How Can School Nurses Help Detect Type 1 Diabetes?

School nurses are often thought just to be ice pack and band-aid providers, but what people do not realize is the important role they can play in maintaining the health of children. Type 1 diabetes is globally on the rise in the pediatric population. Oftentimes children are misdiagnosed and/or symptoms are missed altogether before it is concluded that they have type 1 diabetes. School nurses can play a vital role in watching for red flags in students and ensuring they get the healthcare needed in a timely manner.

What is a Type 1 Diabetic?

Type 1 diabetes is an autoimmune disease that results in the pancreas stopping all production of the hormone insulin. Children diagnosed with type 1 diabetes will require lifelong insulin injections to stabilize their blood sugar. The cause of type 1 diabetes is unknown, but genetics and environment are thought to play a role.

What are the Symptoms?

Diabetic symptoms in children often appear suddenly, with no previous signs pointing to a health concern.

Symptoms in children may include: 

• Increased thirst
• Frequent urination 
• Increased Hunger 
• Unexplained weight loss
• Fatigue 
• Behavioral Changes 
• Fruity Smelling Breath 

These symptoms are often missed in children, or the child is misdiagnosed. If the child continues to go untreated, a life-threatening condition called Diabetic ketoacidosis (DKA) may occur. DKA is the number one cause of death in children with type 1 diabetes and is seen in 30% of children when first diagnosed.

Why are Children often Misdiagnosed?

With type 1 diabetes on the rise globally and present in about 22/100,000 children, the question becomes, why are so many children misdiagnosed in the first place? Why do healthcare providers miss the signs that could prevent a life-threatening condition? If you look back at the signs/symptoms listed earlier, one may notice that they are very broad and nonspecific to just diabetes. Children go through growth spurts and may start eating more. Maybe they are entering the dreaded puberty stage and are more moody than normal. Oftentimes the symptoms are missed because the parents do not suspect anything is wrong and do not voice concerns with pediatricians. If they do voice a concern to the pediatrician, more often than not, the issue can be explained by something much simpler than type 1 diabetes.

The Role School Nurses Play

Children do not see their pediatrician on an everyday basis. Pediatricians rely on information relayed by the parents/guardians who are with the child every day. There is a health care provider that sees the child on a regular basis, the school nurse. School nurses are constantly receiving information from students' teachers about possible health concerns or odd symptoms the child is displaying. It is the job of the school nurse to assess the child and voice any health concerns to the child's parents. For example, a teacher may come to the school nurse to inform him/her that "Johnny" is going to the bathroom a lot and constantly wants to refill his water bottle. He has been falling asleep at his desk a lot and is having outbursts in the classroom. These should all be red flags to the school nurse, and the child should be further assessed.

How to Address the Parents

Calling a student's parents and voicing concern for their child's health can be difficult, especially when the nurse suspects type 1 diabetes. It is important to be prompt about calling them because time is of the essence to prevent DKA. The school nurse should make sure to address the following with the parents:

• The symptoms the child is having
• The possibility of type 1 diabetes
• The importance of the child seeing a pediatrician as soon as possible
• What to watch for at home 
• Outside resources 

Explain to the parents why there is a concern for type 1 diabetes and what it can lead to if not treated promptly. Ask the parents if they have noticed any of the symptoms at home. Inform the parents that if their pediatrician needs additional information about the student, to please call the school nurse. Offer support and encouragement to the parents. Type 1 diabetes is a difficult and stressful disease to be diagnosed with. There will be lots of questions that need to be answered if the child is diagnosed. Let the parents know you are there to support the child while at school.

The complications that arise in children with Type 1 diabetes who are originally misdiagnosed can be life-threatening. Therefore, the role school nurses play in assessing their students can be tremendously beneficial to the child's health, if not life-saving. Guiding parents and providing resources can be an invaluable service to successfully ensure the child's health needs are met. 

References/Resources

Type 1 diabetes in children: Mayo Clinic-Mayo Foundation for Medical Education and Research (MFMER)

Type 1 diabetes: NHS inform

Misdiagnosis and Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes: Patient and Caregiver Perspectives: National Center for Biotechnology Information: National Library of Medicine

Unexpected viral behavior linked to type 1 diabetes in high-risk children: University of South Florida (USF Health)