Diabetes Technology in the School Setting for Preschool-Aged Children

Abstract

Diabetes technology has transformed the management of type 1 diabetes (T1D) and improved glycemic outcomes, yet preschool-aged children with T1D remain a uniquely vulnerable population. Complete dependence on caregivers and practical considerations such as limited body surface area and skin sensitivity create distinct barriers to effective technology use. These challenges are often compounded by the transition to daycare or school setting, where disruption in diabetes care coordination between home and classroom can compromise glycemic outcomes. This review synthesizes the evidence for diabetes technology use, summarizes the current guidelines, provides practical considerations, and reviews guidance for training protocols and competency requirements in the educational setting. School-based legal protections are discussed, including Section 504 plans and Individualized Education Programs, which should outline the diabetes-related accommodations required in the school setting in alignment with the Diabetes Medical Management Plan. Targeted interventions to improve training of school/daycare staff, facilitate communication across home and school settings, and address disparities in technology access are essential to optimize care and improve long-term health outcomes.

Introduction

Preschool-aged children with type 1 diabetes (T1D) represent a distinct and vulnerable population characterized by complete dependence on caregivers, marked insulin sensitivity, and unpredictable eating and activity patterns. The growing annual incidence rate of T1D for US children aged 0 to 19 years by approximately 2.02% annually (1.98% annually for children aged 5-9 years) ¹ creates an increasing disease burden, which must be addressed through targeted management strategies.^2,3 While diabetes technology offers significant glycemic and quality-of-life benefits, ⁴ successful implementation necessitates addressing potential barriers spanning device practicalities, caregiver education, and school/childcare infrastructure.

Diabetes technology such as continuous glucose monitors (CGMs), smart insulin pens, insulin pumps, and automated insulin delivery (AID) systems has enhanced caregivers’ ability to monitor and manage glucose levels in young children; however, real-world use can be hindered by many factors, including health insurance coverage, caregivers’ education and troubleshooting skills, device failure, alert fatigue and device placement limitations on a small child. ⁵ These challenges may lead to decreased device wear or discontinuation and ultimately suboptimal diabetes outcomes. A 2019 to 2021 international study analyzing data from 3 large diabetes registries in the United States, Europe, and Australia revealed that only 36% of children younger than 6 years achieved a recommended target hemoglobin A1c of <7% and diabetes technology use varied significantly, with low utilization of AID systems (ranging from 0.5% to 6.9%). ⁶ Considering the high risk of future diabetes complications in young children due to the extended length of diabetes duration, the International Society for Pediatric and Adolescent Diabetes (ISPAD) 2022 Clinical Practice Consensus Guidelines for preschool-aged children recommend use of CGMs, insulin pumps, and AID systems in children younger than the age of 7 years and emphasize a person-centered approach to diabetes care. ⁷ Diabetes social supports are essential in T1D management ⁸ and accordingly, increased parental involvement in the diabetes care of preschool and school-aged children has demonstrated improved glycemic outcomes. ⁹ However, diabetes technology use extends beyond the home environment, underscoring the need for structured training and system-level support for school/childcare staff involved in care delivery to foster the gradual development of self-efficacy in young children. ¹⁰

Together, these considerations highlight the urgent need to optimize diabetes management across home and school environments in preschool-aged children. This review synthesizes the evidence for diabetes technology use, summarizes the current guidelines, and provides practical considerations and guidance for training protocols and competency requirements in the educational setting through 5 sections: Overview of Modern Diabetes Technologies Used in Early Childhood; Legal, Safety, and Policy Considerations; Training and Competency Requirements for Preschool/Daycare Staff; Practical Considerations for Use in Preschool/Daycare Settings; and Gaps in Current Literature and Future Directions.

Overview of Modern Diabetes Technologies Used in Early Childhood

As diabetes management continues to evolve, school systems must adapt accordingly. Families of young children with diabetes should have autonomy in selecting diabetes technologies that best meet their needs, including in the educational setting. However, barriers to effective integration of diabetes technology, such as limited staff training and insufficient coordination among home, school, and diabetes care team remain common. Targeted interventions are warranted, particularly structured education and training of school personnel in diabetes technologies such as CGMs, AID systems, and smart insulin pens, to ensure safe and effective management in school environments.

Continuous Glucose Monitors

Continuous glucose monitor systems have become the standard of care in pediatric T1D management, and they are proven safe for children as young as 2 years old. ¹¹ With proper education and training, parents, school nurses, or other trained staff can use CGM alerts to take preventative actions that maintain the child’s safety. Continuous glucose monitors contribute to improved glycemic control and reduced hypoglycemia, and caregivers often report improved quality of life.^12-14 An important component of CGM use for young children is the remote monitoring capabilities, ¹⁰ which allows caregivers consistent oversight of the child’s glucose levels and enables them to more effectively manage or guide treatment from afar. A randomized cross-over trial of children aged 2 to 12 years revealed a significant reduction in parental hypoglycemic fear with the use of remote monitoring. ¹⁵ Parents should discuss their role, as well as that of trained childcare/school staff and school nurses, in the use of all diabetes technologies and in remote monitoring to optimize their child’s T1D management at school. While remote monitoring may be provided by a school nurse or staff member, this is not an expectation and must be discussed.

AID Systems

The evolution of insulin pumps has significantly improved T1D management for preschool-aged children through eliminating the need for multiple daily injections and facilitating precise insulin adjustments. Automated insulin delivery contributes to reduced hypoglycemia and hyperglycemia and improved time in range (TIR) in young children.^16,17 An international, randomized, cross-over trial of children aged 1 to 7 years demonstrated that children using closed-loop systems had 8.7% greater TIR compared with sensor augmented pump therapy (95% CI, 7.4, 9.9, P < .001). ¹⁸ The use of AID systems in children younger than 6 years is associated with approximately 3 additional hours of TIR per day compared with those managed with non-AID systems. ¹⁹ In addition, AID use is associated with improved diabetes-related psychosocial outcomes in caregivers of young children including reduced emotional distress and hypoglycemic fear as well as improved quality of sleep. ²⁰ Activity or exercise mode features further accommodate activity in young children by reducing basal insulin delivery and are most effective when activated 60 to 90 minutes prior to the start of activity. Altogether, this supports the use of AID systems as an effective and recommended management tool for preschool-aged children.

A key challenge in glycemic management among preschool-aged children is their low total daily insulin requirement, which can limit the precision of conventional dosing approaches. Automated insulin delivery systems offer enhanced dosing accuracy and adaptability well suited to the variable insulin needs of this age group. Because using diluted insulin carries a severe risk of fatal dosing errors, it demands strict medical supervision, specific pharmaceutical diluents, and rigorous protocols. Only with extensive caregiver education and extreme caution should diluted insulin be considered as a secondary strategy to optimize glycemia alongside AID systems in young children with very low insulin needs.^21,22 Given the enhanced management potential through use of AID systems, children using this technology should use it in the school setting with teachers and school staff receiving tailored training and education specific to the device.

Smart Insulin Pens

A person-centered approach to T1D management is most important for successful outcomes. The emergence of smart insulin pens is an extension of this approach which facilitates insulin management with mealtime dosing assistance for youth not using insulin pumps due to caregivers’ hesitation, ²³ cost, skin sensitivity from adhesives, and other site-related difficulties. App-based dose calculators and tracking support decision-making and data sharing allows for a team-based management system. ²⁴ However, important challenges persist in the use of smart insulin pens for young children, including age-based Food and Drug Administration clearance limitations (eg, only InPen [Medtronic, Minneapolis, Minnesota] is indicated for use in people with diabetes aged 7 and older or under the supervision of an adult caregiver for home-use only) ²⁵ and the complexity of use within the school setting given the need for smartphone access. Furthermore, health insurance coverage may be an additional challenge, and if covered, it may be limited to only 1 device, requiring that the pen be transported to and from school. In a qualitative analysis of endocrinology clinics participating in the T1D Exchange Quality Improvement Collaborative, parental concerns included gaps in data due to loss of phone connectivity and losing the smart insulin pen at school. ²⁶ User alert response and timing are essential to effective management with use of smart insulin pens ²⁷ ; therefore, training preschool staff is a necessity for successful glycemic outcomes.

Legal, Safety, and Policy Considerations

In 2022, approximately 59% of 3- to 5-year-olds in the United States were enrolled in school. ²⁸ A multicenter clinical trial revealed that more than 50% of parents of young children with new-onset T1D-reported diabetes affected their child’s enrollment, rejection, or removal from school or daycare. ²⁹ Education and understanding of the legal protections of students with diabetes are important to ensure the safety and successful management in the school setting.

At a high-level overview, any school that receives federal funding or is considered open to the public must reasonably accommodate the needs of students with diabetes in accordance with Section 504 of the Rehabilitation Act of 1973 and/or the Americans with Disabilities Act.^10,30,31 In addition, some states have laws or regulations applicable to the provision of diabetes care at school (https://diabetes.org/advocacy/safe-at-school-state-laws/legal-protections). A 504 plan should be established for any child with diabetes to ensure appropriate accommodations are made in the school setting, with information available at: diabetes.org/504plan. ³⁰ Alternatively, children with a coexisting learning disability may qualify for special education services and they will have an Individualized Education Program (IEP) that delineates how the school will meet the child’s needs, as protected by the Individuals with Disabilities Education Act. ³⁰ The Diabetes Medical Management Plan (DMMP), or health care professional’s orders, prescribes the diabetes care required in the school setting. Both IEPs and 504 plans should be developed to align with the DMMP, and contain the accommodations to be provided by the school including the trained school staff members responsible for the diabetes care, individualized protocols for field trips and extracurricular events, and any additional accommodations related to diabetes technology access, testing accommodations, absences, bathroom, and food access. ³⁰ Within the context of diabetes technology, access to personal smart devices (such as cell phones) operating diabetes technology and use of school Wi-Fi access should be provided and included in the 504 plan or IEP regardless of the school policy. Federal law prohibits discrimination against people with disabilities such as diabetes and requires schools to provide needed care to enable the child to fully and safely participate in all school activities. ³⁰ Both 504 and IEP plans should be updated with changes in diabetes management.

Although Section 504 protects children with diabetes from unlawful discrimination in the school setting, state laws vary regarding the administration of insulin, glucagon, and monitoring of glucose levels. The American Diabetes Association’s (ADA) Safe at School program (diabetes.org/safeatschool) provides important legal information and resources, including information about the legal protections that exist in each state. ³⁰

Training and Competency Requirements for Preschool/Daycare Staff

Essential Skills

Preschool-aged children should not be denied admission to preschools and childcare programs for having diabetes.10 Basic diabetes training is essential for all school staff who have responsibility for a child with diabetes, including preschool-aged children. ²³ The ADA recommends a tiered training structure including: level 1—basic diabetes awareness for all staff, level 2—hypoglycemia and hyperglycemia management for staff responsible for the child with diabetes, and level 3—student-specific tasks of glucose monitoring, insulin administration, and glucagon administration for a designated small group of staff. ³⁰ Notably, structural and individual challenges exist for school nurses to be the sole supporters of diabetes technology use in the school setting ³² ; therefore, it is recommended that at least 2 additional trained staff members receive level 3 training to ensure continuity of care. ³⁰

Diabetes technology training for school personnel should be delivered by a diabetes health care professional or a health care professional with sufficient diabetes technology knowledge with input from a parent/guardian. ¹⁰ Virtual training structures have demonstrated feasibility and efficacy within the school setting in a pilot study. ³³ Collaboration between the parent/guardian and health care team is necessary to guide the essential training of school staff.

As introduced in the prior section, the DMMP, or health care professional’s orders, specifies the diabetes care required in the school setting. The DMMP should address the level of independence/need for assistance, frequency of blood glucose checks, and use of CGMs; AID system use, smartphones, and other technology; when to confirm CGM readings with a glucose meter; insulin administration via insulin pump, pen, or syringe; dose/timing of insulin delivery; hypoglycemia and hyperglycemia treatment; sick day management; emergency evacuation plans and contacts; storage of insulin while at school; and back-up treatment plan for device failure.^10,30 Detailed information about DMMP is available at: diabetes.org/dmmp. A school cannot prohibit the use of any diabetes technology, particularly when ordered by a DMMP/provider’s order, as established in a 504 plan. Administration of insulin by trained nonmedical staff is included as part of the ADA’s “Safe at School” recommendations.

Ongoing Education

The ISPAD 2024 Clinical Practice Consensus Guidelines emphasize that ongoing caregiver and staff training are key to safe diabetes technology adoption. ¹⁶ As children grow, their diabetes management changes and thus education for school staff and nurses must continue over time. Nurses, parents, students, teachers, school administrators, staff, and student peers are key players in the school systems that influence diabetes management outcomes,^10,30 particularly in young children who are dependent on adults to provide all diabetes care. Accordingly, a team-based approach is central to the successful implementation of a DMMP (Figure 1). Communication strategies with parents, health care teams, and school staff/nurses include early establishment of a mutually agreed upon communication method, pre-arrival briefing by parents, regular supply management follow-up by parents and childcare staff, and consent by the parent/guardian for the childcare program to communicate directly with the health care provider. Multiple lines of communication provide a safety net for a child with diabetes at school. Table 1 outlines school-based responsibilities and resources for key stakeholders. An important resource with detailed information for health care professionals is the ADA Statement, “Care of Young Children With Diabetes in the Childcare and Community Setting: A Statement of the American Diabetes Association.” ¹⁰

Figure 1.

Team-based approach to diabetes management in the preschool setting. Key stakeholders in the management of T1D while at school include: health care providers, parents/guardians, school nurses, teachers/childcare staff, school administrators, coaches/activity supervisors, and the child with T1D. Created in BioRender. Gupta, R. (2026) https://BioRender.com/yd6exjc.

Table 1.

School-Based Responsibilities and Resources for Key Stakeholders.

Stakeholder	Key responsibilities	Resources
Parents/guardians	• Collaborate with diabetes provider to create DMMP • Meet with the school/daycare in advance of the school year to discuss diabetes management • Develop a plan to communicate with school staff about remote monitoring and how to respond to alerts • Provide the school with all necessary diabetes supplies before school starts	• ADA consumer guide: https://consumerguide.diabetes.org/ • ADA Safe at School: Guidance for the Use of Continuous Glucose Monitoring in the School Setting: https://diabetes.org/sites/default/files/2025-06/CGM-Guidance-06-10-25.pdf • School Cell Phone Restrictions Information and Resources: https://diabetes.org/advocacy/safe-at-school-state-laws/school-cell-phone-restrictions • Device-Specific Diabetes Technology Education and Resources: https://diabetes.org/sites/default/files/2025-12/Tech-Resource-List-12-1-25.pdf • Childcare Factsheet: https://diabetes.org/sites/default/files/2023-10/2023-02-01_Childcare_Factsheet-rev-2-14-23.pdf
School/daycare staff/teachers	• Provide secure and prompt access to diabetes supplies • Monitor glucose and ketone levels per DMMP • Recognize and treat hypoglycemia and hyperglycemia • Administer insulin and glucagon as directed • Allow time for child to take insulin before meals to avoid post-meal glucose excursion • Count carbohydrates and manage meals/snacks per dietary plan • Respond appropriately to CGM alerts • Maintain accurate documentation of all diabetes care • Communicate regularly with caregivers about glucose results, insulin, food intake, and activity • Ensure equal participation in all program activities; respect confidentiality	• ADA Childcare Provider Training: https://diabetes.org/sites/default/files/2023-10/ADA%20Childcare%20Provider%20Training12.10.2020.pdf • Substitute Teacher Information Form for Supporting a Student with Diabetes: https://diabetes.org/sites/default/files/2025-12/Substitute-Teacher-Information-12-1-25.pdf • Helping the Student with Diabetes Succeed: A Guide for School Personnel: https://diabetes.org/sites/default/files/2023-10/School-guide-final-11-16-22.pdf • Training Resources for Schools, Childcare, and Camps: diabetes.org/sastraining • State Laws for Delegation of Insulin and Glucagon: https://diabetes.org/advocacy/safe-at-school-state-laws/legal-protections
Health care providers	• Provide a completed and signed DMMP with updates as needed • Provide basic and comprehensive training to childcare staff in conjunction with caregivers • Provide guidance on glucose/ketone monitoring frequency, normal ranges, and treatment protocols • Describe insulin dosing for meals/snacks and carbohydrate amounts for hypoglycemia treatment • Be available to respond to questions about the child’s diabetes management needs (with caregiver consent) • Provide ongoing diabetes expertise and guidance	• Device-Specific Diabetes Technology Education and Resources: https://diabetes.org/sites/default/files/2025-12/Tech-Resource-List-12-1-25.pdf • Diabetes Medical Management Plan (DMMP): https://diabetes.org/advocacy/safe-at-school-state-laws/diabetes-medical-management-plan
School nurse	• Serve as key coordinator and provider of diabetes care • Collaborate with school administration to identify and train adequate staff • Provide or coordinate diabetes-specific training (ongoing, reviewed, and supervised) • Maintain communication with parents, teachers, and health care team • Support the child’s transition toward age-appropriate self-management • Monitor for behavioral health concerns (diabetes distress, anxiety) • Work with parents and staff to develop 504 plans or IEPs based on the DMMP	• School nurse pump training skills checklist: https://diabetes.org/sites/default/files/2023-10/school-nurse-pump-training%20%281%29.pdf • ADA Safe at School: Guidance for the Use of Continuous Glucose Monitoring in the School Setting: https://diabetes.org/sites/default/files/2025-06/CGM-Guidance-06-10-25.pdf • Device-Specific Diabetes Technology Education and Resources: https://diabetes.org/sites/default/files/2025-12/Tech-Resource-List-12-1-25.pdf • States with Undesignated Glucagon Laws: https://diabetes.org/sites/default/files/2025-09/ADA-State-Law-Glucagon-Final.pdf • ADA Brown Bag Lunch Webinars (30 minutes) for School Nurses: https://diabetes.org/advocacy/safe-at-school-state-laws/training-resources-school-staff
School administrator	• Assist in establishment of 504 plan or IEP • Grant permission for accommodations in the school setting • Coordinate training of staff who will be involved in diabetes care	• US Department of Education: Section 504 - https://www.ed.gov/laws-and-policy/individuals-disabilities/section-504 • Health Privacy Laws in the School Setting FAQ: https://diabetes.org/sites/default/files/2024-11/2024_11_HIPPA_FERPA_OnePager_FINAL.pdf • Frequently asked questions on diabetes care for school officials: https://diabetes.org/advocacy/safe-at-school-state-laws/faqs-for-schools
Child	• Ask for help in response to alerts or symptoms of hypoglycemia or hyperglycemia • Begin participating in care by indicating food preferences, choosing finger-stick or injection sites, and alerting caregivers to CGM alerts	• ADA Smartphone Access Card: https://diabetes.org/sites/default/files/2025-02/ADV25_Card_FINAL_DIGITAL-2-10-25.pdf

Practical Considerations for Use in Preschool/Daycare Settings

Meal and Snack Time

Variability in appetite and food choices in young children often leads to mealtime challenges associated with inaccurate insulin dosing and delayed bolus timing which cause wide fluctuations in blood glucose levels and reduced TIR. ¹³ Integration of insulin dosing via pump bolus or smart insulin pen dose by a school staff member with caregiver authorization is recommended by the ADA. ³⁰ Insulin adjustments should be provided per DMMP. In addition, it is important that students always have access to rapid-acting carbohydrates for treatment of hypoglycemia with assistance from a school staff member, as needed. Regular communication between school personnel and caregivers regarding the child’s meal completion at school is recommended to inform management strategies provided by the medical team.

Physical Activity

Students with diabetes should be able to fully participate in recess, physical education (PE) classes, and school sports. Communication with caregivers is important to determine the best management for a child with T1D prior to exercise. Many AID systems feature an exercise or activity mode that attenuates insulin delivery to reduce hypoglycemia risk. School staff should monitor CGM glucose levels and trends before, during, and 2 to 3 hours after activity, providing additional carbohydrate-containing snacks as needed. If CGM is unavailable, glucometer monitoring should occur before and after activity, or more frequently if the student is symptomatic.

For planned physical activity that is postprandial, continuous, sustained, or prolonged aerobic activity, reducing insulin delivery 1 to 2 hours prior to exercise may prevent hypoglycemia during the activity. ³⁴ For spontaneous activity, complex carbohydrate intake may be needed to avoid hypoglycemia during exercise. ³⁵ If the child’s blood glucose is ≤120 mg/dL before light/short duration activities, 5 to 10 g of complex carbohydrates is recommended, and before moderate play (eg, PE or recess), 10 to 15 g of complex carbohydrates is recommended. For prolonged aerobic activities (eg, swimming), 15 to 20 g of complex carbohydrates is recommended if blood glucose is ≤140 mg/dL, although these quantities may vary depending on the individual. For those using an AID system, consuming more carbohydrate than is necessary to reach the algorithm’s target glucose level/range may lead to additional insulin delivery. If a glucose increase is expected (morning activity in fasting state, anaerobic, explosive or competitive aerobic exercises), it may be acceptable to continue usual insulin delivery. Physical activity management (for before, during, and after activity) with insulin modification and/or carbohydrate consumption personalized for the child’s particular diabetes regimen (insulin injections or pump/AID system) should be clearly documented in the DMMP.

Hypoglycemia and Hyperglycemia Management

Young children often cannot express symptoms of hypoglycemia; therefore, CGM plays an important role in allowing caregivers to proactively treat hypoglycemia.^10,30 Importantly, fast-acting carbohydrate access and glucagon availability must be maintained to ensure the child’s safety at school. Within the school setting, designated personnel are responsible for recognizing symptoms, checking glucose, and providing treatment according to the individual DMMP. Five to seven grams of simple acting carbohydrate is typically appropriate to treat hypoglycemia in young children and avoid rebound hyperglycemia. ⁷ Ketone monitoring should occur when blood glucose levels remain more than 250 mg/dL for 2 hours, and blood ketone monitoring is typically recommended for very young children due to challenges for them to urinate on command. ⁷ Parents and diabetes care providers may customize CGM alert settings and educate school staff of appropriate responses for hyperglycemia and hypoglycemia.

Remote monitoring may be provided by a school nurse or staff member; however, this is not an expectation and must be discussed as part of the DMMP if recommended. In cases when remote monitoring is being provided by a school nurse or trained staff, it is important that the school or parent provides a device to link the CGM to, and the staff do not use their personal device. Furthermore, parents, trained childcare/school staff, and school nurses should have agreed upon expectations to promote successful management of diabetes in the school setting.

Device Wear and Site Security

Despite the many benefits of CGM and insulin pump use, occlusions, cannula kinking, and adhesive integrity remain a challenge for many young children wearing these devices. Infusion set failures associated with prolonged hyperglycemia and potential ketosis occur approximately 4 times per year and is more common in children compared with adults. ³⁶ Strategies to maintain adhesive integrity during play, heat, and water exposure include the use of barrier films, wipes, overtapes, patches, and external wraps. In addition, contact dermatitis and skin infection remain important challenges often associated with diabetes technology use. Hydrocolloid patches and fluticasone spray are commonly used off label to mitigate contact dermatitis and allergic reactions to the adhesives.^5,37,38 Health care providers should routine inquire about site issues; resource for health care professional about device placement and skin preparation is at https://www.pantherprogram.org/skin-solutions.

Back-up Supplies

In addition to insulin pens or vials and treatment for hypoglycemia, back-up supplies in case of pump or CGM malfunction (such as syringes or insulin pen tips, glucose meter and compatible strips, and lancets, urine ketone strips, or ketone meter with ketone strips) should always be available for a child using diabetes technology at school. State laws vary regarding the involvement of a school staff member or childcare provider in replacing CGM sensors and infusion sets. ³⁰ Therefore, it is important to consult the policies and laws practiced in each state when developing a comprehensive DMMP. In accordance with the ADA’s Safe at School guidelines, staff who are trained in diabetes management should never be required to make independent decisions about the ongoing management of a student with diabetes. Rather, diabetes care tasks should be prescribed in the student’s DMMP. ³⁰

Gaps in Current Literature and Future Directions

Integrating diabetes technology training for all educational staff responsible for children with T1D is essential, supported by individualized care plans tailored to each child’s developmental and clinical needs.^10,30 While access to diabetes technology remains a significant barrier, particularly among racially and ethnically diverse populations, ³⁹ optimizing system-level support for training and implementation of team-based diabetes management may expand technology uptake in these settings. Future research should examine the effectiveness of structured staff training programs, the impact of standardized care protocols on glycemic and psychosocial outcomes, and strategies to reduce disparities in technology access among young children with T1D in school/childcare environments.