Diabetes Children outdoor camps

8/13/2019 Diabetes Children outdoor camps

1/4

Diabetes Management at Camps forChildren With DiabetesAMERICAN DIABETES ASSOCIATION

Since Leonard F.C. Wendt, MD,opened the doors of the rst di-abetes camp in Michigan in 1925,

the concept of specialized residential andday camps for children with diabetes hasbecome widespread throughout the U.S.and many other parts of the world. In2011, approximately 30,000 children at-tended diabetes camps in North Americaand over 16,000 more campers partici-pated in one of the 180 diabetes camps

throughout the rest of the world.The mission of camps specialized for

children and youth with diabetes is tofacilitate a traditional camping experiencein a medically safe environment. Anequally important goal is to enable chil-dren with diabetes to meet and share theirexperiences with one another while theylearn to be more responsible for their con-dition. For this to occur, a skilled medicaland camping staff must be available toensure optimal safety and an integratedcamping/educational experience.

The recommendations for diabetesmanagement of children at a diabetescamp are not signicantly different fromwhat has been outlined by the AmericanDiabetes Association (the Association) asthe standards of care for people with type1 diabetes (1) or for children with diabe-tes in the school or day care setting (2). Ingeneral, the diabetes camping experienceis short term and is most often associatedwith increased physical activity and morecontrolled access to food relative to thatexperienced at home. Thus, while away atcamp, glycemic control goals are more re-

lated to avoiding blood glucose extremesthan optimizing overall glycemic control(3,4).Themanagementprotocol aimsto bal-ance insulin dosage with activity level andfood intake so that blood glucose levelsstay within a safe target range, especially

with respect to the prevention and man-agement of hypoglycemia (5).

Each camper should have a standard-ized comprehensive health history formcompleted by his/her family and a healthevaluation form (6) completed by the di-abetes care provider that details the camp-ers past medical history, immunizationrecord, and diabetes regimen. The homeinsulin regimen should be recorded foreach camper, including type(s) of insulin

used, number and timing of insulin injec-tions (if on shots), and insulin pumpbasal, bolus, and correction dose settings(if on an insulin pump). Records for in-sulin dosages and blood glucose valuesfor the week immediately before campshould be provided as a baseline. Addi-tional medical information, such as priordiabetes-related illnesses and hospitaliza-tions, history of severe hypoglycemia,previous hemoglobin A1C levels, othermedications, signicant medical con-ditions, and psychological issues alsoshould be available to camp personneland reviewed with diligence by those re-sponsible for the health and well-being ofthe individual camper.

During camp, a record of the campersdiabetes care progress should be docu-mented daily. All blood glucose valuesand insulin dosages should be recordedin a format that allows for review and anal-ysis to determine whether alterations inthe diabetes regimen are required duringthe camp stay. A record of the degree ofactivity and food intake may also be helpfulin determining subsequent alterations in

the diabetes regimen. It is imperativethat the medical staff have advancedknowledge about the exercise scheduleand the meal plan at camp so that theycan make appropriate insulin dosage ad-

justments. Inadvertent schedule delays or

schedule changes (such as for rainyweather) can have a signicant impact

on the risk of hypoglycemia as insulindosing at the previous meal takes into ac-count the planned activities. If a low-,moderate-, or high-level activity event isoriginally planned, a replacement activitywith an equivalent activity level shouldbe substituted when possible.

To ensure safety and optimal diabetesmanagement, blood glucose testing ma-terials and treatment supplies for hypo-glycemia should be readily available tocampers at all times. Multiple bloodglucose determinations should be made

and recorded throughout each 24-h pe-riod: before meals; at bedtime; before, af-ter, or during prolonged and strenuousactivity; in the middle of the night, whenindicated for prior hypoglycemia; after aninsulin pump site change; and after extradoses of insulin. Use of a continuousglucose monitoring system (CGMS) doesnot preclude the need to test nger-stickblood glucose.

Because exercise may still impactblood glucose 1218 h after completion,campers who have repeated lows during

exercise may also need nocturnal testing.Campers with a bedtime blood glucoselevel ,100 mg/dL and campers on an in-sulin pump with a blood glucose .240mg/dL should have their blood glucoserechecked overnight. The interventionfor campers with an overnight blood glu-cose level ,100 mg/dL should be deter-mined based on their insulin regimen andrisk for nocturnal hypoglycemia. Camp-ers on insulinpumps with a bloodglucose.240 mg/dL should follow an estab-lished pump protocol for ketone testingand changing of the insulin pump site.

Campers should be encouraged to checkblood glucose levels at times other thanthe routine times if they have symptomsof hypo-/hyperglycemia or if they haveother physical complaints. These recom-mendations imply that there is adequatestafng andthat they have received trainingin blood glucose monitoring procedures aswell as the indications and treatment pro-tocols for hypo-/hyperglycemic events.

Every attempt should be made tofollow the home insulin regimen of eachcamper as closelyas possible. If a campers

c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c

This updated position statement was peer reviewed by the Professional Practice Committee in September,2011, andapproved by theExecutive Committeeof theAmericanDiabetes Association in November,2011.

DOI: 10.2337/dc12-s072 2012 by the American Diabetes Association. Readers may use this article as long as the work is properly

cited,theuse iseducationaland notforprot, andthe work is notaltered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

S72 DIABETESCARE, VOLUME35, SUPPLEMENT 1, JANUARY 2012 care.diabetesjournals.org

P O S I T I O N S T A T E M E N T


2/4

blood glucose record prior to camp indi-cates tight glucose control and a low ac-tivity level, it may be advisableto decreasethe insulin dosage in anticipation of theincreased activity. Supervision of eachand every insulin administration is im-portant to ensure camper safety and com-pliance with the prescribed insulin dose.

Hypoglycemia may occur at the begin-ning of camp because of increased phys-ical activity, failure to have free access tofood, or other conditions such as a majorchange in altitude. Other alterations in in-sulin dosage may need to be made for ex-treme physical activity, such as prolongedhikes or active water sports.

A rising percentage (and often a ma-jority) of children at camp manage theirdiabetes with an insulin pump, with al-most all of the remaining children on asubcutaneous basal/bolus insulin regimen.The camp medical director and otherappropriate camp staff should be familiarwith the programming of insulin pumps,the replacement of insulin pump infusionsets, and insulin adjustments using abasal/bolus insulin regimen or an insulinpump. The medical staff should ensurethat adequate backup pump supplies, in-cluding extra batteries, reservoirs, andcatheter sets, are available for the durationof camp.

If major alterations of a campers reg-imen appear to be indicated, such as add-ing an additional insulin injection(s) or

changing an insulin type, it is importantto discuss this with the camper and thefamily in addition to the childs local di-abetes care provider before the change ismade. A record of the blood glucose val-ues, insulin doses, and other medical careprovided at camp, with an additionalcopy for the family to share with their pri-mary diabetes team (if they choose),should be available to (and discussedwith) the family at the end of camp. Forcampers returning home by bus or car-pool, the record should be sent with thecamper or mailed to his/her family. Pa-rents and campers should be advised toreturn to their precamp regimen oncethey are home, unless the alterations ap-pear to signicantly improve glycemiccontrol. In this circumstance, the familyshould seek the guidance of its primarydiabetes team.

Dietary planning at camp should beoverseen by a registered dietitian. Mealsshould be given at set times each day andshould accommodate special dietaryneeds, when needed, especially those re-lated to food allergies and the increasing

incidence of celiac disease in the diabeticpopulation. Snacks between meals may beappropriate to prevent hypoglycemia, es-pecially in the youngest campers who maynot recognize their hypoglycemic symp-toms. These meals and snacks should bebalanced, and their composition (speci-cally the carbohydrate content) should be

made known to campers and staff. Car-bohydrate counting is optimally presentedin grams and should be as exact aspossible(not rounded to the nearest completeserving or 15 g). The carbohydrate com-ponent of food should be taught to camp-ers, according to their developmentallevel, to enable them to learn how tobalance food and activity. Supervision ofthe food intake of children by counselorsensures that the campers are consumingadequate nutrition.

A formal relationship with a nearbymedical facility should be secured for eachcamp so that camp medical staff has theability to refer to this facility for prompttreatment of medical emergencies. (The

American Camp Association requires thenotication of all emergency medical sup-port systems local to thecamp.) If the campis located in a remote area, an arrangementshould be made with a medical helicopteror xed-wing aircraft to provide rapidtransport if necessary.

Universal precautions including Oc-cupational Safety & Health Association(OSHA) regulations, Clinical Laboratory

Improvement Amendments (CLIA)standards, and state regulations must befollowed by all, with gloves worn for allprocedures that involve blood draws andappropriate containers placed throughoutthe camp to dispose of sharps withouthazard. Retractable single-use lancets andglucose meters in which blood does nottouch the machine itself are preferablefor group testing. No lancing device thatcan be reset and used again should beavailable to campers. Retractable insulinsyringe/pen needles may be considered tofurther reduce the risk of needle sticksamong campers and staff. Insulin pensare for single person use and should neverbe shared between two individuals. Careshould also be taken to ensure that insulinpumps are individually labeled so thatwhen they are disconnected (for swim-ming or bathing), the proper pump is re-connected to the proper camper to preventuid contamination and improper insulinadministration. Whenever possible, bloodglucose meters should be assigned to anindividual person due to the risk of blood-borne pathogen contamination from blood

on the surface of the meter (7). If bloodglucose meters must be shared, the devicemust be cleaned and disinfected after everyuse, per the manufacturer instructions, toprevent potential cross contamination ofinfectious agents. Glucose meters shouldbe calibrated regularly using control solu-tion to verify accuracy (frequency should

be per the manufacturer instructions).

MEDICAL STAFFCOMPOSITION ANDSTAFF TRAININGdIt is imperativethat each camp have a medical directorwho is a physician with expertise in man-aging type 1 and type 2 diabetes. Themedical director or his/her on-site licenseddesignee ultimately is responsible for thedaily review of blood glucose results, in-sulin logs, and other prescribed medica-tions of all campers and staff with diabetesto make appropriate adjustments. Themedical director or the on-site licenseddesignee also is responsible for providingguidance in all medical emergencies andshould ensure that the medical program isintegrated into the overall camping expe-rience. One licensed physician must be onsite at all times forresidentcamp programsand available on call at all times for a daycamp program.

The medical staff can be comprisedof licensed healthcare professionals andnonhealthcare professionals with an in-terest in diabetes. Physicians, medical

residents, midlevel providers (physicianassistants and advanced practice nurses),diabetes educators, pharmacists, andnurses should also be encouraged toparticipate. In addition, registered dieti-tians with expertise in diabetes shouldhave input into the design of the menuand the education program. It is benecialto include some medical, nursing, phar-macy, physician assistant, nurse practi-tioner, and dietetic students as volunteercounselors or junior medical staff to learnabout diabetes as well as the needs ofchildren with a chronic disease.

All camp staff, includ ing med ica l,nursing, nutrition, and other volunteer orpaid staff, should undergo backgroundchecks to ensure the appropriateness of theirworking with children. All staff should re-ceive training concerning routine diabetesmanagement, issues related to lifestylemodication for type 2 diabetes, and thetreatment of diabetes-related emergen-cies (hypoglycemia or ketosis) beforecamp begins. Camp policies and job de-scriptions for staff should be understoodand available in print before the start of

care.diabetesjournals.org DIABETESCARE, VOLUME35, SUPPLEMENT1, JANUARY 2012 S73

Position Statement


3/4

camp. All camp staff should be familiarwith the signs and symptoms of hypo-/hyperglycemia, indications for bloodglucose testing, and treatment of hypogly-cemia, including the administration ofglucagon to treat severe hypoglycemia(5,8). Competency testing of these skillsfor staff medically responsible for the

campers is strongly suggested. All diabetessupplies should be monitored and distrib-uted by responsible medical staff.

Reliable communication methods toallow contact with on-site medical staffshould exist in every activity area. Suppliesfor routine rst aid and for the treatmentof intercurrent illnesses, such as allergies,asthma, sore throats, diarrhea/vomiting,and minor trauma, should be available.

All medical treatment should be recordedin both the campers le and in the yearlycamp medical log.

TREATMENT OF DIABETES-RELATED EMERGENCIES

HypoglycemiaGlucagon or intravenous glucose solu-tions must be available for administrationby trained camp personnel for treatmentof severe hypoglycemia. All possiblemeasures should be taken to avert severehypoglycemia. These measures may in-clude nighttime blood glucose testing,decreasing insulin dosages for extremeactivity, and altering insulin regimens for

campers with prior severe hypoglycemia.Extra snacks should be provided to chil-dren with blood glucose levels ,100 mg/dLat bedtime. Additional snacks or modi-cations of insulin for children with bloodglucose levels ,80 mg/dL should also beconsidered.

A set protocol for the treatment ofmild-to-moderate hypoglycemia withoral glucose at other times should befollowed so that hypoglycemia is consis-tently managed. Repeat blood glucosetesting should be performed within 1520 min to ensure resolution of hypogly-cemia.

KetosisIt may be possible to treat mild-to-moderate diabetic ketosis at camp. Urineor blood should be measured for thepresence of ketones if a camper has per-sistent hyperglycemia (blood glucoselevel .240 mg/dL [13.3 mmol/l]) or if acamper has an intercurrent illness, re-gardless of blood glucose level. Oral orintravenous hydration (if vomiting)should be administered, and adequate

insulin should be given to reverse ketosis.A ow sheet should be produced to doc-ument the progress of the treatment reg-imen. Referral to an appropriate medicalfacility is required if vomiting and ketosisdo not resolve promptly.

WRITTEN CAMP

MANAGEMENT PLANd

A writtenplan that includes camp policies andmedical management procedures mustbe available at camp. It should be writtenor reviewed by the camp medical directorin collaboration with others, such as thecamp program director, members of thecamp oversight and/or policy commit-tees, local pediatric endocrinologists anddiabetes educators, etc. The plan mustadhere to the American Diabetes Associ-ations standards of medical care and the

American Camp Associat ion accredita-tion standards. All medical staff shouldreview this management plan beforecamp begins.

The written medical management planshould include information about:

c General diabetes managementc Insulin injections/pump therapyc Blood glucose monitoring and ketone

testingc Nutrition, timing, and content of meals

and snacksc Routine and special activitiesc Hypoglycemia and treatment

c Hyperglycemia/ketosis and treatmentc Medical formsc Assessment and treatment of intercur-

rent illnessc Pharmacy compendiumc Universal precautions and policies for

needle sticks and handling of infectiouswaste

c Psychological issues at campc Quality control of medical equipment

according to OSHA and CLIA stand-ards

c Incident/accident reportingc When to notify parents/guardians, pri-

mary care physician, and diabetes careprovider

c Policies for camp closure and returninghome

In addition, camp policies shouldcover emergency procedures (e.g., medi-cal and natural disasters), out-of-campexcursions, and the prevention of physi-cal, sexual, and psychological abuse. Arisk management plan should also bedeveloped and understood by all campstaff. The ADAs Camp Implementation

Guide Modules (9) includes a variety ofresources including sample policies, jobdescriptions, and medical forms.

DIABETES EDUCATION ANDPSYCHOLOGICAL ISSUESdThecamp setting is an ideal place for teachingdiabetes self-management skills. Educa-

tion programs should be developmentallyappropriate. Examples of educational top-ics suitable for the camp setting include:

c Blood glucose monitoringc Recognition and management of hypo-

/hyperglycemia and ketosisc Insulin types and administration tech-

niquesc Carbohydrate countingc Insulin dosage adjustment based on nu-

trition and activity schedulesc Insulin pump trouble shooting and

problem solvingc The importance of diabetes controlc Healthy lifestyles issues, including in-

tegration of healthy eating, physical ac-tivity, and relaxation

c Problem-solving skills for caring fordiabetes at home versus camp

c Life skills for independent livingc Stress management and coping skillsc Sexual health and preconception issuesc Diabetes complicationsc New therapies including technologies

Medical personnel with the aid of

on-site psychologists/social workers, ifavailable, should aim to improve the psy-chological well-being of campers. Thesestaff members should be willing to addressspecic and general psychosocial issuesand be able to offer suggestions for sub-sequent follow-up if indicated. Individu-alized attention may be needed for camperswith type 2 versus type 1 diabetes.

RESEARCH AT CAMPdClinical re-search is often performed and encouragedat diabetes camps. However, if such proj-ects are to be done, they must not in-terfere with the integrity of the campingprogram. All research conducted in thecamp setting should be minimally inva-sive to the camping experience. All stud-ies should be approved by an institutionalreview board in good standing and by thecamp medical and program director be-fore the camping session. Parents andcampers must be provided the consentform, a summary/synopsis of the researchprotocol, and the ability to contact theprincipal investigator before consenting toenter the research study. Informed consent

S74 DIABETESCARE, VOLUME35, SUPPLEMENT 1, JANUARY 2012 care.diabetesjournals.org

American Diabetes Association


4/4

from parents or guardians and assent fromthe camper must be obtained, preferablybefore arrival at camp.

OTHERdAt times, industries related todiabetes may wish to have a presence atcamp. Camp medical staff and adminis-trative personnel should develop policies

for visits from industries while camp is insession. Industry representatives seekingto have a presence at camp should besubject to the same background checksand standards outlined by the Association.Employees of industries should be en-couraged to participate at camp for theirexpertise, ability to educate others, andadded resources, while understandingthat their role is to support the experienceof the campers rather than to solicit orpromote their individual product.

CONCLUSIONSdCamps for chil-

dren and youth focused on diabetes areinvaluable. Most camps have a high re-turn rate for campers, many of whom goon to become counselors, medical pro-fessionals, staff, and role models forcampers. Thus, it is reasonable to assumethat they have beneted not only from thecamp experience but also from the friend-ships that have developed from being in

an environment wherethe norm is to havediabetes. Providing high-standard diabe-tes care is imperative to maximize theexperience offered by camps specializedfor children with diabetes. Using theactive camping environment as a teachingopportunity is an invaluable way forchildren with diabetes to gain skills in

managing their disease within the sup-portive camp community.

AcknowledgmentsdThe original version ofthis Position Statement was prepared by Fran-cine Kaufman, MD, Desmond Schatz, MD, andJanet Silverstein, MD, and approved in 1998.The current revision was prepared by LowellSchmeltz, MD, with contribution from RussKolski, RN, Chair, and other members of theADA National Camp and Youth Subcommittee.

References1. American Diabetes Association: Standardsof medical care in diabetesd2012 (PositionStatement). Diabetes Care 2012;35(Suppl.1):S11S63

2. American Diabetes Association. Diabetescare in the school and day care setting. Di-abetes Care 2012;35(Suppl. 1):S76S80

3. The Diabetes Control and ComplicationsTrial Research Group. The effect of intensive

treatment of diabetes on the developmentand progression of long-term complica-tions in insulin-dependent diabetes melli-tus. N Engl J Med 1993;329:977986

4. Diabetes Control and Complications TrialResearch Group. Effect of intensive diabetestreatment on the development and pro-gression of long-term complications in ado-lescents with insulin-dependent diabetes

mellitus: Diabetes Control and Complica-tions Trial. J Pediatr 1994;125:177188

5. Cryer PE, Davis SN, Shamoon H. Hypo-glycemia in diabetes. Diabetes Care 2003;26:19021912

6. American Academy of Pediatrics Commit-tee on School Health; American Academyof Pediatrics Section on School Health.Health appraisal guidelines for day campsand resident camps. Pediatrics 2005;115:17701773

7. Centers for Disease Control. Infection pre-vention during blood glucose monitor-ing and insulin administration [article

online]. Available from http://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html. Accessed 7 August 2011.

8. American Diabetes Association. MedicalManagement of Type 1 Diabetes. 4th ed.Alexandria, VA, American Diabetes Associ-ation, 2008

9. American Diabetes Association. Camp Im-plementation Guide Modules. Alexandria,VA, American Diabetes Association, 2005

care.diabetesjournals.org DIABETESCARE, VOLUME35, SUPPLEMENT1, JANUARY 2012 S75

Position Statement

Documents

Diabetes Children outdoor camps