For those with T1D kids

[MHDNURSE]

Can you please give me an idea of what a typical day your students with T1D looks like? When are they coming to see you, when are they getting insulin, etc.

Many here know I have been dealing with a first grader since September who is very poorly managed, almost consistently in the 300-400 range. His endo clinic is of little help.

He was out yesterday and mom just dropped him off and there were papers in his folder "for the nurse" that were discharge papers from our local ER, Diagnosis "hyperglycemia" No answer from mom when I call her. I am waiting for the endo clinic to open so I can inform his resource nurse and ask about a plan.

I am feeling very lost in terms of support from anyone really. The last time I reached out to his endo nurse she scolded me saying he is a six year old kid and should be allowed to eat like a six year old kid. Very frustrating all around.

Right now, my instructions from the endo clinic are to just check him before lunch and then 20 minutes after, give him his insulin based on BG and carb count. That's it! Obviously if he is showing any signs of being low (has b=never happened) he gets checked, but I used to check him mid-morning and the nurse questioned why I was "giving him an extra stick"!?! It seems crazy to think that he should only be checked once before lunch. He is not on a pump by the way. He was supposed to be on one as of October and mom keeps failing the pump training appointments.

Anyway, would just love to hear from others and get a sense of what goes on with your students with Type 1.

Thanks

[OldDude]

I have a Type 1 who is in 5th grade that I've had since KG. I check his BG mid morning, before lunch, and mid afternoon. He has worn a pump since KG (when I used an insulin pen) and I bolus him for lunch. Otherwise I seldom give him insulin at school. He is all over the map sometimes and he is very predictable sometimes...which is the norm for this age group. For instance yesterday, he was 258 at 9:45 am, I didn't give him a snack and he was 65 two hours later before lunch.

I too would be frustrated if I was in your position. You might have mentioned this in your other post but do you have orders/instructions to check for ketones?

[Amethya]

Welp, mine is 9 years old, 4th grader. His typical day is that before his PE class or his 4th period class, he comes to my office so he can check himself. He wears an OmniPod (Easier than having to calculate and stick him), so what I do is check his BG, and the machine gives me the amount I should give him. If he's above 250, he has his Ketones checked, but below that, he just gets insulin and off he goes. Then before lunch I check him again, do his carb count, then he gets his insulin and goes.

If his BG was high in any of these instances, I do a extra check between the day around 1 pm- 1:30, to check his BG to make sure he's good. Then I do the last check of the day at 2:40, and he picks up his machine.

Even so, I have my difficulties with him because as I posted before, his diet is horrendous and he tends to not listen about drinking water. But since the last time he had his episode of vomiting and having to go to the UC (He refused to get sticked by his mother at home the night before because his pod malfunctioned.) He has started to drink water more and his BG has been stable.

His BG ranges high too at times, and I have tried so hard to explain to him that he needs to eat better food, but his mother has retaliated that the doctor said he can eat anything he wants as long as he does the carbs. So the only thing is help him with his insulin and hope he gets better soon. As someone said, you can lead a horse to water, but you can't make it drink.

I would want to speak with the physician in person, not the nurse. While my student isn't being cared well with the carbs, the other things he's on top of, and his clinic is there for me when I need help. I would speak with them and explain of the situation, because that kid will have worse problems if he's not cared for properly and it will not be your fault.

Edit: Exactly as OD said too, do you have orders any orders to check his Ketones?

I have a Type 1 who is in 5th grade that I've had since KG. I check his BG mid morning, before lunch, and mid afternoon. He has worn a pump since KG (when I used an insulin pen) and I bolus him for lunch. Otherwise I seldom give him insulin at school. He is all over the map sometimes and he is very predictable sometimes...which is the norm for this age group. For instance yesterday, he was 258 at 9:45 am, I didn't give him a snack and he was 65 two hours later before lunch.

I too would be frustrated if I was in your position. You might have mentioned this in your other post but do you have orders/instructions to check for ketones?

Yes, I have orders to check for ketones if two readings >350 in two hours. I will usually do a ketone check regardless if it is >400. Only once has he had ketones and I ended up paging the endocrinologist on call because mom was not reachable. She finally came to pick him up and have him seen. This entire process has been hard because I feel like I should be checking him more than just before lunch, but when I indicated that I had been doing that, both mom and the endo nurse told me it was unnecessary if he wasn't showing any signs of hypoglycemia. It amazes me that he can run in the high 400's and feel completely fine.

His BG ranges high too at times, and I have tried so hard to explain to him that he needs to eat better food, but his mother has retaliated that the doctor said he can eat anything he wants as long as he does the carbs. So the only thing is help him with his insulin and hope he gets better soon.

This is a HUGE frustration for me as well. HOw can these clinics be telling parents they can "eat anything they want as long as we correct for the carbs". I mean, yes, let them have treats once in a while, but part of managing this disease is managing diet. I have given up on the diet part as well because mom tells me what your family is telling you as well. "Doctor says I can eat what I want". Drives me nuts.

[AdobeRN]

I have 3 - one on insulin pump other 2 use a pen.

Insulin pump - Checks BG before 9:30 snack, bolus pump. Check BG before lunch 12:30, bolus. check BG at dismissal - attends daycare, mom wants to make sure he is not low before attending.

#2 - inuslin pen - he wears CGM that mom monitors from home. Snack at 9:30 - no need to check BG or cover snack unless mom requests it (rare). Check BG before lunch 12:00, give insulin to cover. I never see him unless mom calls to tell me his monitor is reading low or if there is some kind of extra food in class he will come down to check BG and we call mom to make sure ok to eat the extra food.

#3 - insulin pen. Newly diagnosed as of January and so far so good. Student eats a morning snack - I do not check BG or admin insulin at that time. Check BG at lunch 11:30, admin insulin to cover lunch. Will check BG before PE (3 days a week). Check BG at dismissal - student rides a bus to daycare, just make sure she is not low before getting on the bus. She is still learning what it feels like to be low/high - a couple of times a week she will come in at random times because she is feeling "hot" or "weird"

I don't call doctors for anything - I will notify parents and let them know what is going on & make suggestions etc.

[OldDude]

It's a bitter pill to swallow but it seems all you can do now is grit your teeth and go with it. Sounds like you've gone above and beyond and beyond.

[Amethya]

His BG ranges high too at times, and I have tried so hard to explain to him that he needs to eat better food, but his mother has retaliated that the doctor said he can eat anything he wants as long as he does the carbs. So the only thing is help him with his insulin and hope he gets better soon.

This is a HUGE frustration for me as well. HOw can these clinics be telling parents they can "eat anything they want as long as we correct for the carbs". I mean, yes, let them have treats once in a while, but part of managing this disease is managing diet. I have given up on the diet part as well because mom tells me what your family is telling you as well. "Doctor says I can eat what I want". Drives me nuts.

Oh yeah, but that's their decision not to change the diet. So all I can do is just help the child, if the child ends up having worse issues later like his mother (Kidney issues and such), it's not my fault. I just hope he wises up and does the changes himself.

His mother has been getting better on the food though lately since she's been having really bad diagnosis of liver issues, but the thing is the kid is going through a rebellious phase, so he tends to not want to listen, but he's getting better at caring for himself too. His sister worries me lately, especially because I do the AN screening and she always comes positive. I told mother, and we both got on her case on stop eating all the cakes and sweets she likes, but she has the same issue as I do with my kid that she's a picky eater and will not want to try other foods.

[ruby_jane, BSN, RN]

Remember that the insulin for correction is a four-hour medicine. So a stick mid morning won't be of value (you can't treat until the four hours are up) UNLESS he hasn't had insulin in the morning. So....might this be the problem? He is eating in the AM and not correcting for it? That's a big problem with my teens. I finally have the recalcitrant one convinced that he will spend more time at lunch peeing in a cup for ketone testing than he will checking and correcting when he eats school breakfast.

So...when you talk to the endo, ask what the breakfast insulin ratio is (may be different than lunch). Chat with mom about morning management. AM management *should* happen at home....but if it's not it will be better for the kid if it's done at school.

Regarding the "eat like a six year old comment" - assuming the insulin ratio is good, and assuming the long-acting insulin is being dosed properly, that is not a false statement. But what you're seeing here makes you question that advice, right? It would be interesting to see the A1C numbers historically (as far back as they go). Each six months the MD should tinker with the long-acting and the bolus insulins.

Hang in there. You're doing all you can. You can't care more about this than the parent does.

UPDATE:

Nurse from diabetes clinic actually returned my call for once. She was very dismissive and said too me "He's totally fine, just a little hyperglycemia. Mom is great about calling me when she is worried, so if mom is not worried, I am not worried". I don't consider vomiting with high ketones and a BG in the 500s "just a little hyperglycemia", but ok thank you wise endo nurse. She drives me nuts- so condescending to me, like I am "just" a school nurse and know nothing about this family.

[ruby_jane, BSN, RN]

UPDATE:

I don't consider vomiting with high ketones and a BG in the 500s "just a little hyperglycemia", but ok thank you wise endo nurse.

Me, neither. Is there anyone else there with whom you can speak? Document the pants off of this one.

Me, neither. Is there anyone else there with whom you can speak? Document the pants off of this one.

No one other than the attending, who I have paged the one time he had 1.1 ketones and neither mom or his endo nurse were reachable.

He is currently in school, BG 280 about 30 minutes ago and "feels well". I will re-check him before lunch and see how he is doing. I seem to be the only one concerned about his management, including the endo clinic.