Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Help! Will somebody hush that crying baby on this plane?!
(This is an update of an article I wrote some years ago. It also appeared in the New York Times.)
When traveling by air, a lasting nightmare is sitting near a cuddly little baby that suddenly morphs into a nonstop noise machine, emitting high decibel, ear-piercing, headache-producing, sleep-preventing discomfort. An even worse nightmare: it’s your baby.
1. “Crying infants” is one of the more objectionable features of air travel. Surveys show it rivals foul language, being seated next to an obese passenger, body odor, boisterous behavior and inappropriate displays of affection.
[An Australian airline settled a lawsuit by a passenger who said a screaming child caused her to lose some of her hearing. The incident occurred before the aircraft left the ground.]
2. In fact, the vast majority of infants do NOT cry while traveling by air. I base this on (1) my personal observations during hundreds of flights, (2) fifty years of questions from parents in my pediatric and travel medicine office, and (3) a questionnaire regarding crying that I distributed years ago to parents who recently had traveled by air with infants less than three years of age. (True, not a scientific study.) The consensus: most infants sleep like the proverbial baby, sometimes better than they do at home. The droning of the aircraft may lull them to sleep.
3. Yes, some infants do cry during flight. Surprisingly few, though, considering that air travel disrupts their eating and sleeping schedules and places them in new surroundings, away from their own cribs, in new and often uncomfortable sleeping positions and among strange noises and unfamiliar faces. If they are resting on an adult’s lap, they are disturbed every time the adult moves. However, the rare infant who does cry is so disturbing to us, say psychologists, that the event is ingrained into our psyches and remembered for years, the result of mixed feelings of anger at the helpless baby, anger at the hapless parent(s), and guilt for feeling such anger.
4. There are many theories but few facts regarding crying during air travel. “My baby cries all the time” is a common complaint at routine pediatric checkups. Likely, there are many causes that can be lumped together as “general discomfort.” Serious illness as a cause for such crying is an extremely rare finding. Our surveys suggest in-flight criers generally cry excessively at home and often at about the same hour on the clock. (Theories to explain excessive crying come and go. Acid reflux is currently in vogue.)
5. Some parents unwittingly contribute to inflight crying. They give infants lots of fluids, to prevent dehydration. In fact, dehydration during air travel is a myth. Adults erroneously interpret their own parched mouths and throats as dehydration. In fact, this dryness is due to air conditioning removing moisture from the cabin air. Moreover, changes in atmospheric pressure at cruising altitudes increase air in the stomach and intestines by about 20%. (This gives many adults a bloated feeling.) In infants, excessive fluids may cause colic. Feed infants no more inflight than at home.
[From a website for nursing mothers: Carry a lightweight blanket. Nurse discreetly. When someone objects, offer them the blanket so they can cover their eyes.]
6. Ear pain may be a culprit in inflight crying. Again, blame atmospheric pressure. And blame an air sac in the inner ear. Normally, the Eustachian tubes connect that sac with the nose and the outside, equalizing pressure. However, if the tubes become clogged with mucus from colds or allergies, the air in the middle ear is trapped. Atmospheric pressure expands the air, causing it to impinge on surrounding tissue and cause pain. Moreover, infants’ tubes are narrower than those in adults and mucus accumulation is more common. Fortunately, as far as is known, crying does not damage the ears.
7. Can parents prevent inflight crying? Sometimes. Sedating infants for air travel, once commonly done, is no longer recommended. Infants were given antihistamines to make them drowsy. However, this rarely helped. Additionally, antihistamines have many side effects and are now rarely used for any purpose in young children. Also not very helpful is waking sleeping infants for takeoff and landing when crying may be somewhat more common; awake infants swallow more frequently than sleeping ones and swallowing may help open clogged Eustachian tubes. Also, awake infants can be given bottles or be breastfed which also increases the frequency of swallowing. However, more liquids may cause colic. And why wake sleeping infants to prevent crying (though, ironically, crying also increases swallowing)? An age-appropriate dose of acetaminophen or ibuprofen may relieve ear pain.
[To misquote Shakespeare: To sedate or not to sedate infants for air travel, that is an oft-raised question. Is it truly nobler to spurn sedatives, risk a crying child and bravely suffer the scorn of outraged fellow passengers? Or is it more virtuous to sedate infants, perchance they’ll sleep, but endure the thousand humiliations that parental guilt is capable of self-inflicting?]
8. Airlines claim they have no solutions for the “crying infant dilemma.” Proposals include banning infants from scheduled “quiet” flights, setting aside a section of planes for families, and partitioning the back of aircraft with soundproof curtains. Presently, some airlines ban infants from first class. However, in an article asking, “Will new airline seating proposals create ‘baby ghettos?’,’’ the Wall Street Journal says that, likely, segregation won’t “fly.” If family sections are full and seats are available elsewhere, would families be barred from that flight? Must families with well-behaved children sit in the family section? Will adults traveling alone accept seats near children?
[A flight attendant allegedly secretly added Xanax, an antidepressant, to juice and told the mother that it will make her screaming infant sleep. It is unclear if the infant drank the juice; no side effects occurred. Later, the mother noticed that the juice was foamy, contained blue specks, and tasted bitter. She submitted the juice to authorities. Analysis revealed Xanax. The FBI charged the flight attendant with assault, charges he denied. He was fired. The outcome of the charges is unknown.]
9. Try every trick you can think of, bribery included. Bring toys, familiar blankets, bottles, appropriate treats, a DVD player and a pacifier (even if you don’t use one at home). Nurse them. Sing and hum. Walk up and down the aisle – but watch your step. Holding your infant in your arms blocks your view of protruding feet and luggage.
10. Ignore the scorn of fellow passengers. Stay calm, if possible. Infants may feel adults’ stress and cry in response. While fellow passengers may become angry with you, most of them, at some level, realize that no parent is oblivious to a screaming infant in their arms. Attempt to make peace with your neighbors before they make an enemy of you. Apologize for the disturbance. Tell them that you are doing your best to quiet your baby. Likely, they will sympathize with you. Listen to their suggestions; you need not act on them. Politely suggest they ask the flight attendant for another seat, if possible, or for earplugs or earphones.
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Should infants sit in safety seats for air travel?
1. The facts: Infants are the only items on an aircraft that need not be battened down (secured) for takeoff, turbulence and landing. In case of severe turbulence and survivable crashes, an unrestrained 20-pound (9 kilos) infant sitting on your lap instantaneously becomes a 300-pound weight (136 kilos) that you cannot restrain. Infants have hit the aircraft ceiling or been propelled several rows forward, resulting in serious injuries and deaths.
2. You, the parent, must decide whether or not to use a safety seat (child restraint system, CRS.) Few parents do, mainly because airline travel is so safe. US regulations – and those of most other countries – allow infants less than two years of age to be held on an adult’s lap. Millions of young children travel by air annually, though the precise number is unknown. Estimates done some years ago, suggest that, in survivable accidents, if every child sat in a CRS it would prevent one serious accident or death every four years or so. One passenger death, an adult in 2018, was the first fatality on a US airline in nine years.
3. Using CRSs can be expensive. CRSs generally require purchasing an extra airline seat. The cost of such a seat ranges from free (increasingly rare) to full fare, with most such seats costing about half the full fare. Costs vary with airlines, empty seats available, and class of travel. Special rates for an extra seat to accommodate a CRS are rarely advertised; ask to receive a reduced-rate ticket.
4. CRSs have practical limitations. Until recently, a financial limitation was the cost of buying a CRS appropriate for air travel; most car seats did not fit into airline seats. Now, with rare exceptions, car seats meet the requirements. Check your car seat model with your airline. Also check model and rules with airline(s) if you visit other countries; rules may differ markedly.
5. CRS are cumbersome. Carrying a seat, the infant, and items needed by infants is at best a difficult task, a task almost impossible if only one adult is traveling. Moreover, even if you bring a CRS, during the flight, you still spend time holding your infant on your lap or walking the aisles, reducing the effective time the seat is protective. Especially on long flights, infants need to be fed, changed and comforted, tasks difficult to perform in the CRS.
6. Forcing all parents to use CRSs may be counterproductive. According to some experts, the cost of purchasing a seat for a CRS convinces many families who are planning short flights, to drive rather than fly. Road travel is more dangerous than air travel and would increase the number of injuries/deaths. However, such reasoning may be flawed. Driving statistics include all drivers – impaired and reckless ones, for example. Likely, most parents driving children are safer drivers.
7. Partial alternatives to CRSs are available. U.S. authorities have approved Child Aviation Restraint Systems (CARES), but only for children weighing between 22 and 44 pounds (10 to 20 kilos), generally children between one and four years of age. CARES do require purchasing airline seats but eliminates the use of a CRS. CARES consists of a harness worn by the child. The harness attaches to the airplane seat belt and has a strap that goes around the back of the airplane seat. The harness is lightweight and fits easily into a diaper bag.
8. Another partial alternative to CRSs are infants restraining vests. Such vests have straps that attach to the adult’s seat belt, allowing infants to sit on an adult’s lap, making extra airline seats unnecessary. These vests are lightweight and fit into a small pouch. However, vests cannot be used during takeoff or landing. Moreover, the permissibility of both vests and CARES varies from country to country. Check with your airline; most have websites with detailed information regarding infant safety considerations. CARES and vests can be purchased online.
9. CRSs may protect infants from several extremely rare types of mishaps. Unsecured lap infants are injured when adults fall asleep and the infants slides off the lap. And infants are suffocated when an adult falls asleep with their chest atop the infant. Even rarer, several lap infants have died in what may have been cases of SIDS (Sudden infant death syndrome.) However, the incidence of the combined number of these events probably approaches the one in a million frequency.
10. Are CRSs really necessary? Only a government-approved CRS offers infants maximum protection. The use of CRSs is strongly recommended by the American Academy of Pediatric, Centers for Disease Control, National Transportation Safety Board and Federal Aviation Administration. Moreover, these groups are petitioning government regulatory agencies to make the use of CRSs mandatory.
What do you think?
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Seasonal Affective Disorder in Children
A larger dose of sunlight is the antidote for kids who become especially ornery as winter approaches and the hours of daylight dwindle down to a meager few.
1. Sunlight helps minimize being sad and having SAD. Sad (small letters) is having the “winter blues.” SAD (capital letters) stands for Seasonal Affective Disorder, a more serious form of the winter blues. Until recently this condition was regarded with skepticism by mainstream mental health experts. No more. Evidence suggests it does exist – more so in adults but also in children, even young children.
2. The winter blues is feeling gloomy much of the time. Sufferers have less energy and difficulty concentrating, become irritable more easily, need more sleep, and take longer to get up in the morning. In younger children, crankiness and crying spells may occur more often.
3. People with SAD have various degrees of depression. In severe cases, SAD is a debilitating condition, preventing sufferers from functioning normally in their personal and school or professional lives.
4. Seasonality of the symptoms makes the diagnosis. Commonly, symptoms begin in the late fall, become worse as the days grow shorter, peak in January or February, and begin to wane in March and April.
5. The severity of symptoms depends on an individual’s sensitivity to decreased light. The process is complex and poorly understood, involving the body’s sleep/wake cycle, hormones and many other factors. Light enters the body mostly through the pupils of the eyes and then travels to specific points in the brain. The process may be akin to that which causes winter hibernation in some species of animals.
6. The further north you live, the more common the condition. In Canada, Finland, Ireland and the northern United States, 6% to 8% of the population is affected – up to 15% to 20%, if very mild cases are included. While winter blues and SAD occur predominantly in adults, in the United States alone more than one million children are believed to be afflicted. Winter blues and SAD are not seen in the tropics. And cases are rare in the Southern Hemisphere where few people live where winters are long.
7. Winter blues and SAD are more difficult to diagnose in children. Symptoms tend to be milder and, since they occur in the winter months, are often blamed on school-related issues. Signs include being frequently late for school, having difficulty doing homework, experiencing grades dropping as the winter progresses, and avoiding social interactions.
8. An hour of exposure to daylight helps alleviate symptoms. Direct sunlight is best, but overcast daylight is also helpful. Have children walk to school and ask teachers to seat them near windows in classrooms. Let them participate in outdoor winter activities after school and do their homework after dark. Around the house, keep curtains open during the day. Trim tree branches that block light. Place chairs near a window. Rarely, cases may need professional counseling.
9. Electric devices are available which emit specific artificial light to supplement natural light. Learn safety precautions – how far a child should sit from the light, for example. Generally, 30 to 60 minutes of exposure daily relieves symptoms. Rarely, cases may need professional counseling. A good discussion on light therapy is available at the Mayo Clinic.
10. SAD may help explain the popularity of winter vacations in the tropics. People who enjoy such vacations generally give “relaxation” as the main reason. In fact, unknowingly, they may feel better because of longer hours of daylight with plenty of sunshine. However, such “cures” are usually temporary. Symptoms generally reappear soon after vacationers return home.
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Why Travel With Your Children?
Traveling and vacationing with your children are prudent investments into their developing self-assurance.
To write this article, I went to Google (where else?) and typed in “Benefits of family travel.” Within .57 seconds I had a whopping 680,000,000 results. (Full disclosure: not surprisingly, I did not read all the results!) I did scan well over a hundred and read several dozen. Some entries were from scholarly journals; most were practical opinions of pediatricians, teachers, psychologists, travel professionals, and parents.
Here some informative entries:
> Family travel teaches children one important lesson: how to travel. Travel is an ever more important aspect of life and a skill never formally taught. Each year, millions of children travel as “UMs” (airline parlance for unaccompanied minors). We send older kids on teen tours, to visit relatives, and to go to college. Comfort with and willingness to travel often helps adults to compete in the job market.
> The age at which most children will remember traveling is around five years. However, traveling with younger children does have benefits. For example, when they become older, showing them pictures of where they were and what they did makes them feel that they were already part of the family.
> Often, we tell older children that travel to new places will help them see the differences between here and there and us and them. However, the more you travel with kids, the more they begin to see the similarities between cultures and people. When this happens, tolerance and acceptance grow while fear and mistrust start diminishing.
> In a survey conducted in Britain, adults were asked what their happiest childhood memories were. Forty-nine percent said, family vacations. Moreover, about a quarter of the respondents said that those memories helped them get through hard times. Reflecting on joyful times spent together can be extremely powerful in bringing relief when faced with the darker times in life.
> Coordinate your traveling with children’s recent book learning – it literally brings schooling to life. Visit historic sites, seats of government, different cultures, farms if you are a city dweller, and cities if you live in rural areas, for example.
> Don’t fret when children find historical-type destinations “boring” and they tell you that they would rather be swimming. In fact, such places tend to leave positive and lasting impressions. Often later on, you can hear them telling (or boasting to) friends and teachers where they have been.
> Family travel has all kinds of positive attributes for children. However, where you have traveled and vacationed is often used as a sign of snobbishness, especially with millennials. Travel is a more acceptable topic of conversation than other signs of snobbery such as where we live, the cars we drive, and where we went to school.
> Travel and vacationing help children develop their brains, says a psychotherapist. Families together in a pool, walking in the forest, touching tall grasses waving in the wind, or feeling sand between their toes, for example, produce strong social, physical, cognitive, and sensory interactions. Such experiences turn on the “genetic fertilizers” in the frontal lobes of the brain. This enhances functions like stress regulation, attention, concentration, the ability to learn, and improving physical and mental health.
> Never measure the success of vacations by their costs or by how far from home you traveled. More important is how vacations differ from everyday life. My family spends vacations at upscale resorts in the Caribbean and Hawaii. In contrast, I grew up poor. Every summer, my parents pitched a tent next to a small pond in a wooded area behind our home, just out of sight of the house. For a few days we slept in the tent, cooked our meals there, and swam and played with family who came to visit. We went indoors only to use the bathroom. I greatly respect my parents for the vacations they provided me.
> Traveling helps children learn patience. In life, unexpected events are common. When traveling, such events include dealing with bad weather, changes in eating and sleeping patterns, lines at airports and dealing with long car rides – all in the name of having fun. Children, with parents’ help, tend to learn creative ways to occupy their time.
> Family vacations promote curiosity, independence, self-confidence and interpersonal skills. This is further enhanced by the fact that vacations increasingly involve multi-generations: children-parents-grandparents, children-grandparents, or extended families. (Another plus: the grandparents often pick up the tab.)
> Traveling with the family is a gift that keeps giving, returning huge dividends.
(See, “How to plan successful family vacations” at http://kidstraveldoc.com/will-family-vacations-ever-be-all-fun-and-games/ )
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Kids and the Great Outdoors
Kids Playing Video Game Hey, parents! It is time to pry your kids away from their TVs, video games, computers and smart phones – forcefully, if necessary. Ignore their yelling and sarcasm. Then kick them out the front door – literally, if need be. If older kids threaten to report you to child welfare, call their bluff: according to experts, the current cure-all for practically everything that ails kids is merely spending more time in the great outdoors.
1. While wondrous cure-alls come and go, this one is backed by impressive credentials. They include the Harvard Health Letter, The Centers for Disease Control and the American Academy of Pediatrics (AAP), to name just a few. A few of quotes from such organizations: “Letting your children ‘go alfresco’ helps them grow up healthy.” “Children have become ‘dis-connected’ with the outdoors, resulting in physical and mental issues – call it ‘the nature-deficit’ syndrome.’”
2. Do organizations with impressive credentials always get it right? Not necessarily. In fact, some of the support for equating the outdoors with heaven is not based on traditional, evidence-based research. However, the philosophy is worth listening to – while remembering that we tend to exuberantly embrace simple, safe and free cure–alls that promise better health for our children, especially cure-alls that have virtually no known downside. Only time and research may uncover challenges to the current adulation of alfresco.
3. Today’s children are “screen bound.” “The nature of childhood has changed and there isn’t much nature in it.” “Screen time” rates are higher than ever. Children between the ages of 8 and 18 spend half as much time outdoors as they did 20 years ago. On average, preschool children spend 32 hours a week with screen media. The AAP recommends that kids under the age of two years have no screen time, and those older than two watch 1 to 2 hours a day, preferably quality programming.
4. The worst sedentary activity is TV-watching. Children who spend their indoor time watching TV have higher blood pressures than those playing electronic games, involved with computers or texting. TV-watching involves no movement on the part of the child and is often associated with eating, generally foods high in salt and calories.
5. Children are more active outdoors. While kids need not be outside to be active and being outside is no guarantee of activity, indoor living is associated with being sedentary. The younger children start active outdoor recreational play, the more likely they will find ones they enjoy and will continue them as adults.
6. “Green” outdoors may be the best outdoors. Spending time surrounded by trees, grass and plants is superior to being amid buildings, concrete and artificial turf, with the wilderness being the ultimate outdoors. Five minutes of green exercise a day results in improvements in self-esteem and mood. A window view of trees helps hospital patients recover faster than a view of brick walls.
7. Activity should be sufficiently intense to increase heart rates. Brisk walking, biking, or “running around,” for example, have beneficial effects on muscle strength and endurance, bone and cardiovascular health, concentration, memory, and classroom behavior. Children with attention deficit disorders scored higher on tests of concentration after walking through natural surroundings than those walking through residential neighborhoods or downtown areas. Children living in greener neighborhoods maintain lower average body weight.
8. Some children need coaxing to enjoy the outdoors. Others take to it “naturally.” Parents should expose children to various activities, ones appropriate for their ages. Look for activities provided by after-school programs, park departments and neighborhood organizations. Structured play times and activity-friendly environments are conducive to enjoyment. Ideally, children should spend at least one hour a day outdoors.
9. “Nature time” may help family bonding. The natural world seems to invite and facilitate parent-child connection and sensitive interactions. What better way to escape the constant, interrupting beeping of modern life, than spending concentrated time with your child during a walk in the woods?
10. Nature time may be especially important when colder weather tends to keep kids indoors. Less sunshine may cause both “sad” and “SAD”. Sad (small letters) is having the “winter blues.” SAD (capital letters) stands for Seasonal Affective Disorder, a more serious form of the winter blues. Sufferers, including young children, have less energy, difficulty concentrating, become irritable more easily, need more sleep, and take longer to get up in the morning. In younger children, crankiness and crying spells may occur more often. Our next posting, in about two weeks, will be an in depth review of SAD in young children.
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Is global warming harming our children?
Children are in the crosshairs for climate change, says the American Academy of Pediatrics. They are especially susceptible to toxins in the environment and to many of the infectious diseases that spread more readily as the weather becomes warmer.
1. Rising global temperatures decrease air quality. Children spend more time outdoors than adults, breathe in more air per weight, and, due to their age, have more years to breathe in toxins. The toxins, mostly carbon dioxide, emanate from fuels used in cars and power plants. They cause wheezing, coughing and can damage lungs. The younger the child, the more hazardous the toxin.
2. Higher environmental temperatures increase the length of summers. This prolongs the growing season and broadens the geographic area for allergy-causing plants, ragweed, for example, increasing the incidence and severity of allergies and some forms of asthma.
3. Forest fires are especially harmful. They emit fine particulate matter over a much larger geographic area than covered by visible smoke. Global warming increases the number and severity of fires by decreasing rainfall and drying out the underbrush which helps spread fires. The tiny particles reach deep into the lungs. Childhood exposure is associated with decreased lung function, more severe asthma, and chronic bronchitis.
4. The incidence of waterborne infectious diseases will rise. Infectious diarrhea, for example, spreads largely via bacteria, viruses and other microorganisms, found mainly in sewage. The incidence of such illnesses increases following severe storms and floods. (Both drought and floods are associated with climate change.) Increased sewage from runoffs can overwhelm sewage disposal plants, allowing sewage to leak into fresh water reservoirs and into land where vegetables grow.
5. The incidence of insect-transmitted diseases also increases. Warm, standing water from excessive rainfall and flooding creates additional breeding grounds for insects. Milder winters kill fewer insect eggs, allowing the numbers to increase cumulatively every summer. While most insects are merely annoying, some carry potentially deadly organisms which cause malaria, Zika, West Nile, Lyme and dengue, for example.
6. Long-term effects. As atmospheric carbon levels increase, common crops contain less protein and vital nutrients, iron and zinc, for example. Lack of such nutrients impair immune systems, cause cognitive issues, anemia and diarrhea, to mention just a few. Children from poor socioeconomic communities are especially at risk; more likely to suffer from these deficiencies and less likely to have access to dietary supplements to correct them.
7. Complex interactions of climate-warming factors affect young children. Studies suggest that children who spend less time outdoors (to avoid toxic air, for example) exercise less, eat more and are more likely to become overweight and obese. Also, worrisome are the possible effects on developing brains from chemicals necessary to eradicate insects. Likely, both the microorganisms that cause the disease and the insects that transmit them will become more resistant to chemicals used in insecticides. This will require ever more potent chemicals to be used. Some of these chemicals may harm fetuses’ brains when inhaled by pregnant women.
8. Additional factors to consider. “Fracking,” for example, pumps large amounts of chemicals into the ground to extract relatively cheap gas and gasoline. Great for our economy, but possibly harmful for our children. These fuels result in more toxins in the air. Moreover, fracking delays the development of other sources of energy, clean wind and solar power, for example. And some of the chemicals used in fracking may be toxic for the development of children’ central nervous systems.
9. Casualties from global warming-related disasters are usually much greater than stated. Most reports include only immediate deaths and injuries, stemming from drowning, mudslides, falling trees, and the collapse of houses. Not included is the toll from the subsequent lack of electricity, for example. Power outages make healthcare facilities (if, indeed, they survive the disaster), sewage disposal plants and refrigeration virtually useless. People, especially children, become ill and some die from diarrheal diseases from drinking polluted water and eating spoiled food, or from asthma since their ventilators no longer function. Death rates calculated months after disasters are generally much greater than those calculated in the first week.
10. Many young children experience emotional problems from the social turmoil surrounding natural disasters. Children are confused by such events, experience feelings of stress, fear and anxiety, akin to depression and post-traumatic stress syndrome. Especially at risk are children with previous exposure to trauma or pre-existing emotional, developmental, or behavioral disorders.
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