What we know about diabetes: Children are Not Pawns

Here is an authoritative response from Dr. Fran Kaufman, respected pediatric endocrinologist and past-ADA President, on why the nursing groups' position that only a school nurse can administer insulin is "balderdash".

-Lisa Shenson

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What we know about diabetes: Children are Not Pawns
By Francine R. Kaufman, MD

"Imagine you have a life-threatening medical condition that requires a
critical procedure for you to survive." So began Dale Parent's
explanation of why only a medical professional is able to safely
administer insulin to a student with diabetes ("Judge rightly stopped
health outrage" Dec. 10, 2008, LA Daily News). Ms. Parent, president of the California
School Nurses Organization, goes on to provide horror stories of what
might happen if someone without a medical degree were to administer
insulin, a procedure that she makes sound very ominous.

As a pediatric endocrinologist for 30 years, my one word response was
"balderdash". In the time it took me to read Ms. Parent's article I
knew that tens of thousands of doses of insulin were administered across
the country and only a very tiny percentage were given by health care
professionals. Rather, they were being administered by people with
diabetes, parents, friends, and babysitters of children with diabetes *
and even many children. Yet, Ms. Parent seems unaware that the
foundation of modern diabetes management is lay people * not medical
professionals * administering insulin.

So Ms. Parent is thrilled that a Superior Court judge struck down an
agreement between the American Diabetes Association and the California
Department of Education that would have allowed trained non-medical
school personnel to administer insulin at school and school-related
activities when a school nurse isn't present.

While Ms. Parent was thrilled, I, my colleagues (who are doctors,
nurses, and diabetes educators who specialize in diabetes care) and the
families of children with diabetes were appalled. And we were
frightened.

We know that when children with diabetes are able to successfully manage
their disease they can hope to avoid the potentially deadly short term
complications, as well as long term complications of diabetes including
heart disease, amputation and blindness. This requires having immediate
access to insulin before meals and at unpredictable times when blood
sugar levels are higher than what is acceptable.

We know that school nurses are important to the health of all students
and, like Ms. Parent, we would like to see more nurses in our schools.
But we also know that we have but one school nurse for every 2700
California students, one of the worst ratios in the country. Weathering
the current financial crisis, school districts in our state are cutting
positions, not adding them. Even in those rare schools lucky enough to
have a full-time nurse, the nurse isn't there during field trips and
extra-curricular activities. But the child's need for insulin is still
there * and this need simply cannot wait for a phantom nurse to show up.

We know that insulin is given in school by many different kinds of
people other than the school nurse. Parents or their designees * all
unlicensed * can administer insulin in school. Babysitters, aunts,
uncles and grandmas * even siblings * show up to give injections with no
assurance they have been properly trained. The nurse organizations that
brought this lawsuit do not object to this, yet they will not let school
staff members, many of whom have diabetes themselves, volunteer to give
an injection after they have been trained. And worse yet is the
insinuation that Ms. Parent made that we are asking unlicensed people to
determine how much insulin to give. Nothing is farther from the truth.
Each child with diabetes has the dosage pre-calculated, and the parent
or the child's diabetes team are always available * even for the school
nurse to call * to double check prior to giving the dose of insulin.

In short, we know that if only a nurse is allowed to administer insulin
then students with diabetes will not be safe at school. Some will face
long delays in getting insulin or will go without insulin altogether
during school, putting them at increased risk of severe complications.
Sometimes they will be in school sick when they should be thriving. Some
parents will be forced to quit their jobs to be on call to administer
insulin; I've had parents of patients end up on welfare after they lost
their jobs because they had to leave work to give their child an
injection.

We know this is needless hardship when a safe and financially reasonable
alternative is readily available. The American Diabetes Association
(ADA) has supported training non-medical school personnel for years as
have other leading organizations of people with diabetes and diabetes
healthcare professionals. It happens today in over 30 states.

We know about families whose children got sick waiting for a school
nurse. What we don't know are where the horror stories Ms. Parent
relates came from. The lawyers representing the ADA assured me none of
Ms. Parent's stories made it into facts alleged on the record in court.
They also told me that the judge in the case said he agreed with the ADA
as a policy matter, but that it was a matter for the legislature to
decide.

Parents of children with diabetes and health care professionals who have
devoted their lives to caring for children with diabetes are not, as Ms.
Parent implies, mistaken about what is in the best interests of children
with diabetes. We are not mistaken when we say that they are vulnerable
children * not pawns.

Dr. Kaufman is the Director of the Comprehensive Childhood Diabetes
Center and the Head of the Center for Endocrinology, Diabetes and
Metabolism at Childrens Hospital Los Angeles and the former president of
the American Diabetes Association.