Diabetes Care at Diabetes Camps
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INTRODUCTION
Since Leonard F.C. Wendt, MD, opened the doors of the first diabetes camp in Michigan in 1925, the concept of specialized residential and day camps for children with diabetes has become widespread throughout the U.S. and many other parts of the world. It is estimated that worldwide camps serve 15,000–20,000 campers with diabetes each summer.
The mission of camps specialized for children and youth with diabetes is to facilitate a traditional camping experience in a medically safe environment. An equally important goal is to enable children with diabetes to meet and share their experiences with one another while they learn to be more responsible for their condition. For this to occur, a skilled medical and camping staff must be available to ensure optimal safety and an integrated camping/educational experience.
DIABETES MANAGEMENT AT CAMP
The recommendations for diabetes management of children at a diabetes camp are not significantly different from what has been outlined by the American Diabetes Association (ADA) as the standards of care for people with type 1 diabetes or for children with diabetes in the school or day care setting.
In general, the diabetes camping experience is short term and is most often associated with increased physical activity relative to that experienced at home. Thus, goals of glycemic control are more related to the avoidance of extremes of blood glucose than to the optimization of overall glycemic control while away at camp. The management protocol aims to balance insulin dosage with activity level and food intake so that blood glucose levels stay within a safe target range, especially with respect to the prevention and management of hypoglycemia. Each camper should have a standardized comprehensive health history form completed by his/her family and a health evaluation form completed by the physician managing the diabetes that details the camper’s past medical history, immunization record, and diabetes regimen. The home insulin dosage should be recorded for each camper, including number and timing of injections or basal and bolus dosages given by continuous subcutaneous insulin infusion (CSII) and type(s) of insulin used. Records for insulin dosages and blood glucose values for the week immediately before camp should be provided. Additional medical information, such as prior diabetes-related illnesses and hospitalizations, history of severe hypoglycemia, previous A1C levels, other medications, significant medical conditions, and psychological issues should also be available to camp personnel and reviewed with diligence by those responsible for the health and well-being of the individual camper.
During camp, a record of the camper’s diabetes care progress should be documented daily. All blood glucose levels and insulin dosages should be recorded in a format that allows for review and analysis to determine whether alterations in the diabetes regimen are required. A record of the degree of activity and food intake may also be helpful in determining subsequent alterations in the diabetes regimen. It is imperative that the medical staff have knowledge about the exercise schedule and the meal plan at camp so that they can make appropriate insulin dosage adjustments.
To ensure safety and optimal diabetes management, multiple blood glucose determinations should be made and recorded throughout each 24-h period: before meals, at bedtime, after or during prolonged and strenuous activity, in the middle of the night when indicated for prior hypoglycemia, and after extra doses of insulin. Consideration may also be given to parental or camper requests. Because exercise may still impact blood glucose 12–18 h after completion, campers who have repeated lows during exercise may also need nocturnal testing. Any camper with a bedtime blood glucose level
<100 mg/dl and campers on an insulin pump with a blood glucose >240 mg/dl should have their blood glucose rechecked overnight. The intervention for campers with an overnight blood glucose level <100 mg/dl should be determined based on their insulin regimen and risk for nocturnal hypoglycemia. Campers on insulin pumps with a bedtime or overnight blood glucose >240 mg/dl should follow an established pump protocol for ketone testing and change of catheter site. Children should be encouraged to check blood glucose levels at times other than the routine times if they have symptoms of hypo-/hyperglycemia or if they have other physical complaints. These recommendations imply that there is adequate staffing and that they have received training in blood glucose monitoring procedures as well as the indications and treatment excursions of blood glucose.
Every attempt should be made to follow the home insulin regimen of each camper as closely as possible. If a child’s blood glucose record prior to camp indicates tight glucose control and a low activity level, it may be advisable to decrease the insulin dosage in anticipation of the increased activity. Hypoglycemia may occur at the beginning of camp because of increased physical activity and failure to have free access to food. Other alterations in insulin dosage may need to be made for extreme physical activity, such as prolonged hikes or active water sports.
Increasingly, children manage their diabetes with an insulin infusion pump. The camp medical director and other appropriate medical staff should be familiar with the programming of insulin pumps, replacement of insulin infusion catheters, and insulin adjustments using continuous insulin infusion therapy. The medical staff should ensure that adequate backup pump supplies, including extra batteries, are available for the duration of camp.
If major alterations of a camper’s regimen appear to be indicated, such as adding an additional insulin injection(s) or changing an insulin type, it is important to discuss this with the camper and the family in addition to the child’s local diabetes physician before the change is made. The record of what transpired during camp should be discussed with the family when the camper is picked up. However, this may not be possible for campers who go home by bus or car pool; in these instances, the record should be sent with the camper or by mail to his/her family. A record of the blood glucose values, insulin doses, and other medical care provided at camp, with an additional copy for the family to share with their primary diabetes team (if they choose), should be available to the family at the end of camp. Campers should be advised to return to their precamp regimen once they are home, unless the alterations appear to significantly improve glycemic control. In this circumstance, the family should seek the guidance of their primary diabetes team
Three meals and two to three snacks should be given at set times each day accommodating special dietary needs when needed. These meals and snacks should be balanced, and their composition should be made known to campers and staff. The carbohydrate component of food, exchange value, and/or calorie count should be taught to campers, according to their developmental level, to enable them to learn how to balance food and activity. Supervision of the food intake of children by counselors ensures that the campers are consuming adequate nutrition. Signs of eating disorders should be reported to medical staff for assessment and intervention if necessary. In addition to the need for nutrition support for optimal diabetes management at camp, there is likely to be a need for special nutrition expertise in the area of food allergies, in general, and celiac disease, in particular, with increasing numbers of youth being diagnosed with both diabetes and celiac disease.
A formal relationship with a nearby medical facility should be secured for each camp so that camp medical staff has the ability to refer to this facility for prompt treatment of medical emergencies. (The American Camping Association requires the notification of all emergency medical support systems local to the camp.) If the camp is located in a remote area, an arrangement should be made with a medical helicopter or fixed-wing aircraft to provide rapid transport if necessary.
Universal precautions including Occupational Safety & Health Association (OSHA), Clinical Laboratory Improvement Amendments (CLIA), and state regulations must be followed by all, with gloves worn for all procedures that involve blood draws and appropriate containers placed throughout the camp to dispose of sharps without hazard. Retractable single-use lancets and glucose meters in which blood does not touch the machine itself are preferable for group testing. Retractable needles may be considered to further reduce the risk of untoward blood contamination among campers and staff.
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