I think that I put the fear of god into my daughters kindergarten teacher

Type 1 and LADA Parents of Children with Type 1 Diabetes
1

The other day my kindergardener had lunch in the lunchroom to prepare for next year. She was sooo excited so I called the nurse(a substitute)before hand and got the skinny on what was being served and told her what she could have and put everything on a sheet for the nurse. I even gave her a low carb breakfast (not easy to do) so that she could have lunch at 10:00. I have everything covered right? HAHA!!! My daughter apparently goes to the nurse at 9:15 because she wasn’t feeling well and she was 76. So they gave her a juice and sent her back to class. She came back in before 10:00 and they checked her and she went up to 160. Then they send her to lunch. WHAT DID THEY FORGET??? My daughter goes to the lunchroom and turns to her teacher and tells her that she needed her medicine and she needed the nurse. Her teacher tells her that it is OK and she should eat! My husband calls me at 12:30 after she gets home screaming that he has tried to call the nurse 5X’s and no one is answering and she is 400 and is telling him that she didn’t get her medicine. I told him to calm down check her keytones and as long as she is negative bolus her and I would call the nurse. I got on the phone with the nurse and I tell her that Francesca did not get her medicine and she was so apologetic. I told her that it worked out OK but we need to be sure in the future that this does not happen. I get home and my daugther tells me that she told her teacher that she needed her medicine and was told not to worry about it.

Well needless to say Mommy was on the phone first thing in the morning with the school asking the teacher to call me. She actually called me before class even started. I asked her if the nurse had spoken to her and she said that she had. I told her that I didn’t know until after I spoke with the nurse that my daughter had told someone and they told her not to worry about it. I told her we were lucky and that since she is only in school for 1/2 a day she was lucky but any longer and today she would be in the hospital. I told her that per our doctor she has two hours and she could be in real trouble. I told her that I understand that there were alot of children and it was an unusual day but that this is very important and my daughter’s life hangs in the balance.

I explained to her that my daughter is VERY aware of her situation and knows what she HAS to do in order not to be sick. We have tried very hard to make it that way for her because of situations like this one. I told her if she had been in school all day and someone had not noticed she would have been very ill by the time she came home or had to have been taken to the hospital from school. A few more hours and we could’ve had a serious incident. I told her that I have instructed my daughter that if anything like this happens again she should refuse to do whatever it is that they are making her do and insist that they call her father or mother. I told the teacher if you hear her making that request someone needs to listen because there is something wrong.

The next day needless to say my daughter ate a pistachio from one of her friends and the teacher and the nurse called my husband because they were so afraid that she was going to get sick. My husband told them that first of all she does not have a nut allergy and second one nut is not going to kill her she will be fine.

On one hand I am SOOOOOOO proud of my daughter for knowing. One the other hand I am so worried that next year as she will be in 1st grade she will be there all day. All that I can do is pray.

On one hand I am very proud of my daughter but on the other it scares me that now

2

Good job!
My daughter (dx’d last fall) just finished 1st grade. Any chance you could have someone on staff send you a text every day prior to lunch with what her premeal bg is? If not a staff member maybe you could get it approved for your daughter to send you a text (prepaid phone or something) letting you know that she was tested and given her injection? She shouldn’t be having her bg taken just prior to lunch without the injection (unless she’s on NPH - which it doesn’t sound like is your situation)…right, so it would be your way of knowing that she got her insulin when the message comes across and if it doesn’t…then you could phone and figure out what’s going on. Just an idea! BTW…praying goes a long way…you should have heard me when our CGM receiver (not even water resistant) went for a swim last night in the tub…God took care of it, read the posts most CGM receivers are toast after even a simple dip. While ours was a simple dip it lived and didn’t ever stop chuggin’ along! :slight_smile:

3

OK, so I’m a little confused. One, isn’t it in her 504 Plan that she needs insulin before her lunch? and two, doesn’t she get basal insulin as well as bolus doses? The understanding I have from my endo is that the basal insulin (or long-acting insulin in non-pump-users) will prevent ketoacidosis. The two-hour window of time only reflects the situation of having no insulin AT ALL — that is, no basal OR bolus — and that it takes about two hours without insulin before one starts burning fat and developing ketones, and even then, it takes a day or two of having that go unaddressed before the child is in really serious trouble (not that I’m recommending anyone take it less seriously, of course). In this situation, she didn’t get a bolus but she still had her basal turned on, am I right? So she wasn’t in any danger of hospitalization—just of feeling crummy. Not that this matters in the end. If it had been me, I would have done the same thing you did.

I have a pretty good set up with my daycare that I’d recommend you try with this school. My daycare provider created a form in which she has planned out every instance of eating that happens while my son is in her care – and since he’s there all day, that’s breakfast-snack-lunch-snack. So I tell her first thing in the a.m. what his starting BG is, and then she takes and records his BG before giving him each meal. She also records the carb counts of each meal (and how much of those carbs he actually eats, given how picky he is!) and she records much insulin he got, and at what time he got it. We had a couple of cases where the staff wrote down his dose but didn’t give it to him, so now the person entering the info into his pump must initial the sheet after pressing the “ACT” button. It works like clockwork and we’ve never had any instances of missed doses since she put this process in place. AND it gives me great information on what his day was like without me having to upload his pump every day. (If you want to friend me & send a message with your email address, I’d be happy to send you a copy of her form via email so you can offer it to your school).

Ultimately, though, if there’s a 504 Plan in place and the school isn’t following it, that’s an issue. (If there’s no 504 Plan in place, you should probably take this incident as a reason to create one—and that’s where you can insist, in a friendly but legally binding way, that they confirm in writing that they gave her the insulin she needs.)

4

according to our endo. since we got the pump that since she is only getting short acting insulin she could still go into ketoacidosis(sp?) within two hours. You have to remember she had lunch at 10:30 and was 400 by 11:30 when she got off the bus. Like I said another hour and there would’ve been some real problems. Not only did she eat but she was low just before that so she also had 15 carbs before her 40 carb lunch that she had no medicine for. We do have a 504 plan in place but the normal nurse was out for the last three months of school and when I spoke to the nurse that was there she basically told me that she had never delt with this type of thing before. We also have a sheet that gets filled out with all of her food and carb numbers etc that they have to put all of the information in. This is why I just can not understand how this could happen. We did everything that we could do to make sure that our DD is safe and…

The only thing that was good in all of this is that my daughter actually was aware of what was going on and tried (although the adults didn’t) to make sure that she got what she needed. Also I can tell you that the next time that teacher has a diabetic in her class she will be more aware as well. I guess you have to look for the positive or wallow in the negative.

I choose to look at the positive.

5

Well, I am glad your daughter had the knowledge and good sense to speak up. My stepdaughter’s T1D friend had a substitute who tried to prevent her going to the nurse (hadn’t read her class prep documents, apparently) and the girl, who is quite shy, would’ve just sat right back down and quietly passed out from a low if my stepdaughter (who’d just gotten trained for her brother’s care) hadn’t spoken up. So if your child has learned this young to stand up for herself (even if the adults don’t listen, and boy does that cheese me off!) she’s doing well.

You’d think that if the normal nurse has been out that long, they really should’ve given her replacement some training – “I’ve never dealt with this sort of thing before” is a pretty poor excuse, when a kid’s health is on the line. I would suggest you put it into your 504 Plan next year that in the event the regular nurse isn’t at the school, the school is responsible for contacting you so you can either train the replacement yourself, or have a diabetes educator give the new nurse the details. To have someone who doesn’t know what they’re doing watching over your child daily is just plain scary.

As for the ketoacidosis, I still think you may have misunderstood your endo. I understand that only short acting insulin is being used because Eric is on a pump too, and it uses Humalog exclusively, but the Humalog is delivered as both the bolus AND the basal. So assuming that she has an adequate basal rate set on her pump, that basal insulin will ensure that she doesn’t start producing ketones even if she doesn’t get her bolus. The only way she would develop ketones would be if her basal dose delivery is somehow blocked or nonfunctional – like if there’s a crimp in the site cannula, or bubbles in the line, or some other issue with insulin delivery being impaired. Then, as your endo has told you, in about 2 hours she’s going to start producing ketones, and ketones coupled with high blood sugars is a bad thing. But even then, it takes a day or two of this problem going completely unattended before she’ll need hospitalization, and for the most part if parents are on top of things and taking blood sugars regularly, they should be able to catch the problem long before it gets that bad (I just had this discussion with Eric’s endo while we were working on our book, so it’s fresh in my mind).

So in short, if her basal insulin is operating as it should, she is getting insulin continually even if she didn’t get a bolus, and therefore, even if she goes wicked high, she’s not going to develop ketones or ketoacidosis. But doesn’t your school keep any ketone sticks on hand? If she’s above 240, the very first thing they should do is test for ketones. That’s how they’d know whether the problem was related to insulin delivery or not. And that way, if she goes high and they do find ketones, they can alert you to come give her an injection with a syringe and change her site.

I’m telling you all this because it sounds like your poor husband went into a total freak out panic when he found her at 400, and while 400 is definitely too high, panic isn’t called for if a BG that high isn’t accompanied by moderate to high ketones. A syringe and some insulin will take care of a 400 BG pretty quickly; elevated ketones are the only factor that makes a 400 BG problematic and worthy of (mild) panic. Don’t get me wrong, I’m not saying that a 400 BG is something to take lightly – but without ketones, it’s not life-threatening in the immediate term.

What we have set up with Eric’s daycare provider is that if she finds him high, she tests for ketones. If there are no ketones, she gives him a correction through the pump (after checking for and priming out any bubbles) and then rechecks in an hour to see if he’s gone down as he should. If there are ketones, or if he doesn’t start to go back down an hour after a correction, she calls me or my husband, then puts EMLA cream on his tush to start a new site. My husband or I will go over to the daycare to give a correction by syringe immediately, and then when the EMLA cream has done its work, we change the site. That way, whatever high BG he has, is short in duration, and while it’s a nuisance, it keeps us from having to worry about ketoacidosis.

6

My husband is not as calm as I am when it comes to my daughters care. He tends to overreact. I probably did misunderstand my endo but I think that saying it the way I did will make the teacher think twice next time she has a child like mine in her class. School does have keytone strips on hand the only problem is that they didn’t even know to check her because they didn’t realize they hadn’t done their job. I work an hour away and if there is a problem with her pump my husband is out of work so he is the first line of defense. I have told him that he needs to calm down but she is his little girl and it is a lot easier said than done with him.

Thanks for the suggestion with the substitute nurse. Actually since then my daughter and husband were at the store and saw the regular nurse there and apparently she had already heard about what happened. I think that they were a little worried.

You are working on a book? I wrote one too. Just about my feelings about all of this during the first year. Good luck with yours I hope it turns out well.

7

My daughter is T1 and just finished kindergarten.

One step we’ve taken which could help avoid this sort of issue is that we got a cell phone for her, and instructions for her to call us on it if anything is ever going in a way that she doesn’t think is correct. In her 504 plan is permission for her to carry this phone with her. In a situation as above, since your daughter was aware of the problem she could have called to report it to you at the time.

More importantly though, the nurse was clearly not adequately informed if she did not come to the lunchroom to administer insulin at the needed time. She should have this on her regular schedule, as part of her job is to do this whenever you daughter is at school!

8

I know that and the thing is I had everything that we thought we needed in place. I even called the school to go over the menu and make sure that everything was OK. Maybe a cell phone would be a good idea. Thanks for the thought.

9

Hi. New to group. I agree with putting “the fear of God” in the teachers, nurse, administrators, etc. I’ve had an occasion or two where my son was in danger from lack of paying attention. In fact, I’ve written the nurse off completely! I have a similar plan as Elizabeth’s where every meal is accounted for and everything is written down. Last year, it was the teacher’s aide who did the recording. This year there was no aide and my son had to do it himself. The most helpful thing was that the school allowed my son to have a cell phone in class, and he called me 2x/day to let me know what his BGs were and discuss much insulin to bolus (Animas Ping) for the meal. Worked perfectly! It put my 9yr old in control and gave me more peace of mind.

10

Hi, just one quick comment…I think there is a misunderstanding between basal and ketones…from what I learned our child can still have ketones even if his/her basal is right…your body starts to produce ketones after being with high glucose for a while or if they are sick…that’s why some doctors say that if your child is high 2 times in a row you should check ketones… The basal alone is not going to get rid of the ketones, depending how high your child is you should have a scale with how much insulin he/she need to get rid of the ketones. You can verify this info with your doctor.
Regarding the teacher I think that teaching her about diabetes would probably help her understand a little bit more how your daughter should be treated…