Creating Healthy Camp Experiences

For 150 years, children have been attending camp.¹  Today, approximately 11 million children attend day or resident camp, supported by 1.2 million staff members.²  Currently, camp programs exist in myriad forms and cater to any interest or population imaginable. The camp experience has been proven to have a lasting effect on psychosocial development, including significant effects on self-esteem, peer relationships, independence, leadership, values, and willingness to try new things.³  Camps 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  Safety research has revealed that camps have a safety profile equivalent to, or better than, many other activities that parents choose for their children.⁵ 

Camp health care providers can expect to care for campers with any of the medical and psychological issues seen daily by primary pediatric providers. As a result, the precamp health evaluation takes on increased importance. Parents, the primary health care provider, camp administrators, and camp health care providers should openly share information to ensure that a camper is appropriate for his or her new environment. In addition, parents should medically and psychosocially 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 that off-site support is in place.

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 mission statements and promotional handouts can help guide parents when choosing an appropriate camping environment for their child. Before enrolling their child, parents should be aware of preadmission medical requirements for campers and the scope of health services available at camp.

   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.

2. All campers should provide the camp with a complete annual review of their health by a licensed health care provider, preferably before the first day of camp. This recommendation is consistent with the Bright Futures initiative.⁶  The appropriateness of the camp's program for the individual camper should be addressed during that review, which, in turn, means that the health care provider must be provided pertinent information about the camp. An evaluation within the 6 months before camp arrival should be considered for children with ongoing health care needs.

   The annual review should include a comprehensive health history. The history should include the child's significant previous illnesses, surgeries, injuries, and allergies and present state of physical and psychological health. Campers with clinically significant medical histories or those with conditions that require long-term management (eg, asthma, seizures, diabetes, anaphylactic allergies, immunocompromise, congenital anomalies, mood or anxiety disorders, attention-deficit/hyperactivity disorder) should have specific medical clearance before participation. A management plan appropriate to the camp program that addresses any ongoing medical or psychological issues should be created. This plan should also address medications, both prescription and over-the-counter, to be used by the child while at camp.⁷  Written orders from a licensed health care provider should be obtained for prescription medications, diets, physical activity limitations, or special medical devices. Additional information about coding and documentation related to providing these services is included in the Appendix.

3. Parents or guardians are responsible for providing to the appropriate camp representatives information about any changes in health status, recent travel, new medications, or any changes in maintenance medications. Elective interruption of medications (drug holiday) should be avoided by campers on long-term psychotropic therapy or those on maintenance therapy required for a chronic medical condition.^8,–,10 

4. Before starting camp, all campers 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, and the American Academy of Family Physicians.¹¹  Camp administrators should be aware that individual states might require other immunizations in addition to those recommended by the AAP. Polices must also be in place regarding participation in the camp program by campers who are incompletely immunized or unimmunized. People who travel internationally as part of a camp program should consult the Centers for Disease Control and Prevention traveler's health Web site or visit a traveler's clinic for information regarding particular immunization requirements or health concerns that may be associated with their destination.¹² 

5. Some inexperienced campers experience acute psychological distress associated with separation from home and loved ones, which is commonly known as homesickness. The following interventions may be helpful for prospective campers and their parents, because they have been found to significantly reduce the incidence and severity of homesickness⁹ :

   • 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.

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

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. Health care providers should discuss these interventions as part of the anticipatory guidance associated with the health evaluation before camp.

1. Camp administrative officials should have a clear understanding of the essential functions of a camper insofar as their specific camp program is concerned.¹³  It is the responsibility of the camp to provide to parents, children, and precamp examiners expectations for successful participation in the camp program. Certain camp activities may increase the risk of complications from specific medical conditions (eg, scuba diving 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 that child.

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 providers.^14,15  Camp administrators should inquire about the previous training and camp experience of the camp health care provider and provide additional training or support if necessary.¹⁶ 

   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. Local emergency medical services providers should be contacted before camp begins to ensure prompt and coordinated response in the event of an emergency.^16,17  Camps should also establish relationships with local dentists and/or orthodontists who are willing to treat dental emergencies if the need arises and 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.

   Illnesses and conditions that commonly affect camp life should be considered for inclusion in protocols for treatment by camp health care providers, including:

   • fever;

   • conjunctivitis;

   • upper respiratory tract infections;

   • otitis externa and media;

   • streptococcal pharyngitis and sore throat;

   • vomiting and diarrhea (including large outbreaks);

   • asthma, anaphylaxis, and allergy management, including food allergies;

   • skin infections: impetigo, fungal, abscess;

   • lice and scabies;

   • dermatitis, including poison ivy and poison oak;

   • insect bites, stings, and tick exposure;

   • common injuries, head injury and concussion;

   • heat- or cold-related illness;

   • homesickness; and

   • behavioral or psychiatric episodes.

   The 2009–2010 H1N1 influenza pandemic and the emergence of methicillin-resistant Staphylococcus aureus (MRSA) have highlighted the need for increased screening and surveillance at camps and the ongoing importance of teaching good hygiene practices, the most important of which are good hand-washing and cough/sneeze behaviors. Camps should have in place management plans for infectious outbreaks.¹⁸  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, Rocky Mountain spotted fever).¹⁹  A camp disaster plan should also be in place.

   On initial arrival at camp, all campers and staff should undergo a screening supervised by the camp health staff to assess the potential for communicable diseases, establish a health status baseline, and identify health problems such as impetigo or lice. Updated medication orders and health history should be made available to camp health staff at this time.

3. Camp health care providers with appropriate knowledge and training should be responsible for the safe storage and administration of medications. This responsibility varies with the type of camp (eg, a camp for children with diabetes or a camp for children with cancer). 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.⁷ 

   Camps that maintain oxygen or other emergency medication or equipment should periodically check supplies and ensure that necessary training has been completed. Recent guidelines support the use of automated external defibrillators (AEDs) in children 1 year or older.²⁰  All camps should critically review the populations they serve and the need for an AED on site. Camps with an AED should comply with local regulations regarding required protocols and training for their use. With regard to personal emergency medications or medical devices such as inhalers or epinephrine autoinjectors, campers should be instructed in their use before arrival at camp. Parents should also make clear to the camp staff primarily responsible for the camper the situations that may require use of these medications and whether the child is competent in their administration. Specific protocols for administration of these medications or use of specialized equipment by the camper, counselors, or other nonlicensed providers should be created. These devices should be kept in locations that are easily accessible to the people who may need them.⁷ 

4. A health record system should be maintained that documents all camper and staff illnesses and injuries and that allows for surveillance of the camp illness and injury profile. In addition, camps should consider use of an electronic health record that is compliant with federal guidelines.²¹  Camp records should include emergency contacts for all children. 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 address, and the date of the last health care visit should be noted.²²  Written authorization to obtain treatment, to transport children in camp vehicles for nonemergent care, and to share medical information should be provided by the parent or guardian.²³  Camps should make clear their requirements for health insurance coverage, and parents or guardians should ensure that their policy is in force at the camp's location. Confidentiality of health information should be maintained.²⁴  Camp health history and physical examination forms that meet the aforementioned recommendations and that have been reviewed by the AAP are available to camps and health care providers from the American Camp Association.²⁵ 

5. It is important for all camps to have personnel who can administer on-site first aid and cardiopulmonary resuscitation (CPR), irrespective of their distance from definitive medical care. This statement does not address specific camp staff issues; however, those who are involved in waterfront activities should be certified in cardiopulmonary resuscitation.

6. Obesity and related cardiovascular risk factors are important public health priorities, and camp communities should adhere to principles of healthy living.²⁶  Food that is served and sold in camps should, at least, follow federal guidelines for school nutrition. Camp staff should model healthful 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 sport drinks, should be strictly limited or simply not used.²⁷ 

7. 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 that camps designed to serve that population of children and adolescents specifically will be equipped differently. Camp authorities should work with local pediatricians and other health care providers to conduct health appraisals for children before their participation in camp and determine appropriate services and programs for children with special needs.²²  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 that are appropriate to their programs and facilities.²⁸ 

Parents 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 camp experience.

Edward A. Walton, MD

Alison S. Tothy, MD

Robert D. Murray, MD, Chairperson

Cynthia DiLaura Devore, MD, Chairperson-Elect

Mandy Allison, MD

Stephen E. Barnett, MD

Robert C. Gunther, MD, MPH

Breena Welch Holmes, MD

Jeffrey H. Lamont, MD

Mark Minier, MD

Jeffrey Okamoto, MD

Lani S. M. Wheeler, MD

Rani Gereige, MD, MPH

George Monteverdi, MD

Evan Pattishall III, MD

Michele Roland, MD

Wendy Anderson, MD

Mary Vernon-Smiley, MD

Centers for Disease Control and Prevention

Linda Davis-Alldritt, RN, MA, PHN

National Association of School Nurses

Linda Grant, MD, MPH

American School Health Association

Veda Johnson, MD

National Assembly on School-Based Health Care

Robert Wallace, MD

Independent School Health Association

Alex B. Blum, MD

Section on Residents

Sandi Delack, RN, MEd, NCSN

National Association of School Nurses

Linda Ebner Erceg, RN, MS, PHN

Association of Camp Nurses

Edward A. Walton, MD

Alison S. Tothy, MD

Madra Guinn-Jones, MPH

[email protected]

American Camp Association. American Camp Association's Accreditation Process Guide. Martinsville, IN: American Camping Association; 2007

American Camp Association. Health forms and records. Available at: www.acacamps.org/knowledge/health/forms.php

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

Pediatric providers should become skilled at and comfortable with establishing coding practices of (and expecting appropriate reimbursement for) their services in performing and documenting camp, school, and sports examinations.

1. When possible, use the preventive medicine services codes (99381–99397). These codes most accurately describe both the comprehensive examination and counseling services rendered. Many camp, school, and sports forms require additional examinations (eg, measuring heart rate and blood pressure after exercise) or counseling (eg, asthma management related to exercise or high altitude) above and beyond the “standard” parameters included in annual evaluations.

2. If the need for examination arises after a patient has already received an annual preventive medicine services examination, health plans typically do not cover the cost of a second examination. Providers may elect to complete camp forms on the basis of a recent preventive medicine services visit or schedule an additional visit. If allowed by the child's insurance, parents may be billed for the additional noncovered services.

3. Office or other outpatient services codes (99201–99215) may be used if a problem is identified during the visit.

4. Office or other outpatient consultation codes (99241–99245) provide a possible alternative method if the “rule of 3 'Rs” is met:

   • The service is requested by the camp or school (the office record should verify the request).

   • The services (examination and documentation) are rendered by the provider.

   • A written report (the completed camp or school form) is provided to the requesting camp or school.

5. In addition, the special report code (99080) may be reported if a provider is required to complete a specific camp or school form.

1. Use code V20.2 if the camp or school service is incorporated into the annual “well-child care” visit.

2. Use code V70.3 if the camp or school service is a separate preventive medicine services, consultation, or office or other outpatient services visit.

3. Use specific problem-based code(s) if specific problems are found and addressed.

1. Specific forms are usually provided by the camp or school. Once completed by the provider, these forms should contain documentation consistent with the provider's chart records.

2. Care should be exercised to avoid breaches of issues of confidentiality, especially with preteen and teenaged patients.

3. The American Camp Association has excellent resources to serve as guidelines for proper documentation of camp-related examinations (www.acacamps.org/knowledge/health/forms).

For coding questions, please contact the AAP coding hotline at [email protected].

Reference: American Academy of Pediatrics. Coding for Pediatrics 2011. Elk Grove Village, IL: American Academy of Pediatrics; 2010. Available at: https://www.nfaap.org/netFORUM/eweb/DynamicPage.aspx?webcode=aapbks_productdetail&key=f7dd77bd-2bdb-49f8-b660-8a78ec6f9441.