Good afternoon, everyone. The American Diabetes Association's Safe at School Program and Johns Hopkins Division of Pediatric Endocrinology welcomes you this evening to the final webinar of our seven-part series designed for school nurses. My name is Christine March, and I am a pediatric endocrinologist and a member of the ADA Safe at School Working Group. I am presenting this evening's program entitled Continuous Glucose Monitors in the School Setting. The ADA Safe at School Program is devoted to protecting the legal rights of students with diabetes so these students may learn and thrive in a safe and healthy school environment and be treated fairly. School nurses play a critical role in making sure the needs of children with diabetes are met in the school setting. And our hope is tonight's program will provide school nurses with increased knowledge, skill, and competence to best support students with diabetes to optimize their education and have the ability to safely participate in all school-sponsored opportunities. The school nurse is the student's advocate and the key provider and coordinator of diabetes care in the school setting. With school nurses, parents, providers, and students working together, we can make sure our children with diabetes are indeed safe at school. Please type your questions in the chat box, and I will do my best to answer your questions at the end of my presentation. Soon after this program concludes, attendees will receive an email containing a link to an evaluation and a post-test. Free continuing education credits will be awarded upon the completion of the evaluation and post-test. This program is also being recorded and will soon be available on the ADA's professional member website. So once again, this is just a reminder that this session will be recorded and made available to the public, which means that any questions or comments that are included in this talk will be part of the recording. We also want to mention that while the ADA attempts to ensure all information is accurate and current, this is general information about potential legal protections and medical best practices, and this is not a substitute for individualized legal or other expert advice and assistance. Certainly, for any individualized advice you may need as pertains to your student's medical care, you should consult with their professional health care provider. Now the objectives of the talk today are as follows. First, we will review the use of continuous glucose monitor or CGM use in the pediatric population. Next, we will discuss the benefits for using CGM in children with diabetes, talk about the functional similarities and differences between the currently approved CGM devices, understand the accuracy of these CGM, and review special considerations for using them in the school setting. And we'll conclude with some information about remote monitoring of CGM using follow apps in the school setting. Now CGM have truly become the standard of care in pediatric type 1 diabetes management. The American Diabetes Association releases recommendations based on evidence from the scientific literature and expert opinion every year. And in the most recent chapter dedicated to the care of children and adolescents with diabetes, there were two recommendations that are relevant to the use of CGM for you as school nurses. First, continuous glucose monitors should be offered to people with newly diagnosed type 1 diabetes early in their disease, even at the time of diagnosis. And the second highlights that students with diabetes should be supported in the use of their devices while they are at school. And that includes CGM, insulin pumps, smart pens, and automated insulin delivery systems or AID systems. Now to understand some of the features of CGM, it's important first to know how it works. The CGM consists of three components that are illustrated here. There's a thin flexible cannula with a sensor that is inserted under the skin, a transmitter that sits on top of the skin, and then a receiver or other device which will actually display the sensor glucose reading. Now the sensor is measuring the glucose concentration in the interstitial fluid, meaning in the fluid of our skin. And that is going to take some time to filter from the blood up into the skin. And for that reason, there can be about a 5 to 15 minute lag time between what is happening with the blood glucose and what the sensor glucose will be displaying. Now CGM is intended to replace the majority of finger stick blood glucoses in people with type 1 diabetes, though we will discuss exceptions to the rule. Continuous glucose monitors first hit the market in 2004, and they were first approved for pediatric use in 2011. And since that time, CGM use has risen exponentially. This figure is from the Type 1 Diabetes Exchange, which is one of the largest registries for pediatric and adult type 1 diabetes in the United States. And on the y-axis, you can see the percent of the population using CGM. On the x-axis, at different times from 2011 to 2017. And there are three different groups here, children under 6, 6 to 13, and 13 to 18. And you can see the increase in all three age groups, though the rise was fastest in the youngest children. Now in a more recent study from Colorado, a single center, they estimated that utilization of CGM in children with diabetes is now closer to 75 to 80% across all age groups, which is also the experience that we have at My Diabetes Center. Now despite the increasing use, we also know that access to CGM is not equitable. This figure is taken from a study from the Children's Hospital of Philadelphia, which found that non-Hispanic white youth with type 1 diabetes were nearly twice as likely to use a CGM compared to black or African American youth with type 1 diabetes. These inequities persisted even after statistically controlling for insurance status, meaning whether the child was on private or public insurance. And these inequities have been demonstrated in other studies, as well as with other types of diabetes devices. Now these inequities may occur for various reasons, and this is a source of a great deal of research in the diabetes community. The first is that it could be affected by engagement of the family with the health care system. And that may happen for different reasons. One is that there is a lack of representation among practicing physicians. Patients and families want to feel that their care is culturally congruent, and historically minoritized populations have been underrepresented in medicine. Another reason may be social determinants of health, and you likely see this in your work as school nurses. We may be spending more time focusing on transportation, housing, or food insecurity, or access just to insulin, let alone have time to discuss these devices. A third factor is insurance access. This is highly influenced by state Medicaid systems, which are going to be different in terms of how they will cover and reimburse for these devices. And certainly a fourth factor may be implicit bias among the part of prescribers who will decide who these devices are offered to and how that is discussed. And certainly, I think as a school nurse, what you can do is discuss these devices with your students, and if there's interest, certainly help to advocate for their use with their parent and their medical provider. Now, continuous glucose monitors provide us with a lot of different types of data, and this is usually represented by this type of figure here, which looks sort of like a stoplight. These different bars represent the proportion of time the sensor glucoses are in certain ranges. Green represents our goal, which is time and range, or time and target, and that is a glucose readings between 70 and 180. The recommendations are that children and adults try to achieve 70% or more of their day in this range. The orange and yellow represent two degrees of time above range, and the red and purple here represent, again, a moderate and more severe range for hypoglycemia, or time below range. The ADA recommends that time below range be less than 4% per day. When we look at a report, we can also get an idea of the mean glucose, different measures of the variability in the glucose, as well as a calculated surrogate measure for hemoglobin A1c, which is called the Glucose Management Indicator, or GMI. Why use CGM? Well, we have data now, both from randomized control trials and real-world patient data, which have demonstrated that CGM can help lower hemoglobin A1c, increase time and range, reduce hypoglycemia, and reduce the overall roller coaster of glycemic variability. But these advantages are not necessarily seen if you just wear a CGM. You need to be actively engaged with the CGM, reviewing data, and making adjustments to behaviors and insulin doses based on that data. There are many potential features of the CGM, which can be of benefit. The first is that you have immediate access to your glucose levels every one to five minutes depending on the type of system. So you get substantially more information than you would with an ordinary glucometer. The second is that you can set personalized alarms for different reasons. For example, for when your blood sugar is out of range at a certain high or low level, if it's changing rapidly, or if there is some loss in the signal where you would no longer be getting data. And many systems also have a predictive alert feature, so you can predict whether your blood sugar may be going low, for example. The third is the use of trend arrows, which demonstrate both the direction and the speed that the glucose is changing in addition to the reading at that time. Fourth, we can gain some insight into cause and effect with the ability to track events. This may or may not be something that you have been asked to do in the past as a school nurse, but many CGM allow you to put in when you dose insulin, how many carbs you ate, if you've exercised, if you're sick. And we can retrospectively review that data and understand what happened with the sugar in response to those different activities, and that again helps us better understand how to manage our diabetes. That retrospective review of data is a benefit, and both parents and teens and healthcare providers can take advantage of that, and we can look at different durations or intervals of data. Remote monitoring is something that can happen with CGM, where, for example, a parent could be following along with their child's blood sugars, even if that parent is at work while their child is in school. And then lastly, we can pair CGM, some of them, with insulin pumps for automated insulin delivery, where that insulin pump is adjusting some aspects of insulin in order to help keep the blood sugars in range. CGM can generally be worn in the same places that insulin injections are given, but each company tends to specify specific sites where the CGM should be worn. So for example, the Dexcom G7 is approved for the upper arm, and in young children can also be placed in the upper buttocks. The Freestyle Libre 3, for example, should only be placed in the upper arm. Now the sensor itself is waterproof and can be worn in the shower, the bath, or the pool, but the device that it communicates with, which could be a proprietary receiver or a phone, is not waterproof. Some people do well with the adhesive that comes with the CGM and it stays on. Others may use some additional adhesives or bandages to help it stay in place. We also encounter patients who have struggles with skin reactions to the adhesive from CGM, which you may see, and that is something that we often can pre-treat with different medications to reduce that inflammatory response. There are different types of continuous glucose monitors currently available, and in the U.S., the three that are approved in children are the Dexcom, the Freestyle Libre, and the Medtronic Guardian. You can see a picture here of the Medtronic Guardian on the left. The two most recent generations of the Dexcom are in the middle, and the Freestyle Libre is on the right, and we are going to go through each of these in detail. We'll start with the Dexcom G6 continuous glucose monitor. So the G6 gives you a sensor reading every five minutes. This sensor has a separate transmitter, and the transmitter is changed every three months, whereas the sensor is changed out every 10 days, and that's important to know. If this system were to fall out while that child was in school, it would be important to make sure that transmitter gets home so they can reuse it. This sensor has a warm-up period of approximately two hours before it is fully functional, and you can use either the proprietary receiver or the G6 phone app to display your sensor readings, and from that phone app, you can Bluetooth to other devices like an Apple Watch, for example. Your primary receiver or phone must be within 20 feet of the transmitter to function. Calibrations are not required for the G6. This is considered to be factory calibrated, and when you initially put on a new sensor, there's a code that the family has to enter so that it works properly. If they don't have that for whatever reason, some initial calibrations would be required. Dexcom has actually released some documentation about calibrating this device subsequently, and that is a question that I frequently get about when to calibrate it. What they have shared is that calibrating the system could have a negative, positive, or no effect on the accuracy of the system, so generally, it is not recommended, and we'll talk about accuracy in more detail in a bit. This sensor has trend arrows, which can help you predict a low blood sugar. You do have the ability to track events, and it is approved for insulin dosing in pediatric populations, so if that is something that is prescribed by the diabetes provider, it can be used for that purpose. Using the Dexcom Follow app, a student could have up to 10 people following their sensor readings, and the only medication which truly may interfere with its accuracy is hydroxyurea, which is a medication we use to treat sickle cell disease. Tylenol historically has been an interfering medication, though recently, they've said only in doses in excess of 4 grams per day, which is higher than the recommended dose for an adult. There are a few major differences between the G6 and the G7 from Dexcom. You still get readings every 5 minutes, however, now the sensor and transmitter are integrated into one piece, and the overall device is 60% smaller than the G6. You still wear it for 10 days, but now, when you take it off, the whole thing can go in the trash. The warm-up period is shorter. It's only 30 minutes as opposed to two hours. There's no difference in the receiver options or in the recommendations for calibrations. But some additional special features are that this has a 20-minute as opposed to 30-minute predictive alert and an urgent low soon alert, which is new. Another nice feature is that the student can set multiple alert profiles. So for example, their alarms could be set to look different when they're in school versus when they're at home, or perhaps different during the day versus at night. You can still do event tracking. You can still dose off the sensor, have up to 10 followers, and there's no difference in the interfering medications. Both the G6 and the G7 can pair with the Tandem T-Slim Control IQ pump, the Beta Bionics iLit pump, and the InPen, which is a smart pen. The G6 currently will only pair with Omnipod 5, though that is likely expected to change in the next year. So these are some of the devices you may see your students using with their Dexcom. Now, moving on to the Freestyle Libre. The original Freestyle Libre was actually considered a flash glucose monitor, meaning you would scan it with a device to get the sugar reading. The Libre 2 is sort of a hybrid between a flash and a continuous glucose monitor. This can give you a reading up to every minute, includes an integrated sensor and transmitter, and the warm-up time is one minute. The stop time is one hour with 14 days of wear, so longer wear time than the Dexcom. This also has a proprietary receiver, which you can see pictured here, or you can use their phone app. Calibrations are also not generally required, though you may be prompted to calibrate. And in this case, you would scan either your phone or your receiver over your sensor to see the sugar reading. And if you scan at least every eight hours, you will get a continuous data tracing. If you don't scan every eight hours, then at some point, you just won't see that tracing, but it will come back when you scan again. This also has event markers, and it can pair with a tandem T-Slim pump, but I personally have not had any patients using this combination. It is also approved for dosing. You can have up to 20 followers with their app, the Libri Link Up, and that can include text message alerts to your followers, and the company states that high-dose vitamin C may interfere with its accuracy. The Libri 3 is a newer version, which has moved to a more true continuous glucose monitor. It's no longer considered a flash system. This is also an integrated sensor and transmitter, but it's smaller than the Libri 2. This image up here shows you it's about the size of two stacked pennies. They are recommending you just use the cell phone They are recommending you just use the cell phone app. At one point, there was a discussion of a receiver, though I don't believe one was ever released, so you use the cell phone to obtain your data. Calibrations, again, are not required. There is a scan only when you initially insert the sensor, but subsequently, that tracing will automatically populate. You can also enter events and all the other features of this device are the same as the Libri 2. The Medtronic Guardian 3 has been a bit more tricky and, in my experience, is a bit less widely used. This is approved only for ages 7 and up. This one will give you a reading every five minutes, has a separate sensor and transmitter, and the transmitter is actually good for up to one year. This also has a two-hour warmup like the G6, but only seven days of wear. You have to use the Guardian Connect phone app with this one, and it's typically used when paired with one of the Medtronic pumps, which, of the ones available, this would pair with the 770G. This device requires a calibration every 12 hours, which is one of the reasons why it's perhaps not been quite as widely used. It does include 60-minute predictive alerts and event markers. It is not approved for insulin dosing, so any student who uses this particular sensor would still need to have a finger stick for all meal and snack insulin dosing. You can have a follower using the CareLink app, which will send text alerts, and Tylenol can interfere with the accuracy of the sensor. The Guardian 4 was recently released and is definitely an improvement upon the Guardian 3. This is also an integrated sensor transmitter with no change to the warmup time or wear or receiver. The calibrations, though, are only at the time of insertion or are not required subsequently unless prompted. This one will pair with the Medtronic 780G insulin pump, which is their newest among the automated insulin delivery systems. And unlike the Guardian 3, you are FDA-approved to use this device to dose insulin, unless, of course, symptoms don't match readings. Otherwise, the CareLink and the Tylenol are the same. Now, I get many questions about the accuracy of CGM, and we assess this using the 20-20 rule, which is the same rule, actually, that we use to assess the accuracy of a glucometer. And this is based on a lab glucose, meaning a serum glucose, which is considered the gold standard. So if the lab glucose is greater than 100, the CGM value must be no more or less than 20% different. So we don't directly compare the CGM value to the meter. We compare it to a lab glucose. Now, for the CGM that are currently on the market, over 90% of readings will meet this rule. And for the newest versions, like the G7 and the Libre 3, it's more like 95% or higher. Now, if you were to have a finger stick reading at the time of a sensor reading, you may notice at times they look off, and there could be different reasons for this. So the first is that it may be the first day of sensor wear. They all have a warmup period, and there may be some less accurate readings that first day. The other things to keep in mind, if you recall, that CGM reading will lag five to 15 minutes behind the blood glucose. And so that could lead to a small discrepancy. But if the glucose is changing rapidly, that could lead to a much greater discrepancy in what you see between the two. The last potential is that the glucometer or the sensor may need to be replaced. Certainly not every device is perfect, and sometimes they do fail. And this is actually a reason why we usually test both the sensor and the patient's glucometer against a calibrated measure at their clinic appointments. Now, dosing off the CGM, we did mention. So technically, all these sensors, except for the Guardian 3, are approved from the FDA for insulin dosing. However, you should always follow the instructions in the child's diabetes medical management plan, which will indicate whether or not you should do this. Generally, as long as that sensor is functioning properly and the child is not exhibiting symptoms to suggest they could be low when that sensor is reading elsewise, it should be fine. The most important thing I emphasize is that consistency is key. So if we are going to dose off the sensor, we use the sensor. If we're going to dose off the meter, we use the meter. Now, when should you finger stick? Because there are times. Now, the most important is the first point. If a child has symptoms which do not match the CGM reading, we should do a finger stick to see what's going on. But there may be other times. Some children may have instructions on their DMMP to do a finger stick if their glucose is either low or high above a certain level. The other time would be if there's concern for sensor error. And for each system, that may look different. For the Dexcom, you have to have both a reading and a directional arrow. So if one is missing, there's concern that sensor isn't working properly. And then for the Libre or the Guardian, you would have an alert or a symbol indicating that you need to check a glucose. The other reason certainly would be with the Guardian if you're not approved for the Guardian 3, or if there's any other indications. And that's as instructed by that child's medical provider. Now, what are the expectations for schools when it comes to the use of CGM? Well, for children who choose to use a continuous glucose monitor, that is functionally their glucometer. So schools cannot prohibit the use of a CGM in the school setting. We should use the CGM readings and the trend arrows that blood glucose would normally be checked with a glucometer. So for example, meals, snacks, if you check a student when they come into school in the morning before recess, or before they get on the bus to go home at the end of the day. We also expect that trained staff respond promptly to CGM alarms in the school setting. And here I would recommend some advanced work with the parent as you ordinarily do before the start of the school year. So communicate with the parents about what alarms are actionable and what alarms should be set on that student's device during the school day. And there may also need to be some education of students, parents, and staff in the school that students may need to visit the school nurse when that CGM alarms if appropriate. Certainly that may depend to some degree on the student's level of independence in their self-management and also the urgency of the alarm. And if that child has remote followers, meaning their parents following, their parents should ensure that the student has an appropriate device for that, meaning they need to have essentially that Dexcom Follow app, for example, available. And then the student would need access to the Wi-Fi of the school so that their parent can see that data. Now, when it comes to alarms, I could say there are maybe some recommendations, but certainly no firm rules as to which alarms should or should not be set with the exception of a low alarm. These are generally at the discretion of the parent and the healthcare provider and something that we would discuss at their appointments. But sometimes alarms may need to be customized for the school day. Now, this may mean that certain alarms get turned off or on, that could be cumbersome. And this is certainly one advantage to the newer Dexcom G7 in that you can set a separate profile for the school day. But these are some suggestions for which alarms we would consider recommending the student turn on versus turn off. But again, these would be individualized to the student's specific needs. I wanna just talk briefly about trend arrows and what they mean. And this is an example of what they would look like using the Dexcom system. Now, again, what this is telling you is the direction that the glucose is changing as well as how quickly it is changing. So one arrow slightly up or slightly down indicates that the sensor is detecting a change in glucose of one to two milligrams a minute. And I think easier to understand that means it may differ by 15 to 30 milligrams per deciliter in 15 minutes. An arrow straight up or straight down is a two to three milligrams per deciliter change per minute or 30 to 45 milligrams per deciliter in 15 minutes. And two arrows up or two arrows down would be a change of over 45 milligrams per deciliter in 15 minutes. And remember, given the potential lag time, that's why you could see a larger discrepancy in a finger stick and a sensor reading. Now, there are some providers that actually recommend using the trend arrows in deciding how to adjust an insulin dose at the time of a bolus. That isn't a standardized practice, but it is possible that some recommendations to that end could be written into your school orders. Regardless, I think the trend arrow is just helpful information to know. For example, if a student is double arrows down with a blood sugar that's already in the normal range, maybe in the low 100s, right before they're going to gym class or getting on a bus, we may need to intervene as they are at risk for hypoglycemia. Now, on the note of hypoglycemia, another question that comes up is whether or not you need to test a meter sugar. And the answer is maybe. This is a situation where I would again advise you to look to that child's diabetes medical management plan to see whether or not that is requested. Regardless, the treatment of hypoglycemia when identified on a meter or a CGM is usually to follow the 15 by 15 rule, meaning treat with 15 grams of carbs and wait 15 minutes before you would reassess. Now, the trouble here is the delay. You may not initially see that response in the sensor if their glucose had been falling still. Our diabetes educators sometimes recommend waiting 20 minutes, although another option is to test with a meter at that time to have a better sense of where that student is in their recovery. Another thing that I would like to mention is that for students who are using an automated insulin delivery system, their treatment may look a little bit different. That device is going to use the sensor reading to adjust insulin, and it will decrease the basal rate insulin and then suspend it when the device senses a low is coming and then once that student is low. And so for that reason, there's less insulin on board at the time of the low blood sugar than there would be for a child who is on traditional injections. So we frequently find that students using an AID need fewer carbs to treat their low. It may be only seven or eight grams of carbs, you know, about half, and that's something that again should be discussed with a parent and in the diabetes medical management plan. Now testing, this is something that also can come up and it should be addressed in the student's 504 plan. But some options would include for that child to use the non-smart device or receiver if that is an option during the test so they can still track their sensor readings. But if that is not an option, then generally we recommend the teacher keep their phone, the student's phone on their desk within 20 feet of that student just on airplane mode so the Bluetooth functionality is still enabled and they can still get alarms. Now we're gonna take a few moments to talk about remote monitoring. And what I mean by this is children who use a smartphone which has Wi-Fi or cellular connectivity to view their CGM readings can be remotely monitored or followed by specified caregivers. And their data is then viewable on a different approved device so the parent would be looking at their data on their phone. And the parent can set their own alarms that may differ from the alarms that the student has set on their device. Remote monitoring by parents has been associated with better time and range and lower time above range in both children and adolescents. And that indicates that remote monitoring is helping to facilitate some active co-management between the parent and child, even in a student who might otherwise be capable of self-management. We've also seen improvements in parents' psychosocial outcomes as well as parents' sleep when they are engaging in remote monitoring. Now, remote monitoring by school nurses has been a matter of some debate over the past four to five years since CGM use has really skyrocketed. And two studies have looked at the experience of school or daycare caregivers with remote monitoring. In one qualitative study, school nurses reported that CGM remote monitoring felt like a safety net, so they could catch highs or lows and help the student get back to where they needed to be. Another surveyed a small group of parents and their child's school nurse, and 100% of parents and 80% of school nurses reported less worry while engaging in remote monitoring. And one nurse had commented that she liked having the readings available during her workflow, and the parents commented that they liked the awareness of being able to see what is happening at school. But certainly it's not without its challenges. Now, remote monitoring by school nurses is not considered a universal expectation. There are some states in the US that are encouraging it, but that is still, I believe, the exception than the rule. We consider remote monitoring to add an extra layer of supervision by school nurses, and this is an individualized decision for the district based on the needs of that student and the recommendations also from their provider. And certainly there are many factors which will influence the school's capacity to do this as well. Now, if you do engage in remote monitoring, these are the recommendations from the ADA CGM guidance for how this could best be practiced. First, the school or school district really should provide a device that allows you to do this. That's because you can follow multiple students on one device, and generally you should not be asked to use your personal device. That's for your privacy, but also for the privacy of the student and their family. If you're using a personal device, then you have access to their data when they're not in school, which some families don't mind, but others do mind. It's very, very important to review expectations with parents in advance. That would include what alarms are going to be set and what is the plan to respond to alarms, what alarms need to be responded to. It also includes the duration of monitoring, meaning you'll be looking at that when you can between school hours, after school activities, but certainly not at other times. And then what communication is there going to be between you and the parent and the student and what actions would be taken? And I wanna emphasize that I would see school nurse remote monitoring as just one of multiple systems that are already in place to try to identify that that child is out of range. Most importantly, that student should still have their device on their person, which would alarm. So this is some added information for you, but certainly not the only system by which we would identify hypoglycemia, for example. So I'll just wrap up by mentioning a couple of things regarding troubleshooting with the CGM. Now, one thing that can come up is signal loss. This can also happen a lot of times, I think just in the school setting because of the physical infrastructure. So a lot of concrete in the walls of schools that can interfere to some degree. So some things to think about, is the receiving device of that student too far away from their transmitter? Do they have too many apps open on their phone? Did they close their CGM app? Do they have more than one sensor transmitter paired? For a follower, are there more than 10 students being followed? Did the Wi-Fi or cellular connectivity go out? And then is that transmitter just faulty or perhaps expiring? One thing that can be done simply is just trying to turn Bluetooth off and on and see if that fixes the problem. Another concern is for inaccurate readings. And here I would encourage you to take a moment to consider what the different reasons are and discuss with the parent. Is calibration indicated as something to think about? But again, depending on the system, it may not be helpful unless it's specifically prompting you to do that. And then lastly, with the dislodged sensor, similar to a student who's on an insulin pump, we should always have a backup system there in case the insulin pump fails. And in this case, we should have a glucometer and all of the other supplies needed in case a student loses their sensor while they're in school. We would still encourage you to place the equipment that came out into a bag just in case they are on one of those systems that uses a transmitter for a longer period of time and is not integrated. And certainly touching base with a parent is always a good idea. And finally, I want to conclude by sharing a picture and a link to the CGM guidance from the American Diabetes Association. This document includes much of the information I've shared today, a little more detail even about the actual devices. And this is updated regularly as new evidence-based research emerges and new devices are approved by the FDA. So certainly you can check back there. So now we will address questions in the chat box in our remaining 15 minutes. Okay. Thank you, Dr. March. If anyone has questions, please do type them in the chat box now. This is a great opportunity to get those questions you've been thinking about answered. So please do take advantage of this opportunity. So some questions. Child goes to the nurse when alarms? I thought treating child where they are was the standard versus pulling them out of the class or participation. So that is something I think that is very individualized and it partly depends on the self-management of the child and whether or not they have been approved to carry all of their supplies with them in the school classroom. So that is something that, you know, I can't give you a one-size-fits-all answer. Certainly there are children who are going to be able to treat or manage a low in the classroom by themselves. But if they are asked to go to the school nurse, it's usually written into the 504 plan that they would be accompanied by another person to make sure that they are safe. Why does ADA state remote monitoring is not universal expectation? Obviously young children need that support and the nurse needs data to keep them safe. Parents following doesn't help when they aren't at school as caregivers and they are working. Why is the school district the default to decide this? They don't understand the medical need. This is pitting nurses against parents, against districts, against providers. Well, I'm sorry to hear that it has been an antagonistic relationship between those groups in trying to determine the plans for this. And certainly that's not the goal. You know, we always want to focus on working collaboratively so that we can ensure that these children, these students are safe while they're in school. And the important thing is that we are using the CGM and we have a plan to respond to their alarms. And that plan to respond to the alarms may include remote monitoring by the school nurse if they have a school nurse. But we also know that not all children in this country have access to a school nurse and may be relying on other trained diabetes personnel. So that plan to keep them safe may look a little different depending on where they are, but we definitely encourage, we advise that all schools should have a plan to respond to alarms with whatever method they take. Thank you. Can you administer insulin in the same arm as the CGM? So you can, but it should be some distance away. A student comes to the nurse with a CGM reading that is low, but they have no symptoms of hypoglycemia. With the lag time, do we have the student do a finger stick to confirm the low reading? I think that is a very reasonable thing to do. Whenever you have a student who does or does not have symptoms that would be discrepant with what their sensor reading is, I think it's appropriate to check on the meter. So I did talk a lot about checking that meter if the child feels low when their sensor says they're not, but the inverse is also true. There can be times that the sensor may inappropriately read a low blood sugar. The time that we see most often actually is what we call a pressure low. So for example, while they're asleep in the middle of the night, if they are sleeping on that sensor, there can sometimes be a very sharp drop down to what's a low level, and then you may see it sharply go right back up. And that is usually a sign of artifact. Now, if the student has a sensor in an area where they might be sitting or leaning, it's possible that could happen at school. So that's one other thing to consider, but certainly I don't think you'd be wrong to confirm what you're seeing with a meter. One of my T1D parents frequently asked the health room staff to calibrate the students' Dexcom G6. What should I say to her to discourage the calibrating in school? Yeah, so that could be difficult. And I would also be curious maybe what advice that parent is getting from the healthcare provider, because it could be that she's doing that at their direction. You know, one thing you could do is reach out to that child's healthcare provider and just let them know that you are getting that request. If that is something that, you know, they then could take and they could counsel the family about, which may be helpful. So I would consider, you know, kind of looping them in and at least letting them know. And certainly there is some additional information on the Dexcom website about this. If you would feel comfortable sharing that information with the parent, then certainly you could, but I'd also not want you to feel like you're putting yourself in a difficult position there. Thank you. I have noticed many of my students with diabetes using CGM have inconsistent readings the last day or two before their sensor expires. The finger stick doesn't reflect the same as their CGM sensor. Do others find this? I have heard this at times from some people. So I would validate your experience and that some have shared that with me as well. Sometimes it's a matter of connectivity issues. That's what I hear most frequently once it's going to be that last day or two. But if this is a recurrent issue, you know, I think that the student in question and their parents should discuss that with their healthcare provider because certainly it might be something they need to go back to the company. If there's a true issue, think about why maybe that sensor might not be reading properly and potentially request a new one. Okay. Can you talk more about which alarms are actionable? Yeah, so this may also be a little different depending on the student. And we would recommend that that be included in their diabetes medical management plan. And most importantly, a low alarm really should be set on all students. And I recommend that a low alarm be turned on with a repeat. So in case for some reason that alarm weren't heard, we would have a second opportunity. Some may also wish to turn on then that urgent low soon that should be done if they're using a Dexcom G7. I think a high alarm can be useful, but we need to be thoughtful about at what level we set that and I wouldn't recommend turning on the repeat for that alarm because we can only dose insulin every two hours and, you know, having that alarm go off every 15 minutes, there won't be anything that we can actually do about that. Some children do use the rate of fall or rate of rise alarm. I think in both of those, I don't tend to use as frequently, but the rate of fall may be helpful in younger children who do not have as many symptoms with their low blood sugars. And I think lastly, having an alarm for signal loss or no readings is very important because certainly we want to make sure that we're able to see that data, you know, whether it's being remotely monitored or on that student's personal device. And so if there was something interfering, we would want to have the ability to look into that. Okay. Thank you. My clinic sees dozens of students every day. How can a school nurse possibly have time to remotely monitor? So, you know, in my work, I have talked with school nurses in different states and heard a little bit about their different experiences with this. I can share that, you know, I recently talked with a group of school nurses in Pennsylvania and about 30% were choosing to remotely monitor. Although I don't know, you know, how many students they have with type one diabetes that they might be seeing. I know that some like to have that information readily available as they go about their workflow and find it useful so that they just are more prepared. But certainly we also understand that there are many demands on a school nurse's time. And in addition to, you know, your students with diabetes, you may have other urgent health issues come up or, you know, more routine things come up, the children with tummy aches and headaches and things like that. You know, so I think the expectation with remote monitoring, if you do it, is that you have that information there, but you're not staring at that remote, you know, that device. It's not like a telemetry, right? It's just another way for you to hear that alarm. And, you know, when surveyed parents also don't, you know, stare at that CGM sensor reading at all times, they're using it to pay attention to alarms and checking at certain intervals. So I might think differently about how you use that remote monitor. Again, it's not that you're staring at that device at all times while you do all of your other work. It's just a place where you can check in without that student having to physically be in your health office. And certainly our goal is to keep children in the classroom as much as possible. Let's see, one last question. Let's see. Is there a concern about safety if a sensor accidentally dislodges or falls out during sports or physical activity? Safety, I'm assuming you mean in terms of just being able to detect what's going on with that student's sugar. So, you know, we glucometers are trusty and can work. Very well. And there are still a certain number of patients who choose to only use a glucometer and to not use a continuous glucose monitor. So I would make sure that we always have a means by which to monitor that student's glucose. And if they are using a glucometer during any kind of sports or physical activity, it's a good idea to periodically stop and test. If it's a younger child that does not have symptoms of hypoglycemia, if they have hypoglycemia on awareness, that's very important. But otherwise it would be perfectly safe for a student to continue participating in physical activity, assuming we have a glucometer to monitor their sugar. Okay. Okay. And this back to you, Dr. March for closing us out. Okay. And thank you so much for your attendance and all your wonderful questions. Thank you for attending. And you should receive an email soon from the American Diabetes Association, directing you to the evaluation and the post-test. Thank you and have a good evening. Thank you.

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