Type 1 Diabetes NOW

46 Inject Insulin in the Sickbay While in School…

Children with type 1 diabetes may be injecting insulin four times a day by the time they reach the senior grades in elementary school.
In that case, they need to inject insulin at school before lunch.

If they can do by themselves
When child patients are having a hard time controlling their blood glucose with two- or three-time injections and may soon need to start four-time injections, we at our Diabetes Center of Tokyo Women's Medical University, recommend four-time injections only if they can do it by themselves. We do not force them to inject insulin four times a day. If they have been able to have good glucose control with three-time injections, they do not have to change it.
Even so, as their grade in school advances, their lives become more complex with after-school cram school, extracurricular activities, club and so on, and they tend to have a late dinner. They may munch on something before dinner or eat something with their club mates. This is a part of socializing with friends, so it is important. Sometimes, a portion of these snacks may be worth a single meal. I hope they eat properly without causing their blood glucose to fluctuate too much.
In these cases, it is actually easier to control blood glucose with multiple dose regimen.
As children get older, they awake to themselves wanting to do everything on their own including lunchtime insulin injection. I always want to respect their self-motivation - willingness to try rather than being forced.

Starting in summer vacation for practice
Before we switch to multiple dose regimen, we make sure to ask them, "Can you do it on your own? Can you?" If they hesitate even a little, we do not force them.
It may be a good idea to try multiple injections only during vacation such as summer vacation for practice and go back to the original regimen when school starts. Or it may be also good to try four-time injections only on holidays such as Sundays.

Injecting insulin at school
Our center has one of the largest pediatric patient (under 20 years old) populations with specified chronic diseases in Japan. Naturally, kindergartens, elementary or junior high schools they attend are diverse. In addition, the schools are scattered not only around Tokyo but also the whole country as child patients visit our hospital from all over Japan.
In dealing with schools and kindergartens throughout the country, I have experienced a number of things including some sort of trouble. The main reason for such troubles was that the schools had not been used to insulin treatment that requires lunchtime insulin.
There was a school that instructed a student with diabetes to wear a hat in PE class. This was because the school did not know they could treat the student just like they treat other students. The instruction was of course avoided.
We had a patient who was told by his school that he could only attend a school for the handicapped. We called and explained to the school, and the school was convinced in the end. There was another patient who was told by her school that she could not take summer swimming lessons, but in this case too, the school teacher understood after we explained.
In fact, there has been almost no trouble our patients had with their schools recently.

Where do they inject insulin while in school?
Nowadays, schools seem to have shorter lunch break. If a student happens to be in charge of serving school lunches, he barely seems to have time for himself during lunch break.
Some patients prefer injecting insulin in the sickbay while others do no mind injecting insulin in the classroom and being seen by their classmates. It varies from patient to patient.
I hear that they have many friends who have come to understand by seeing them inject insulin that they are obtaining energy through injections. I also hear that they have friends who have stood up for them even when they developed hypoglycemia and acted strange.
Even the boss of the class seems to be kind to his classmate on insulin, being impressed by the fact that the classmate has got courage to make injections that he hates.
Recently, I had a patient who has done insulin injections in the classroom with no problems but was instructed by his school to "inject insulin in the sickbay".
As I was very surprised to hear the story, I immediately phoned the school principal and told him gently, "Though I have had many school-age patients, this was the first time I heard something like this." I also asked him if any trouble has happened in the classroom, but he answered, "There has been no trouble. It is to prevent troubles." There is a saying, "Once bitten, twice shy." His explanation, however, sounded like, "Shy before getting bitten". I was surprised to learn that there was such school.

I really would like school nurses and health education teachers to support these children with diabetes so that there will be no school like the one mentioned above. They are courageous children who are strong enough to inject insulin in the classroom. I hope the teachers will respect their feelings and nurture their self-reliance. I ask those school nurses and health education teachers who visited this website to stand up for them. Of course, we doctors will also do our best to support them.

For reference
What is XX-time injection? What is multiple dose regimen?
XX shows the frequency of insulin injections per day.
Twice-daily injection regimen typically involves pre-mixed insulin injections before breakfast and dinner.
Three daily injection regimen typically involves two pre-mixed insulin injections and one short-acting (or regular) insulin injection at lunchtime, or pre-mixed insulin injections before breakfast and dinner and one short-acting (or regular) insulin injection before snack, or regular (or short-acting) insulin before breakfast and lunch and one pre-mixed insulin injection before dinner.
Four or more injections per day is called multiple dose regimen (intensive insulin therapy), and it involves short-acting (or regular) insulin injections before breakfast, lunch and dinner and one or two long-acting soluble (or intermediate-acting) insulin injection(s) before breakfast, dinner or at bedtime.
©2009 Yasuko Uchigata

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学校ではインスリン注射は保健室で・・・

　小学生の高学年になると、1型糖尿病のお子さんのほとんどは4回注射になっているかもしれません。
　4回注射になると、昼食前に学校で注射することが必要となります。 　東京女子医大の糖尿病センターでは、2回とか3回注射でうまくいかなくなってそろそろ4回注射の時期かなと思われるとき、自分でできるなら、4回注射をおススメしています。無理に4回注射するのをお願いはしておりませんが、もちろん3回注射でうまくいっている場合は、3回注射のままでいいですね。
　3回注射でやっていても、学年が上がれば上がるほど生活が複雑になり、塾や課外活動、部活などで、夕食時間が遅くなりがちです。
　よって、夕食までに、なにかつまむこともあったり、部活仲間と一緒に何か食べるときもあるでしょう。これは友達付き合いだから、付き合いを大事にやっていきたいですね。もう間食の量が普通の食事の1回分になることもあります。血糖値をあまり乱すことなく、しっかりと食べていただきたいと思います。
　このような状況になりますと、頻回注射法のほうが、血糖値のコントロールをやりやすくなります。
　学年が上がると、そろそろなんでも自分でやってみたい、という自我が目覚めてきて、「自分で昼は注射できるよ」というようになってきます。
　この気持ちを大事にしたいな、といつも思っています。押しつけではなく自分からやってみる、という気持ちを大事にしたいです。 　「自分でできるかな？」、「できる？」と本人にしっかり聞いてから、頻回注射法に切り替えていきます。すこしでも、躊躇するようなら、無理強いはしません。
　また、足慣らしに、夏休みなど休み中だけ頻回注射をしてみる、というようなやり方でもいいですね。学校が始まったら、もとに戻す・・・。なんなら、日曜日など休みの日だけ4回注射にしてみる、というのもいいですね。 　当センターには小児慢性特定疾患（20歳未満の方ということ）に該当する患者さんが、たぶん全国でも1、2位を争うほど、多く、受診されています。よって、通学している小学校、中学校の数も多い、ということになります。
　数も多いのですが、都内だけでなく、関東甲信越に分布していますし、また小さい患者さんは全国からやって来られますので、小学校、中学校、また幼稚園も、全国に散らばっているといえます。
　全国の学校、幼稚園ともなりますと、それはいろいろありました。これまでにもいくつか、トラブルめいたこともありました。昼に注射する必要のあるインスリン療法に、学校側が慣れていなかったことが大きな原因でしょう。
　体育のときも普通でいいのに、どうしてよいか、わからないために「1人だけ帽子をかぶれ」と言われた学校もありました。もちろん、回避。
　養護学校でなければ通学はだめ、と言われて、こちらから学校に電話して説明して大丈夫になったことも、過去にはありました。夏のプールの課外活動もだめと言われたことも。しかし、お話しすると、学校の先生はわかってくれますね。
　最近では、全くといっていいほど、トラブルはありませんでした。 　最近の学校の昼休み時間は短く、また給食なので、給食当番にでも当たったりしたら、それこそ時間が全くないようです。
　「保健室で注射したい」というお子さんもいますし、「教室でみんなが見ていても大丈夫、注射できる」というお子さんもいます。みな、それぞれです。
　みんなが見ることによって、「そうなんだ、○○ちゃんは注射してエネルギーをもらっているのだ」と理解するお友達も多いと聞きます。たとえ、低血糖になって変な行動をしてもお友達がかばってくれた、ということも聞きます。
　どんなに餓鬼大将がクラスにいても、注射しているお友達にはやさしいようです。自分がきらいな注射をいとも軽々とできるすごい子だ、というわけです。
　最近、教室内で、なんの問題もなく注射してできていたのに、「保健室で行うように」と学校側から言われたお子さんがいました。私はとてもびっくりしました。さっそく、校長先生に電話しました。「多くの学校に通学するお子さんを見てきましたが、このような学校ははじめてです」と柔らかくお伝えしました。何か教室で問題でもおこったのか、これはたいへんと思い、これもお聞きしましたが、「なにも問題はおきていない。予防的だ」という説明でした。「羹（あつもの）に懲りて膾（なます）を吹く」といいますが、「羹に懲りない前に膾を吹く」ような説明で、こんな学校もあることに、びっくりしました。
　是非、養護の先生や保健の先生にがんばってもらって、このような学校がなくなるように、お願いしたいと思います。
　教室内で注射できる勇気のあるお子さん達です。この気持ちを大きく伸ばしてあげてほしいと思います。

　このサイトをごらんになった養護の先生、保健の先生、是非、お声を上げてこのような学校がなくなるようにお願いします。もちろん、医師もがんばります。