Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Locking the door on measles!
Your family no longer has to travel overseas to come home with one souvenir you didn’t bargain for, a vaccine-preventable disease. Such “souvenirs” may be coming to visit you. Currently, measles is the prime example.
1. Measles, which had become a rarity in this country, is popping up all over. As of mid-April 2019, cases have been reported in 19 states. Virtually all originate overseas. They are brought here by American travelers who became infected overseas and by infected foreigners coming to the US as tourists and students. The virus then spreads, mostly to people who were not or were incompletely vaccinated against measles.
2. Measles was once a common childhood disease, an expected part of growing up. Most children recovered completely. However, one or two in a thousand died, usually from measles complications such as pneumonia or encephalitis, and some others were left with serious permanent disabilities. An average of 450 deaths occurred annually, mostly in previously healthy children.
3. Measles is one of the most infectious diseases. The virus is transmitted through the air: an infected person coughs or sneezes and someone in close proximity then inhales the droplets. Transmission also occurs by touching objects and surfaces contaminated with infected nose or mouth fluids. The virus can remain infectious for up to two hours. Brief exposures suffice to become infected.
4. Aspects of measles help delay diagnosis and subsequent isolation of patients, abetting the spread. Infected individuals begin exhaling the virus about three days prior to showing symptoms of being ill. The earliest symptoms, fever and cough, are not specific to having the disease. Even the eventual rash is not necessarily diagnostic; it resembles other rashes. Moreover, the vast majority of American healthcare providers have never seen a case, further delaying diagnosis. Tell providers about your recent trips if they do not ask you.
5. In the US, since 2000, the percentage of children under two years of age not optimally vaccinated has quadrupled. While this percentage remains small, the trend is troublesome, especially for infants less than six months of age. Measles vaccines are not very effective under this age while many infants are susceptible and tend to experience complications. The best way to protect young infants is to make sure all individuals in contact with them are vaccinated.
6. There are many reasons why parents refuse to vaccinate their children. Ironically, one reason is the success of vaccination programs. Most parents have never seen cases of vaccine-preventable diseases and erroneously conclude that vaccines are no longer important. Some parents believe vaccines cause the diseases that the vaccines are designed to prevent, or cause other adverse reactions. (In fact, the achiness following some vaccines is due to the immune system “revving up” to boost protection.) Other parents believe that vaccines cause autism although there is no evidence to support this. Still others refuse vaccines for ethical or religious reasons.
7. Don’t ask healthcare providers to alter accepted vaccination schedules. Parents ask providers to delay starting vaccinations until children are older, to increase the interval between doses, to dilute doses, or to give one vaccine at a time rather than many. Some providers acquiesce, reasoning that some protection is better than none. This is not a good idea. Accepted schedules are prepared by recognized experts, are based on the latest data, and change from time to time. Altering schedules results in confusion: unknown immunization status, ultimately more doses to correct the situation, and turmoil in record keeping.
8. The risk of acquiring vaccine-preventable diseases increases substantially when traveling outside the US. Most countries have less comprehensive vaccination programs than the US. Some governments cannot afford the costs, vaccination protocols are haphazard with poor record keeping, and children are immunized against fewer diseases. The result: diseases remain common, even in developed countries. Moreover, traveling with children likely increases your family’s odds of interacting with local children, the primary source of such diseases.
9. Consult your healthcare provider if a family member may have been exposed to measles. The time between exposure and the appearance of symptoms varies between seven and fourteen days. A dose of measles vaccine given within three days of exposure will usually prevent or ameliorate the disease. A dose of gamma globulin may help to ameliorate the disease after the three-day period. When making the appointment, notify providers of a possible measles exposure. They may want to see you when there are no other patients in the office.
10. Inform healthcare providers of upcoming foreign travel as soon as you finalize your plans. Family members may require additional vaccines (and preventive medications), especially when visiting developing countries. Some destinations require vaccines that require multiple doses over a period of a several months. Attending large gatherings and staying at the homes of friends and relatives are common ways people are exposed to infection.
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Eating outdoors/ food safety / kids
Eating meals outdoors – at picnics, barbecues, tailgating parties and buffets – substantially increases your risk of getting an intestinal illness, says the US Centers for Disease Control. Moreover, infants and young children, due to their immature immune systems, are especially susceptible to such illnesses.
1. Pack a hand sanitizer. Soap and water are somewhat more effective than hand sanitizers to cleanse hands but are often not available outdoors. Clean your kids and your own hands before eating, and before and after handling food, especially raw meat, poultry, or seafood.
2. Wicker picnic baskets may be quaint but are outdated. High tech, relatively inexpensive coolers help keep foods safe for prolonged periods. When filling, use large pieces of ice or frozen chemical gel, not ice cubes, which melt quickly. Transport coolers inside cars; car trunks can become very hot. Place coolers in the shade, leave closed, and open as infrequently as possible. Leave food items in the cooler until you need them.
3. Proper refrigeration is essential. Even optimally stored meat, fish, and dairy products frequently contain disease-causing organisms. Refrigeration keeps the number at levels sufficiently low to prevent illness. Refrigeration does not kill organisms, it merely prevents them from multiplying. Interruptions in refrigeration – as often happens when meals are moved outdoors – allow organisms to multiply rapidly. Subsequent re-refrigeration preserves the number of organisms at the new higher level, a level that may be sufficient to cause illness. In young children, this level is lower than in adults.
4. Disease-causing organisms are most often found on the surface of foods. When meats and fish thaw, those organisms mix with moisture from the food. The “juices” then drip onto other food items, food-preparing surfaces and peoples’ hands. Transport meats and fish in sealed plastic bags. Carry tin foil to cover surfaces. Never use the same plate or surface for both raw food and prepared food.
5. Keep all foods cool and clean. Wash fruits and vegetables before leaving home. Organisms can be transferred from the skins of melons and other fruits and vegetables to the inside by the knife. Scrub skins and cut them with a clean knife. Keep them cool after cutting.
6. Keep a food thermometer in the cooler. Bacterial count can double in fifteen minutes at high air temperatures. Temperature-sensitive foods should remain at about 40 °F. (4 °C). Such food items may no longer be safe to eat if exposed to higher air temperatures for more than two hours; one hour, if outdoor temperatures are above 90 °F (32° C).
7. Use a food thermometer for outdoor cooking. Items made of ground meat (hamburgers and meatballs, for example) have surface meat mixed throughout. Grilling browns the outside rapidly – sometimes, before critical temperatures are reached at the center. Even centers may turn brown before critical temperatures are reached. Familiarize yourself with food thermometers and how to use and clean them between uses. See https://www.cdc.gov/foodsafety/keep-food-safe.html for critical temperatures for various meat and fish products.
8. Cook eggs well. Organisms may be present inside raw eggs; they enter while the egg is formed in the hen. The organisms can pass through cracks in shell and even the pores in an intact shell. Raw eggs have a coating that prevents organisms to penetrate the shell. Boiling destroys the coating. Keep eggs clean after boiling.
9. Plan to keep insects away. Most insects are merely annoying. But some – flies, for example – can carry disease-causing organisms. Choose picnic sites away from refuse and rotting fruit. Spray your site before unpacking the food – though most outdoor liquid sprays, candles and coils are of questionable efficacy. Bring tablecloths and food hoods to cover food.
10. Be near the front of the line at outdoor buffets. Such meals contain large numbers of different food items. Some foods need to be kept warm, others cold. Generally, all items are placed on the serving table at the same time and may remain there for prolonged periods. The food may be exposed to the sun, insects, peoples’ hands and people breathing on it. Many desserts, some especially prone to spoilage, may remain on the table the longest.
Miscellaneous. Don’t drink untreated natural water; even when crystal clear such water may contain disease-causing organisms. Children may be especially sensitive to certain organisms. Clean work surfaces, utensils, and grills before and after cooking. Bring sunscreens, sunglasses, first aid kits and trash bags.
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Should children miss school for vacations?
You find a package to Disney World that seems almost perfect for your family: working parents with little leisure time for their children, one child in sixth grade, one in third. The package: off-season, reasonably priced, a good fit for your work schedules. But it means that your kids will miss three school days.
To go or not to go? It’s an issue of family bonding versus teaching kids priorities.
And it’s a common question. Search “Missing school for vacations” on Google and you’ll see 169 million entries, likely with almost as many shades of opinion! Obviously, no one can read them all. I browsed a large number and selected some pertinent comments from parents, educators, child psychologists and pediatricians, below.
> In most school districts, keeping children out of school for other than medical reasons or family emergencies is illegal and can result in parents being summoned to court by attendance officers and facing child welfare authorities. Some districts do allow four or fewer days absences per school year for “personal reasons.” In fact, absences of less than ten days per school year are rarely, if ever, investigated. “Chronic” absenteeism, or truancy, is a serious offense and parents may be investigated and punished. Children are never disciplined when parents keep them out of school.
> A majority of school districts are funded by states on the basis of daily attendance. Absenteeism for any reason costs schools large amounts of badly needed money.
> In Britain and the Netherlands, truant officers are posted at airports and train stations before school holidays to ensure that families don’t start vacations early.
> No studies exist on the effects of occasional absenteeism on a child’s school performance. However, numerous studies show that the more absences, the poorer the child’s academic and social performance.
> Decisions to take a child out of school should be based on the grade the child is in, the child’s scholastic abilities, whether essential lessons will be missed, the child’s feelings about missing school, the philosophy of the teacher(s) on the subject, and the school’s policy. Likely, children in lower grades will miss little essential work.
> A child being absent from school disrupts the class and increases teachers’ workloads. Some children are out for a week or two for travel. For the family, a child out of school is one absence. For the teacher of a class of 20 or 30, there may be numerous absences. This means repeating lessons and assigning and checking makeup work, slowing learning for everyone. Classes should not be held back for non-essential absences.
> Travel should be an integral part of a child’s education. A semester overseas is becoming the norm at colleges. Younger children should be encouraged to travel, obviously during vacation time, if possible. However, meaningful, short trips – to historical places or to provide exposure to a different culture, for example – trumps missing a few days of school.
> When you take children out of school for unauthorized reasons, do you level with the teachers or do you make up excuses – a family emergency, for example? Once you start on the road of deceit with the school, and worse, if your kids are old enough to understand what you are doing, what appears to be merely a few days of unauthorized absences becomes a big lie.
> When I was in junior high school my father took me along to attend his conference in Athens, Greece. I missed a week of school. When I think of joys in my youth, Athens comes first to mind.
> Our school administration is supportive of short trips during school time. On returning, children are expected to give a “show and tell” performance about their trip. Possible negative fallout from this is that other children are envious. Remarks heard – probably emanating from parents – are that kids who travel are rich and spoiled.
> The advantage of home-schooling children – an option that seems to becoming increasingly popular – is that you take your children anywhere at any time. Their education travels with them.
> What are you teaching children when you swap a week of school for a sunny beach? They learn that attendance, and by extension, education, isn’t a priority. Schooling comes first.
> I teach in an affluent community. I am appalled by how often parents tell me (they don’t ask) that the student will be absent for an upcoming trip. They say that trips are “educational” when they are not. The lies show a lack of respect for teachers and education.
> My family is poor. It’s vacationing when prices are low or staying home. Missing a few days of school is no big deal.
> Teachers work hard to create dynamic learning experiences that build deep conceptual understanding. These experiences, especially in math, cannot be “made up.” Absences are like when buttoning a shirt and missing one, the whole series is off-kilter.
> Parents erroneously believe that homework assignments in advance of taking kids out of school cover all bases. These students miss classroom discussions, partnering in group, and other activities. Is getting to Disney a day before the masses that important?
> A profession that compresses their work life into 9 months of the year has little standing to be offering criticism of how the rest of us balance schooling and family life.
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Safe sleeping away from home
“Safe sleeping arrangements” should be at the top of your list when you plan nights away from home with your infants and young children, says the American Academy of Pediatrics (AAP). The safe sleeping practices you have developed at home are often difficult to duplicate in new surroundings. This may result in you making rash rather than sound decisions, ones that can lead to serious mishaps.
1. Infants up to one year of age should be put to bed on their backs in a crib with a fairly hard surface with no nearby toys or bumpers, says the AAP. Ideally, make no exceptions to these rules. Not for one night. Not for short naps. Not even if your child wakes up at night – which may occur more frequently away from home. Also, advise baby sitters to follow the rules. One in five infants who experienced SIDS (Sudden Infant Death Syndrome) was in the care of someone other than a parent.
2. Never “co-sleep.” Intuitively, away from home, the simplest solution is to have infants sleep in bed with you. However, infants have been injured when an adult rolled onto them or the infant fell off the bed – no matter how ingeniously the adults tried to prevent such accidents. Breathing issues may occur when infants bury their heads in pillows, comforters and loose bed linen. Also, co-sleeping when traveling may make it difficult to get infants to sleep alone when you return home.
3. Don’t medicate. Until recently it was a fairly common practice for parents to medicate infants for air travel and for other “special situations,” a custom now frowned upon. Generally, antihistamine-type cough and cold remedies were used. The rationale was that occasional medicating couldn’t hurt. However, present thinking is that cold remedies have no place in pediatrics, at any time and for any reason, because of possible side effects. And sedating young children for social reasons is considered irresponsible.
4. Car seats are not for overnight sleeping. Infants sleep well in car seats but should never be left unattended in them. Problems that have occurred include compromised airways when the infant’s head flops onto its chest, entanglement in straps wrongly secured, and falling out of seats. Many car seats are unstable unless properly strapped into cars. (Also, infants should not sleep unattended on sofas, recliners, bouncy chairs or swings.)
5. Check cribs in hotels and hosts’ homes for safety. Cribs should look new, feel solid (no “shaking” parts) and have firm, tight-fitting mattresses: two fingers should not fit between the edge of the mattress and the side of the crib; a 12-ounce soda can should not fit between slats. The mattress level may need adjusting for your child’s size; children’s ability to climb improves continually. Cribs with drop-side rails have been banned, as have decorative cutouts in the headboard or footboard, where a child’s head or limbs could become trapped.
6. “Heirloom” cribs and cradles may not meet current safety specifications. Very old cribs may have been painted with lead-containing paints. Cradles are popular overseas. While they are quaint, infants in cradles can roll so far to one side that the cradle topples over. Most cradles have pins to prevent this but the pins may be broken or missing.
7. Place cribs in safe locations. For older infants, avoid areas near window blinds, shades and drapes to prevent strangulation, and away from furniture that can make it easier for the infant to climb out. Place cribs either flush against the wall or several feet from the wall so that if infants do climb out they will not become wedged between the wall and the crib. Place pillows on the floor around the crib, just in case. For cribs with wheels, check that the wheels are locked.
8. On flights, try not to fall asleep with an infant on your lap. Infants have slipped off laps, landing on the floor and, very rarely, suffocating when a parent’s sleeping body rested over the child’s face. Safety officials recommend using an airline-approved safety seat. Some car seats serve this purpose but few parents use them. The seats are clumsy to carry and may require paying an extra fare.
9. Devise a safe “changing table.” Choose a sturdy place where you can easily prepare babies for sleep and diaper changing – a place where all your supplies, including a receptacle to temporarily store dirty diapers – is within reach. Avoid high surfaces in case your infant falls off. The floor in a corner of the room may be your best choice.
10. Familiarity seems to help infants sleep in new surroundings. While travel necessitates change, try to follow home feeding/napping/going outdoors/bathing schedules. Avoid keeping infants awake for gala get-togethers and such. Take along your infants’ blankets, sheets, pajamas and stuffed toys; familiar textures and smells seem to make infants more comfortable.
Miscellaneous. Portable travel cribs are handy for car trips. They are available for different ages, are lightweight, can be used outdoors, fold easily and compactly, and have not been used by others. Have infants sleep in one for a week before leaving home. Ask for non-smoking rooms at hotels. Ask hosts not to smoke. Night-lights help you get around in unfamiliar surroundings. Check for smoke and carbon monoxide alarms and window guards.
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Adults Getting Vaccinated Protects Children
Parents! Having your children optimally immunized against every vaccine-preventable disease may still not suffice to fully protect them from these diseases. Such protection may require that you, too, are immunized.
1. Experience has shown that there are optimum ages to administer vaccines to children and adults. It is the age before (1) the person is likely to become infected with that disease, (2) the vaccine provides maximum protection, and (3) the protection is long-lasting. These features vary greatly for different vaccines; some give lifetime protection while others do not.
2. Well-functioning programs exist for vaccinating children, but not for adults. Pediatric immunization schedules are prepared by a national board of respected experts and the vast majority of parents comply with their recommendations. They take their infant/young children to the same pediatric facility every month or two to receive a slew of shots to prevent fourteen diseases. These facilities maintain records and the records are freely available to parents.
3. Programs to vaccinate adults function poorly. The importance of vaccinating adults is a fairly new development. Many adults’ physicians are not well informed on vaccinations and most adults are unaware that they too need routine vaccines. Moreover, many adults see physicians only when they are ill and, increasingly, they see specialists who treat one body part and do not offer vaccines. When adults do receive vaccines, it may be from different facilities, sometimes pharmacies, with no central location keeping records.
4. Vaccinating adults protects children. For example,during the first year of life infants are only partially protected against many vaccine-preventable diseases. One reason: it requires several months and multiple doses for some vaccines to establish optimal immunity. One way to protect the infants is to eliminate the most important source likely to make infants ill – unvaccinated adults.
5. Having yourself vaccinated to protect your children protects yourself. Vaccines provide excellent protection. However, some vaccines are not providing protection for as long a time period as previously anticipated. Maintaining protection requires booster doses. Some childhood vaccines require boosting already in teenage years. Maintaining protection for adults is especially important because many vaccine-preventable diseases are far more serious for adults than children. For example, some infections during pregnancy may cause catastrophic damage to the unborn child.
6. Vaccines are especially important for the elderly. Being up-to-date with vaccines throughout adulthood negates the need to give certain vaccines. Advanced age weakens the immune system. This tends to worsens the severity of some vaccine-preventable diseases while lessening the protection afforded from the vaccines. Moreover, many elderly have chronic illnesses, some immune system-related, or are taking medications or treatments that affects the immune system, further complicating the situation.
7. Travel increases your chances of being exposed to an infected individual. Overseas, even in developed countries, vaccination programs are less comprehensive than in the US. This increases the risk of exposure to an infected individual. And traveling with children makes it more likely to have contact with local children, the major source of such diseases. And you need not travel overseas to be exposed. Millions of tourists enter the US. You encounter tourists on local fights, at amusement parks and in national parks. Diseases may also be imported by college students (1.2 million entered the US in 2017), hundreds of thousands of immigrants, and adoptees from overseas.
8. Fewer American children are being vaccinated. The percentage of children under two years of age who are incompletely or not at all vaccinated has quadrupled since 2000. While that percentage remains relatively small, the trend is troublesome. About 100,000 children in this age group aren’t fully vaccinated against the fourteen vaccine-preventable diseases. Some health care providers acquiesce to parents’ requests to start vaccination for infants at a later date, give fewer vaccines at a time, or increase the intervals between doses. Such actions postpone optimum protection.
9. Start keeping records of the vaccines you receive. This is an obvious recommendation but one that few adults follow. Many medical facilities now print summaries of the reason for your visit, diagnosis, and treatment and immunization, if any, given. Store the reports with your other important papers. (Confession: I am a retired (elderly) pediatrician. I have received immunizations in recent years but have no written proof of when, where and what I received, and if and when booster doses are due. I am changing my ways as of now.)
10. Retrieve your immunization records from the past. Ask your parents or relatives if they recall the medical facilities you were taken to as a child. Records may still exist. Large clinics, colleges and the military tend to keep records longer than private medical offices. If you traveled internationally you may have a booklet listing the vaccines you previously received plus the vaccines you needed for the trip. Your age can be a clue; you may need vaccines that were not yet available when you were a child. In some situations a blood test determines susceptibility or immunity. If immunity cannot be established, giving you an additional dose of the vaccine is not known to be harmful.
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Playground safety – a kid’s point of view
Hey Kids! Grownups need our help in keeping us kids happy, healthy and, especially, safe. True, nothing makes us happier (or safer) than staying home, lying on the floor and watching cartoons on TV. However, we kids are told that we need fresh air and exercise, like going to playgrounds to run around aimlessly and climb on strange-looking contraptions that send 200,000 of us to ERs every year. Where’s the logic?
Here’s some advice we kids need to give grownups about playgrounds.
1. Bear in mind why you take us to playgrounds. You’re there to keep an eye on us, not to schmooze with your friends on getting us into a popular kindergarten while we’re getting hit by someone on a swing trying to reach the sky. Better supervision of us could prevent about 40% of playground accidents.
2. Many home playgrounds are unsafe. The equipment is placed into any available space, with little thought to the surroundings — next to the driveway for the family car, for example. We kids love exploring, like running around to where we can’t be seen, like a neighbor’ back yard or into an unlocked car. Often the play equipment in home playgrounds is old and was assembled from a do-it-yourself kit by someone who had never done it before and then the equipment is never checked again.
3. Take us to recently-built, public playgrounds. These are generally planned and equipped by experts who know about proper spacing between rungs on ladders, where to place hand rails and the size of openings we kids should and shouldn’t fit through. Modern playgrounds are fenced in with single exits, all areas in sight, and equipment spaced far apart. They have segregated area with different equipment for our various age groups: infants and toddlers (under 2), preschoolers (2- to 5-year-olds), and school-age kids (5 to 12-year-olds). Sure, we know that we are put into a corral but it lets us make believe that we are free-range kids for a while.
4. Falls are the most common cause of us getting hurt. We kids love to climb high. But sometimes, when we look down, we panic and let go. Never coax us into activities that scare us. Stay within arm’s reach when we climb – and be ready to catch us if we do fall.
5. Preventing falls on our heads is especially important. Most such falls occur from monkey bars, playground gyms and swings. Kids between 5 and 9 years of age are most frequently involved, boys more frequently than girls. If after such falls we act weird or can’t recall exactly what happened, it’s time for a ride to an ER.
6. Grownups, make sure that the playground has special groundcover around equipment to cushion our falls. Us kids learn the day we take our first step that falling is scary and hurts, especially falling on hard stuff like concrete. “Good” stuff to fall on includes wood chips, mulch and various rubber-like substances. Dirt and grass can feel like concrete in cold weather. Good ground cover is rarely found in home playgrounds.
7. And let us kids play only on equipment meant for our age. Seesaws, for example, are no-no’s for us toddlers and preschoolers. Such equipment requires coordination between two kids, something we can’t manage yet. And school-agers can get entangled in equipment meant for younger kids. Also, older kids, who think they’re smart alecks because they already go to school, can roughhouse or bully us younger kids, hurting us in the process. (Safety information for each type of equipment is available on the web.)
8. Dress us for safety, not to impress other grownups. Do we really care if we look like ragamuffins? Safety means no hooded jackets, scarves or clothing with ties and loose cords; these can get caught in playground equipment. No sandals or flip-flops; they may cause tripping. Long hair should be tied back. Shoes should be on securely.
9. Trampolines and sandboxes are not well-suited for us kids. On trampolines, too often we land on our heads, collide with other kids or fall off. Sandboxes are rarely covered when not in use and attract animals. And we know what animals do in sandboxes. Also, many of us real young kids are curious about what sand tastes like.
10. On family vacations, grownups, check the safety of playgrounds, pools, beaches, water slides, and such. (And, kids, no temper tantrums, if such checking delays us from having fun.) Non-professionally installed equipment is frequently found at small resorts and traveling carnivals. Be especially careful overseas. In many countries medical facilities to take care of us kids aren’t as good as they are back home.
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