pediatrics
July 2019, VOLUME144 /ISSUE 1

Improving Health and Safety at Camp

  1. Michael J. Ambrose, MD, FAAPa,
  2. Edward A. Walton, MD, FAAPb,
  3. COUNCIL ON SCHOOL HEALTH
    1. aSt Joseph Mercy Hospital, Ann Arbor, Michigan; and
    2. bAscension St John Hospital, Detroit, Michigan
    1. Dr Ambrose conceptualized and designed the initial manuscript and revised the final manuscript; Dr Walton conceptualized and designed the initial manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

    Abstract

    The American Academy of Pediatrics has created recommendations for health appraisal and preparation of young people before participation in day, resident, or family camps and to guide health and safety practices at camp. These recommendations are intended for parents and families, primary health care providers, and camp administration and health center staff. Although camps have diverse environments, there are general guidelines that apply to all situations and specific recommendations that are appropriate under special conditions. This policy statement has been reviewed and is supported by the American Camp Association and Association of Camp Nursing.

  1. Abbreviations:
    AAP
    American Academy of Pediatrics
    ADHD
    attention-deficit/hyperactivity disorder
    AED
    automated external defibrillator
    CDC
    Centers for Disease Control and Prevention
  2. Benefits of the Camp Experience

    For more than 150 years, children have been attending camp.1 Today, more than 14 000 day and resident camps exist in the United States, and approximately 14 million children attend day or resident camp supported by 1.5 million staff members.2 When there is a successful match between a camp’s philosophy, practices, and methods and a child’s developmental, experiential, and temperamental readiness, abilities, and nature, the camp experience has been proven to have a lasting effect on psychosocial development, with positive effects on self-esteem, peer relationships, independence, leadership, values, and willingness to try new things.3 Camps can also offer an opportunity to overcome a lack of connection with the natural environment, which has been associated with depression, attention disorders, and obesity.4 In addition, research has shown that camps are safe.5

    Camp health care providers can expect to care for campers with any of the physical and emotional conditions seen daily by primary care providers. Because of these issues, the precamp health evaluation is extremely important. Parents, camp administrators, and camp health care providers should openly share consented information to help ensure that a camper is appropriately prepared for his or her new camp environment. In addition, parents and families should prepare their child for camp. Camp administration must create appropriate policies and procedures and work in cooperation with local health care providers and facilities to ensure off-site support is in place (eg, hospitals, police department, and fire department).

    Role of Parents and Guardians and Primary Care Providers

    Roles of parents and guardians and primary care providers include the following:

    1. Before choosing a camp, parents or guardians should be encouraged to assess their child’s interests, skills, and overall physical, mental, and emotional well-being and evaluate his or her ability to effectively participate in a particular camp setting. Camp Web sites, mission statements, and promotional handouts can help guide parents when choosing an appropriate camping environment for their child. Although many camps are inclusive and able to care for campers with chronic illnesses or specific psychosocial needs, camping programs for children with special needs are available (eg, camps for children with cancer, diabetes, asthma, attention-deficit/hyperactivity disorder [ADHD], autism spectrum disorder, and learning disabilities). Camps for special populations exist, including camps for lesbian, gay, bisexual, transgender, or questioning youth; grief and bereavement camps; and camps for gifted and talented children. The locations of camp programs may vary as well, with some camp programs being run on college and university campuses and others being run by municipalities (eg, parks and recreation). Before enrolling their child, parents should be aware of preadmission medical requirements for campers and the scope of health services available at camp. Parents are encouraged to discuss all camper health needs, including any special physical, emotional, or dietary needs, with camp health staff and camp directors before enrolling their child and before the start of the program.6

    2. Some day and overnight camps offer programs that require an increased level of physical fitness because of strenuous activities and/or geographic factors, such as altitude or remote location. These camps may require a more extensive health evaluation relevant to the nature, conditions, and activities of the camp. Exact health requirements for participation will depend on the program. All campers, including day campers, resident campers, and family campers, should provide the camp with a complete health record before the first day of camp. The health record should be completed by the child’s parents and/or guardians with input from the camper’s primary care provider. This health record includes an annual review of the camper’s health by a licensed health care provider and an annual physical examination as required by the program. It is recommended that the annual review and physical examination be completed by the child’s primary care provider who is well known to him or her. This recommendation is consistent with those of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Fourth Edition.7 The appropriateness of the camp’s program for the individual camper should be addressed during that review. The health care provider should be provided with pertinent information about the camp before the visit. For children with ongoing health care needs, it is important that the health record be updated before their arrival at camp.

    The annual review should include a comprehensive health history, which addresses significant illnesses, surgeries, injuries, allergies, medications, and the present state of physical health of the child. The annual review should also include a history of the child’s mental, emotional, and social health, including any family stressors and history of emotional trauma. Campers with clinically significant medical or psychosocial histories or those with conditions requiring long-term management should undergo further review by the medical provider before participation (eg, asthma, diabetes, anaphylactic allergies, mood or anxiety disorders, and ADHD). An action plan appropriate to the camper’s condition and to the camp program should be created by the camper’s medical provider and provided to the camp as needed (eg, asthma action plan, seizure action plan, and allergy action plan).8 If provided, this plan should also address all medications, both prescription and over the counter, to be used by the individual while at camp.9 The medical provider should perform the annual review on the basis of current practice guidelines, physician examination, history, and any appropriate testing, and if no obvious reasons for exclusion from camp have been identified, parents must also consider the child’s individual risks and benefits of participation and understand that clearance is not a guarantee against adverse outcomes or future medical problems.

    Written orders from a licensed health care provider should be obtained for prescription medications, medically indicated diets, physical activity limitations, or special medical devices.

    • 3. Once the health record has been submitted to the camp, parents and guardians are responsible for providing the program with any changes in the camper’s health status, allergies, medications, or recent travel before the camper arrives. Elective interruption in medications (ie, drug holidays) should be avoided in campers on long-term psychotropic therapy or those on maintenance therapy required for a chronic medical condition. If elective interruption is in the best interest of the child, this should be disclosed to the camp before the camper arrives.1012

    • 4. Before starting camp, all campers and staff should be in compliance with the recommended childhood immunization schedule published annually by the American Academy of Pediatrics (AAP), the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC), and the American Academy of Family Physicians.13 Camp administrators should be aware that individual states might require other immunizations in addition to those recommended by these organizations. Immunization requirements for participation at camp provide a safe environment for those participating. Nonmedical exemptions to required immunizations are inappropriate, and these exemptions should be eliminated by camps. Participation by campers and staff who are incompletely immunized or unimmunized because of nonmedical exemptions is inappropriate for individual, public health, and ethical reasons. Camps should support medical exemptions to specific immunizations as determined for each individual (eg, those with congenital conditions, with compromised immune systems, or taking specific medications).14 Individuals traveling internationally as part of a camp program should consult the CDC “Travelers’ Health” Web site15 or visit a traveler’s clinic for information regarding particular immunization requirements or health concerns that may be associated with their destination.

    • 5. Some inexperienced campers may experience acute psychological distress associated with separation from home and loved ones, commonly known as homesickness. Primary care providers may recommend the following interventions to provide help for prospective campers and their parents because they have been found to significantly reduce the incidence and severity of homesickness11:

      • ○ involve the child in the process of choosing and preparing for camp;

      • ○ discuss homesickness openly, be positive about the upcoming camp experience, and avoid expressing personal doubts or concerns;

      • ○ arrange practice time away from home with friends or relatives before camp; and

      • ○ frame the time to be spent at camp in comparison with previous enjoyable experiences the child may have had of similar duration.

    Although homesickness is traditionally believed to affect resident campers, younger children attending day camp may suffer from homesickness as well. Parents should avoid making “pick-up” arrangements in the event of homesickness because these arrangements may undermine the child’s confidence in his or her own independence.11 Health care providers should discuss these interventions as part of the anticipatory guidance associated with the health evaluation before camp.

    Role of the Camp

    Roles of the camp include the following:

    1. Camp administrative officials should have a clear understanding of the essential functions of a camper insofar as their specific camp program is concerned.16 It is the responsibility of the camp to provide parents, children, and primary health care providers with expectations for successful participation in the camp program. Certain camp activities may increase the risk of complications from specific medical conditions (eg, horseback riding, which may trigger an asthma exacerbation). It should be a combined effort of parents, health care providers, and camp personnel to identify children who might be at risk and specify the extent of accommodations necessary for safe participation for those children.

    2. All camps should have written health policies and protocols that have been reviewed and approved by a physician with specialized training in children’s health, preferably a pediatrician or family physician. These policies and protocols should be tailored to the training and scope of practice of the on-site camp health care providers and should be developed with the input of those individuals.17,18 Camp administrators should inquire as to the previous training and camp experiences of camp health care providers and provide additional training or support if necessary. It is strongly recommended that camp health care providers have specialized training in children’s health, including all physicians, nurses, nurse practitioners, and physician assistants who will provide care to children while they are at camp. If pediatric health care providers practice a subspecialty, their knowledge and practice of general pediatrics should be assessed before arrival to camp.19

    Camp health policies and protocols should address both major and minor illnesses and injuries and include information on the camp’s relationship and coordination with local emergency services.20 Local emergency medical service providers should be contacted by camp directors before camp begins to ensure a prompt and coordinated response in the event of an emergency.21,22 Camps should also establish relationships with local dentists and/or orthodontists who are willing to treat dental emergencies if the need arises as well as with local mental health professionals. The AAP encourages its members to cooperate with local camps in reviewing such policies and protocols and by providing medical support if practical.

    • 3. The 2009–2010 H1N1 influenza pandemic, the emergence of methicillin-resistant Staphylococcus aureus, and the Zika and West Nile virus epidemics have highlighted the need for increased screening and surveillance at camps. There is increased importance for camps to teach good hygiene practices, including good hand-washing and coughing and/or sneeze behaviors and to ensure the appropriate use of insect repellent.5 Camps should have management plans for infectious disease outbreaks in place.23 These plans should include guidance for caring for ill campers or staff and for isolating ill people from the healthy population. Camp health care providers should also be aware of health hazards that are particular to their area (eg, Lyme disease and Rocky Mountain spotted fever).24 A camp emergency plan should also be created because children are particularly vulnerable and limited in their ability to escape or protect themselves from harm in the event that a natural or manmade disaster occurs.25

    For resident camps, all campers and staff should undergo a screening supervised by camp health providers on arrival. This screening should assess the potential for communicable diseases, establish a health status baseline, and identify health problems, such as febrile illness or lice. Children with febrile illness (temperature higher than 38°C) should be isolated from the general camp population until they have been fever free for 24 hours. Camps should abandon “no-nit” policies, and children with active lice infestations should be allowed to return to camp activities after treatment.26 Updated medication orders and health history should also be made available to camp health staff on initial arrival at camp.

    • 4. Whenever possible, camper medications should be sent to camp before the camper arrives so that camp health care providers have adequate time to review and sort all medications and address any concerns. Camp health care providers with appropriate knowledge and training should be responsible for the safe storage, transport, and administration of medications. Relying on handwritten instructions when administering medications can lead to medication errors.27 The use of an electronic medication administration record is encouraged to minimize the potential for human error and ensure the right camper, right drug, right dose, right route, right time, and right documentation when administering medications. Prepackaged medication services should be considered to reduce preventable medication errors and eliminate the risk of missed medications or incorrect dosing. A protocol should be established for safe transport of medications during out-of-camp trips, and a determination should be made by the on-site health care provider as to the skill of camp personnel to administer medications and the safety of sending a particular child on the trip.9

    • 5. Camps that maintain over-the-counter and emergency medication, oxygen, or other emergency equipment should routinely check supplies and expiration dates and ensure that necessary training has been completed. Recent guidelines support the use of automated external defibrillators (AEDs) in children 1 year or older.28 All camps should have an AED on-site. Camps with an AED should comply with local regulations regarding required protocols and training in their use. Campers should be instructed in the use of personal emergency medications or medical devices, such as inhalers or epinephrine autoinjectors, before arrival at camp. Many states have legislation allowing camps to stock unassigned epinephrine autoinjectors, and some states have laws requiring that camps stock unassigned epinephrine devices. Camps should review local regulations and requirements for stocking unassigned epinephrine and other emergency medications for seizures, diabetes mellitus, or opioid overdose. Parents should also make clear to the camp staff primarily responsible for their campers the situations that may require use of these medications and whether the children are competent to carry or administer the medication themselves. Specific protocols and training for administration of these medications or use of specialized equipment by the camper, counselors, or other unlicensed providers should be created. These devices should be kept in locations that are easily accessible to individuals who may need them.9,29

    • 6. Use of an electronic health record to capture camper and staff medical information that is compliant with federal guidelines is encouraged to ensure easy access to medical records and emergency contact information at all times.30,31 The parent or guardian with legal custody should be clearly indicated. Protocols for parental notification should be established. In addition, if a chronic condition exists, the child’s primary care physician and any subspecialty physicians should be identified by name, telephone number, and e-mail, and the date of the last health care visit should be noted.32 Written or electronic authorization to obtain treatment, to transport children in camp vehicles for nonemergency care, and to share medical information should be provided by the parent or guardian.33 Camps should make their requirements for health insurance coverage clear, and parents or guardians should ensure that their insurance policy is in force at the camp’s location. Supplemental travel and emergency medical insurance may be recommended for travel camps or camps where higher-risk activities occur. Confidentiality of health information should be maintained.34

    • 7. All illnesses and injuries should be documented for campers and staff. This documentation should be consistent with state or local licensing requirements and allow for surveillance of the camp illness and injury profile.5 Documentation in the “SOAP” note format (subjective, objective, assessment, and plan), a widely adopted documentation format for interdisciplinary health care providers, to capture a camper’s or staff’s initial visit and monitor progress during follow-up care is encouraged.35

    • 8. It is important for all camps to have personnel who can administer on-site first aid irrespective of their distance from definitive medical care (eg, cardiopulmonary resuscitation, epinephrine for anaphylaxis, glucagon for hypoglycemia, and rescue treatments for seizures). A health care provider or staff member with the appropriate training must be on duty at all times, both at camp and on off-site trips. This statement does not address specific camp staff training issues; however, those who are involved in waterfront activities, including lifeguards, should be certified in cardiopulmonary resuscitation.

    • 9. Pediatric campers with food allergies are at greater risk for exposure and anaphylaxis when outside their usual environment. Children with food allergies represent about 8% of the pediatric population, with nearly 40% of those children having a history of severe reaction requiring immediate intervention.36 Those who are directly responsible for care of the camper’s with food allergies should receive hands-on training to recognize anaphylaxis and administer epinephrine. Camps should create and provide their food allergy policies to families before the start of camp and discuss those policies with food vendors. Cross-contamination prevention policies should be established, including washing tables before and after meals, hand-washing practices, serving peanut butter in packets with separate utensils, and not allowing food in camper cabins.

    • 10. Head injuries can cause long-term symptoms and complications, and appropriate management is essential for reducing physical and cognitive deficits.37 Camp activities should be designed to limit the risk of head injuries, and camps should provide the proper equipment and supervision to decrease the incidence and severity of head injuries. Camp staff should have a clear understanding of the definition, signs, and symptoms of concussion and should follow CDC and state-specific return-to-play guidelines before an individual with a head injury participates in competitive or recreational activities to avoid reinjury or prolonged recovery. If a qualified health care provider is not available on-site to evaluate children with suspected head injuries, children should be taken to the nearest medical facility for urgent evaluation.38

    • 11. Camp staff should be trained to effectively respond to camper mental, emotional, and social health needs. Many children who attend camp will have had a diagnosis of ADHD, autism spectrum disorder, or eating disorders, among other diagnoses. Camps should educate their staff about mental health problems, teach staff to support campers who need extra help, and help facilitate communication with parents. Camps should consider using a camp social worker who can assist with psychosocial concerns. A full-time administrator who oversees health care at the camp should also be considered for continuity of care during camp because many camp physicians and nurses rotate and may only be present for short periods of time.39

    • 12. Obesity and related cardiovascular risk factors are important health priorities, and camp communities should adhere to principles of healthy living.40 Food that is served and sold in camps should, at least, follow federal guidelines for school nutrition. Camp staff should model healthy food choices for their campers. Food should not be used as a reward, nor should withholding food be used as a punishment. At least 30 minutes of daily physical activity should be included as a component of any camp program. Plain water should be available throughout the day, and sweetened beverages, including sports drinks, should be strictly limited or simply not used.41

    • 13. The principles promoted in this statement apply to all camps. It should be noted, however, that inclusion of children with disabilities and other special health care needs may require the establishment of additional assessments and services, and it is strongly recommended that all camps adhere to the Americans with Disabilities Act and make the necessary accommodations to maintain an atmosphere of inclusion for all. Appropriate pairing of the camper with camp facilities and camp resources should take place at the application stage of camp enrollment.42 Camps should address accessibility and have equipment available so that all campers and staff can participate in camp activities (eg, adaptive bath chairs and pool lifts). Camp staff should be trained to assist campers who require help with routine activities of daily living, such as dressing, bathing, and toileting.32 In addition, camp personnel should be familiar with the health and safety guidelines for child care centers developed by the AAP, American Public Health Association, and Maternal and Child Health Bureau and should adhere to those appropriate to their programs and facilities.43

    Parents and guardians should feel confident that their children are ready for camp and that their chosen camp is well prepared to care for their children. To this end, the AAP offers the aforementioned recommendations for creating a healthy and safe camp experience.

    Additional Resources

    American Academy of Pediatrics. Coding at the AAP. Available at: https://www.aap.org/en-us/professional-resources/practice-transformation/getting-paid/Coding-at-the-AAP/Pages/default.aspx.

    American Camp Association. American Camp Association’s accreditation process guide. Available at: https://www.acacamps.org/staff-professionals/accreditation-standards/accreditation.

    American Camp Association. Health forms and records. Available at: www.acacamps.org/resource-library/forms/health-forms-records.

    Donoghue EA, Kraft CA. Managing Chronic Health Needs Children in Child Care and School. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

    Erceg LE, Pravda M. The Basics of Camp Nursing, 2nd ed. Monterey, CA: Healthy Learning; 2009.

    Harris SS, Anderson SJ, eds. Care of the Young Athlete. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2010.

    Louv R. Last Child in the Woods. Chapel Hill, NC: Algonquin Books; 2008.

    Thuber CA, Malinowski JC. The Summer Camp Handbook. Los Angeles, CA: Perspective Publishing; 2000.

    Thurber CA. The Secret Ingredients of Summer Camp Success: How to Have the Most Fun with the Least Homesickness [DVD/CD]. Martinsville, IN: American Camp Association; 2006.

    Lead Authors

    Michael J. Ambrose, MD, FAAP

    Edward A. Walton, MD, FAAP

    Consultants

    Tracey Gaslin, PhD, CPNP, FNP-BC, CRNI, Association of Camp Nursing

    Linda Ebner Erceg, RN, MS, PHN, Association of Camp Nursing

    Council on School Health, 2018–2019

    Marc Lerner, MD, FAAP, Chairperson

    Cheryl De Pinto, MD, MPH, FAAP, Chairperson-Elect

    Marti Baum, MD, FAAP

    Nathaniel Savio Beers, MD, MPA, FAAP

    Sara Bode, MD, FAAP

    Erica J. Gibson, MD, FAAP

    Peter Gorski, MD, MPA, FAAP

    Chris Kjolhede, MD, MPH, FAAP

    Sonja C. O’Leary, MD, FAAP

    Heidi Schumacher, MD, FAAP

    Adrienne Weiss-Harrison, MD, FAAP

    Former Executive Committee Members

    Mandy Allison, MD, MSPH, FAAP

    Richard Ancona, MD, FAAP

    Elliott Attisha, DO, FAAP

    Breena Welch Holmes, MD, FAAP, Immediate Past Chairperson

    Jeffrey Okamoto MD, FAAP, Past Chairperson

    Thomas Young, MD, FAAP

    Liaisons

    Susan Hocevar Adkins, MD, FAAP

    Laurie Combe, MN, RN, NCSN

    Delaney Gracy, MD, FAAP

    Shashank Joshi, MD, FAAP

    Former Liaisons

    Nina Fekaris, MS, BSN, RN, NCSN

    Linda Grant, MD, MPH

    Veda Charmaine Johnson, MD, FAAP

    Sheryl Kataoka, MD, MSHS

    Sandra Leonard, DNP, RN, FNP

    Staff

    Stephanie Domain, MS

    Footnotes

    • Address correspondence to Michael J. Ambrose, MD, FAAP. E-mail: ambrosem{at}gmail.com
    • Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    • The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    • FINANCIAL DISCLOSURE: Dr Ambrose has indicated he is CEO and Founder of DocNetwork, Inc, an electronic health record system for camps, child care, and schools. Dr Walton has idicated he has no financial disclosures related to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: Dr Ambrose has indicated he is CEO and Founder of DocNetwork, Inc, an electronic health record system for camps, child care, and schools. Dr Walton has indicated he has no potential conflicts of interest to disclose.

    References