial ativity are part of the daily shedule, suffiient staff should reeive omprehensive training in diabetes management and be prepared to provide diabetes are as needed. At least one staff member should be available at all times to help with food deisions, blood gluose monitoring, and insulin administration. Inreased sensitivity in aring for the hild around speial oasions (suh as parties/elebrations), physial ativities, or illnesses is partiularly important. The hild should be allowed to partiipate in elebrations, but speial onsiderations mayberequiredtoaommodatethe hild s diabetes needs. Effetive ommuniation between the hild are staff and the parent/guardian to antiipate the adjustments (e.g., administering additional insulin to aount for the birthday ake) will enable the young hild to feel inluded. Resoures are available to parents/guardians, hild are providers, and health are providers to assist with this eduation and training (12 15). Children who partiipate in programs for only a few hours may onsume snaks and not meals; therefore, insulin administrationmaynotberequiredinthe hild s DMMP. However, at a minimum, in order to failitate safe diabetes are in all hild are programs, hild are staff must have a basi understanding of diabetes; be able to hek blood gluose levels; be able to prevent, reognize, and treat hypoglyemia; be able to handle diabetes emergenies; and know who to ontat for help (12 14,16). Hypoglyemia For the very young hild, the diabetes management priority is the prevention and management of hypoglyemia and the avoidane of wide flutuations in blood gluose levels. Parents/guardians fae the perpetual struggle of balaning the risk of long-term ompliations from hyperglyemia with the fear of aute hypoglyemia, all while trying to failitate a normal hildhood. More notably, parents worry about the possibility of ognitive defiits and/or death if a severe hypoglyemi event is undeteted and untreated. Therefore, hypoglyemia prevention is ritial. Child are staff should be eduated on how to prevent and reognize hypoglyemia by monitoring the hild s food onsumption, ativity, and behavior and onfirming a suspeted low with blood gluose monitoring (5,8,17). Parents/guardians should provide speifi

3 2836 Position Statement Diabetes Care Volume 37, Otober 2014 Table 1 Major developmental issues and their effet on diabetes in hildren and adolesents Developmental stages (ages) Infany (0 12 months) Toddler (13 26 months) Preshooler and early elementary shool (3 7 years) Older elementary shool (8 11 years) Early adolesene (12 15 years) Later adolesene (16 19 years) Normal developmental tasks Developing a trusting relationship or bond with primary aregiver(s) Developing a sense of mastery and autonomy Developing initiative in ativities and onfidene in self Developing skills in athleti, ognitive, artisti, and soial areas Consolidating self-esteem with respet to the peer group Managing body hanges Developing a strong sense of self-identity Establishing a sense of identity after high shool (deisions about loation, soial issues, work, and eduation) Type 1 diabetes management priorities Family issues in type 1 diabetes management Preventing and treating hypoglyemia Coping with stress Avoiding extreme flutuations in Sharing the burden of are to avoid blood gluose levels parent burnout Preventing hypoglyemia Avoiding extreme flutuations in blood gluose levels due to irregular food intake Preventing hypoglyemia Coping with unpreditable appetite and ativity Positively reinforing ooperation with regimen Trusting other aregivers with diabetes management Making diabetes regimen flexible to allow for partiipation in shool or peer ativities Child learning short- and long-term benefits of optimal ontrol Inreasing insulin requirements during puberty Diabetes management and blood gluose ontrol beoming more diffiult Weight and body image onerns Starting an ongoing disussion of transition to a new diabetes team (disussion may begin in earlier adolesent years) Integrating diabetes into new lifestyle Establishing a shedule Managing the piky eater Limit-setting and oping with toddler s lak of ooperation with regimen Sharing the burden of are Reassuring the hild that diabetes is no one s fault Eduating other aregivers about diabetes management Maintaining parental involvement in insulin and blood gluose management tasks while allowing for independent self-are for speial oasions Continuing to eduate shool and other aregivers Renegotiating parent and teenager s roles in diabetes management to be aeptable to both Learning oping skills to enhane ability to self-manage Preventing and intervening in diabetes-related family onflit Monitoring for signs of depression, eating disorders, and risky behaviors Supporting the transition to independene Learning oping skills to enhane ability to self-manage Preventing and intervening with diabetes-related family onflit Monitoring for signs of depression, eating disorders, and risky behaviors strategies, if needed, to help the hild are staff address the individual hild s speifi needs. Routine blood gluose monitoring at prespeified times may help to detet hypoglyemia before it manifests with aute symptoms in the hild. Hyperglyemia Although hypoglyemia is a signifiant onern, hyperglyemia should be managed as well. The hild may experiene frequent urination (polyuria), whih may be onfused with heavy diapers or wetting aidents, a ommon ourrene in this age-group anyway. A hild are provider unfamiliar with diabetes and polyuria may not realize that the hild is hyperglyemi, requiring insulin, and instead may feed the hild or give him or her juie, inadvertently aggravating hyperglyemia. Untreated hyperglyemia may lead to ketone prodution, whih may be measured by heking urine ketones. The ADA has previously reommended higher blood gluose targets for young hildren in an effort to prevent hypoglyemia. However, the ADA has reently adjusted its target reommendations to an A1C of <7.5% in all pediatri age-groups (<19 years of age) but with the goal of ahieving the best A1C possible without hypoglyemia. The new reommendation is a produt of redued hypoglyemia seen with newer rapid-ating insulin analogs and improved gluose monitoring devies and the awareness of the potential impat of hroni hyperglyemia on the development of future longterm ompliations (6). Blood Gluose Monitoring Blood gluose monitoring allows hild are providers to assess if a hild is hypo- or hyperglyemi and perform appropriate interventions. Blood gluose levels need to be heked before meals/snaks, before physial ativity, and when the hild exhibits symptoms of hypo- or hyperglyemia. These symptoms may be subtle, espeially in young hildren. For this reason, blood gluose needs to be heked more frequently in young hildren.

4 are.diabetesjournals.org Siminerio and Assoiates 2837 Continuous Gluose Monitors Some hildren use a ontinuous gluose monitor (CGM) to reord blood gluose levels. CGM results must be onfirmed with blood gluose tests. Parents/guardians should disuss CGM management with hild are providers. A basi understanding of CGM use is warranted, but detailed management should not be expeted of hild are providers. Safe monitoring must inlude the following reommendations: 1. Avoid ommunity exposure to sharps and other medial waste. 2. Minimize trauma to the finger orrelevant laning site. Blood laning devies must not be reused, point-of-are devies should only be used for the designated hild, and hild are providers should use gloves when testing (8). The ADA s Safe at Shool program is a helpful resoure to assist shools (18). Insulin Administration Children with diabetes who attend hild are programs must have aess to insulin, gluagon, and other mediations to safely partiipate in the programs. Training hild are staff on insulin administration is a ritial omponent of diabetes management, espeially for those aring for hildren who partiipate in daylong (4- to 8-h) programs and who will likely need insulin administered during the programs. For resoures, please see RESOURCES for ADA s Safeat Shool program. Gluagon Gluagon may be indiated if a hild has severe hypoglyemia and is unable to onsume gluose or is having a hypoglyemi seizure. Although a gluagon kit requires a presription, any individual may administer gluagon. Child are staff should be trained in the administration of gluagon or, if indiated, mini-dose gluagon (19). It is also important to ensure that the gluagon kits are not expired (5). The DCCT showed that improved glyemi ontrol dereases long-term diabetes ompliations in adolesents ($13 years of age) and adults and helped establish intensive therapy as the standard of are. Although young hildren were not inluded in the study, the same priniples apply to this age-group. Regardless of the amount of time the hild spends in the hild are setting, staff should monitor arbohydrate intake and understand the impat of arbohydrates and physial ativity as set out in the hild s DMMP. Trained hild are staff should be available to meet the hild sbasidiabetes needs, inluding the reognition and treatment of hypo- and hyperglyemia, blood gluose monitoring, and insulin and gluagon administration. Diabetes management requirements may vary depending on the length, frequeny, and ativities of the hild are program. The key diabetes management priority for younger hildren is the prevention, reognition, and treatment of hypo- and hyperglyemia to keep the hild safe and healthy. DMMP The hild s written are plan, suh as the DMMP, failitates appropriate diabetes management and is essential to ahieving optimal glyemi ontrol. The DMMP ontains the medial orders that are the basis for the provision of are in the hild are setting and is the hild s individual are plan. It is developed by the hild s own diabetes health are provider with input from the parent/ guardian. A sample DMMP for the hild are setting may be found at the end of this doument or at The DMMP should address the speifi needs of the hild and provide instrutions for eah of the following: 1. Blood gluose monitoring, inluding the frequeny and irumstanes requiring blood gluose heks and the use of CGM systems; 2. Insulin administration inluding doses and administration times presribed for speifi blood gluose levels and for arbohydrate intake, the storage of insulin, and the use of the presribed insulin delivery devie, inluding syringe, pen, or pump; 3. Symptoms and treatment of hypoglyemia, inluding the administration of gluagon; 4. Symptoms and treatment of hyperglyemia, inluding insulin administration; 5. Urine or blood ketone heks and appropriate ations based on a hild s ketone level. The hild are program needs to oordinate and arrange diabetes eduation provided by a diabetes health are professional and/or the parent/ guardian at an appropriate level and with proper onsiderations for the hild are staff. All staff members responsible for the hild should have a basi knowledge of the hild s diabetes, understand basi diabetes management, and know whotoontatforhelp.designated staff members who will be performing diabetes are tasks need advaned diabetes eduation that inludes blood gluose monitoring, insulin and gluagon administration, monitoring of arbohydrate intake and physial ativity, and reognizing and treating hyperglyemia (monitoring for exessive urination or thirst, allowing bathroom privileges, and administering insulin) and hypoglyemia (monitoring for sleepiness, lethargy, shakiness, or other symptoms and providing appropriate arbohydrate soures even if outside the allotted snak or meal time frames). Emergeny treatment, inluding gluagon administration, should also be taught with lear instrutions for the next steps if the interventions are unsuessful (Table 2). LAWS PROTECTING CHILDREN WITH DIABETES Federal antidisrimination laws, inluding the Amerians with Disabilities At (20) and Setion 504 of the Rehabilitation At of 1973 (Setion 504) (21), prohibit disrimination on the basis of disability. The Individuals with Disabilities Eduation At (IDEA) requires prekindergarten programs to identify hildren with disabilities and to provide them with a free and appropriate eduation (22). The Amerians with Disabilities At prohibits disrimination against people with disabilities by plaes of publi aommodation, inluding amps and hild are programs. This inludes even a home-based setting, if the program is open to the publi. Programs operated by religious organizations, suh as a hild are program run by a hurh, are not subjet to the nondisrimination obligations under federal law unless the program reeives federal funds. Child are providers with obligations under the Amerians with Disabilities At must make reasonable

5 2838 Position Statement Diabetes Care Volume 37, Otober 2014 Table 2 Diabetes are tasks presribed by DMMP to be provided by hild are staff Task Frequeny Equipment/supplies (provided by parent/guardian) Blood gluose monitoring Before food intake and physial ativity and when low or high blood gluose is suspeted Blood gluose meter, lanet, laning devie, test strips, CGM* Insulin administration Before or after food intake and to treat high blood gluose Insulin, delivery devie (pump, pen, syringe) Food intake sheduling and monitoring Hypoglyemia treatment Hyperglyemia treatment Ketone monitoring *This devie may or may not be used by the hild. Snaks and meals provided and/or monitored to ensure food onsumption is in aordane with insulin dosing Awareness that unusual behaviors after physial ativity or insulin administration may signify hypoglyemia Awareness that inreased urination or drinking may signify hyperglyemia Chek ketones if repeated blood gluose tests show elevation above target range or if the hild is ill Food, arbohydrate information Quik-ating arbohydrate and gluagon Nonarbohydrate-ontaining liquid, insulin Urine or blood ketone strips, ketone monitor modifiations to their poliies and praties to enable a hild with a disability, suh as diabetes, to fully partiipate in the program unless the modifiations impose an undue hardship or ause a fundamental alteration to the nature of the program (20,21,23). The hild are program must ondut an individual assessment to determine whether or not it an meet the hild s needs without imposing undue hardship or fundamentally altering the program. Setion 504 prohibits disrimination on the basis of disability by any entity reeiving federal fundsdinluding religious organizations. Types of programs overed by Setion 504 might inlude after-shool hild are programs offered by a publi shool system and hild are programs run by universities. The obligations of a hild are program subjet to Setion 504 are very similar to those obligations under the Amerians with Disabilities At, inluding a requirement to ondut an individualized assessment of a hild s needs. Both the Amerians with Disabilities At and Setion 504 require programs to provide disability-related aommodations if they are neessary and reasonable. Many of the needed aommodations an be provided by the hild are program without signifiant osts. Some aommodations that may be needed inlude having a trained employee who an perform blood gluose heks, administer insulin and gluagon, reognize and promptly treat hypo- and hyperglyemia, and make sure the hild onsumes needed arbohydrates. In addition, many states have laws that impat the provision of diabetes are in the hild are setting. Even though federal laws provide protetion for hildren with disabilities, suh as diabetes, state laws,regulations,orpoliiesandguidelines often affet whether nonnursing staff in the hild are setting an administer mediation, inluding insulin and gluagon, to a hild with diabetes. Some states have speifi hild are rules that plae requirements on hild are programs to provide are to hildren with hroni illness, speify how staff must be trained, or speify whether and how mediation may be administered to hildren. State laws annot, however, lessen a hild are program s obligations under federal law. Children with diabetes in hild are programs still fae disrimination despite the protetions and requirements of federal and state laws. For example, some hild are programs refuse to enroll a hild with diabetes, and some programs refuse to allow a newly diagnosed hild bak into the program. Some enters will enroll a hild only if the parent/guardian agrees to ome to the enter to provide needed are. Many other programs have no injetion or no mediation poliies that do not onsider the individual hild s needs. This type of treatment jeopardizes the health and safety of the hild, and suh blanket poliies are unlawful. For more information and resoures to help with diabetes management in the hild are setting or if a hild is experiening disrimination in the hild are setting, all DIABETES ( ) or go to Federal and some state laws provide protetions for hildren with diabetes in the hild are setting. Despite federal and state laws, hildren in hild are programs still fae disrimination, jeopardizing their health and safety or making it diffiult for them to enroll in hild are. KEY PRINCIPLES Here, we reiterate the disussed onepts; however, the setion is strutured so that it outlines the legal priniples and the roles and responsibilities of the individuals involved. 1. Aeptane for enrollment. Child are programs should not deny admission to a hild based on diabetes or the need for diabetes are. The parent/ guardian should share strategies for overoming hallenges speifi to their hild, suh as poor ommuniation or resistane to diabetes are tasks. If a hild are enter refuses to enroll or provide diabetes are to a hild, it is important to determine the enter s onerns and see if the onerns an be addressed through eduation and training. 2. Written are plans. As stated previously, a written are plan, suh as an individualized DMMP, should be developed by the hild s personaldiabetes health are team in ollaboration with the parent/guardian. 3. Provision of are by hild are staff. After onsulting with the parent/ guardian and reviewing the hild s

6 are.diabetesjournals.org Siminerio and Assoiates 2839 urrent DMMP, the hild are program should perform an assessment of the hild s needs to determine how it will provide diabetes are. An identified group of hild are staff who are willing to provide diret are for the hild with diabetes should reeive advaned training from a diabetes health are professional or the parent/guardian on routine and emergeny diabetes are so that at least one staff memberisalwaysavailabletoprovide diabetes are. 4. Basi training for all staff in a hild are setting. The hild are provider should work with the parents/ guardians to arrange for training by a diabetes health are professional or the parent/guardian in basi diabetes eduation and identify additional training resoures as needed. All hild are staff members who are responsible for the hild with diabetes should reeive basi training that provides: 1) An overview of diabetes that inludes information on how to reognize and respond to hypo- and hyperglyemia and 2) Instrution on identifying medial emergenies and ontating the right personnel with questions or in ase of an emergeny. 5. Advaned training for a small group of hild are staff. Advaned training provided by a diabetes health are professional or parent/guardian should inlude: 1) All omponents of basi diabetes training as listed above; 2) Instrution on how to perform blood gluose monitoring, insulin and gluagon administration, and urine and/or blood ketone heks; 3) Training on the reognition and treatment of hypo- and hyperglyemia; and 4) Basi arbohydrate ounting/ monitoring arbohydrates. 6. Instrution should inlude demonstrationofthearetasksanda plan for ongoing training. The number of staff members trained should be suffiient to ensure that at least one staff member who an provide routine and emergeny diabetes are, suh as insulin and gluagon administration, will be available at all times. 7. Partiipation in diabetes are should be allowed for apable hildren. Child are programs should support the hild in his or her development by allowing partiipation in diabetes tasks in aordane with the hild s ompetenies, as outlined in the DMMP. A preshooler may be able to partiipate in his or her diabetes are by heking blood gluose or hoosing a fingerprik or injetion site, all under the supervision of an adult. Child are enters should not deny admission on the basis of a hild having diabetes. A written are plan with medial orders, suh as a DMMP, should be provided by the diabetes are provider and parent/guardian to the hild are setting. All hild are staff responsible for the hild with diabetes should reeive basi training. Advaned, hild-speifi training should be provided to a small number of hild are staff, and there should be at least one trained staff member available to provide are at all times. RESPONSIBILITIES OF STAKEHOLDERS 1. The parent/guardian should provide the hild are program with: Information about diabetes management and training resoures if needed A ompleted written are plan, suh as a DMMP, signed by a hild s diabetes health are provider Current and aurate emergeny ontat information inluding phone numbers for the parent/guardian and the hild s diabetes healthare provider All materials, equipment, supplies, insulin/mediation, and food needed for diabetes management and ongoing monitoring of supplies for replenishment or replaement if expired An appropriate ontainer for the disposal of sharps A method of ommuniation between the parent/guardian and the hild are program, suh as a logbook or eletroni diabetes management appliation Basi diabetes training (if needed) for all hild are staff members who have responsibility for the hild and advaned hild-speifi training for the designated hild are staff members who are responsible for providing regular daily are to the hild Information about fators that may impat blood gluose levels, suh as the hild s daily ativity level, food intake prior to arrival at the enter, and whether the hild is experiening an illness Consent to release onfidential health information so that the hild are program an ommuniate diretly with the hild s diabetes health are provider and diretion on when suh ommuniation is appropriate 2. The hild are program should: Understand federal and state laws and regulations as they apply to hildren with diabetes Assess how the hild are program will provide routine and emergeny are after onsulting with parent/guardian and reviewing the DMMP Reruit and designate staff who will be responsible for the provision of diabetes are to the hild Work with parents/guardians to arrange for training for all staff members who have responsibility for the hild and advaned hildspeifi training for designated hild are staff members who are responsible for providing daily are to the hild Provide seure and immediate aessibility of diabetes materials, equipment, supplies, insulin/mediation,andfoodtotrainedstaff members Provide support to all families of hildren in its are who are faed with language barriers and limited resoures and be aware of and share ommunity resoures for families of hildren with diabetes Maintain aurate doumentation of all diabetes are provided to a hild in its are Collaborate with parents/guardians and/or diabetes health are providers to obtain urrent information about the are of hildren with diabetes

7 2840 Position Statement Diabetes Care Volume 37, Otober 2014 Regularly ommuniate blood gluose results, insulin administration, treatment of hypo- and hyperglyemia, food intake, and physial ativity using a logbook, eletroni appliation, or other method provided by the parent/ guardian Treathildrenwithdiabetesthe same as other hildren, exept to meet their diabetes needs Respet the hild s and family s onfidentiality and right to privay 3. The hild s diabeteshealthare provider should provide: A ompleted and signed written are plan ontaining medial orders, suh as a DMMP, with updates as needed In onjuntion with the parent/ guardian, basi and advaned training to hild are staff Availability to respond to questions about the hild s arewith parental onsent Ongoing diabetes expertise and guidane as needed Advoay, as needed, to ensure a hild s needsaremetwhileinthe hild are setting Parents/guardians, hild are staff, and the hild s health are provider all play important roles in ensuring appropriate are of the hild with diabetes in a hild are program. Eah has speifi roles and responsibilities to ensure that the hild is maintained in a healthy and safe hild are environment. CONCLUSION It is well understood that young hildren with diabetes have unique needs. Young hildren require a arefully thought-out, proative diabetes are plan and not a reative one (i.e., risis management) that must be developed with the health are provider, parents/ guardians, and hild are staff. Unfortunately, despite all the best efforts of the parents/guardians, are may be suboptimal in the hild are setting. For those instanes, there are federal laws that protet the rights of the young hild. Violation of these rights may be subjet to legal ation. Reommended resoures for parents are listed below. We enourage parents/guardians of young hildren with diabetes to share this Position Statement with their hild are providers. Ensuring the long-term health of and providing the best are to these young hildren should be of paramount importane. RESOURCES Amerian Diabetes Assoiation. Child Care Setting tools (inluding Child Care DMMP): hildare and forparentsandkids. Amerian Diabetes Assoiation. Safe at Shool resoures and information: Amerian Diabetes Assoiation. Diabetes Care Tasks at Shool: What Key Personnel Need to Know: shooltraining. National Diabetes Eduation Program. Helping the Student with Diabetes Sueed: A Guide for Shool Personnel (2010): Youth_NDEPShoolGuide.pdf. Aknowledgments. The authors thank Erika Gebel Berg (ADA) for her editorial assistane and Shereen Arent (ADA) for her review of the manusript. The authors also thank the members of ADA s Professional Pratie Committee and Exeutive Committee of the Board of Diretors for their review of the manusript. Duality of Interest. No potential onflits of interest relevant to this artile were reported. Referenes 1. Torpy JM, Campbell A, Glass RM. Chroni diseases of hildren. JAMA 2010;303: Pettitt DJ, Talton J, Dabelea D, et al. Prevalene of diabetes in U.S. youth in 2009: the SEARCH for Diabetes in Youth study. Diabetes Care 2014;37: Dabelea D, Mayer-Davis EJ, Saydah S, et al. Prevalene of type 1 and type 2 diabetes among hildren and adolesents from 2001 to JAMA 2014;311: Vehik K, Hamman RF, Lezotte D, et al. Inreasing inidene of type 1 diabetes in 0- to 17-year-old Colorado youth. Diabetes Care 2007;30: Amerian Diabetes Assoiation. Standards of Medial Care in Diabetesd2014. Diabetes Care 2014;37(Suppl. 1):S14 S80 6. Chiang JL, Kirkman MS, Laffel LMB, Peters AL. Type 1 diabetes through the life span: a position statement of the Amerian Diabetes Assoiation. Diabetes Care 2014;37: Child Care Aware of Ameria. Child Care Resoure and Referral Agenies for Child Care Aware of Ameria s 2012 State Fat Sheet Survey [Internet]. Arlington, VA. Available from Aessed 3 June Peters AL, Laffel L (Eds). Amerian Diabetes Assoiation/JDRF Type 1 Diabetes Sourebook. Alexandria, VA, Amerian Diabetes Assoiation, Diabetes Control and Compliations Trial Researh Group. The effet of intensive treatment of diabetes on the development and progression of long-term ompliations in insulindependent diabetes mellitus. N Engl J Med 1993;329: Diabetes Control and Compliations Trial Researh Group. Effet of intensive diabetes treatment on the development and progression of long-term ompliations in adolesents with insulin-dependent diabetes mellitus: Diabetes Control and Compliations Trial. J Pediatr 1994;125: Barnea-Goraly N, Raman M, Mazaika P, et al. Alterations in white matter struture in young hildren with type 1 diabetes. Diabetes Care 2014;37: Amerian Diabetes Assoiation. Diabetes are in the shool and day are setting. Diabetes Care 2014;37(Suppl. 1):S91 S Amerian Assoiation of Diabetes Eduators. Management of hildren with diabetes in the shool setting [Internet]. Chiago, IL, Amerian Assoiation of Diabetes Eduators, Available from statements.html. Aessed 3 June National Diabetes Eduation Program. Helping the Student with Diabetes Sueed: A Guide for Shool Personnel. Bethesda, MD, National Institutes of Health (NIH publiation no , revised September 2010) 15. Amerian Diabetes Assoiation. Diabetes Care Tasks at Shool: What Key Personnel Need to Know [Internet]. Alexandria, VA, Amerian Diabetes Assoiation, Available from Aessed 3 June International Diabetes Federation. Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolesene. Brussels, Belgium, International Diabetes Federation, Seaquist ER, Anderson J, Childs B, et al. Hypoglyemia and diabetes: a report of a workgroup of the Amerian Diabetes Assoiation and The Endorine Soiety. Diabetes Care 2013;36: Amerian Diabetes Assoiation. Safe at Shool [Internet]. Alexandria, VA, Amerian Diabetes Assoiation. Available from Aessed 25 June Haymond MW, Shreiner B. Mini-dose gluagon resue for hypoglyemia in hildren with type 1 diabetes. Diabetes Care 2001;24: Amerians with Disabilities At of U.S.C Rehabilitation At of U.S.C Individuals with Disabilities Eduation At. 20 U.S.C et seq 23. Rapp JA, Arent S, Dimmik BL, Gordon K, Jakson C. Legal Rights of Students with Diabetes. 2nd ed. Alexandria, VA, Amerian Diabetes Assoiation, 2009

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9 2842 Position Statement Diabetes Care Volume 37, Otober 2014