In your 504 Plan, don't forget the lunch ladies

Eric's endo visit today gave me a bit of a shock. His a1c had gone up substantially, from 7.4 to 7.9. I knew his numbers hadn't been great, but that bad??

The CDE and I assessed his numbers, and while we agreed that we needed to do an overnight basal check, she also said that perhaps a basal check for the afternoon would be valuable too. I'd noted a strange pattern... not daily, but certainly fairly frequent... in which he got on the school bus in range and was sky high when he reached his daycare a half hour to 45 minutes later. The CDE thought maybe he needed a bump upward in his basal. I agreed tentatively, but couldn't help wondering why this happened some days, but not every day.

It was when I returned Eric to school and sat down with the nurse to discuss the findings that we got clarity. I showed her the numbers and said in passing that his father and I had initially suspected Eric of getting candy (or something) from other kids on the bus, but that the bus driver was now keeping a watch for that and had reported no such incidents. The nurse said thoughtfully, "Well, there was something that happened yesterday that might well answer your question..."

To make a long story short, it seems Eric has been going into the lunch line and helping himself to the milk now and again. The lunch ladies knew this, but as long as he took white milk and not chocolate, they thought it was OK. How could they know otherwise? Chocolate milk has sugar, white milk "doesn't", and diabetic children like Eric are "supposed to avoid sugar." We probably never would've figured it out, except that yesterday, Eric had taken a chocolate milk, and had been obliged to discuss this with the nurse. When quizzed on the subject today, the head lunch lady allowed as how she'd seen Eric take white milk once or twice, but that most of the time, he came through the line when her back was turned, so she couldn't say for sure what he had or hadn't taken. And therefore, it is quite possible that from time to time he's been taking a milk, or even a chocolate milk, without anyone knowing.


It actually fits the scenario pretty well. Eric's typical response to chocolate milk is a slow BG increase for about 90 minutes, then a sharp bump upwards at ~2 to 2.5 hours. It's why I usually bolus chocolate milk with a square wave bolus. If he's been taking a milk box sans insulin at lunch, which they serve at 12:30, I would expect the blood sugar to be in range/high by 2:00 (just before he's tested for the bus) and then to be sky high by 3:00. Which is exactly what we've been seeing.

We informed the head lunch lady that the cafeteria staff needs to keep Eric from going through the line altogether (because heaven knows what ELSE he might be taking when their backs are turned!). She asked me to give her a written instruction that she could pass out to all the lunch ladies on staff. I sat down and wrote it out there and then: "Eric is to have no food other than what comes out of his lunch box unless the nursing staff gives it to him."

Addendum to my 504 documents is about to be made. And in the future... the lunch ladies will be informed up front.

Wow, glad you were able to troubleshoot this! Well done ;)

I'm still troubleshooting it, actually. I asked Eric last night if he knew why he's not supposed to take milk from the lunch line and he said "Because Mrs. Sanborn doesn't like it." with tears in his eyes. Oh lordy. I don't want the kid to feel ASHAMED about what he's doing; I just want him to know that he shouldn't do it because it's harmful! So I'm trying to negotiate some help for the poor kid on days when the lunch menu is something he enjoys, so he can HAVE what he wants without feeling like he's being "bad" in taking it.

What is a square wave bolus?

A square wave bolus is a setting on Eric's pump that infuses the bolus over a set period of time rather than all at once. So, for instance, I can put his carbs in and calculate the insulin he needs, but instead of delivering it all right then and there, I can input a time frame of, say, half an hour or an hour, and the pump will deliver the bolus incrementally over that time period. So, if he's low but not wicked low, I will give him a juice box and set a bolus to infuse over about an hour. That way, the juice has plenty of time to bring his BG up before the insulin kicks in and starts working on it. I find it's a lot better than giving him juice and then finding it's pushed him high and having to correct 1/2 an hour later.

There's also a setting called "dual wave bolus" where you give half of the insulin as a standard bolus and the other half as a square bolus. This is very useful for foods that have lots of fat in them, like pizza, or french fries. I was finding that if Eric ate french fries and I bolused the full amount up front, he'd drop low, then shoot high. But if I give him *some* up front and the rest as square wave bolus, he doesn't do that.

Good info! Thanks Elizabeth.