Are children and adolescents with type 1 diabetes in Saudi Arabia safe at school?

Discussion

The present study aimed to examine safety of schools and availability of trained staff who may assist in the management of children with T1DM and glycemic control, taking into consideration parents’ perceptions of the 2 types of school (public versus private) and how they care about children with this disease. We view this as the first survey in Saudi Arabia to tackle this subject, which is important since T1DM is widely regarded as one of the most common chronic diseases moreover, Saudi Arabia has been ranked seventh in prevalence worldwide.7,8 In order to achieve a safe school for students with T1DM, glucagon injections should always be available, since this is the only approved first-line therapy for severe hypoglycemia (loss of consciousness and/or seizures).3 However, in this study most parents indicated that there was limited availability of glucagon injections at school (7%), and trained staff for administration of glucagon was also deemed insufficient (8.6%). These percentages should be close to 100%.2,3 Unavailability of glucagon or lack of trained staff at school is considered unsafe, as severe hypoglycemia in T1DM may lead to seizure, coma, and eventually death.9 Unfortunately, 12.7% of the children in this study had already experienced severe hypoglycemia with coma at school.

With regard to the person responsible for management of DM at school, a high proportion of parents implied that their children were performing the management of DM, glucose checking, and insulin administration. In contrast, in studies in the USA and Spain, the school nurses were responsible of diabetes care.5,6 In terms of differences between public and private schools regarding diabetes care, we noticed that public schools had no healthcare provider (namely, nurse or physician) available to assist the children with their diabetes care needs. This is in agreement with the results of a previous study in Saudi Arabia, where a healthcare provider was available in only 5% of schools.4

It is also disappointing to observe that 8% of children with T1DM are not receiving insulin during school hours; this is likely to have an impact on glycemic control and should be closer to 100%. Insulin therapy should always be available at schools, taking into consideration eating meals and snacks at school and managing sick days. This finding has been corroborated by Amillategui et al,6 who found that most children are checking their glucose level at school but few needed insulin administration. The parents, teachers, and children acknowledged that no glucagon kits were available at school, and surprisingly, teachers were not familiar with glucagon kit indication.

This study also revealed that 29% of children reported negative comments from peers regarding diabetes, which may also compromise their glycemic control. This may be addressed by establishing a private location at school for glucose testing and insulin administration.10 Parents also reported that their children were rarely allowed to eat a snack in the classroom (13%), to use the restroom if necessary (4%), or provided with a proper meal for the diabetes setting (67%). In addition, 79% of children child had no written care plan at their school. Such a plan is recommended for daily DM management at school in order to maintain glycemic control and prevent DM acute complications.3 In this study, the parents had a poor perception of diabetes care at schools. This result is in agreement with the findings of Jacquez et al11 in their assessment of parents’ perspectives of diabetes management in schools. Another notable finding in this study was the high prevalence of uncontrolled HbA1c levels (85%); the inadequate DM management at school can be a potential factor.

Furthermore, we assessed differences between school types regarding characteristics of children with T1DM at school. We determined that private schools had more glucagon availability, trained staff for glucagon injection, a written plan for DM from treating physician, easy access to the treating physician during school hours, a person responsible for DM care at school, child performance scale, and parents’ confidence in the school. These findings confirmed better DM care at private schools. When measuring the association between HbA1c level and selected characteristics of patients with T1DM, we detected that insulin regimen and child performance scale at school are significantly associated with HbA1c level.

With regard to the insulin regimen for treatment of DM, only 39% of the children were using MDI with carbohydrate counting or an insulin pump, the standard for care in T1DM.2 Furthermore, it is notable that 17.8% of subjects had a first-degree relative with T1DM (father 5.3%, mother 4.3%, sibling 8.2%); a study in Finland revealed 12.2% to have a first-degree relative with T1DM.12

We trust that this is the first paper to elaborate on these types of criteria. Although some previously published papers determined the relationship between characteristics of DM at school against certain groups, none presented the association between HbA1c level against sociodemographic characteristics. Thus, we hope that the findings of this study can be used for reference for future research.

Taken together, the results of this study reveal that schools in Saudi Arabia have not met the standard level of care for safety for children with diabetes.2,3 These results also highlight the need to improve schools DM care.

There are several limitations of this study, including that it relied on parents’ reports about diabetes care in the school rather than observational measures. Also, HbA1c levels were self-reported and the technique may vary between regions and hospitals. School staff who help in DM care may be included in future research.

Finally, there is a need for ministries of education and health to take initiatives developing a safe school environment for the T1DM students. The plan may include (i) a trained nurse or healthcare provider should be always available at school or instead implementing a strategies for training school personnel, (ii) provide a written diabetes medical management including medication direction, timing and emergency plan including sick-day management. Additionally, (iii) create a school policy that every child with DM is required to have glucagon kit, (iv) ask diabetes educator or endocrinologist to educate school nurses and the staff, parents also are encouraged for educating the staff, (v) provides material and links for school staff education. Resources are ADA guidelines,10 Colorado kids with diabetes websites,13 American Association of Diabetes Educators.14

In conclusion, the parents of children and adolescents with T1DM in this study had a very low perception of diabetes care at their schools. Availability of glucagon kits and trained staff at school for management of children with T1DM were either non-existent or very limited. This study suggests the need to improve the management of diabetes at school. Cultivation of a diabetes care plan is necessary; this includes interventions involving healthcare providers, parents, teachers, and the school administration to enable complete assimilation of these groups of children at school.

We further discovered that private schools had better DM care compared to public schools with regard to glucagon availability, trained staff for glucagon injection, possibility of contacting a treating physician during school, nurses responsible for DM care, a written plan for DM from the treating physician, and parents’ confidence in the school. Moreover, students who tend to have a controlled HbA1c level are likely to have glucagon kits available at their school. In addition, the insulin regimen and child’s performance at school are statistically related to their HbA1c level.