Diabetes Care in the School Setting: A Statement of the American Diabetes Association

Diabetes is a chronic condition requiring a balance of medications, nutrition, and physical activity. Diabetes affects 352,000 children and adolescents <20 years of age in the U.S. and is one of the most common chronic diseases of childhood (1). The incidence of childhood diabetes has been increasing steadily worldwide (2). The rising incidence and prevalence of type 1 and type 2 diabetes in children over time have been documented in the SEARCH for Diabetes in Youth (SEARCH) study, with a population-based registry from five large diabetes centers in the U.S. (3). For youth with type 1 diabetes, the estimated prevalence showed a 45% relative increase over the past two decades (4). Over the same interval, the prevalence of type 2 diabetes in youth nearly doubled (4). The incidence of type 1 and type 2 diabetes is rising faster in adolescents of racial and ethnic minoritized populations, who are often more likely to experience inequities in access to treatments and health outcomes (5).

Most young people with diabetes spend many hours at school and/or in some type of childcare program. While there, all children with diabetes should have access to care and support from trained and knowledgeable staff to provide a safe environment. The rising prevalence of children and adolescents with diabetes places increased demands on schools to assist with diabetes management. This includes providing care during the school day, field trips, and all school-sponsored activities in all school settings, including preschool, daycare, and camp programs. In addition to providing routine diabetes care, trained staff can play a critical role in helping to optimize glucose management, foster students’ self-management skills, and offer psychosocial support. School staff support may help to reduce the risk of short- and long-term complications of diabetes and maximize the potential for academic success and optimal development for these youth. Each child’s parents or guardians and health care professional should work together to provide school and childcare staff with the information necessary to enable children with diabetes to participate fully in all school and childcare experiences (6–8).

The purpose of this statement is to provide diabetes management recommendations for students with diabetes in elementary and secondary school (from pre-K to 12th grade) settings based on the American Diabetes Association (ADA) “Standards of Care in Diabetes” (7). This statement provides guidance updated from that of the 2015 position statement from the ADA (9) to clarify roles and responsibilities commensurate with modern diabetes management practices. Specifically, more information is included on the optimal use of diabetes technologies in school, management of type 2 diabetes in school, behavioral health considerations for students with diabetes, and the approach to diabetes care in special situations, such as emergency scenarios or clinical trial participation. The statement is intended for diabetes health care team, parent or guardian, and school staff audiences. For information on young children aged <5 years, the ADA statement “Care of Young Children With Diabetes in the Childcare and Community Setting” (6) should be reviewed for specific recommendations regarding settings such as daycare centers, preschools, and camps.

Diabetes is a legally protected disability. Federal laws that protect children with diabetes include Section 504 of the Rehabilitation Act of 1973 (10), the Individuals with Disabilities Education Act (11), and the Americans with Disabilities Act (12). State and local laws may provide additional protections. It is illegal for schools to discriminate against students with disabilities, including diabetes. Any school that receives federal funding (i.e., public, charter, private, and parochial schools and postsecondary institutions) and any facility considered open to the public must reasonably accommodate the needs of students with diabetes. Indeed, federal law requires an individualized assessment and plan of care for any student with diabetes (10,11). The required accommodations need to be documented in a written plan developed under the applicable federal law, such as a 504 plan (named from Section 504), or Individualized Education Program (IEP), and should be based on the student’s individualized Diabetes Medical Management Plan (DMMP). The DMMP is a plan developed and approved by the student’s health care provider that prescribes the diabetes care needed in the school setting.

A 504 plan, a document describing the diabetes-related accommodations in accordance with the DMMP, states that students with diabetes need to safely access their diabetes care, participate in all school-sponsored activities, and benefit from their education. All students with diabetes should have a Section 504 meeting that includes their parents or guardians, teachers, school nurse, and other staff trained to support the student with their diabetes care. During the meeting, the parents or guardians and school staff work together to determine the student’s accommodations or support for full participation in all school activities. These accommodations need to be delineated in a written plan. The plan should specifically include the following:

• Identification of school staff—school nurses, teachers, aides, substitutes, coaches, bus drivers, or other staff or contractors with responsibility for the student with diabetes throughout the school day, including after-school care and extracurriculars, field trips, transportation, detention, sports, clubs, dances, and school breakfast—who will receive training on diabetes care, including glucose monitoring, treatment of hypoglycemia and hyperglycemia, diabetes technology, glucagon administration, and insulin administration.

• The location where the student will receive diabetes care ensures that the student is not segregated from classmates and will miss as little instruction as possible. This can include having glucagon stored in all locations that the student frequents, as much as possible.

• Any additional accommodations needed, such as access to a phone or Wi-Fi to support the student’s diabetes care technology, testing accommodations, bathroom and food access, make-up work missed due to diabetes-related care or absences, or elevator access.

In the case of children with an IEP, the needs of the student with diabetes will be addressed by the IEP team. Accommodations will generally be memorialized in the IEP as related services, supplementary aids and services to be provided to the student, program modifications, and support for school personnel. Whether the 504 plan or IEP, the plan for a student with diabetes must be individualized for that student’s needs and grounded in the student’s DMMP. Revisions to the plan should be made whenever the student’s needs change (e.g., change from an insulin pen to a pump, change in glucose monitoring system, or change in the student’s level of diabetes care autonomy and responsibility).

Despite these protections, students with diabetes still face discrimination at school. It is inappropriate and unlawful to require parents or guardians to provide diabetes-related care at school. All students with diabetes are entitled to a free appropriate public education. Free means that a school may not charge a cost to the parent or require the parent or guardian to supply the service (13). Additionally, for schools receiving federal funding, concerns about resources cannot be used as a reason to deny accommodations, e.g., claiming a lack of sufficient nurses to provide diabetes care (14). Unlawful discrimination may include students not receiving the assistance necessary to monitor glucose and administer insulin (14–18) or being inappropriately prohibited from attending to diabetes care needs in the classroom, including checking blood glucose levels and drinking or eating. In some cases an attempt may be made to require that a student attend a different school from their assigned school to receive diabetes care (15), that a student convert to virtual school full time, or that parents or guardians attend field trips and sporting events to provide diabetes care (19). Federal law prohibits such discriminatory practices.

Additional laws may impact a student’s diabetes care in school. Some states have laws that prevent trained non-nurse school staff from administering medications such as insulin and glucagon. On the other hand, some states have laws that explicitly allow trained non-nurse staff to administer insulin and glucagon. Information on these state laws can be found at diabetes.org/safeatschool. At the federal level, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) generally prohibit schools from disclosing personally identifiable information in a student’s education record without prior parent or guardian or eligible student consent. Regardless of state laws or available resources, federal law requirements must always be met so that students with diabetes have access to the care they need to be safe and able to fully participate in all school activities.

For more information and resources about the legal protections in the school setting or if a child is experiencing discrimination in the school setting, call 1-800-DIABETES (342-2382), e-mail [email protected], or go to diabetes.org/safeatschool.

• In addition to federal laws, some state laws provide legal protection for students with diabetes in the school setting such as permitting trained non-nurse school staff to administer insulin and/or glucagon.

• All students with diabetes should have a 504 plan, IEP, or other written accommodations plan that aligns with the DMMP and describes the diabetes-related care and accommodations they will receive as part of safely attending school and participating in all school-related activities.

• Despite federal and state laws, students with diabetes still face discrimination, potentially jeopardizing their health and safety and making it difficult for them to participate in school activities safely.

• Federal law works to ensure the safe and fair treatment of children with diabetes in the school setting.

Appropriate diabetes care in the school setting is necessary for the student’s immediate safety, long-term well-being, and optimal academic performance. The Diabetes Control and Complications Trial (DCCT) showed that improved glycemia decreases the risk of complications in children as young as 13 years of age (20–22). To optimize glycemic management, children must monitor glucose levels frequently, follow a healthy meal plan, take insulin/medications, and engage in regular physical activity. Insulin is often administered with multiple daily injections or an insulin infusion pump. An understanding of the relationship of food and beverages, physical activity and stress, and insulin with glucose levels is crucial in optimizing glycemic management.

To facilitate appropriate diabetes care, the school nurse and other trained non-nurse school staff must understand diabetes and know how to manage both daily diabetes-specific tasks and diabetes emergencies (6,23–28). Knowledgeable and trained school staff are essential to help the student avoid the immediate health risks of low and high blood glucose levels (hypoglycemia and hyperglycemia, respectively) and to optimize the glycemic management required to decrease the risk for long-term diabetes-related complications (23). Studies have shown that many school staff members did not have adequate understanding of diabetes and lacked appropriate training in diabetes-related care (26–28). Consequently, diabetes education must be tailored for teachers and other school staff who interact with the student including school nurses, administrators and their support staff, coaches, health aides, and bus drivers (8,24,25,29). Current ADA recommendations and resources for the care of students with diabetes are available for all school staff (8,25).

• Students with diabetes must receive appropriate care in the school setting to reduce the risk of short- and long-term complications.

• The school nurse and other school staff need to be trained to meet the needs of students with diabetes.

Diabetes management encompasses glucose monitoring, medication administration, the use of diabetes technology devices, nutrition, physical activity, behavioral health, self-management, and communication.

Students with diabetes monitor their glucose levels throughout the day. This can be done with a (finger-stick) glucose meter or a continuous glucose monitor (CGM). Cell phones and other smart devices can permit the use of remote glucose monitoring for those using CGM. (See diabetes technology devices in school.) At a minimum, glucose levels need to be checked before each meal or snack, before and after physical activity, and when the child exhibits symptoms of hypoglycemia or hyperglycemia. Glucose levels may also be checked at other times throughout the school day in accordance with the DMMP. Trained non-nurse school staff should be able to competently check glucose levels if the student is unable to do so independently. Prompt action is needed to avoid a delay in treatment that could result in disrupted class time or result in escalation to a diabetes emergency. A diabetes emergency would be a severe episode of hypoglycemia requiring treatment with glucagon or a student vomiting with high glucose levels, in which case they may have ketones or diabetic ketoacidosis, requiring treatment.

Students with type 1 diabetes and some students with type 2 diabetes need insulin at specified times during the school day, with additional doses to cover hyperglycemia, as indicated in their DMMP. Specified school staff should be trained on the student’s insulin delivery system (e.g., syringe, insulin pen, or insulin pump) and understand the differences between these systems. For students using insulin pumps, backup insulin for administration with syringe or pen must be available. Situations where this may be needed include a pump or site malfunction, a natural disaster or emergency that extends a student’s stay at school, or a student experiencing elevated ketones. Pump replacement supplies should be available in addition to these backup methods. Despite the potential for dosing errors, diluted insulin is sometimes necessary to permit accurate and appropriate insulin dosing for very young and/or very insulin-sensitive individuals. The concentration and specific dose must be documented in the DMMP. The concentration should be verified with the parent, and dilution should ideally be performed by a compounding pharmacy. Finally, the doses should be verified by a second individual. All children who take insulin require access to glucagon (intramuscular, subcutaneous, or intranasal) for treatment of severe hypoglycemia. Similar to the scenario for insulin, specified school staff should be trained on indications for and proper administration of glucagon. Some students, particularly those with type 2 diabetes, may receive other medications as part of diabetes management in school.

Diabetes technology devices, including insulin pumps, CGMs, automated insulin delivery (AID) systems, and the cell phones used with these technologies, are increasingly incorporated into diabetes management strategies for youth. The use of devices has steadily increased in pediatric populations in recent years (30). In both clinical trials and real-world studies, use of CGM and AID systems has been shown to increase time with glucose in goal range (usually glucose levels 70–180 mg/dL), reduce both hypoglycemia and hyperglycemia (31,32), and improve perceived diabetes burden and/or psychosocial outcomes for children and caregivers (33–35). School systems must adapt to the changing nature of diabetes management with these devices and follow medical orders as per the DMMP. If the student’s prescribed method for glucose monitoring and insulin administration involves a CGM and/or an AID system, schools are required to provide assistance to the student that is appropriate for the student’s level of competence as per the DMMP.

Trained non-nurse school staff must understand how to operate and use the devices to assist a student who is unable to self-manage or must remove their device for any reason. Another consideration is how the devices will be used in the classroom. CGMs provide substantially more data about glucose trends, including programmable alarms for identification of hypoglycemia and hyperglycemia and rapid changes in glucose. CGMs can be remotely monitored, facilitating communication among parents or guardians, students, and school staff. CGM remote monitoring in school can increase parental or guardian reassurance and facilitate school nurse decision-making (27,36). To minimize the potential for classroom disruptions, parents or guardians and school staff are encouraged to discuss a plan for which alarms will be set and how to respond to CGM alarms during school. Appropriate accommodations to support device use in school, including access to cell phones and Wi-Fi regardless of school policy, should be included in a student’s 504 plan or IEP. For updated guidance on the use of CGM in school, see diabetes.org/sascgm (37).

The general nutritional needs of students with diabetes do not differ from those of students without diabetes, including consumption of fruits and vegetables, whole grains, proteins from various sources, water, and other unsweetened beverages (38). There may be differences in the timing, amount, and nutrient content of food. Attention should be given to ensure carbohydrates are carefully matched and that the student has enough time to consume meals to balance insulin action, for those using insulin. In addition to providing healthy meals for all students, schools need to provide the nutritional information, including carbohydrate and other macronutrient content, for school meals. This information should be available in advance, such as with meal menus, to ensure timely and safe insulin dosing. Timing of meals should be similar to that for other students whenever possible.

Students with diabetes may need additional or alternative foods to ensure they consume sufficient carbohydrates to cover their insulin dose. School food service staff should be educated on how to assist students with diabetes during mealtimes and emergencies. Students should always have access to food, such as glucose tablets, hard candy, juice, or gummies, to prevent and treat hypoglycemia. Students should be able to participate in special occasions involving food with planning and communication with the parent or guardian, in advance, to determine (adjustments to) food selections and/or insulin doses.

The physical activity recommendations for students with diabetes are the same as those for all students. Physical activity improves insulin action, general health, and well-being. Students with diabetes should be able to fully participate in physical education classes, recess, and team or individual sports. Trained non-nurse school staff should be available to respond to hypoglycemia, which can occur during or after physical activity. Some students adjust their insulin or food intake for physical activity, and a fast-acting source of carbohydrates, such as glucose tablets, and hydration should be readily available to prevent and treat hypoglycemia. Students using AID may need to activate their device’s exercise/activity mode prior to the physical activity (7). The DMMP and 504 plan will provide guidance and orders for the use of these features.

Students with diabetes must deal not only with the usual developmental issues of growing up but also with learning how to manage this chronic disease. The daily demands of diabetes management are associated with unique behavioral health vulnerabilities, which can, in turn, negatively affect students’ diabetes management and well-being (39–41). Depression is common among children and teens with diabetes (42). Symptoms of depression, including appetite and sleep disturbance and low motivation, can lead to suboptimal diabetes management (43) and academic performance (44,45). Each individual with diabetes copes differently with having diabetes. Some students may feel uncomfortable disclosing their diagnosis. For the most part, students with diabetes do not want to be singled out or made to feel different from their peers. Diabetes care tasks, however, can set them apart and put them at risk for teasing and bullying, which can further contribute to a preference for discretion and exacerbate their behavioral health risks. This is especially concerning as school personnel are more confident in accommodating students’ needs when students are open about their diabetes (46). School personnel should consider each student’s feelings about and experiences with diabetes and identify ways to maintain communication to ensure the student is treated the same as others and optimally supported. The use of resources that do not require verbal communication (e.g., medical pass, electronic devices for diabetes management, and wallet card) may be helpful.

Sometimes, students feel pressured to please their health care team or parents or guardians, which may lead to diabetes distress, reporting fictitious glucose levels, and/or refusing to check ketones. Some students may use their diabetes to assert their independence by not following their diabetes care plan. Aiming to engage in shared decision-making is key (7,47). Students who fear the potential for hypoglycemia may administer a fraction of their insulin dose to avoid low blood glucose levels. If a student exhibits fear of hypoglycemia, remote monitoring of glucose data via a CGM and follow-up intervention by a behavioral health professional with expertise in diabetes and fear of hypoglycemia may be beneficial (34,36).

Youth with diabetes are also at risk for disordered eating behaviors and eating disorders (48–50). Some students may omit insulin or take less insulin than indicated to lose weight, putting them at risk for hyperglycemia and ketoacidosis. Other students may engage in binge eating.

Many resources are available to assist in identifying and addressing the behavioral health aspects of diabetes in students (51). Each student’s health care team has a critical role in the detection of potentially problematic psychosocial issues. According to the ADA Standards of Care, routine screening for psychosocial concerns (e.g., symptoms of depression and anxiety, diabetes distress, and disordered eating) is recommended when a student is diagnosed and during follow-up care. When needs and challenges are identified, parents or guardians and the diabetes care team should be notified and advised to collaborate with a school psychologist or other behavioral health professional. School-based therapy and referral to a behavioral health professional in the community with expertise in diabetes are viable options depending on the individual needs of the student (Table 1).

All school staff should have a basic understanding of diabetes and recognize an emergency requiring urgent help. The school nurse and other school staff should understand the symptoms and signs of hypoglycemia and hyperglycemia. Specific individuals, including the school nurse, need to be identified and trained to provide prompt treatment, including the administration of glucagon to treat severe hypoglycemia and insulin to treat hyperglycemia. In some states, school systems are legally permitted to purchase undesignated glucagon so that this life-saving medication is always available (52–54).

Some students can self-manage their diabetes, whereas others need supervision. Students who require assistance with their self-management need to have their diabetes care provided by a school nurse and/or trained non-nurse school staff (8). All students, even those who can independently manage their diabetes, will need assistance in the event of a diabetes emergency.

The student’s competency and capability in the performance of diabetes-related care tasks should be determined in collaboration with the student, parents or guardians, school nurse, and the student’s diabetes care team and documented in the DMMP. The information in the DMMP is applied to the school setting by the school health team and is applied to any written accommodations plan.

Self-management does not necessarily depend on chronological age or duration since diagnosis but, rather, depends on the child’s developmental and psychosocial abilities, which may change over the school term (55). As such, the age for transfer of various responsibilities from caregiver to student varies from student to student and from task to task (8,56). Staff assistance and support should be provided during the various stages of the student’s transition to self-management. Although age at which students can perform diabetes care tasks independently is highly individualized and differs for each student, general abilities and levels of self-care by age are described in Table 2.

The school health team consists of the student with diabetes, the student’s parents or guardians, the student’s health care professional, and school staff members who interact with the student (e.g., school nurse, teachers and specialists, administrators, counselors, cafeteria staff, bus drivers, sports coaches, and other staff members). Good communication among all team members can help to ensure that the student with diabetes receives safe and effective diabetes management during the school day and all school-sponsored activities. These team members should work together to implement the medical orders outlined in the DMMP, authored by the student’s diabetes care team; the diabetes care strategies outlined in the individualized health plan created by the school nurse; and the written educational plans such as 504 plan or IEP, to meet the student’s educational needs. Creating positive and productive collaboration among all team members is an essential first step in the optimal support of students with diabetes in the school setting (8,57).

An individualized DMMP should be developed by the student’s health care professional in collaboration with the student and parents or guardians to set out the student’s diabetes management needs during the school day and all school-sponsored activities. The DMMP should be developed and implemented for all students with diabetes regardless of their level of independence to ensure they receive needed assistance in an emergency, natural disaster, or unexpected school closure or lockdown. Inherent in this process is the delineation of responsibilities assumed by all parties, including the parent or guardian, the school staff, and the student (8,58,59). In addition, the DMMP should be used as the basis for developing emergency health plans and written education plans such as the 504 plan or IEP. The DMMP needs to be updated annually or whenever the student’s care plan or diabetes management changes. The DMMP addresses the specific needs of the student and provides specific instructions for each of the following.

• 1. Glucose monitoring, including but not limited to:

  • The frequency of and circumstances requiring blood glucose checks.

  • The use of CGM, smartphone, and smartwatch applications, or other technology, if applicable.

• 2. Insulin administration (if applicable) with the student’s preferred insulin delivery system, including:

  • Doses and injection times prescribed for specific glucose values and for carbohydrate intake.

  • When appropriate, health care professional authorization of adjustments to insulin dosage by parents or guardians.

  • Storage of insulin.

• 3. Administration of other glucose-lowering medication, e.g., metformin, or other medications for students with type 2 diabetes or other forms of diabetes.

• 4. Treatment of hypoglycemia (low blood glucose), including administration of rapid-acting carbohydrates and glucagon/diabetes emergency medication if recommended by the student’s health care professional.

• 5. Treatment of hyperglycemia (high blood glucose), including insulin administration if recommended by the student’s health care professional.

• 6. If requested by the student’s health care professional, checking for ketones as well as appropriate actions to take for abnormal glucose and ketone levels.

• 7. Participation in physical activity, including school-related physical activity classes, recess, and sports.

• 8. Emergency evacuation or school lockdown instructions and emergency contacts and plans.

A sample DMMP may be accessed online at diabetes.org/dmmp and customized by the student’s diabetes health care professional for each individual student (60).

Stakeholders in a student’s diabetes management at school typically include parents or guardians, the school, the nurse and/or trained staff, and the student.

• 1. Provide all materials, equipment, supplies.

  • Insulin and other prescribed medications.

  • Glucose meter, test strips, lancets, and lancing device, regardless of whether the student uses a CGM, and a backup sensor if the student uses a CGM.

  • Backup syringes, insulin pens and pen needles, and insulin pump supplies (if applicable).

  • Electronic receiver or device for reviewing CGM data and other medications necessary for prescribed diabetes management, including glucose monitoring and insulin administration (if needed).

  • Glucose tablets, glucagon emergency kit (nasal spray, prefilled syringe, or auto-injector), urine or blood ketone monitoring materials, and food/snacks.

  • Parents or guardians are responsible for maintaining the student’s glucose monitoring equipment (i.e., cleaning and performing controlled testing per the manufacturer’s instructions) and must provide supplies necessary to ensure proper handling and disposal of materials.

• 2. Provide emergency supplies in case of natural or other disasters, ideally for a 72-h period.

• 3. Provide the DMMP, completed and signed by the student’s diabetes care team and parent or guardian, along with information on changes to insulin dosing as indicated.

• 4. Provide information about the student’s diabetes and diabetes technology and the student’s performance of diabetes-related tasks such as glucose monitoring and insulin administration.

• 5. Provide current emergency phone numbers for the parents or guardians, emergency contact if parent or guardian is unavailable, and the student’s health care provider so that the school, with parental or guardian consent, can contact these individuals with diabetes-related questions and/or during emergencies. Parents or guardians should be accessible for illness or emergency communication within a reasonable amount of time and have an emergency contact identified if parents or guardians will be unavailable for an extended period of time.

• 6. Provide information about the student’s meal and snack schedule.

  • Parents or guardians should work with the school before the beginning of the school year or before the student returns to school after being diagnosed with diabetes to coordinate this schedule with that of the other students as closely as possible so that the student is not singled out as different from the rest of the class.

  • Instructions should be given for situations when food is provided during school parties and other activities to promote the student’s involvement in all school activities.

• 7. Plan and provide information about the student’s involvement in before- and after-school activities that so the school can ensure that trained personnel are available. Diabetes should not be used as a reason to limit the student’s participation in activities except as necessary for acute medical issues.

• 8. Support minimal disruptions to classroom activities in communicating with students about diabetes management.

• 9. In some locations, and increasingly, a signed release of confidentiality limited to diabetes-related care will be required to permit communication between the student’s health care provider and school staff. Copies should be retained by the school and health care teams.

• 1. Provide opportunities for the appropriate level of ongoing training and diabetes education for the school nurse and/or trained non-nurse school staff.

• 2. Provide training for school staff (including substitute staff) as follows (8):

  • Level 1 training for all school staff members, which includes a basic overview of diabetes, typical needs of a student with diabetes, recognition of symptoms of hypoglycemia and hyperglycemia, and the contact information for help.

  • Level 2 training for school staff members responsible for students with diabetes, which includes all content from level 1 plus the treatment of hypoglycemia and hyperglycemia and required health-related accommodations for those students.

  • Level 3 training for a small group of school staff members who will perform student-specific routine and emergency care tasks such as glucose monitoring, insulin administration, and glucagon administration when a school nurse is not available to perform these tasks. This will also include level 1 and level 2 training.

• 3. The school must ensure that if the school nurse is not present, at least one trained school staff member is available to perform the student’s diabetes care tasks in a timely manner while the student is at school; on field trips; participating in school-sponsored extracurricular activities such as before-school breakfast programs, intramural sports, after-school clubs, detention, and school dances; and on transportation provided by the school.

• 4. Ensure immediate access to hypoglycemia treatment by a trained school staff member. The student should remain supervised until appropriate treatment has been administered, and the treatment should be available as close to where the student is as possible. Trained school staff should be available while the student is transported to school and/or school functions.

• 5. Grant permission for the student to check glucose, administer insulin, and treat hypoglycemia and hyperglycemia anywhere in the school, including their classroom, near their school activity, or in a private location, if desired, as indicated in the student’s DMMP; to carry equipment (which may include a smartphone or smartwatch), supplies, medication, and snacks; and to perform diabetes management tasks.

• 6. Have available school nurse and non-nurse school staff available who are trained to check the student’s glucose levels and ketones as well as administer insulin, glucagon, and other medications as indicated in the student’s DMMP during the school day, field trips, and all school-sponsored activities.

• 7. Ensure access to insulin at scheduled times and/or immediate access to treat hyperglycemia as per the DMMP.

• 8. Have school nurses and trained school staff responsible for the student who are aware of the student’s meal and snack schedule and work with the parent or guardian to synchronize this schedule with that of the other students. Parents or guardians should be notified in advance of any expected changes in the school schedule that affect the student’s mealtimes or exercise routine and should be given access to information on serving size and caloric, carbohydrate, and fat content of foods served in the school.

• 9. Support the student transitioning to diabetes self-management and independence.

• 10. If needed for the diabetes technology in use, students should be able to have a cell phone or other electronic equipment necessary for their devices. Students also should be permitted to have direct communication access to reach parents or guardians and health care professional and document treatment. In the case of the parent or guardian direct communication with student via smartphone, parents or guardians should notify the school nurse or designated staff when treating high and low glucose levels.

• 11. Make school Wi-Fi accessible for student’s use of diabetes technology.

• 12. Grant permission for the student to see the school nurse and other trained school staff as often as requested regardless of independence level.

• 13. Grant permission for the student to eat a snack anywhere, including the classroom or the school bus, if necessary to prevent or treat hypoglycemia.

• 14. Grant permission to miss school without consequences for illness, diabetes management, and required medical appointments for monitoring the student’s diabetes management. Such absences should be categorized as an excused absence, with a doctor’s note if required by usual school policy.

• 15. Grant permission for the student to use the restroom and access fluids (i.e., water or carbohydrate-containing beverages) as necessary.

• 16. Set aside an appropriate location for insulin and/or glucagon storage, if necessary.

• 17. Create a plan for sharps disposal based on an agreement with the student’s family, local ordinances, and standard precautions.

• 18. An appropriate record-keeping system should be maintained at school, enabling staff or students to record glucose and ketone results; glucose values should be transmitted to the parent or guardian and student’s health care professional for review as indicated in the DMMP. Some students maintain a record of glucose results in the glucose meter memory or through other electronic means.

• 19. Support collaboration among stakeholders, e.g., parents or guardians, student’s diabetes care team, student, school nurse, teachers, and school administration, for a team approach to diabetes care in the school setting.

• 20. Recognize the impact of the diagnosis of diabetes on the student, parents or guardians, and community and the potential for diabetes distress, anxiety, and depression related to the diagnosis. Communicate any concerns with appropriate stakeholders.

• 21. Understand the school’s responsibilities under federal and state laws and work with parents or guardians, students, and school staff to develop the student’s individualized 504 plan, IEP, or other written accommodations document based on the student’s DMMP.

• 1. The school nurse should be the key coordinator and provider of care. The school nurse and/or other qualified health care professional with expertise in diabetes should work with the school principal or other school administrator in identifying school staff to be trained to provide care and in coordinating the training of an adequate number of school staff as specified above.

• 2. The school is responsible for providing appropriate training to an adequate number of school staff on diabetes-related tasks and treating diabetes emergencies as indicated above in responsibilities of the school, no. 2, on training levels. This training should be provided by the school nurse or another qualified health care professional with expertise in diabetes. Training should be ongoing, reviewed, and supervised. The training is needed to enable the student’s full and safe participation in school activities. The school staff who will be trained need not be health care professionals.

• 3. The school nurse and school administration should make parents or guardians aware of the staff who have received level 2 or 3 training and can participate in the student’s diabetes care. Parents or guardians should also be informed of additional individuals who are notified about the student’s diabetes diagnosis, and, if possible, permission should be sought regarding notification to protect the student’s privacy.

• 4. The school nurse should collaborate and maintain communication with the student’s parents or guardians, teachers, and health care professional. This may include written diabetes logs.

• 5. The school nurse should support students in the transition to self-management of diabetes care at an appropriate age, including those who are only partially independent and still need support in certain care areas, such as carbohydrate counting.

• 6. Monitor for behavioral health concerns related to the burden of diabetes, including diabetes distress, anxiety, and/or depression; communicate with appropriate stakeholders as needed.

• 7. Understand the school’s responsibilities under federal and state laws and work with parents or guardians, students, and school staff to develop the student’s individualized 504 plan, IEP, or other written accommodations document, based on the student’s DMMP.

• 1. A student should be allowed to perform diabetes self-care at school to the extent appropriate based on the student’s development, capabilities, and experience with diabetes. The extent of the student’s ability to participate in diabetes management should be agreed upon by the parent or guardian, the student’s health care professional, the student, and school staff. Students’ competence and capability in performing diabetes-related tasks should be documented in the DMMP for adaptation to the school setting.

• 2. The student is expected to follow the diabetes care tasks indicated in the DMMP.

• 3. The student is encouraged to seek assistance if experiencing symptoms of hypoglycemia or hyperglycemia and/or if an alert or alarm sounded.

• 4. The student using a smartphone, electronic tablet, and/or smartwatch to manage their diabetes should have access to their devices and school Wi-Fi.

• 5. The student is encouraged to reach out to the school nurse and school staff if experiencing feelings of diabetes distress, anxiety, or depression.

• Diabetes care at school should be provided in accordance with the protocols prescribed in the student’s DMMP and 504 plan, IEP, or other written accommodations plan.

• Parents or guardians, the school, the student’s health care professional, and the student all have responsibility for diabetes care at school.

• Regardless of a student’s ability to perform diabetes self-care, adult supervision will be required in a diabetes emergency.

• The ADA has a wealth of comprehensive resources to aid in training school employees to provide diabetes care to students (www.diabetes.org/safeatschool).

Students with diabetes should be able to participate in all school-sponsored activities such as field trips, extracurricular activities, before-school breakfast programs, classroom celebrations, intramural sports, after-school clubs, detention, and school dances. Students need access to their supplies and a school nurse or trained school staff person who can assist with diabetes care. Parental or guardian attendance cannot be a requirement. The student may opt to remove wearable devices during sporting events as indicated in the DMMP and 504 plan.

Like all children, students with diabetes need to attend school regularly. Some absences may occur but only when they are medically necessary, such as when an illness or medical appointment occurs. When absences occur, there should be no consequences for missing class time, and appropriate accommodations should be implemented.

Standardized testing and licensing agencies are prohibited from discriminating against students with diabetes under the Americans with Disabilities Act. Agencies must provide reasonable modifications to accommodate such students. Applicants taking various scholastic exams (e.g., the SAT and ACT) may request reasonable modifications in administration of these exams, including access to self-monitoring equipment, medications, and food and bathroom privileges.

In 2020, the COVID-19 pandemic led to the unprecedented closure of schools to avoid the virus’s rapid spread, resulting in virtual learning. A pandemic can lead to significant disruptions in families’ lives. Transitioning to online school can place increased demands on working parents or guardians and disrupt school-day routines, which may create challenges for diabetes management (61). Schools can assist by helping to establish plans for supporting the student with diabetes during a pandemic or endemic/epidemic situation that impacts or interrupts school. Along with an assessment of the student’s basic needs (e.g., food and diabetes supplies), academic needs, and behavioral health needs, the plan should include the student’s transition to and from online or on-site education.

The U.S. Food and Drug Administration requires that children be included in clinical trials for all new therapies. Students with diabetes may participate in clinical trials for various potential treatments. Parents should notify the school nurse or other trained staff if a student is participating in a clinical trial that would affect their health care plan in school. The primary investigator of the clinical trial, along with the student’s parent or legal guardian, should communicate with the school health staff the essential information needed to ensure the student’s safety and confidentiality. Necessary accommodations should be included in the DMMP and 504 plan, to include:

• Overview of the trial procedures, duration, required training, and educational resources offered by the research team.

• Potential risks and benefits to the student.

• Specific accommodations to keep students safe and to maintain flexibility for appointments and procedures.

• Contact information of the research team for questions and concerns.

Detailed information regarding clinical trials in the school setting is summarized in the ADA’s “Safe at School: School Support for Students with Diabetes Participating in Clinical Trials” (62).

Emergencies such as fires, power outages, gun violence, and natural disasters (e.g., earthquakes, flooding, and tornados) can occur in the school setting. Students should have immediate access to all of their diabetes supplies, including a fast-acting source of glucose, such as tablets, to prevent and treat hypoglycemia; insulin; and glucagon. This can be accomplished by self-carry of diabetes supplies or having supplies readily available in a known location that, ideally, has a refrigerator or insulated container for storage of insulin. A 504 plan must indicate who will be responsible for ensuring that these diabetes care supplies are made available to the student and how that will occur (57,63).

• Students should be permitted to participate in all school-sponsored activities, with the school nurse or other trained school staff available to provide diabetes care.

• Students with diabetes cannot be penalized for medically necessary absences related to diabetes.

• Students with diabetes need reasonable modifications by testing agencies for standardized tests.

• A plan to support students during a pandemic or endemic/epidemic situation to continue the educational process should be in place.

• Students participating in a clinical trial may need modifications to their school health plan.

• A plan in the case of school lockdown should be in place.

Young children with diabetes have unique developmental and psychosocial needs and require a carefully thought out, proactive diabetes care plan. Federal and some state laws protect the rights of the young child in the childcare setting. ADA’s statement on childcare, “Care of Young Children With Diabetes in the Childcare and Community Setting” (6), includes specific recommendations for children aged <5 years in the childcare setting.

At camps and in recreational settings, staff need to provide a safe environment for children with diabetes. Trained staff, including health care professionals and knowledgeable camp counselors, must be in attendance at all times and prepared to provide diabetes care. The recommendations for the camp setting are similar to those outlined by the ADA in Standards of Care, and attendees with diabetes are protected under Section 504 and the Americans with Disabilities Act (64). The availability of carbohydrates and fluids is essential. The camp must have staff experienced in managing both type 1 and type 2 diabetes. Lastly, the family and professional camp staff should review a formal written plan that includes camp policies and medical management.

Students with diabetes are protected under Section 504 and the Americans with Disabilities Act. Students may request reasonable modifications, i.e., “changes made to educational programs that permit postsecondary students to participate on an equal basis” (65), from the institution’s Office of Disability. A written accommodation plan or letters of accommodation may be composed to notify professors that certain modifications should be provided. ADA’s “Going to College With Diabetes: A Self Advocacy Guide for Students” (65) includes specific recommendations for postsecondary students with diabetes.

• Reasonable modifications under federal and state laws should be made for students in preschool, camp, and postsecondary education settings.

Federal and state laws protect the legal rights of students with diabetes to have equal opportunities in school. As diabetes care has evolved to include intensive insulin therapy and increasing dependence on technologies, a substantial portion of students’ diabetes care is provided in schools. Depending on their age, developmental stage, and capabilities, students with diabetes need support from school nurses or trained school staff. Schools are obligated to assist these students in partnership with the student’s family and health care provider. Clear communication, written care plans, and teamwork can help to ensure students with diabetes are safe at school and able to achieve their academic goals and to promote their overall well-being.

Acknowledgments. The authors thank Dr. Elizabeth A. Beverly (Ohio University) for assistance on content in Table 1 and Jessica McKinney (American Diabetes Association) for review of the manuscript.

Funding. C.A.M. is supported by National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, grant 1K23DK135800.

Duality of Interest. No potential conflicts of interest relevant to this article were reported.

Handling Editors. The journal editor responsible for overseeing the review of the manuscript was Steven E. Kahn.