Diabetes Care

Diabetes Care in School

Brief 09.05

What every paraprofessional should know about supporting students with diabetes

Why this brief

Roughly 350,000 U.S. children and adolescents have type 1 diabetes; the number with type 2 diabetes is rising rapidly. Diabetes is the most common chronic medical condition that requires daily school-day management, and it is the condition where school nurses spend the highest share of their time. Paraprofessionals are often the closest non-nurse adult to a student with diabetes — at lunch, at recess, on field trips, during exercise, during a hypoglycemic episode.

This brief covers the basics of type 1 and type 2 diabetes, what hypoglycemia and hyperglycemia look like, the equipment students use (continuous glucose monitors, insulin pumps, finger-stick monitors), what paras can typically do and not do, glucagon for emergencies, and what the team has to coordinate. It does not replace the student's specific Diabetes Medical Management Plan (DMMP) — which lives in the file and tells the team what to do for that specific student.

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| This brief is general; the student's plan is specificAny student with diabetes will have a DMMP signed by their physician and family. Read it. Know who is trained to administer glucagon, where the supplies are stored, what the trigger criteria are, what to do if the meter alarms. If any of that is unclear, raise it with the school nurse — before, not during. |

1\. Type 1 vs. type 2 (the basics)

1.1 Type 1 diabetes

Autoimmune destruction of the insulin-producing cells in the pancreas. Most common in children and young adults; about 90%+ of pediatric diabetes is type 1. Requires insulin from outside the body — there is no "managing without insulin" or "reversing" type 1. Lifelong condition.

Daily school-day picture: students typically wear a continuous glucose monitor (CGM), often pair it with an insulin pump, count carbohydrates at meals and snacks, and adjust insulin accordingly. The student often knows their own management better than school staff.

1.2 Type 2 diabetes

Insulin resistance — the body produces insulin but doesn't use it effectively. Historically rare in children; rising due to multiple factors. May be managed with lifestyle, oral medications, or insulin — different students manage differently.

Daily school-day picture varies. Some students need limited school-day intervention; others wear CGMs and use insulin similarly to students with type 1.

1.3 Other forms

MODY (mature-onset diabetes of the young) and other monogenic forms exist. Cystic-fibrosis-related diabetes is a feature of CF in older children and adolescents. Most school-management protocols generalize from type 1 frameworks.

2\. The equipment students use

2.1 Continuous glucose monitor (CGM)

A small sensor worn on the body (arm or abdomen, typically) that measures interstitial glucose every 1–5 minutes. Common brands: Dexcom, Freestyle Libre, Medtronic Guardian, Eversense. CGMs:

Display current glucose on a phone, dedicated reader, or paired insulin pump.

Sound alarms when glucose is too high or too low, or trending toward it.

Are typically worn continuously and changed every 7–14 days depending on brand.

Are accurate but slightly trail blood glucose by minutes — they read interstitial fluid, not blood.

2.2 Insulin pump

A small device worn on the body that delivers insulin continuously through a thin tube and infusion site. Common brands: Tandem t:slim, Medtronic, Omnipod (no tube). Pumps:

Deliver basal insulin continuously and bolus doses for meals or corrections.

Are programmed by the family and the diabetes team; doses are not adjusted by school staff.

May connect to the CGM and adjust insulin automatically (closed-loop or hybrid closed-loop systems — Tandem Control-IQ, Medtronic 780G, Omnipod 5).

Need to be protected from water in some models, kept secure during physical activity, accessible for bolusing at meals.

2.3 Finger-stick blood glucose meter

Manual blood glucose check using a lancet and test strip. Less common as a primary tool now (CGMs have largely replaced it for many students), but still used for confirmation when CGMs alarm or are unreliable, and as a backup.

2.4 Insulin pen or syringe

For students who don't use a pump. Insulin is given by injection, usually before meals and corrections. The student may self-inject (older, trained) or have a school nurse administer.

2.5 Glucagon

Emergency medication for severe hypoglycemia. Available as injection (Glucagon Emergency Kit), nasal (Baqsimi), or pre-filled pen (Gvoke). Stored in a place trained staff can access fast — typically the nurse's office, the student's locker, or both.

3\. Hypoglycemia (low blood sugar)

The most common diabetes emergency in school. Hypoglycemia happens when blood glucose drops too low — usually below about 70 mg/dL, with severity scaling. The student's plan specifies thresholds for them.

3.1 Causes

Too much insulin relative to food eaten.

Skipped or delayed meal.

Unplanned physical activity.

Illness.

Hot weather.

Hormonal changes.

Stress.

3.2 Recognition signs

| Severity | What it can look like |

| :-: | :-: |

| Mild | Shaky, sweaty, hungry, headache, irritable, anxious, fast heartbeat, pale, tingling in lips, blurred vision. |

| Moderate | Confusion, difficulty concentrating, slurred speech, weakness, behavior change, drowsiness, severe mood shift. |

| Severe | Loss of consciousness, seizure, unable to swallow safely. Medical emergency. |

Some students lose hypoglycemia awareness over time and don't feel the early signs. The CGM alarm may be the first signal.

3.3 Response — Rule of 15

If the student is conscious and able to swallow, treat with 15 grams of fast-acting carbohydrate. Per the student's plan, but commonly: 4 oz juice, 4 glucose tabs, regular soda (not diet), or specific fast-acting carb snack.

Wait 15 minutes.

Recheck blood glucose.

If still below threshold, repeat with another 15 grams.

Once above threshold, follow up with a longer-acting snack (with protein and complex carb) if a meal isn't soon.

3.4 Severe hypoglycemia — emergency

If the student is unconscious, having a seizure, or unable to swallow safely — DO NOT give food or drink. Aspiration risk.

Call 911.

Trained staff (school nurse or specifically delegated and trained personnel) administers glucagon per the student's plan.

Position student on their side.

Stay with the student until EMS arrives.

Notify family per protocol.

After-event documentation.

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| Glucagon authorizationAll 50 states have laws addressing diabetes care in schools; specifics vary. Most authorize school nurses to administer prescribed glucagon, and most also authorize specifically trained, designated school personnel (which may include trained paraprofessionals) to administer in emergencies. ADA's Safe at School advocacy has been central to this expansion. Know your state's specifics and your district's authorization. |

4\. Hyperglycemia (high blood sugar)

Less acute than hypoglycemia in most situations, but can become a medical emergency if untreated. Hyperglycemia happens when blood glucose is too high — usually above about 180 mg/dL with thresholds varying.

4.1 Causes

Not enough insulin.

Eating more than insulin covered.

Pump malfunction or infusion site failure.

Illness, infection, fever.

Stress.

Certain medications.

4.2 Recognition signs

Frequent urination, increased thirst.

Fatigue, sluggishness.

Headache.

Blurred vision.

Sweet or fruity breath.

Stomach pain or nausea (more concerning — possible early diabetic ketoacidosis).

Vomiting (concerning — possible DKA).

Rapid breathing (concerning — possible DKA).

4.3 Response

Per the student's plan — typically: confirm with finger-stick, allow water, allow extra bathroom access, follow correction-dose plan (usually administered by the student or school nurse, not the para).

If the student vomits, has fruity breath, abdominal pain, rapid breathing, or unusual drowsiness — these are signs of possible diabetic ketoacidosis (DKA), a medical emergency. Call the school nurse and follow the plan; DKA can require hospitalization and is potentially life-threatening.

5\. Daily school-day rhythm

5.1 Pre-meal routine

Carbohydrate counting — student or family typically provides carb counts for meals.

Glucose check via CGM or finger-stick if needed.

Bolus dose calculation — done on the pump or via insulin pen, by the student or with nurse oversight.

Eating begins.

5.2 Physical activity

Glucose check before activity.

Some students need a snack before exercise; some need to suspend insulin delivery.

Watch for signs of hypoglycemia during and after exercise — exercise can lower glucose for hours.

CGM access during PE is appropriate; pumps may need to be temporarily disconnected for swim or contact sports per family plan.

5.3 Recess, lunch, transitions

Para often the closest adult to monitor. Watch for signs.

If CGM alarms — confirm with the student or finger-stick; respond per plan.

Student access to glucose tabs, juice, or other fast-acting carbs at all times. These should travel with the student, not be locked in the nurse's office.

5.4 Field trips and special events

Pre-trip planning required. Supplies travel — meter, pump infusion sets, glucagon, fast-acting carbs.

Trained adult travels with the student or available within reasonable response time.

Communication plan with family during the trip.

Schedule disruption (different meal times, longer activity stretches) increases hypoglycemia risk; plan for it.

6\. What paras typically do (and don't)

6.1 Commonly authorized

Walk with student to the nurse for blood glucose checks.

Stay with the student during checks.

Watch for signs of hypoglycemia or hyperglycemia.

Treat mild hypoglycemia with the prescribed fast-acting carbohydrate per the plan.

Carry glucose tabs or juice on field trips for the student.

Where specifically authorized and trained: administer glucagon.

Carry CGM-receiver or backup devices when designated.

Assist the student in self-care without doing it for them where appropriate.

6.2 Typically not authorized for paras

Calculating insulin doses (this requires clinical judgment).

Programming or adjusting the insulin pump.

Inserting a CGM or pump infusion site.

Administering insulin (in many districts; varies by state).

Making decisions about whether to override the student's plan.

6.3 Self-management is the norm

Many students with diabetes — especially older students — manage substantial portions of their daily care themselves. The para's role is supportive and emergency-aware, not to take over what the student is competently doing.

7\. Documentation

Diabetes management generates documentation requirements. Specifics vary; common elements:

Glucose check results with time.

Insulin doses given (typically by nurse or student, with documentation by the administrator).

Hypoglycemic episodes — time, severity, treatment, outcome.

Hyperglycemic episodes — time, treatment, outcome.

Glucagon administration — full incident report.

Missed snacks, missed boluses, schedule disruptions that affect glucose.

Family notification of significant events.

The school nurse usually maintains the formal log; the para is often the closest observer and the source of information.

8\. Diabetes burnout, mental health, and stigma

Diabetes care is relentless — every meal, every activity, every illness, every change requires management. Students experience real fatigue with the daily burden, and rates of depression and anxiety are elevated in pediatric diabetes populations.

Watch for signs of "diabetes burnout" — increased non-compliance, glucose ranges drifting, missed doses.

Stigma is real — some students hide their diabetes from peers and avoid the nurse to avoid being noticed. Privacy in the school setup matters.

Eating disorders and disordered insulin use ("diabulimia") — particularly in adolescent girls — are documented complications. Watch for unexplained glucose patterns, weight changes, food avoidance.

Mental health support is part of comprehensive diabetes care. Surface concerns to the school nurse and counselor.

9\. Common pitfalls

Treating diabetes as fully self-managed when the student is in fact struggling and needs support.

Treating the student as fragile when they are competently managing.

Ignoring CGM alarms because "the student knows."

Withholding fast-acting carbs because of fear of "giving food during class."

Trying to give food to an unconscious student. Aspiration risk; never.

Carrying out activities that require clinical judgment without authorization.

Forgetting glucagon and supplies on field trips.

Assuming glucose problems are "just behavior" or "just attention." Confusion, irritability, and fatigue can be hypoglycemia.

Public attention on the student's diabetes that the student doesn't want.

Documentation errors that misrepresent what happened.

Letting peers tease or bully a student about their equipment or eating schedule.

10\. Resources

Major organizations

American Diabetes Association — Safe at School — diabetes.org/safe-at-school — State-by-state legal landscape and resources for families and schools.

ADA — Helping the Student with Diabetes Succeed — diabetes.org — Federal guide for school personnel.

JDRF — jdrf.org — Type 1 diabetes research and family support.

Beyond Type 1 / Beyond Type 2 — beyondtype1.org — Patient-community resources.

Children with Diabetes — childrenwithdiabetes.com — Family community and resources.

School-specific

National Association of School Nurses — Diabetes resources — nasn.org — School nursing position and protocols.

CDC — Schools and Childhood Type 1 Diabetes — cdc.gov/diabetes — Federal resource.

Cross-references

Brief 09.04 — Medication Administration — this library

Brief 09.06 — Seizure Recognition and Response — this library — Hypoglycemic seizures fall here.

Brief 09.08 — Allergies and Anaphylaxis — this library — Co-occurring with diabetes in some students.

Brief 12.07 — Working with the School Psychologist and Counselor — this library

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