My 12 year old son, who has had type�1 diabetes since the age of two and is going through puberty, recently went from a three shot regimen to a four shot daily regimen to further tighten control. He checks his blood sugars up to six times daily, and regimen adjustment has resulted in an average 4:00 pm blood glucose reading going from 340 to 89 mg/dl [18.9 to 4.9 mmol/L] based upon a three-day sample in a school setting.

My son’s endocrinologist has consistently considered him to be in good to excellent overall control over the past years and appears supportive of the four shot regimen, but his school nurse states, “The four shot regimen is not recommended in a school setting and it is unnecessary”. She further states, “He does not need to be tested every day if he has a balanced diet.”

Over the past ten years, we periodically and routinely have had a dietitian meet with us and our son to examine his dietary needs. This was just done last month, and the dietitian finds his diet to be excellent and considers him to be in good health.

Should a child with type 1 diabetes who going through puberty not check blood glucose levels at various points throughout the day under certain conditions? If so, what are those conditions? Are there any issues that would make a four-shot daily regimen that appears to have successful results (noted above) inappropriate for a school setting?

I would maintain that now, especially during puberty with the various hormonal changes that occur, changes in appetite, growth spurt, and associated mild changes in insulin sensitivity, that your son in no way should check glucose readings any less often. I’d suggest that he at least check before meals and at bedtime and, depending on the insulin regimen, even some readings two hours after meals!

I don’t know which 4-shots he is on: Regular with meals and NPH at bedtime? Regular (or Novolog or Humalog) at meals and Lantus (insulin glargine) at bedtime? The major obstacle of this succeeding in the school revolves around the willingness and ease of taking insulin with meals at school (and apparently the willingness of your school nurse for help).

In general, I am confused regarding the school nurse’s suggestions opposing a four-shot daily regimen and her statement of not needing to check blood glucose levels on a daily basis (even once-a-day) because they seem to conflict with advice from endocrinologists we’ve worked with over the past decade as well as the American Diabetes Association recommendations. [ED: See Clinical Practice Recommendations.] I think your school nurse is misinformed or has somehow mis-communicated something. Any clarifying comments you can provide would be much appreciated. My only other consideration, just to perhaps make things a bit easier (but maybe not) would be the use of an insulin pump.

DS

[Editor’s comment: I completely agree with Dr Schwartz. In addition, it is certainly not the school nurse’s responsibility to determine your son’s treatment. In fact, her comments, if heard by your son could interfere with his ability to carry it out and be deleterious to his control and overall well-being.

I would be certain that you have a 504 plan in place outlining your son’s treatment plan as well as her responsibilities with regard to it. (See The Law, Schools, and Your Child with Diabetes. ) I would also print out this response and give it to her, along with letters of concern written by you and your son’s diabetes team which states that any further such comments will warrant the need for further action. The school nurse might also benefit from a visit by a member of your son’s diabetes team. It sounds to me like she needs a refresher course in present day management of diabetes.

If you further assistance. contact your local chapter of the American Diabetes Association.

SS]