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Safe At School: Diabetes Core Concepts Recording
Diabetes Core Concepts
Diabetes Core Concepts
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Hi everyone, thanks for joining me for our first webinar in the summit series about diabetes core concepts. My name is Kelly Buesen and I am a certified diabetes care and education specialist at the Johns Hopkins Hospital Pediatric Diabetes Center. I've been a diabetes educator for about three years now and I've really found a passion working with the school nurses who are caring for my patients in the school setting. So I'm really excited to be here with you tonight. I'd love to answer all your questions at the end of this presentation, so feel free to enter any questions that come up as we go along into the chat box and then I'll answer them at the end. Please remember to remain HIPAA compliant and don't include any information that could easily identify a student or a parent. Just some housekeeping things, just so you're aware, this webinar is being recorded and it will be made public for public access and viewing on the American Diabetes Association professional website. So any images, comments, or questions that are in this webinar will be part of the recording. And then just as a disclaimer, please note that any recommendations, medical best practices, or legal protections discussed during this presentation should not overrule any recommendations from your healthcare team and the American Diabetes Association, its staff, and volunteers do not provide legal or direct medical advice or provide legal representation. Tonight we'll be reviewing foundational concepts about diabetes to help you on your journey of caring for children in the school setting who have diabetes. We'll review the different forms of pediatric diabetes. We'll also review insulin storage and signs of spoiled insulin. We'll review the different types of insulin, how they work, and how to administer them appropriately. And we'll also discuss insulin dosing components. And then to wrap up, we'll review some of the type 2 medications that are used in the pediatric population that you may or may not administer in the school building, but more importantly, we'll define some of the side effects that would impact student learning and how you can best advocate for your students if they're taking those medications. So before we get started, let's quickly review what diabetes is. All forms of diabetes have the common theme that the pancreas is either not able to produce insulin or is not able to produce enough insulin to sustain the body's metabolic needs and take glucose into the blood cells so that it can be converted to energy. The most common form of diabetes that's seen in the school setting is type 1. But in the last few years, there's been an influx of type 1 and type 2 diabetes diagnoses in the pediatric population. So that means that even though you may not have seen children with type 2 diabetes in the school setting in the past or cared for them, it's very likely that you will begin to encounter them more and more. The two other forms of diabetes that are seen less commonly in the school setting is steroid-induced diabetes and cystic fibrosis-related diabetes. And we'll discuss these four types of diabetes in more detail shortly. And then just for knowledge sake, some of the even less common forms of diabetes are post-pancreatectomy diabetes, meaning that the pancreas has been removed. And so it's very similar to type 1 diabetes because there's no insulin being produced. And then there's also some rare genetic forms of diabetes called MODY, which stands for maturity-onset diabetes in youth, and neonatal diabetes. So going into a bit of a deeper dive now, type 1 diabetes is a condition where the autoimmune system attacks and destroys the beta cells in the pancreas, which are what create insulin. And when this happens, it means that the pancreas can no longer create or excrete insulin to control blood sugars. There's a common myth that type 1 diabetes only occurs in childhood. And while it is more commonly diagnosed in childhood, it can actually occur at any age. And generally, type 1 diabetes has a gradual onset, with most people exhibiting symptoms like excessive thirst, increased hunger, and frequent urination that kind of slowly progresses over a few weeks to a few days. And this is because as the beta cells are slowly being destroyed over a period of time, glucose remains circulating in the blood. And without enough insulin to take it into the cells, there will come a time where the glucose is really high in the bloodstream. And so large amounts of ketones will form, and this patient will become really sick. And then they'll go into, you know, they'll be in diabetic ketoacidosis, they'll present to the hospital, and at that point, they'll be diagnosed with type 1 diabetes. So since there's no insulin production, treatment always requires external insulin administration, which can be through subcutaneous insulin injections. Some people use insulin pumps. And more recently, you can receive insulin through an inhaled insulin form. In recent years, more research and evidence is showing the positive impact of continuous glucose monitors, or CGMs, and insulin pumps on glycemic control, and just overall quality of life, and reducing the burden of diabetes. And so in the last few years, the American Diabetes Association has actually included CGMs and insulin pumps as a recommendation in the standard of care for people living with diabetes. And with this, more and more people, including children, are starting to use these diabetes technologies in their daily management. So you'll also be seeing these technologies more frequently in the school setting as well. Type 2 diabetes is different from type 1 because with type 2, the pancreas is still able to produce insulin, but it's usually not enough to sustain the body's metabolic needs. Or the insulin that's being produced by the pancreas is, quote unquote, mutated. So the body can't actually utilize it appropriately, which results in higher blood sugars. Like type 1, type 2 can be diagnosed at any age. However, if it's diagnosed in childhood, it typically coincides with the early teenage years due to puberty and hormonal changes that lead to insulin resistance. Type 2 is more common in racial and ethnic minority youths, such as the Latino and Hispanic populations, African Americans, American Indians, and Asian Americans. Other risk factors for type 2 diabetes are obesity, which is sometimes caused by food choices, especially if it's paired with a sedentary lifestyle, if you have a family history of type 2 diabetes. And interestingly enough, children are at higher risk for developing type 2 diabetes if their mother had gestational diabetes with any of her pregnancies. Generally, type 2, when it's diagnosed in childhood, tends to be more aggressive than if they were to be diagnosed in adulthood. And so children with type 2 have a higher risk of diabetic ketoacidosis and an earlier progression to chronic complications and comorbidities like kidney disease, cardiac disease, diabetic retinopathy, or diabetic neuropathy. And because of its aggressive nature and the higher risk for long-term complications, treatment options are also more aggressive with the goal of tighter glycemic control, which is why you might see children with type 2 diabetes being treated with insulin in addition to oral medications. Lifestyle modifications like increasing physical activity and making nutritional and dietary changes are also recommended in the treatment course. And really, those two modifications can have an incredibly positive effect on blood sugars, and it might actually lead to reduction of their medications. And then more recently, non-insulin injectables like Viderian or Zempik have been approved in pediatric populations. And these have also been really beneficial for glycemic control and long-term management. And they generally just have a reduced burden than everyday insulin injections or injections with their meals. Moving into some less common diabetes diagnoses, but some that are still occasionally seen in the school setting, is steroid-induced diabetes. Similar to hormonal effects that we discussed with type 2, steroids interfere with how the body responds to insulin and regulates glucose. So because corticosteroids mimic the action of cortisol, and cortisol makes the body more insulin resistant, just like certain hormones, insulin resistance will cause hyperglycemia. So if someone is receiving a steroid treatment and they develop hyperglycemia as a result, the treatment is usually oral medications like metformin, or they may also require insulin depending on the severity of the hyperglycemia and insulin resistance. The insulin regimen may be as simple as just a dose of long-acting insulin once a day, or depending on how severe the hyperglycemia is, it might actually require long-acting insulin paired with rapid-acting insulin at mealtimes or just given throughout the day if they're having higher blood sugars. This type of diabetes can often be reversible once the steroids are discontinued. So this means that you might have a student who comes to the health suite one day saying that they're now taking insulin, and then in a month or two, they no longer require insulin. But for our children who are on chronic steroids for management of conditions like severe asthma, cystic fibrosis, kids who are receiving chemotherapy, or maybe they require long-term immunosuppression for an organ transplant, they will need steroids for a much longer time and will need it for their chronic management of their diabetes. So unfortunately for people who are diagnosed with steroid-induced diabetes at any point in their life, they're at a higher risk for developing type 2 diabetes in the future. And then the last type of diabetes that we'll talk about in the PEDS population is cystic fibrosis-related diabetes, or CFRD. CFRD has a different cause than any of the other forms of diabetes because the pancreas becomes scarred over time related to mucus production, which is part of the disease process of cystic fibrosis. And when this happens, the beta cells in the pancreas are damaged, and they're unable to produce the amount of insulin that's needed for metabolic needs. And because there's direct involvement with destruction of beta cells, symptoms of CFRD are very similar to type 1 diabetes. And that means that the treatment for CFRD is also very similar to type 1, and these students are usually placed on an insulin regimen consisting of long-acting insulin. And sometimes they're also paired with rapid-acting insulin if they're having a lot of post-meal spike, blood sugar spikes. Honestly, CFRD is seen more rarely in the school system. So if you do have someone who is in the school setting and you're helping to manage their CFRD, it would be important to call their diabetes team just to get more information about their particular disease process and management. So now that we've reviewed some core concepts about the different types of diabetes, let's shift gears a little bit and move into some general concepts for management of diabetes. Regardless of the type of diabetes that your student has, they're most likely going to need blood sugar checks throughout the day. And common times that blood sugar should be checked are before meals, before, during, or after exercise. Anytime a student is showing symptoms of a higher or low blood sugar. And really, the new ADA DMMP does a great job of pinpointing the student's symptoms so that you have a better idea of what to look for during the school day. You'd also want to check if the student is walking or taking a bus home so that you can make sure their blood sugars are high enough to be sitting on a bus or walking home unattended. And then, of course, any other time that the DMMP indicates for a blood sugar check would be necessary. Something to note is that blood sugar should always be checked before your student eats, even if they're going to be after meal dosed. Because once food is ingested, the blood sugar will naturally rise as the carbohydrates are being digested and absorbed. And you don't want to base a correction dose off of a blood sugar that is higher from carbohydrates that just haven't been dosed for yet. So dosing for a blood sugar taken after a student has already started eating could cause a low blood sugar. And that's why checking before they eat is always the standard for care. You also want to check before they eat simply for the fact of knowing what their starting blood sugar is before giving a dose of insulin. Knowing the starting point of the blood sugar before they eat is really important in itself just so that we can evaluate insulin dose effectiveness. But it's also so that if the blood sugar is below 70, you can treat the low blood sugar first and then administer insulin once the blood sugar has risen above 70 just to be safe. And in regards to exercising, depending on the duration, you would definitely want to know what their starting blood sugar is and give a snack based on their DMMP orders. And then check intermittently or after the exercise is over to make sure that another intervention and treatment isn't needed to prevent a low or a downtrending blood sugar. Taking blood sugar checks a little further, it's important that blood sugar goal or it's important that you know that blood sugar goals vary depending on which type of diabetes the student has. Since type 1 and type 2 are the most prevalent types of diabetes seen in the school setting, we'll discuss these more in depth. So type 1, it's generally recommended that before meals and in between meals, a student's blood sugar should ideally be between 80 and 180 at least 70% of the time. And the research has shown that when a student's blood sugar is in this goal range 70% of the time, it reduces both the immediate and the long term health complications and comorbidities that are associated with diabetes. And so when blood sugars are in this goal range two to four hours after the last insulin dose and then in between times that they're eating, it signifies that the prescribed insulin doses are appropriate and the insulin that was given was able to effectively take the blood glucose into the cells. However, when blood sugars are outside of these parameters, caregivers and providers can identify patterns to make adjustments to the student's diabetes management. Now for type 2, because these students' pancreases are still working and they can still regulate their insulin, their blood sugars targets are a little bit tighter. And the recommendation is that generally blood sugars should fall between 80 and 140 outside of mealtimes. For children with either type 1 or type 2 diabetes, it's recommended that during periods of higher activity, their starting blood sugars should be 120 or higher, which can be student specific, so always check their DMMP because that target might vary based on whether they're receiving insulin injections or maybe they're using a hybrid closed loop insulin pump or even just based off of what the parents and their providers have kind of discovered with their patterns when they're exercising. So the reason why this target is slightly higher for exercise is because the body burns sugar for energy and during exercise, you obviously need more energy to sustain the higher activity. And so children who receive insulin from an outside source aren't able to turn this insulin off once it's injected. And so our job is really just to set them up so that they have a high enough blood sugar that even if their blood sugar falls, which is expected during exercise, they won't go low immediately after starting. Now moving into the different types of insulin that are used in the PEDS population, I think it's really beneficial to have a background understanding of how the different types of insulin work so that you can make better treatment decisions. The first type of insulin that we'll talk about is called long acting insulin, and this is the insulin that slowly is slowly released throughout the day. And the way I think about the purpose and the way that long acting insulin works is that your body constantly needs energy to perform basic bodily functions like breathing or muscle contractions so that the heart can beat. And that requires a constant source of energy. So long acting is important for these processes because it helps take the blood glucose into the cells, even when rapid acting insulin is not present in the body. Generally, long acting insulin works in the body for about 12 to 24 hours, depending on the type, and there's no peak action. So you don't have to worry about insulin stacking when you are also giving rapid acting insulin. Some long acting insulins are given once per day and some are twice per day. It just depends on the type that the student's endocrinologist has prescribed. But the important concept about long acting insulin administration is that it should be given around the same time every day, whether they're taking it once a day or twice a day. Occasionally, it might be requested that the school nurse help administer or oversee administration of long acting insulin at school because it really does help with compliance for students who might not be as compliant if they're taking it at home. And so really most of the time, those school nurses are not interacting with long acting insulin. However, you might see it ordered or you might have to administer it. If you're accompanying a student who's receiving insulin injections on an extended day field trip or maybe an overnight school trip. The next form of insulin that we'll talk about is rapid acting insulin. And you're all are probably a little bit more familiar with this one since it's what's given most often during the school day. Rapid acting insulin is given before meals or for blood sugars above the target goals to take glucose into the blood cell. And it usually takes about 10 to 30 minutes to begin working once it's been injected. Within 30 to 90 minutes, these insulins should be peaking and that's when you'll start to notice an effect on blood sugars. Most significantly, you'll start to see that the insulin is really starting to work. And then this type of insulin usually lasts in the body for about three to five hours and that's called insulin action time. Insulin action time is described in a range because each insulin might have slight variations but it's also very dependent on how fast the individual metabolizes the insulin. So generally younger children metabolize insulin a little bit slower on average like three to four, maybe even five hours. And then older children usually metabolize insulin a little faster. So their insulin action time might be closer to two and a half or three hours. It's also important to discuss rapid acting insulin because more and more we're starting to see this insulin used in the pediatric population. Like rapid acting insulin, these insulins are also used at meal times and for higher blood sugars. And they start working within five to 15 minutes of injection. They also peak around 30 to 90 minutes and they last in the body for about four to six hours. The difference between ultra rapid acting insulin and rapid acting insulin is that it can help with post-perennial blood sugar spikes or after meal blood sugar spikes. And it usually helps with a decreased amount of time before like pre-meal bolus time. So it helps the student not have to wait so long before they can start eating after they receive their injection. So the biggest consideration if you have a student using ultra rapid acting insulin is the pre-meal bolus timing because a student really might only need to receive their insulin five minutes before they start eating when they're using this insulin. Of course, that is provider and DMMP specific, but it might require the nurse to get a little bit creative about how they're gonna administer this insulin during the school day, especially if the student doesn't typically eat right away or maybe they need to buy lunch and wait in line or they have a long walk to the cafeteria. So always check your DMMP. And then it would be important to communicate with the student's parents about what an ideal pre-meal bolus timing would be for that student to make sure that you're not having to deal with lows in the setting of faster insulin onset time. It's also essential to know how insulin should be stored both at home and in the school setting so that you know for yourself, but also so that you can educate parents if that needs to happen because storage can impact the effectiveness of doses. So insulin that's not yet been used or open should be stored in a refrigerator at the temperature per the manufacturer's recommendations, which are usually found on the back of the vial or on the pen. Most insulins can be stored in the refrigerator for up to a year before it needs to be thrown away due to expiration. So that means that if you have a student who's using an insulin pump and they've provided an extra insulin vial for school as an emergency backup, which is always recommended, the parents don't need to supply a new vial every month unless that vial or pen at school has been open for any reason. However, once the insulin has been used for the first time, the insulin can be stored at room temperature or it can be placed back in the refrigerator based on what your policy is at your school. Of note, children do complain that insulin burns more when it's given right after it's been taken out of a refrigerator. So if you're finding that this is happening with your students, you may consider taking the insulin out of the fridge ahead of time so that it can warm up to room temperature before you administer it. And then once the insulin has been used, they expire about 28 days later. So it'd be important to always write the first use date or the expiration date on the pen or vial so that you know when you need to request new supply from the parents. Again, this expiration after opening is manufacturer dependent, so always check the label. And then if you need to travel with students and their insulin due to a field trip or some other trip that takes them away from the school building, it's important that you make sure that the insulin remains in a cool, dry area to prevent the insulin from heating above the recommended temperature, which is usually around 85 degrees. A good way to travel with insulin is to put it in a designated lunchbox with a cool pack, making sure that the insulin does not lie directly on the ice because that might cause it to freeze or become too cold, and that would result in spoilage. And if you need to travel with insulin, you could also ask the parents if they have a special way that they travel with the insulin because there really are a lot of cool gadgets or products out there now for insulin storage while traveling, and if the parents have that, they may be willing to let you use that for the day as well. Insulin should be completely clear and see-through. So most of the time, if your insulin is spoiled, it will have visual signs like the insulin might become cloudy, you might see particles floating in it like black floaters or crystals, or if it changes color. And the last thing is that it might not be visually indicated that you have spoiled insulin, but another sign that you've got spoiled insulin is that all of a sudden, this insulin doesn't appear to be affecting blood sugars as it normally would for that particular student, and so it would be better to just rule out the fact that you're not using spoiled insulin as a cause of persistently high blood sugars in the school day. It may be the student's pattern of high blood sugars, but if it's just an acute change, that would be an indication for the potential of spoiled insulin. Again, it's really important to note that there might not be any visual changes with your insulin, even though it might be spoiled, and since insulin is such a potent and important medication for children with diabetes, you always wanna make sure that you're storing it properly to reduce the risk of it going bad and having any complications. So now that we've talked about the core concepts of insulin itself, let's move into insulin dosing, and I'd like to talk a little bit about the different components of insulin dosing before we get into how to calculate doses for students at school. So there are two different dosing regimens for children who receive rapid acting insulin. You've got the traditional regimen that most people are really familiar with, and that uses carb ratios and correction factors, and correction factor is sometimes called insulin sensitivity factor, so you might hear me refer to that a little later. And then the second regimen that you might also intermittently see is fixed insulin dosing, and this is seen a little less often, but a fixed insulin dose means that the student is going to use a prescribed correction factor, or most of the time for these students, they use a sliding scale, which we'll review shortly, and then they'll add a set amount of insulin for carbohydrates consumed at each meal. A lot of people don't totally understand how a fixed dose is calculated in a world where carb counting is primarily used, or how it's even determined by a provider. So I think it's important to review this because it can help you decide when the fixed dose is appropriate versus when you might want to talk to the parent or the diabetes team about whether or not the full fixed dose should be given. Fixed doses are calculated by an endocrinologist with the aid of a nutritionist, and what usually happens is the patient and their parents will sit down with the nutritionist and do a complete food recall of what they typically eat at their meals. Once the team gets an idea of what the child regularly eats, the endocrinologist and the nutritionist will determine an average carb amount and then use an estimated carb ratio that would be recommended for this patient based on standard calculations using weight and age. And then once the diabetes team determines the theoretical carb ratio that they would use for this student, if they were to be carb counting, then they come up with the fixed dose that should be given at each meal. So for example, if a student or if a child reports that they typically eat about 100 grams of carbs at every meal, and the endocrinologist feels that they should receive one unit for every 10 grams of carbs, if they were to be carb counting, the endocrinologist would prescribe the child to take 10 units of insulin at each meal for their food. Fixed meal doses are typically used for families or patients where we wanna improve compliance. And because we know that carb counting can sometimes be really tedious and it can be very mathematically challenging, we wanna make it easier and kind of simplify a little bit. And research actually shows that there's not a huge difference in glycemic control for children with type two diabetes who use fixed doses versus carb counting. And because fixed doses are just easier in general, because it's the same amount of insulin that's given with each meal plus the correction, people with this regimen have a higher compliance and they're able to more safely administer their insulin. A common question I get from school nurses about fixed dosing is kind of sounds like, well, the student is supposed to get 10 units for their fixed dose today at lunchtime, but all they're gonna eat is a chicken patty. Should I still give the 10 units? And the best answer to this question is that you should ask the student if what they're eating is a typical food choice and amount. And if it is, then you could administer the fixed insulin dose. But if it's not, then it would be appropriate to call the diabetes team to determine if the prescribed insulin dose should be given or if they would advise reducing the fixed dose to prevent the possibility of a low blood sugar. Really, any person using a fixed dose insulin regimen should eat around the same amount of carbohydrates at every meal to ensure that the insulin dose is appropriate. So if you find the student receiving fixed doses is consistently eating less than normal during the school day, and you don't feel that the fixed dose that was prescribed originally is appropriate for that student anymore, at least at school, then you should contact the parents and or the diabetes team so that they can reevaluate their eating patterns and possibly readjust their dose for school. So doing the traditional regimen with calculations of correction factor and carb ratio, let's first talk about the carb ratio, which is basically a prediction of the amount of carbohydrates that can effectively be taken into the blood cell by one unit of insulin. So if a student has a carb ratio for breakfast of one to 20, that means that their diabetes team is predicting that one unit of insulin will take the glucose produced from about 20 grams of carbs into the blood cell. And carb ratios can range depending on an individual's needs. Adolescents tend to need slightly stronger carb ratios, like one unit for every five or six grams of carbs due to insulin resistance and other growth factors and just factors in general. And then others and smaller children tend to need slightly weaker carb ratios for a variety of factors as well, but in general, they're just not as insulin resistant. So to calculate your carb dose, you would add up all the carbs that would be eaten in a meal and then divide that by the prescribed carb ratio, which equals the amount of insulin that should be given for what they're eating at that meal. Remember to always check the serving size whenever you are looking at the nutrition label to determine how many carbs should be used for the calculation, because there are times where a label might be written for two servings or maybe it's a half serving. So you'd wanna adjust your math accordingly. Your carb ratios will be found in table 6A on the ADA DMMP. The other component to the traditional insulin regimen is the correction dose or the insulin sensitivity factor, like I mentioned before. The correction factor is the predicted number of points that the blood sugar will decrease for every unit of insulin given. So in the example on the slide of one unit per 50 over 150, that denotes that the diabetes team has determined that one unit of insulin will bring the student's blood sugar down by about 50 points. If you're using the formula method and doing a manual calculation to determine the correction dose, you would use the blood sugar taken before the meal or snack subtracted by the target blood glucose, which can be found in the DMMP, and then divide it by the prescribed correction factor. If you forget how to calculate a correction dose, there is a formula in table 6A on the DMMP that can guide you on how to manually calculate. It is incredibly important to note that when you're using insulin injections, if you have given an insulin dose in the last three hours, regardless of if it's only for carbohydrates or maybe it was for carbohydrates and a correction, then you should not give another correction dose within three hours of that last dose, or as indicated by the DMMP, as it can cause insulin stacking. So insulin stacking is the concept of injecting rapid acting insulin at close intervals before the prior dose has had time to fully work in the body. And this causes the doses to inevitably overlap each other at some point, which creates a higher risk for hypoglycemia. And then when we talked about fixed dose insulin before, I mentioned the idea that some students might be using a sliding scale. The sliding scale is equivalent to a correction factor, but it's just simplified into a table for students and their families who just need a little bit more simplicity to their diabetes management. If you have a student who's prescribed the sliding scale on their DMMP in table 6B, it's likely that the family is also using it. That the family is also using the sliding scale at home, and in order for the doses to match what's being given at home, the same table is provided in the DMMP. A lot of nurses ask that both the correction factor be entered into table 6A for calculations, and the sliding scale be filled out in table 6B in case there's a substitute nurse or there's a visiting nurse who's not as familiar with diabetes. But it's important to note that doing a manual correction may occasionally, I'm sorry, a manual calculation may occasionally result in a different value than what's determined on the sliding scale on your orders. And while it doesn't happen often, it can make a big difference in an insulin dose, especially for younger children who get small doses of insulin to begin with. So really you should use one or the other based on whatever the student is using at home. So once you've calculated both components of your insulin dose, it's time to determine your final dose. But in order to do that, you need to know what rounding factor your student is using. This can be found in your DMMP in section six, and some students round to the half unit and some round to the whole unit. But no matter what their order state, it's important to note that depending on how the parents were taught to round when their child was first diagnosed, the doses might be slightly different from what is calculated at home. Versus what's calculated at school by the school nurse. So you'd also wanna know if your students should get dosed before they eat, or if they should receive their insulin after they are finished with their meal. And in most cases before mule or pre-meal bolusing is recommended to prevent a prolonged high blood sugar because the insulin is already in their system and beginning to work as the food is being digested. But there are times where pre-meal bolusing is contraindicated. And this would be for students who have unreliable eating patterns, like maybe they have a history of not finishing their meals, or maybe they have just slower digestion. So their food might take a little bit longer. And then maybe they have a history of vomiting after they eat, or maybe they simply just take more than 30 minutes to finish their meals. And so bolusing before they eat and before their food begins to digest, whatever it is that they're eating, before their food begins to digest would actually just cause a low blood sugar. So generally speaking, most children under the age of six aren't recommended for pre-meal bolusing because they tend to have these unreliable eating patterns that I just mentioned. So if you have a student under the age of six and they do reliably eat all of their meals, it would be appropriate to still pre-meal dose if their parents and their diabetes team indicate that it's appropriate. Of course, this might require frequent reassessment if you're finding that the student isn't as reliable, at least in the school setting, maybe because they're distracted by their friends in the cafeteria, or maybe they just don't have enough time to eat their lunch before the lunch period is over. And so you should discuss that with the parents so that you can determine a different dosing regimen or dose timing. So now putting it all together, let's do an example of an insulin calculation at a meal. In this particular example, our student is going to eat 58 grams of carbs and their starting blood sugar before they ate was 259. This student uses half unit dosing. Their correction factor is one unit for every 50 grams over 150. And using the calculation method for obtaining the correction dose, we would use the blood sugar target of 100, which is found in the DMMP. And first we'll take the current blood sugar of 259 and subtract it by 100, which is the blood sugar target. And then we divide by 50, which is the prescribed correction factor. And this would equal to 3.18 units. And then next we need to determine how much insulin is needed for the carbohydrate consumption. And their carb ratio is listed as one unit for every 22 grams of carbs. And since the student is eating 58 grams of carbs, we'll divide 58 by 22, which equals 2.63 units. It is important not to do your rounding before you add the two values together because it might change the final insulin dose. So in our example, 2.63 units plus 3.18 units would equal 5.81 units. And now we need to round now that we've added them together. And so in this example, the final decimal point is above the threshold for rounding up, using the whole unit dosing guidelines, which is greater than 0.5 units. And the half unit, it's also higher than the half unit rounding guidelines, which is greater than 0.75 units. So in this example, regardless of the rounding factor, this student would really receive six units of insulin. On the chart shown on this slide is an example of a fixed insulin dosing chart that a student might receive from their diabetes team. On the left-hand side of the chart, which is highlighted in yellow, you can see the student's sliding scale. And on the far right-hand side of the chart, you can see that the student is receiving a standard of 10 units of insulin for their carbohydrate consumption. The second column in the chart adds the correction dose or the sliding scale to the fixed meal dose so that the patient really only needs to find their current blood sugar and then slide their finger over to the total dose of insulin column and determine their dose. So as you can see, this chart definitely simplifies the dosing calculations so that students and parents are able to more accurately deliver their prescribed insulin doses. If your student is using a fixed meal dose, you can find the fixed dose that's prescribed for each meal in the third column from the left in table 6A. So now that we've got our insulin dose, it's time to get it ready for administration. If you have a student who uses insulin syringes for their insulin administration, it is incredibly important that you only use insulin syringes to draw up your dose. Insulin syringes typically have an orange or red safety cap, and it would be important that whenever parents bring in their child's diabetes supplies, that you check to make sure that they've given you the correct insulin syringes based on their rounding guidelines as well. So the picture on the slide shows an insulin syringe with half unit markings, and you can see those on the left side of the syringe, and then you can see the whole unit markings on the right side. If anything besides an insulin syringe is used for insulin dosing, it can result in a serious medication error, so always be really careful whenever you're drawing up your insulin doses. Another important concept for insulin dosing in the PEDS population is that children are not typically using insulins that can be mixed. This might be different in the adult population, but for children, long-acting insulin and rapid-acting insulin should not be mixed in the same syringe. However, you can give long-acting insulin and rapid-acting insulin at the same time using two different syringes and two different injection areas because they won't have an effect on each other due to their different insulin onsets and action times and durations. So this idea would be really important to note for the nurses who are giving long-acting insulin during the school day when the student comes into the health suite for their mealtime dosing. Once you're ready to give your insulin injection, you need to pick the area that you're going to administer it. So as a core concept, insulin must be administered in fatty tissue for appropriate absorption. The picture on this slide shows all of the areas that are generally used for insulin injections. However, some children may not have enough fatty tissue in all of these areas depending on their age, weight, or even their body type. So you will need to continually evaluate if these areas are suitable for insulin injections in your individual students. And you might find that you can really only use two to four of these general areas in the picture, which is okay as long as the sites are being rotated appropriately. So leading into the importance of insulin site rotations, the reasons why it's so crucial to evaluate and quickly identify issues with site rotation is the development of scar tissue, which is called lipohypertrophy. And this can develop if an area is used repeatedly. Lipohypertrophy is basically a lump of fibrous fatty tissue that develops under the skin as a form of scar tissue. And even though it does have some fatty components, it's not the same as subcutaneous fatty tissue. And so insulin doesn't absorb well in these areas. Long term, if the person continues to use that area over and over, despite the presence of an area of lipohypertrophy, the area can become eventually so scarred that it can't be used ever again in the future. So the first signs of lipohypertrophy may just be a slight redness to the area, but it will eventually progress to a feeling of firmness or denser tissue under the skin. The area might become raised or swollen. You might feel a distinct lump at the area or the skin or the underlying tissue might might feel rubbery. The picture on the slide is an extreme case of lipohypertrophy, but it does show you the significance of how large these lumps can become and how detrimental it could be for children or people who have to give themselves insulin for the rest of their life in order to maintain their bodily functions. So if you notice that a student is starting to develop lipohypertrophy because we all know that we have those students who want to use the same area over and over again, and maybe that's because they want to be discreet or maybe it's because it's an easily accessible area in the school day without requiring them to disrobe or even maybe it's because that area has become desensitized from repeated use and it makes the injections or pump insertions a little less painful. It would be important to first discuss with the student the importance of sight rotation. You could also show them other areas that they can use for their injections and maybe you guys set goals together about one other area that they can try to use when they receive their injections and maybe they just do that at school just to start. It would also be important to contact the parents if you notice these areas so that they can also work with their child at home to identify different areas to give their injections but also to make sure that they're monitoring the insulin injections. And really this is important for nurses to know because if lipohypertrophy is identified early enough, it is possible for the scar tissue to break down and heal as long as the site isn't continued to be used. So helping a student identify these other areas for injections or even just identification of an area of scar tissue could make a huge difference for them in their lifetime of insulin injections and diabetes management. I already kind of went into this a little bit, but some other strategies for helping students avoid the development of lipohypertrophy are ensuring or requesting that even the older kids use a different area for injections each time they come into the health suite or if they're using an insulin pump, making sure that they're changing their insertion area every two to three days, they shouldn't be reusing their needles. It might also be really helpful to develop a schedule with them with their input about site rotation and this might involve just making a chart that notes that on Mondays they use their left arm and Tuesdays they might use their right arm and so on. You also want to make sure that you're inspecting the skin before each insulin administration, whether that's by, you know, you're giving the injection or the student is just for any signs of the lipohypertrophy and then also keeping track of where the injections are given so that you can space them apart using the guidelines on the slide. And then while students, diabetes teams and endocrinologists should be assessing their injection sites or their pump sites at every in-person visit and advising them if they're, if that area is developing some scar tissue. Because school nurses spend a lot of time with these children during the school year, you really have a really great opportunity to educate and kind of help identify and you might be the first set of eyes who can identify this so that there can be an earlier intervention. So now that we've talked about the core concepts of insulin, let's talk about the actual injection. So whether you're using a pen or an insulin syringe to administer your students injections, you always want to inject at a 90 degree angle because injecting at anything less than a 90 degree angle might result in insulin administration in tissue other than fatty tissue, which impacts your absorption. And then just to quickly run through, after you clean the skin, you want to gently pinch the skin in the area you're going to inject, inject the insulin and try your best to wait 10 seconds before withdrawing the needle. And I know that waiting 10 seconds is not completely realistic for all of our pediatric patients, especially our pre-K and kindergarten friends. So you really just want to try and hold the needle in place for as long as you can, even if that's only five seconds. A good tactic for the younger children who might struggle with holding still for five seconds or more would be just the art of distraction. Maybe you guys sing a song or do something else. But really, you just want to keep them still long enough so that the needle can stay under the skin and give the insulin a chance to get into the tissue without coming right back out as soon as the needle is withdrawn. And then, in my opinion, the most important part of this entire process is that you release the skin that you had been pinching before you withdraw the needle. And the reason for this is because when you continue to pinch the skin as you pull the needle out, it creates pressure underneath the skin. And then there's a higher likelihood that some of the insulin might seep back out of the skin and the student won't get their full insulin dose. And so even small amounts of leakage can make a big difference in the insulin dose that's received. And this can be detrimental for all the students, but especially for younger children who receive smaller amounts of insulin to begin with. Now, when you're administering insulin with a pen, there are a few concepts that you want to keep in mind that are very specific to insulin pens. The first consideration would be that whenever you're getting a new insulin pen out of the box and using it for the first time or whenever you're putting a new needle on the pen to deliver a dose, you always want to prime the pen. Priming of the pen is used to help get any small air bubbles out of the insulin cartridge before you begin to use it on a regular basis, which is why it's important to do that before you use it for the first time. And then you'd also want to do that any time after, whenever you are putting a new needle onto the pen, so that any air that is between the rubber stopper and the tip of the needle is expelled. And then that way they can get their full dose as well. So to prime an insulin pen, you'd attach the pen needle, dial to two units, hold the pen upright so that the needle is facing the sky. And if you see any small air bubbles, you can flick the cartridge a few times just to try to get the bubbles to rise to the top. And then you'd push the plunger all the way to the bottom so that you can see insulin at the tip of the needle. During your initial prime, if you have primed with two units and you still see air bubbles in the cartridge, you'd want to repeat these steps until you no longer see any air bubbles. And then, as I already mentioned, you'd also want to prime your pen needle with two units every time that you attach a new needle before dialing up and giving the insulin dose that you've calculated. And then just as a side note for students getting larger doses of volumes or larger doses or just general volumes of insulin with an insulin pen, it can sometimes take a lot of pressure to push that plunger all the way down to the bottom, and this can make it a little bit more painful for them. So if you're finding that you're either not able to deliver a full dose because there's too much pressure and you can't get the plunger all the way down or the student is just complaining of a lot of pain, it would be important to let the parents know so that they can reach out to their diabetes team for any troubleshooting tips or also to maybe determine a different solution for insulin administration that allows the student to get the correct amount but also reduces any pain. Aside from making sure to use an insulin syringe when withdrawing insulin from a vial, drawing up insulin is really very similar to drawing up any other medication if you're using a vial. But the biggest difference with drawing up insulin from a vial is that it's really important that you inject air into the vial that totals the same amount of units of insulin that you'd like to withdraw. So, for example, if you'd like to withdraw 10 units of insulin, you should inject 10 units of air into the vial before you withdraw the insulin. And this just equalizes the pressure inside of the vial and reduces the amount of air bubbles that might be produced from the force or pressure when you're withdrawing the liquid. Aside from that, you'd use any all the other normal medication withdrawal techniques, obviously making sure that you hold the vial upside down and then making sure that you remove any small air bubbles that accumulate in the syringe after you withdraw it. I find that sometimes pulling out an extra unit or two can help with if you have to push any small air bubbles through that you're not sacrificing any insulin with the dose. And just to quickly mention, another pen that can be used for insulin injections is the InPen, and this is technically a smart pen. It's a reusable pen injector with Bluetooth capabilities that connects to the student's InPen phone app, which has their prescribed correction factor and carb ratios programmed. The phone app is used to enter the blood sugar and carb amount, and then the app will actually calculate the insulin dose that should be administered at that time, taking into account insulin action and then any insulin on board or any insulin that's still working in the body from previous doses within the last few hours. The doses are tracked in the app, and this feature is really helpful for caregivers and providers to be able to view reports that record injection frequency, how much someone's giving, and so on, and so that we can make appropriate insulin dose adjustments at appointments or even in between appointments if someone is having blood sugars that are outside of those target ranges. You would treat this pen the same as you would treat other insulin pens in the same way that you prime with, you know, every time you put a new needle on, as well as the injection technique, and of note, this pen uses disposable insulin cartridges, which should be replaced every 28 days or per the manufacturer's recommendations, and then the pen itself should be replaced on a yearly basis. So that was the long and short of the core concepts surrounding all things insulin, so let's move into some common type 2 medications that you might see in the school setting and some considerations that you may have so that you can best advocate for your student and assist them as needed in their diabetes management during the school day. The most commonly used type 2 medication is metformin, and it is typically the first line in treatment for children with type 2 diabetes, as long as they're over 10 years old. It's an oral pill or liquid, and it's usually taken twice per day, usually with breakfast and dinner, and the most common side effects with this medication are nausea, vomiting, or diarrhea, and these symptoms can be alleviated a lot by taking the medicine on a full stomach, so if you've got a student taking metformin and you hear that they're frequently missing class, or maybe they're coming to the health suite often due to nausea or diarrhea, it would be important to ask them if they're taking the medicine on a full stomach, and if not, encouraging them to have a larger meal when they are taking it in the morning with their breakfast. However, if you have a student who is taking their metformin and they're doing everything right, meaning they're taking it on a full stomach, and they're still experiencing these side effects that are leading to a lot of missed class time, it would be important to let the parents know, because the parents can reach out to the diabetes team to see if there are any other options to help with management or just alleviate some of the symptoms. Jardiance is another type 2 medication that's used in the PEDS population as long as they're over the age of 10 years old, and the way that Jardiance works is by helping the body get rid of extra glucose in the blood by excreting it through the kidneys. People taking this medication typically need to go to the bathroom more frequently, and aside from needing frequent bathroom passes, the increased urination can actually lead to dehydration. So for students taking this medication, you may need to advocate for them to have frequent bathroom breaks if that's not already part of their 504, or you may need to request that they're allowed to have water with them at all times, and potentially explain to teachers the reason why they require frequent bathroom breaks so that they're not penalized. And then finally, Bidurian, Ozempic, Ectoza, and Loraglutide are all names of GLP-1 medications, which are also type 2 medications that can be used in the PEDS population. Again, these are usually used in children over the age of 10, and these medications are subcutaneous injections usually given either once a day or once a week. And similarly to metformin, the most common side effects of these medications are nausea, general GI upset, and a decreased appetite. So again, if the student's missing frequent class time because of these side effects, it'd be important to let the parents know so that they can reach out to the diabetes team because they may just need a little bit, they may just need an adjustment of the dose to help out with some of these symptoms. So the important thing to remember about all of these medications is that if you have a student taking them, you wanna monitor for the side effects and then of course how they might be affecting them during the school day so that you can advocate. But another important thing to keep in mind is that if you have a student who is on insulin and then they start using any of these adjunct medications, they might start to have some lower blood sugar as the adjunct medications begin to work to bring the blood sugars down. So this might mean that they need their, they can wean their existing insulin regimen, especially if they start to experience low blood sugars. So of course, notifying the parents that the student is having low blood sugars so that the parents can reach out to the diabetes team is important. And so just to sum all of this up, I wanted to go over some key takeaways that will help you ensure that your students have safe and healthy school environments. The first would be to make sure that your student's treatment plan and orders or the DMMP is current and complete. Also based on your school staffing, you should be prepared to train non-clinical staff to help with management of your students with diabetes. And if this happens, it would be really important to notify the parents as to who's been trained, what they've been trained on and what will be delegated to those individuals during the school day, just so that they have a level of comfort with that and they just kind of know what's happening during the day. And we'll discuss some training resources for non-clinical staff next. School nurses should also be really involved in the IEP and development, the development of IEP and 504 plans. And it can be important for the nurse to be involved just because you're more familiar with the medical needs that should be included as far as just like general accommodations that can improve their learning experience and just allow them to participate in the learning environment equally. And then another important thing to remember is that prompt responses to parents' inquiries are crucial to establishing rapport and trust with the school nurse. And this will hopefully lead to a good working relationship between you and the parents. And then along the same thread, frequent communication with the parents is also really helpful, especially for younger children who require all of their diabetes management to be provided by the school nurse. And this might be something really simple like a communication log that gets sent home daily or maybe an event log if something happens outside of the norm. But basically you just wanna establish a method that works for both you and the parents as to how you can best communicate about things that happen during the school day. And then the last thing that would be really important is if your school district has any specific policies surrounding diabetes management or care for the child with a disability, you'd wanna communicate these to the parents so that you can help establish expectations both on the student and parent side, but also on the nurse side so that everybody's on the same page. Just quickly, I'd like to mention some American Diabetes Association resources that are available to school nurses regarding the management of diabetes in the school setting. The first one is the Helping the Student with Diabetes Succeed resource, which was most recently updated by the ADA Safe at School Working Group in November of 2022. The purpose of this guide is to educate school personnel about effective diabetes management and share a set of practices that enable school personnel to ensure a safe learning environment for students with diabetes, particularly the ones that are managed with insulin. And this can be found on the diabetes.org website. The next resource is a 19-module training curriculum that can be used for both clinical and non-clinical staff. And this would be a great resource for any staff that you need to train based on staffing and delegation. And each module provides a PowerPoint slide deck containing key information about specific diabetes care tests. There's a post quiz at the end of each of the modules to assess for competency and also provide talking points. And these modules are free of charge and available on the ADA's website. So some examples of the modules provided in these training resources are diabetes basics, hypoglycemia, ketones, glucagon administration, just to name a few. So they really do have some really great and thorough topics just about general management of diabetes. The ADA has also recently updated the continuous glucose monitors guidance document in October of this year. And even though the school nurse needs to follow the student's DMMP, these additional guidelines are just some general recommendations provided by the safest school working group. And they worked really hard to make sure that best care practices surrounding CGM monitoring for children with diabetes in the school setting are represented in the guidelines and presented just so that it can really improve management. So this document's continually updated based on evidence-based research and as new technology and devices are approved by the US Food and Drug Administration. So check back on it frequently because there's usually a lot of updates. And then last but not least, there are some additional resources available to school nurses on the ADA's safest school website, diabetes.org slash SAS training. These include case studies and overview of insulin concentration, emergency lockdown preparation and guidance, as well as some general tips for school nurses, just to name a few. So that concludes the presentation for tonight. I appreciate you all attending and giving me your time. We'll move into the Q&A session for about 10 minutes. And then if there are any questions that we can't answer before the 10 minutes is up, we'll send out a communication with the answers to those questions. Again, this will be available, the recording will be available on the ADA's professional website. And these webinars are, they're worth one, you can get credit for one CEU for attendance, so. Thank you, Kelly. I'm gonna read these questions. These are all great questions. Is ultra rapid active insulin being used frequently in the PEDS population in the US? I will say that it is becoming more common. I would say in our practice, we are using it more and more frequently, especially for children using injections. It's even being used in insulin pumps. Sometimes some of them are FDA approved to be in insulin pumps. And so it's definitely being incorporated more and it really does have a great benefit because the children typically don't wanna wait that really long time for a pre-meal bolus before they can start eating. And so it really helps with that. And then it also just helps with that long-term, like blood sugar spike. And so I do think endocrinologists are starting to kind of incorporate it into their practice more and more. You mentioned a nutritionist, are you referring to a registered dietitian with a CDCES credential? Yeah, so most diabetes clinics are using registered dietitians as nutritionists and they can kind of help guide patients to better nutritional choices and just kind of do an evaluation of their current management food-wise and then make some alternative recommendations and that sort of thing. So yeah, they are an integral part of our team and they really help us out, especially really with all of our children who have diabetes because they make some great recommendations and they can kind of guide the management a little bit differently than just medication. You mentioned no dosing less than three hours from previous dose. My student orders always have indicated two hours. So if your student is on an insulin pump and we're gonna have a couple more, we'll have a bunch more sessions in the new year, one will be on insulin pumps, but it may be that your student has an insulin pump and because insulin pumps can subtract insulin that is still left in the body from a prior dose, from an hour or two hours ago, it is okay to give insulin through a pump more often than every two hours. Or if your student's getting injections, the diabetes team might have determined that it's safe for them to get an injection more often than every two hours instead of every three. But if you have a specific question about that one, I'd probably reach out to that student's care team just so that they can kind of explain their reasoning a little bit better. Thanks, we have a bunch of great questions here, Kelly. I wonder if syringes with safety needles are available for school staff to use when a child is a really squirmy one during injections. So the safety part is the question? Yeah, I wonder if syringes with safety needles are available for school staff to use when a child is really squirmy. Yeah, they do have all different kinds of syringes, some that have better safety features if you've got a really squirmy kid. So I would reach out to the diabetes team and ask them if they could prescribe something a little bit different, or maybe they could try to just figure out something else that might be a little bit more beneficial. Obviously, they're still gonna have to get their insulin injections, but they may be able to kind of change the syringe. Maybe it's the size or the gauge or something like that to make it a little bit easier to administer. A student I have is needing coverage for an elevated blood sugar prior to going to lunch using the sliding scale per doctor's orders. Parent had asked could cover when carbs of lunch at one time after finishing lunch rather than two injections. Otherwise would cover the blood sugar and cover the carbs. A difference of time would be approximately 20 to 30 minutes. So can they just have it? Correction does, I think, coverage for carbs in one. Yeah, that one might be a question for that student's diabetes care team. As long as, from my perspective, as long as you're using the blood sugar that they started with before they started to eat, you could still administer the correction dose after, like when they're getting their after meal dose because they might not be a reliable eater. It's just that when you're giving insulin after someone has already started to eat, you're kind of playing catch up because the onset is, once it gets to where it needs to go within 15 to 30 minutes, and then it's not gonna peak for another hour, you're just gonna have a higher blood sugar for a longer period of time. And so if you administer the correction dose after they finished eating as well, you just might not see the effects of that insulin correction dose for a little bit longer than normal. So that would have to probably be provider and parent dependent. But that's a really great question because a lot of kids don't wanna get multiple injections. How should skin be cleaned before the injection? Alcohol wipes, no cleaning needed, also prior to finger sticks. Can the site be cleaned with alcohol wipe, hand wipe or soap or water? So it's generally recommended that any areas of finger sticks or injections should be cleaned with alcohol. If the student prefers that they wash the area with soap and water, maybe because they've got sensitive skin or using alcohol kind of dries their skin out and causes more irritation, that's fine. People tend to do different things at home than they would do in a medical like area or like with a medical provider. So I would say just for like infection purposes, it would be really important in the school setting that you clean at least with alcohol for a finger stick or an injection. How often should the student change the needle on an insulin pen? Every time they go to give a new dose. So if they're giving themselves insulin with a pen six times a day, they have to change the pen six times a day. At least that's what's recommended most of the time. So it really, over time the pen needle is gonna get dull anyway. So it would probably be more comfortable for you to change the pen needle every single time. Is it possible that an eight year old student never experiences symptoms of hypo or hyperglycemia or are they just not cognitively able to link the symptoms to their blood sugar? Also, is it possible to pinch arm site for someone self-administering? Yes, it is possible for someone to not recognize the symptoms of a high or low blood sugar. And that might be because they're really new to the diagnosis and they just haven't had time to be able to piece that together. Like, oh, every time I feel really shaky, my blood sugar is low. And so now I know that when I feel shaky, it's probably cause I have a low blood sugar. And so it might be just that they haven't had that time yet. It may be just age related. Like I don't expect my five-year-old patients to consistently be able to tell me that they have a headache or that something is indicating them that their blood sugar might be low. Or maybe it's that their blood sugars are really in range a lot. So I find that a lot of my patients who have blood sugars that are more consistently in that 80 to 180 range, they may not feel effects of a low blood sugar, like physical symptoms, because their blood sugars are kind of like, maybe they kind of ride at 120. And so it just isn't as apparent to them when their blood sugars are a little bit lower. On the flip side though, they usually can feel when their blood sugars are a lot higher just because their body's not used to that. And then Crystal, I'm sorry, can you repeat the second question? What is the best, I'm sorry. Is it possible to pinch arm site for someone self-administering? Yeah, definitely. If they wanna do it themselves, I love when children wanna be independent and kind of do things for themselves. I think that that is a great empowering tool that you can give them. So if they just need a little bit of help to give them, pinch the area so that they can get the insulin into the right tissue, that's totally fine. There's also a really nice technique that you could use for students who want to independently, like inject their insulin into their arms, but it's really hard to do that with if you only have one hand. So if you have them go over to like the end of a chair or a table or something like that and kind of like press their arm on the edge, it kind of makes the skin come out a little bit more and then they can just reach around and give the insulin in their arm without having to pinch. So some people are comfortable with that, some people aren't, but that's a really good way for people who want to inject in their arms independently to be able to do that. And this will be the last question, Callie, that we have time for. Can you use the CGM reading for correction and carb dosing or should it be a finger stick? No, if a student is using a CGM, CGMs are FDA approved to base your blood sugars for corrections off of. So you should not have to do a finger stick on a child using a CGM unless they are, their CGM is reading below 70 or if their blood sugars are above the indication on their DMMP, some people are 250, some are 300, some are even a little bit higher, but use that as your guidance, but you really shouldn't have to do finger sticks outside of those parameters and you can safely use the blood sugar from the CGM at a mealtime for the correction. Okay, that concludes our Q&A for this evening and we will go through the questions and communicate the answers of the questions we didn't get to, but this, Callie, thank you so much and thanks to everyone for attending the program tonight. You should receive an email sometime post program in order to receive your CEU credit, you will have to complete, hopefully you've already completed the pre-test, but there will always be a post-test and evaluation and that's how you'll receive your credit. Okay. Any final remarks, Callie? Close it down. No, thank you guys for having me tonight and spending your Wednesday evening with me. I hope that everything goes well and we look forward to the next series that the next one will be day-to-day management and that will take place on January 11th at 6 p.m. Eastern time. So you should get an email when that's gonna happen. So we look forward to seeing you all at the next summit session.
Video Summary
In a comprehensive webinar on diabetes core concepts, Kelly Buesen, a certified diabetes care specialist at the Johns Hopkins Pediatric Diabetes Center, discussed essential diabetes management strategies in school settings. Kelly emphasized the importance of understanding pediatric diabetes, highlighting the prevalence of type 1 and the increasing diagnoses of type 2 among school-aged children. The session covered insulin storage, different types of insulin, and their administration, along with handling insulin dosing and recognizing spoilage. Additionally, Buesen explained various diabetes management techniques including traditional carb counting and fixed insulin dosing, offering insight into safe and effective practices. The importance of site rotation to prevent lipohypertrophy was noted, reiterating the necessity of precise injection techniques. Kelly also detailed common type 2 medications such as metformin and Jardiance, emphasizing potential side effects and school-based advocacy for students. Lastly, she introduced ADA resources like the Helping the Student with Diabetes Succeed guide and a 19-module training curriculum for school staff, ensuring a well-rounded approach to diabetes care. The webinar concluded with a Q&A session, allowing participants to clarify aspects of diabetes management in the educational environment.
Keywords
diabetes management
pediatric diabetes
type 1 diabetes
type 2 diabetes
insulin storage
carb counting
lipohypertrophy
metformin
Jardiance
school-based advocacy
ADA resources
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