ADA Step Out: Walk to Stop Diabetes

Care of Young Children WithDiabetes in the Child Care Setting:A Position Statement of theAmerican Diabetes AssociationDiabetes Care 2014;37:2834–2842 | DOI: 10.2337/dc14-1676

Diabetes is a relatively common chronic disease of childhood (1); however, captur-ing prevalence data in childrenwith type 1 and type 2 diabetes has been challenging.The comprehensive SEARCH for Diabetes in Youth (SEARCH) study has made signif-icant strides in better understanding disease prevalence in the pediatric population.A recent SEARCH study found that 1.93 per 1,000 youth (aged ,20 years) werediagnosed with type 1 diabetes (2), an increase of 21.1% from 2001 to 2009, withincreases seen in all ethnic groups but with non-Hispanic whites disproportionatelyaffected (3). For type 2 diabetes, the SEARCH study reported a prevalence of 0.46per 1,000 youth (aged 10–20 years), an increase of 30.5% from 2001 to 2009 in allethnicities (3). As youth rarely die of diabetes, the increase in prevalence is mostlikely attributed to increased incidence.An annual increase of 2.3% in type 1 diabetes incidence has been reported in

children, with children aged,5 years experiencing the greatest increase relative toall children (4). As type 2 diabetes is rarely seen in children younger than 10 years ofage (3), this Position Statement will primarily focus on type 1 diabetes. The primaryobjective of this Position Statement is to explain that young children (aged #5years) are a vulnerable population and have unique diabetes management needs.Our goal is to describe the diabetesmanagement recommendations in the child caresetting. The child care setting includes day care, camp, and other programs whereyoung childrenwith diabetes are enrolled. This Position Statement ismeant to guidechild care providers in caring for young children with diabetes and is not intended toprovide specific advice on the medical management for this population. WhilePosition Statements contain evidence-based recommendations, all of the informa-tion that pertains to young children is expert opinion only. For more detailed in-formation on themedical management of type 1 diabetes in children, please refer tothe American Diabetes Association’s (ADA’s) “Standards of Medical Care inDiabetesd2014” (5) and “Type 1Diabetes Through the Life Span: A Position Statementof the American Diabetes Association” (6).

UNIQUE CHALLENGES FOR THE YOUNG CHILD

Infants, toddlers, and preschool-age children (#5 years of age) are enrolled in themore than 330,000 child care programs across the country (7). These childrenwhollydepend on adults for most, if not all, aspects of their care. Pediatric health careproviders, parents/guardians, and child care staff must work together to ensure thatyoung children with diabetes are provided with the safest possible child care envi-ronment. This collaboration is essential to achieve a seamless transition in care fromhome to the child care setting.Managing type 1 diabetes in young children in child care programs presents

unique challenges due to the young child’s developmental level. The limited com-munication and motor skills, cognitive abilities, and emotional maturity of youngchildren can challenge even the most experienced child care provider. For example,young children with hypo- or hyperglycemia may or may not exhibit abnormalbehavior or irritability. As erratic behavior is typical in this age-group, the childcare provider may not recognize hypo- or hyperglycemic symptoms and may miss

1University of Pittsburgh Diabetes Institute,Pittsburgh, PA2Department of Pediatrics, University of FloridaCollege of Medicine, Gainesville, FL3American Diabetes Association, Alexandria, VA4Northwestern University Feinberg School ofMedicine, Ann and Robert H. Lurie Children’sHospital of Chicago, Chicago, IL5Alaska Department of Labor, Anchorage, AK6Popper & Yatvin, Philadelphia, PA7Florida State University College of Medicine,Tallahassee, FL

Corresponding author: Jane L. Chiang, [email protected].

This Position Statement was reviewed and ap-proved by the Professional Practice Committee inJuly 2014 and approved by the Executive Commit-tee of the Board of Directors in July 2014.

© 2014 by the American Diabetes Association.Readers may use this article as long as the workis properly cited, the use is educational and notfor profit, and the work is not altered.

Linda M. Siminerio,1

Anastasia Albanese-O’Neill,2

Jane L. Chiang,3 Katie Hathaway,3

Crystal C. Jackson,3

Jill Weissberg-Benchell,4 Janel L. Wright,5

Alan L. Yatvin,6 and Larry C. Deeb7

2834 Diabetes Care Volume 37, October 2014

POSITION

STATEMEN

T

the fact that the behavior is caused bylow or high blood glucose levels thatmay require treatment.The diabetes regimenmust be adapted

quickly to the child’s dynamic growth anddevelopment. As the child develops anddesires greater autonomy, child care pro-viders and parents/guardians may facechallenges with the toddler ’s refusal tocooperate with his or her diabetes careregimen (8). Once the child enters theprekindergarten years, he or she may be-gin to be able to participate in his or herown care by indicating food preferences,checking blood glucose, and choosing afinger-prick or injection site.With furthercognitive and physical development, heor she may verbalize symptoms and be-come more cooperative, but the childstill needs constant supervision andblood glucose monitoring to detecthypo- or hyperglycemia. The age atwhich children are able to performself-care tasks is variable and dependson the individual child’s capabilities, butself-care is not expected from the youngchild and the parent/guardian or othercaregiver must provide diabetes man-agement and perform associated diabe-tes care tasks such as blood glucosemonitoring and insulin administration(5,8) (Table 1).Language barriers, ethnic and cultural

practices, limited resources and sup-port, geography (rural vs. urban setting),and health literacy and capabilities mustalso be considered in developing thecare plan.Another challenge in the child care

setting may be staff turnover and ensur-ing that trained staff members remainavailable. Regardless, the child care pro-gram must be prepared to provideneeded care to the child, and parentsand health care providers play a pivotalrole in partnering with the child carestaff.

Key Points

c The safety, health, and well-being ofthe child as he or she transitions fromhome to the child care setting areachieved through effective collabora-tion between the diabetes healthcare provider, parents/guardians,and child care staff.

c Adults must provide most, if not all, ofthe diabetes care to young children be-cause of their limitedmotor, cognitive,and communication skills as well as

other abilities that are necessary toparticipate in self-management.

c As the child grows older and becomescloser to school age, he or she mayparticipate in care tasks as appropri-ate for the individual child, but adultsupervision must always be present.

c Challenges in the child care settinginclude staff turnover, language bar-riers, ethnic and cultural practices,limited resources and support, geog-raphy (rural vs. urban setting), andhealth literacy and capabilities.

DIABETES CARE

The Diabetes Control and ComplicationsTrial (DCCT) showed a significant link be-tween blood glucose control and aslower onset and progression of diabe-tes complications in adults and adoles-cents, with improved glycemic controldecreasing the risk of micro- and macro-vascular complications (5,9,10). Althoughthe DCCT did not include young chil-dren (the lower age limit at enrollmentwas 13 years), the general messagedoptimize blood glucose control whileavoiding hypoglycemiadhas been clini-cally applied to young children. Further-more, recent data from cross-sectionalneuroimaging studies in young childrenappear to reinforce the importanceof aiming for blood glucose levels inrange and avoiding hypo- and hypergly-cemia (11).

Nutrition and Physical ActivitiesThe parent/guardian remains primarilyresponsible for determining and provid-ing healthy food choices for the child.The parent/guardian should educatethe staff on general information on thecarbohydrate content of the food, re-gardless of whether it is provided bythe parent/guardian or child care pro-gram. If a child care program providesthemeals and snacks, the parent/guard-ian and the child care provider shouldwork together to determine appropriatefood choices and portion sizes for thechild. The child care program should en-sure that the child eats the appropriateamount of food that is being covered byinsulin in accordance with the diabetesmedical management plan (DMMP). Seethe section on DMMP for further details.

For children who regularly attend childcare programs for longer durationsor where meals or snacks and physicalactivity are part of the daily schedule,

sufficient staff should receive compre-hensive training in diabetes managementand be prepared to provide diabetes careas needed. At least one staff membershould be available at all times to helpwith food decisions, blood glucose moni-toring, and insulin administration.

Increased sensitivity in caring for thechild around special occasions (such asparties/celebrations), physical activities,or illnesses is particularly important. Thechild should be allowed to participate incelebrations, but special considerationsmay be required to accommodate thechild’s diabetes needs. Effective commu-nication between the child care staff andthe parent/guardian to anticipate the ad-justments (e.g., administering additionalinsulin to account for the birthday cake)will enable the young child to feel in-cluded. Resources are available to pa-rents/guardians, child care providers,and health care providers to assist withthis education and training (12–15).

Children who participate in programsfor only a few hours may consume snacksand not meals; therefore, insulin admin-istration may not be required in thechild’s DMMP. However, at a minimum,in order to facilitate safe diabetes care inall child care programs, child care staffmust have a basic understanding of dia-betes; be able to check blood glucose lev-els; be able to prevent, recognize, andtreat hypoglycemia; be able to handle di-abetes emergencies; and know who tocontact for help (12–14,16).

HypoglycemiaFor the very young child, the diabetesmanagement priority is the preventionand management of hypoglycemia andthe avoidance of wide fluctuations inblood glucose levels. Parents/guardiansface the perpetual struggle of balancingthe risk of long-term complications fromhyperglycemia with the fear of acute hy-poglycemia, all while trying to facilitate a“normal” childhood. More notably, pa-rents worry about the possibility of cogni-tive deficits and/or death if a severehypoglycemic event is undetected and un-treated. Therefore, hypoglycemia preven-tion is critical. Child care staff should beeducatedonhow toprevent and recognizehypoglycemia by monitoring the child’sfood consumption, activity, and behaviorand confirming a suspected low withblood glucose monitoring (5,8,17). Pa-rents/guardians should provide specific

care.diabetesjournals.org Siminerio and Associates 2835

strategies, if needed, to help the childcare staff address the individual child’sspecific needs. Routine blood glucosemonitoring at prespecified times mayhelp to detect hypoglycemia before itmanifests with acute symptoms in thechild.

HyperglycemiaAlthough hypoglycemia is a significantconcern, hyperglycemia should be man-aged as well. The child may experiencefrequent urination (polyuria), whichmay be confused with “heavy diapers”or “wetting accidents,” a common oc-currence in this age-group anyway. Achild care provider unfamiliar with dia-betes and polyuria may not realize thatthe child is hyperglycemic, requiring

insulin, and instead may feed the childor give him or her juice, inadvertently

aggravating hyperglycemia. Untreated

hyperglycemia may lead to ketone pro-

duction, which may be measured by

checking urine ketones.The ADA has previously recommended

higher blood glucose targets foryoung children in an effort to preventhypoglycemia. However, the ADA hasrecently adjusted its target recom-mendations to an A1C of <7.5% in allpediatric age-groups (<19 years ofage) but with the goal of achievingthe best A1C possible without hypo-glycemia. The new recommendationis a product of reduced hypoglycemiaseen with newer rapid-acting insulin

analogs and improved glucose monitor-ing devices and the awareness of thepotential impact of chronic hyperglyce-mia on the development of future long-term complications (6).

Blood Glucose MonitoringBlood glucose monitoring allows childcare providers to assess if a child ishypo- or hyperglycemic and perform ap-propriate interventions. Blood glucoselevels need to be checked beforemeals/snacks, before physical activity,and when the child exhibits symptomsof hypo- or hyperglycemia. These symp-toms may be subtle, especially in youngchildren. For this reason, blood glucoseneeds to be checked more frequently inyoung children.

Table 1—Major developmental issues and their effect on diabetes in children and adolescents

Developmental stages(ages) Normal developmental tasks

Type 1 diabetes managementpriorities

Family issues in type 1 diabetesmanagement

Infancy (0–12 months) Developing a trusting relationship orbond with primary caregiver(s)

Preventing and treating hypoglycemia Coping with stressAvoiding extreme fluctuations in

blood glucose levelsSharing the burden of care to avoidparent burnout

Toddler (13–26 months) Developing a sense of mastery andautonomy

Preventing hypoglycemia Establishing a scheduleAvoiding extreme fluctuations in

blood glucose levels due toirregular food intake

Managing the picky eaterLimit-setting and coping with toddler’slack of cooperation with regimen

Sharing the burden of care

Preschooler and earlyelementary school(3–7 years)

Developing initiative in activities andconfidence in self

Preventing hypoglycemia Reassuring the child that diabetes isno one’s faultCoping with unpredictable appetite

and activity Educating other caregivers aboutdiabetes managementPositively reinforcing cooperation

with regimenTrusting other caregivers with

diabetes management

Older elementary school(8–11 years)

Developing skills in athletic, cognitive,artistic, and social areas

Making diabetes regimen flexible toallow for participation in school orpeer activities

Maintaining parental involvement ininsulin and blood glucosemanagement tasks while allowingfor independent self-care for specialoccasions

Consolidating self-esteem withrespect to the peer group Child learning short- and long-term

benefits of optimal controlContinuing to educate school andother caregivers

Early adolescence(12–15 years)

Managing body changes Increasing insulin requirements duringpuberty

Renegotiating parent and teenager’sroles in diabetes management to beacceptable to both

Developing a strong sense ofself-identity Diabetes management and blood

glucose control becoming moredifficult

Learning coping skills to enhanceability to self-manage

Weight and body image concerns Preventing and intervening indiabetes-related family conflict

Monitoring for signs of depression,eating disorders, and riskybehaviors

Later adolescence(16–19 years)

Establishing a sense of identity afterhigh school (decisions aboutlocation, social issues, work, andeducation)

Starting an ongoing discussion oftransition to a new diabetes team(discussion may begin in earlieradolescent years)

Supporting the transition toindependence

Integrating diabetes into new lifestyle

Learning coping skills to enhanceability to self-manage

Preventing and intervening withdiabetes-related family conflict

Monitoring for signs of depression,eating disorders, and riskybehaviors

2836 Position Statement Diabetes Care Volume 37, October 2014

Continuous Glucose MonitorsSome children use a continuous glucosemonitor (CGM) to recordbloodglucose lev-els. CGM results must be confirmed withblood glucose tests. Parents/guardiansshould discuss CGM management withchild care providers. A basic understandingof CGM use is warranted, but detailedmanagement should not be expected ofchild care providers. Safe monitoring mustinclude the following recommendations:

1. Avoid community exposure to sharpsand other medical waste.

2. Minimize trauma to the finger or rel-evant lancing site.

Blood lancingdevicesmust not be reused,point-of-care devices should only be usedfor the designated child, and child careproviders should use gloves when testing(8). The ADA’s Safe at School program is ahelpful resource to assist schools (18).

Insulin AdministrationChildren with diabetes who attend childcare programs must have access to in-sulin, glucagon, and other medicationsto safely participate in the programs.Training child care staff on insulin ad-ministration is a critical component ofdiabetes management, especially forthose caring for children who partici-pate in daylong (4- to 8-h) programsand who will likely need insulin adminis-tered during the programs. For resources,please see RESOURCES for ADA’s Safe atSchool program.

GlucagonGlucagon may be indicated if a child hassevere hypoglycemia and is unable toconsume glucose or is having a hypogly-cemic seizure. Although a glucagon kitrequires a prescription, any individualmay administer glucagon. Child care staffshould be trained in the administration ofglucagon or, if indicated, mini-dose gluca-gon (19). It is also important to ensurethat the glucagon kits are not expired (5).

Key Points

c The DCCT showed that improved gly-cemic control decreases long-term di-abetes complications in adolescents($13 years of age) and adults andhelped establish intensive therapy asthe standard of care. Although youngchildren were not included in thestudy, the same principles apply tothis age-group.

c Regardless of the amount of time thechild spends in the child care setting,staff should monitor carbohydrate in-take and understand the impact ofcarbohydrates and physical activityas set out in the child’s DMMP.

c Trained child care staff should be avail-able to meet the child’s basic diabetesneeds, including the recognition andtreatment of hypo- andhyperglycemia,blood glucose monitoring, and insulinand glucagon administration.

c Diabetes management requirementsmay vary depending on the length,frequency, and activities of the childcare program.

c The key diabetes management prior-ity for younger children is the preven-tion, recognition, and treatment ofhypo- and hyperglycemia to keepthe child safe and healthy.

DMMPThe child’s written care plan, such as theDMMP, facilitates appropriate diabetesmanagement and is essential to achiev-ing optimal glycemic control. TheDMMP contains the medical ordersthat are the basis for the provision ofcare in the child care setting and is thechild’s individual care plan. It is devel-oped by the child’s own diabetes healthcare provider with input from the parent/guardian. A sample DMMP for the childcare setting may be found at the end ofthis document or at www.diabetes.org/childcare. The DMMP should ad-dress the specific needs of the childand provide instructions for each ofthe following:

1. Blood glucose monitoring, includingthe frequency and circumstances re-quiring blood glucose checks and theuse of CGM systems;

2. Insulin administration includingdoses and administration times pre-scribed for specific blood glucoselevels and for carbohydrate intake,the storage of insulin, and the useof the prescribed insulin delivery de-vice, including syringe, pen, or pump;

3. Symptoms and treatment of hypo-glycemia, including the administra-tion of glucagon;

4. Symptoms and treatment of hypergly-cemia, including insulin administration;

5. Urine or blood ketone checks and ap-propriate actions based on a child’sketone level.

The child care program needs to co-ordinate and arrange diabetes educa-tion provided by a diabetes healthcare professional and/or the parent/guardian at an appropriate level andwith proper considerations for the childcare staff. All staff members responsiblefor the child should have a basic knowl-edge of the child’s diabetes, understandbasic diabetes management, and knowwho to contact for help. Designatedstaff members who will be performingdiabetes care tasks need advanced di-abetes education that includes bloodglucose monitoring, insulin and gluca-gon administration, monitoring ofcarbohydrate intake and physical activ-ity, and recognizing and treating hyper-glycemia (monitoring for excessiveurination or thirst, allowing bathroomprivileges, and administering insulin)and hypoglycemia (monitoring forsleepiness, lethargy, shakiness, or othersymptoms and providing appropriatecarbohydrate sources even if outsidethe allotted snack or meal time frames).Emergency treatment, including gluca-gon administration, should also betaught with clear instructions for thenext steps if the interventions are un-successful (Table 2).

LAWS PROTECTING CHILDRENWITH DIABETES

Federal antidiscrimination laws, includ-ing the Americans with Disabilities Act(20) and Section 504 of the Rehabilita-tion Act of 1973 (Section 504) (21), pro-hibit discrimination on the basis ofdisability. The Individuals with Disabil-ities Education Act (IDEA) requires pre-kindergarten programs to identifychildren with disabilities and to providethem with a free and appropriate edu-cation (22).

The Americans with Disabilities Actprohibits discrimination against peoplewith disabilities by places of public ac-commodation, including camps andchild care programs. This includeseven a home-based setting, if the pro-gram is open to the public. Programsoperated by religious organizations,such as a child care program run by achurch, are not subject to the nondis-crimination obligations under federallaw unless the program receives fed-eral funds. Child care providers with ob-ligations under the Americans withDisabilities Act must make reasonable


modifications to their policies and prac-tices to enable a child with a disability,such as diabetes, to fully participate inthe program unless the modificationsimpose an “undue hardship” or cause a“fundamental alteration” to the natureof the program (20,21,23). The childcare programmust conduct an individualassessment to determine whether ornot it can meet the child’s needs withoutimposing undue hardship or fundamen-tally altering the program.Section 504 prohibits discrimination

on the basis of disability by any entityreceiving federal fundsdincluding reli-gious organizations. Types of programscovered by Section 504 might includeafter-school child care programs of-fered by a public school system andchild care programs run by universities.The obligations of a child care programsubject to Section 504 are very similarto those obligations under the Ameri-cans with Disabilities Act, including a re-quirement to conduct an individualizedassessment of a child’s needs. Both theAmericans with Disabilities Act and Sec-tion 504 require programs to providedisability-related accommodations ifthey are necessary and reasonable.Many of the needed accommodationscan be provided by the child care pro-gramwithout significant costs. Some ac-commodations that may be neededinclude having a trained employeewho can perform blood glucose checks,administer insulin and glucagon, recog-nize and promptly treat hypo- and hy-perglycemia, and make sure the childconsumes needed carbohydrates.

In addition, many states have laws thatimpact the provision of diabetes care inthe child care setting. Even though fed-eral laws provide protection for childrenwith disabilities, such as diabetes, statelaws, regulations, or policies and guide-lines often affect whether nonnursingstaff in the child care setting can admin-ister medication, including insulin andglucagon, to a child with diabetes. Somestates have specific child care rules thatplace requirements on child care pro-grams to provide care to children withchronic illness, specify how staff mustbe trained, or specify whether and howmedication may be administered tochildren. State laws cannot, however,lessen a child care program’s obligationsunder federal law.

Children with diabetes in child careprograms still face discrimination de-spite the protections and requirementsof federal and state laws. For example,some child care programs refuse toenroll a child with diabetes, and someprograms refuse to allow a newly diag-nosed child back into the program.Some centers will enroll a child onlyif the parent/guardian agrees to cometo the center to provide needed care.Many other programs have “no injection”or “no medication” policies that do notconsider the individual child’s needs.This type of treatment jeopardizes thehealth and safety of the child, and suchblanket policies are unlawful. For moreinformation and resources to help withdiabetes management in the child caresetting or if a child is experiencing dis-crimination in the child care setting, call

1-800-DIABETES (342-2382) or go towww.diabetes.org/childcare.

Key Points

c Federal and some state laws provideprotections for children with diabetesin the child care setting.

c Despite federal and state laws, chil-dren in child care programs still facediscrimination, jeopardizing theirhealth and safety or making it difficultfor them to enroll in child care.

KEY PRINCIPLES

Here, we reiterate the discussed con-cepts; however, the section is structuredso that it outlines the legal principles andthe roles and responsibilities of the indi-viduals involved.

1. Acceptance for enrollment. Child careprograms should not deny admissionto a child based on diabetes or theneed for diabetes care. The parent/guardian should share strategies forovercoming challenges specific to theirchild, such as poor communication orresistance to diabetes care tasks. If achild carecenter refuses toenroll orpro-vide diabetes care to a child, it is impor-tant to determine the center’s concernsand see if the concerns can be ad-dressed througheducationand training.

2. Written care plans. As stated pre-viously, a written care plan, such asan individualized DMMP, should bedeveloped by the child’s personal di-abetes health care team in collabo-ration with the parent/guardian.

3. Provision of care by child care staff.After consulting with the parent/guardian and reviewing the child’s

Table 2—Diabetes care tasks prescribed by DMMP to be provided by child care staff

Task Frequency Equipment/supplies (provided by parent/guardian)

Blood glucose monitoring Before food intake and physical activity and whenlow or high blood glucose is suspected

Blood glucose meter, lancet, lancing device, teststrips, CGM*

Insulin administration Before or after food intake and to treat high bloodglucose

Insulin, delivery device (pump, pen, syringe)

Food intake scheduling andmonitoring

Snacks and meals provided and/or monitored toensure food consumption is in accordance withinsulin dosing

Food, carbohydrate information

Hypoglycemia treatment Awareness that unusual behaviors after physicalactivity or insulin administration may signifyhypoglycemia

Quick-acting carbohydrate and glucagon

Hyperglycemia treatment Awareness that increased urination or drinking maysignify hyperglycemia

Noncarbohydrate-containing liquid, insulin

Ketone monitoring Check ketones if repeated blood glucose tests showelevation above target range or if the child is ill

Urine or blood ketone strips, ketone monitor

*This device may or may not be used by the child.


current DMMP, the child care pro-gram should perform an assessmentof the child’s needs to determinehow it will provide diabetes care.An identified group of child carestaff who are willing to provide di-rect care for the child with diabetesshould receive advanced trainingfrom a diabetes health care profes-sional or the parent/guardian onroutine and emergency diabetescare so that at least one staff mem-ber is always available to providediabetes care.

4. Basic training for all staff in a childcare setting. The child care providershould work with the parents/guardians to arrange for trainingby a diabetes health care profes-sional or the parent/guardian in ba-sic diabetes education and identifyadditional training resources asneeded. All child care staff memberswho are responsible for the childwith diabetes should receive basictraining that provides:1) An overview of diabetes that in-

cludes information on how to rec-ognize and respond to hypo- andhyperglycemia and

2) Instruction on identifying medicalemergencies and contacting theright personnel with questions orin case of an emergency.

5. Advanced training for a small groupof child care staff. Advanced trainingprovided by a diabetes health careprofessional or parent/guardian shouldinclude:1) All components of basic diabetes

training as listed above;2) Instruction on how to perform

blood glucose monitoring, insulinand glucagon administration, andurine and/or blood ketone checks;

3) Training on the recognition andtreatment of hypo- and hypergly-cemia; and

4) Basic carbohydrate counting/monitoring carbohydrates.

6. Instruction should include demon-stration of the care tasks and aplan for ongoing training. The num-ber of staff members trained shouldbe sufficient to ensure that at leastone staff member who can provideroutine and emergency diabetescare, such as insulin and glucagonadministration, will be available atall times.

7. Participation in diabetes care shouldbe allowed for capable children. Childcare programs should support thechild in his or her development by al-lowing participation in diabetes tasksin accordance with the child’s compe-tencies, as outlined in the DMMP. Apreschoolermay be able to participatein his or her diabetes care by checkingblood glucose or choosing a finger-prick or injection site, all under thesupervision of an adult.

Key Points

c Child care centers should not denyadmission on the basis of a child hav-ing diabetes.

c A written care plan with medical or-ders, such as a DMMP, should be pro-vided by the diabetes care providerand parent/guardian to the childcare setting.

c All child care staff responsible for thechild with diabetes should receive ba-sic training.

c Advanced, child-specific trainingshould be provided to a small numberof child care staff, and there shouldbe at least one trained staff memberavailable to provide care at all times.

RESPONSIBILITIES OFSTAKEHOLDERS

1. The parent/guardian should providethe child care program with:� Information about diabetes man-

agement and training resources ifneeded

� A completed written care plan,such as a DMMP, signed bya child’s diabetes health careprovider

� Current and accurate emergencycontact information including phonenumbers for the parent/guardianand the child’s diabetes health careprovider

� All materials, equipment, supplies,insulin/medication, and food neededfor diabetes management andongoing monitoring of suppliesfor replenishment or replacementif expired

� An appropriate container for thedisposal of sharps

� A method of communication be-tween the parent/guardian andthe child care program, such as alogbook or electronic diabetesmanagement application

� Basic diabetes training (if needed)for all child care staff memberswho have responsibility for thechild and advanced child-specifictraining for the designated childcare staff members who are re-sponsible for providing regulardaily care to the child

� Information about factors thatmay impact blood glucose levels,such as the child’s daily activitylevel, food intake prior to arrivalat the center, and whether thechild is experiencing an illness

� Consent to release confidentialhealth information so that thechild care program can communi-cate directly with the child’s dia-betes health care provider anddirection on when such communi-cation is appropriate

2. The child care program should:� Understand federal and state lawsand regulations as they apply tochildren with diabetes

� Assess how the child care programwill provide routine and emer-gency care after consulting withparent/guardian and reviewingthe DMMP

� Recruit and designate staff whowill be responsible for the provi-sion of diabetes care to the child

� Work with parents/guardians toarrange for training for all staffmembers who have responsibilityfor the child and advanced child-specific training for designatedchild care staff members who areresponsible for providing dailycare to the child

� Provide secure and immediate ac-cessibility of diabetes materials,equipment, supplies, insulin/med-ication, and food to trained staffmembers

� Provide support to all families ofchildren in its care who are facedwith language barriers and limitedresources and be aware of andshare community resources forfamilies of children with diabetes

� Maintain accurate documentationof all diabetes care provided to achild in its care

� Collaborate with parents/guard-ians and/or diabetes health careproviders to obtain current infor-mation about the care of childrenwith diabetes


� Regularly communicate blood glu-cose results, insulin administra-tion, treatment of hypo- andhyperglycemia, food intake, andphysical activity using a logbook,electronic application, or othermethod provided by the parent/guardian

� Treat children with diabetes thesame as other children, except tomeet their diabetes needs

� Respect the child’s and family’s con-fidentiality and right to privacy

3. The child’s diabetes health careprovider should provide:� A completed and signed written

care plan containing medical or-ders, such as aDMMP,with updatesas needed

� In conjunction with the parent/guardian, basic and advancedtraining to child care staff

� Availability to respond to ques-tions about the child’s care withparental consent

� Ongoing diabetes expertise andguidance as needed

� Advocacy, as needed, to ensure achild’s needs are met while in thechild care setting

Key Points

c Parents/guardians, child care staff, andthe child’s health care provider all playimportant roles in ensuring appropri-ate care of the child with diabetesin a child care program. Each has spe-cific roles and responsibilities to ensurethat the child ismaintained in a healthyand safe child care environment.

CONCLUSION

It is well understood that young chil-dren with diabetes have unique needs.Young children require a carefullythought-out, proactive diabetes careplan and not a reactive one (i.e., crisismanagement) that must be developedwith the health care provider, parents/guardians, and child care staff. Unfortu-nately, despite all the best efforts of theparents/guardians, care may be subop-timal in the child care setting. For thoseinstances, there are federal laws thatprotect the rights of the young child.Violation of these rights may be subjectto legal action. Recommended resourcesfor parents are listed below. We encour-age parents/guardians of young children

with diabetes to share this PositionStatement with their child care pro-viders. Ensuring the long-term health ofand providing the best care to theseyoung children should be of paramountimportance.

RESOURCES

c American Diabetes Association. ChildCare Setting tools (including ChildCare DMMP): www.diabetes.org/childcare and www.diabetes.org/forparentsandkids.

c American Diabetes Association. Safeat School resources and information:www.diabetes.org/safeatschool.

c AmericanDiabetesAssociation.DiabetesCare Tasks at School: What Key Person-nel Need to Know: www.diabetes.org/schooltraining.

c National Diabetes Education Program.Helping the Student with Diabetes Suc-ceed: A Guide for School Personnel(2010): http://ndep.nih.gov/media/Youth_NDEPSchoolGuide.pdf.

Acknowledgments. The authors thank ErikaGebel Berg (ADA) for her editorial assistanceand Shereen Arent (ADA) for her review of themanuscript. The authors also thank the mem-bers of ADA’s Professional Practice Committeeand Executive Committee of the Board of Direc-tors for their review of the manuscript.Duality of Interest. No potential conflicts ofinterest relevant to this article were reported.

References1. Torpy JM, Campbell A, Glass RM. Chronicdiseases of children. JAMA 2010;303:6822. Pettitt DJ, Talton J, Dabelea D, et al. Preva-lence of diabetes in U.S. youth in 2009: theSEARCH for Diabetes in Youth study. DiabetesCare 2014;37:402–4083. Dabelea D, Mayer-Davis EJ, Saydah S, et al.Prevalence of type 1 and type 2 diabetes amongchildren and adolescents from 2001 to 2009.JAMA 2014;311:1778–17864. Vehik K, Hamman RF, Lezotte D, et al. In-creasing incidence of type 1 diabetes in 0- to17-year-old Colorado youth. Diabetes Care2007;30:503–5095. American Diabetes Association. Standards ofMedical Care in Diabetesd2014. Diabetes Care2014;37(Suppl. 1):S14–S806. Chiang JL, Kirkman MS, Laffel LMB, PetersAL. Type 1 diabetes through the life span:a position statement of the American Diabe-tes Association. Diabetes Care 2014;37:2034–20547. Child Care Aware of America. Child Care Re-source and Referral Agencies for Child CareAware of America’s 2012 State Fact SheetSurvey [Internet]. Arlington, VA. Available

from http://www.naccrra.org/. Accessed 3June 20148. Peters AL, Laffel L (Eds). American DiabetesAssociation/JDRF Type 1 Diabetes Sourcebook.Alexandria, VA, American Diabetes Association,20139. Diabetes Control and Complications Trial Re-search Group. The effect of intensive treatmentof diabetes on the development and progres-sion of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med1993;329:977–98610. Diabetes Control and Complications TrialResearch Group. Effect of intensive diabetestreatment on the development and progressionof long-term complications in adolescents withinsulin-dependent diabetes mellitus: DiabetesControl and Complications Trial. J Pediatr1994;125:177–18811. Barnea-Goraly N, Raman M, Mazaika P,et al. Alterations in white matter structure inyoung children with type 1 diabetes. DiabetesCare 2014;37:332–34012. American Diabetes Association. Diabetescare in the school and day care setting. DiabetesCare 2014;37(Suppl. 1):S91–S9613. American Association of Diabetes Educa-tors. Management of children with diabetes inthe school setting [Internet]. Chicago, IL, Amer-ican Association of Diabetes Educators, 2012.Available from http://www.diabeteseducator.org/ProfessionalResources/position/position_statements.html. Accessed 3 June 201414. National Diabetes Education Program.Helping the Student with Diabetes Succeed: AGuide for School Personnel. Bethesda, MD, Na-tional Institutes of Health (NIH publication no.10-5217, revised September 2010)15. American Diabetes Association. DiabetesCare Tasks at School: What Key PersonnelNeed to Know [Internet]. Alexandria, VA, Amer-ican Diabetes Association, 2008. Available fromwww.diabetes.org/schooltraining. Accessed 3June 201416. International Diabetes Federation. GlobalIDF/ISPAD Guideline for Diabetes in Childhoodand Adolescence. Brussels, Belgium, Interna-tional Diabetes Federation, 201117. Seaquist ER, Anderson J, Childs B, et al. Hy-poglycemia and diabetes: a report of a work-group of the American Diabetes Associationand The Endocrine Society. Diabetes Care2013;36:1384–139518. American Diabetes Association. Safe atSchool [Internet]. Alexandria, VA, American Di-abetes Association. Available from http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school. Accessed 25June 201419. Haymond MW, Schreiner B. Mini-dose glu-cagon rescue for hypoglycemia in childrenwith type 1 diabetes. Diabetes Care 2001;24:643–64520. Americans with Disabilities Act of 1990. 42U.S.C. 12181-1218921. Rehabilitation Act of 1973. 29 U.S.C. 79422. Individuals with Disabilities Education Act.20 U.S.C. 1400 et seq23. Rapp JA, Arent S, Dimmick BL, Gordon K,Jackson C. Legal Rights of Students with Diabe-tes. 2nd ed. Alexandria, VA, American DiabetesAssociation, 2009




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