A "new" indication for the insulin pump: poor compliance of the teachers

We have read with interest the commentary of Howard Taras (1) published in the number of September of Pediatrics about the controversy on who should administer insulin in diabetic school children in USA. We would like to report a paradigmatic Italian “case- story” about the difficulty of managing diabetes at school despite the fact that in Italy we were persuaded to have a very advanced legislation. Case-Story: Caterina I. is a 10 years old girl, diagnosed with type 1 diabetes, and well trained to self administering insulin and self monitoring blood glucose: all in all, a “perfect” patient for the age. She practices an insulin intensive multi-injection therapy 4 times a day. At the moment of diagnosis she was 9 years old and we adviced, as usual, her parents to inform the teachers of her primary schools about the new condition of their daughter, in order to provide a school assistant for administer insulin. The school, after some months, communicated us that they hadn’t any school assistant available for the specific training in order to inject insulin to a child and, in the same moment, Caterina was forbidden from self administering insulin or other drugs at school according to Italian laws. In the meanwhile the parents asked for permission from their works in order to take care of the child at school with serious risk of losing their job. At this point, we submitted the possibility of Continuous Subcutaneous Insulin Injection (CSII) to the school director and to the parents. The situation was verging on a paradox: Caterina was forbidden from self injection of insulin but she was allowed to wear a pump and modify the therapy on her own. Neither in the international guidelines about the CSII (2) nor in the Italian recommendations published in 2008 (3), we can find a similar indication to prescribe a pump: Caterina is the first patient to receive CSII for “poor-compliance of the teachers”. The Italian legislative system is formally one of the most advanced in pediatric diabetes care, the first law dedicated to the non discrimination of citizens with T1DM, is dated 1987 (4) and the Italian Ministry of Public Instruction, with a recommendation dated November 25, 2005 (5) individuated the possibility of a specific training for volunteer school personnel and offered supports to the schools that need caregivers for children. Our regional statement has receipted this directive in 2009 (6) promising funds and dedicated personnel but until now the promises were disattended. Therefore we have good laws but their application can fall down in the big black hole of the regional reality: who will have to administer the drug in school time if we miss a professional assistant in the schools because they haven’t the requested funds? Our regional health system provides for free pump, upon medical prescription, but it doesn’t assure a caregiver for make a multi drug injections therapy in children. Next year Caterina will start the middle school with her well-dressed pump; but, probably, to avoid too much querrels about her diabetes, she will decide to give out her secret just to her best school friend keeping her new teacher in a concerning blindness. REFERENCES 1) Taras H Who Should Administer Insulin in Schools? Sorting Out the Controversy PEDIATRICS Volume 124, Number 4, October 2009 2) Phillip M, Battelino T, Rodriguez H, Danne T, Kaufman F; European Society for Paediatric Endocrinology; Lawson Wilkins Pediatric Endocrine Society; International Society for Pediatric and Adolescent Diabetes; American Diabetes Association; European Association for the Study of Diabetes: Use of insulin pump therapy in the pediatric age-group: consensus statement from the European Society for Paediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2007;30:1653-62 3) Pinelli L, Rabbone I, Salardi S, Toni S, Scaramuzza A, Bonfanti R, Cherubini V, Franzese A, Frongia AP, Iafusco D, Sulli N, Tumini S, Curto O, Miassimelli M; Diabetes Study Group of the Italian Society of Paediatric Endocrinology and Diabetology. Insulin pump therapy in children and adolescents with type 1 diabetes: the Italian viewpoint. Acta Biomed 2008;79: 57-64. 4) Gazzetta Ufficiale della Repubblica Italiana Legge n115 del 16 marzo 1987, text availabe on http://www.progettodiabete.org/indice_ie1000.html?leggi/r1.html 5) Gazzetta Ufficiale della Repubblica Italiana del 25 novembre 2005, text available on http://www.fdgdiabete.it/fdgleggi/scuola/scuola_lg.pdf 6) Legge Regionale della Campania n9 del 22 Luglio 2009 from official Region’s website http://www.sito.regione.campania.it/leggi_regionali/index_leggi.htm