Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Children/Air Travel/Ear infections/Prevention/Treatment
Should children fly with ear infections and colds?
1. No studies exist to help you make the decision. While saying “no” is prudent, doing so ruins long planned family trips, often unnecessarily. Worse, sometimes it strands families on vacation. The scenario: An infant is cranky and has a fever or an older child complains of an earache. They are seen at a medical facility, a diagnosis of ear infection is made, medication is prescribed, and a delay in air travel is recommended. The delay recommended may be until the pain/temperature subsides, or until a course of antibiotics is completed, which may last five to ten days.2. Ear infections are greatly over diagnosed. Especially in emergency care clinics, the kind often found in resorts. Infants/children are often seen by personnel with limited experience in examining screaming, struggling young children, in removing wax from the ear canals to visualize the ear, and in deciding if there is an infection. In order not to miss infections, inexperienced personnel tend to treat.
3. Air travel-related ear pain is quite common. The source: the Eustachian tube, which connects an air space in the middle ear with the back of the nose. Normally, air passes freely from the air space through the tube and nose to the outside. Problems arise when the tube is blocked by mucus from colds (common in kids) and you fly. As airplanes ascend and descend, air pressure changes. During ascent air, including the air in the middle air expands. The increased volume of air has no place to go. This exerts pressure (pain) on surrounding tissue. During descent, the air contracts, creating a vacuum in the middle ear. The vacuum sucks in surrounding tissue causing pain. The vacuum is more forceful than expansion, hence pain occurs more frequently and is more severe during descent than ascent.4. Ear infections decrease the risk of ear pain during flight. Infection tends to fill the middle ear with pus/fluid, leaving no air to expand/contract, hence no pain. Children with aerating tubes in their ears (to prevent infections) can also fly safely. These tubes connect the middle ear with the outside through the ear canal, bypassing the Eustachian tubes and neutralizing pressure changes.
5. Ear pain during air travel does not appear to cause permanent ear damage in children. It may do so in adults who have other medical issues. Tens of millions of children fly annually. Yet surveys of hundreds of pediatric ear specialists, airline physicians, and pediatricians found no one who was aware of a child whose ears were permanently damaged by ear travel. However, this does not prove it never happens. But if it does, it is an extremely rare event.6. When infants cry during flight, is it because their ears hurt? Older children complain of earaches during air travel, so presumably infants also experience pain. Their Eustachian tubes are narrow making blockage by mucus more likely. But, in fact, surprisingly few infants cry, considering that air travel disrupts their sleep and feeding schedules, they rest in unfamiliar and often uncomfortable positions and, if they are on a parent’s lap, are disturbed every time the parent moves. They do seem to cry more frequently during descent when ears are more likely to hurt, but that is also the time they are most likely to be disturbed.
7. Conventional wisdom says to feed infants during ascent and descent, and often during flight. Such “wisdom” is both true and false. Sucking does help to keep Eustachian tubes open. However, at cruising altitudes the air in the stomach and intestine is already expanded by 20%, the result of air pressure changes. (This is what gives many adults a bloated feeling.) For infants, sucking adds more and unnecessary air and food to the stomach, which may cause fussiness and crying. Feed infants no more often in flight than at home.8. Many commonly used remedies given to children are of questionable usefulness. Oral antihistamines to reduce nasal secretions/congestion are no longer recommended for children under any circumstances. Nose drops/sprays and drinking lots of fluids to loosen secretions and unplug Eustachian tubes are ineffective in children.
9. Preventing ear pain. Pain most commonly occurs during descent. Note that descent may commence before the captain announces it. Ask flight attendants to inform you when descent begins. Keep infants awake during landings. Sleep reduces the frequency of swallowing. Acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) reduces pain. Give about 30 minutes before descent if your child has a history of ear pain while flying.10. Treating ear pain. Administer acetaminophen or ibuprofen. Teach children the Valsalva maneuver: blow firmly, as if blowing your nose, while pinching your nostrils and keeping your mouth closed. Repeat several times. Encourage children to swallow. Older children can chew gum, suck on hard candies, yawn, and move their jaws from side to side, maneuvers that may help open the Eustachian tubes.
Children/Safety/Crossing streets
The number of children eight years of age and older injured or killed in pedestrian accidents is increasing, some from causes that did not exist a few years ago, says the America Academy of Pediatrics. On the positive side, children’s street safety is being studied intensely and systematically, revealing why mishaps occur and how to minimize them.
1. Children, some as young as eight years, are crossing streets while listening to music, talking on cell phones, and texting. Using these devices makes children less attentive to traffic. They leave less safe time between their crossing and the next arriving vehicle, resulting in more accidents and close calls.2. Start teaching street safety to four year olds. Make it fun and games. Show them where and when to cross and why. Point out cars going slowly and rapidly,and how many steps it takes to cross the street. Tell them why never to run into the street to retrieve a ball.
3. Children aged seven can be taught basic pedestrian safety. Ask them to identify traffic signs and lights and to explain what they mean. Point out drivers that are breaking rules: not making full stops where they should, for example. Tell them they are in charge of crossing you, the parent, and compliment them when they make the right decision.
4. Most children are ready to cross streets alone at about ten years. The precise age depends on maturity, judgment and traffic patterns in your neighborhood. For starters, pick a route that they use often, such as to school or to a friend’s house. Point out hazards. Ask them what they would do if they were driving a car and saw children preparing to cross.5. Looking left and right before crossing is not sufficient. Before crossing children should come to a full stop and judge the speed and distance away of oncoming traffic. Then they should look left, look right and, at intersections, look over their shoulders to see if cars are coming from a side street, and then look left again. Ditto at driveways and garages, where cars may back out. Listening for oncoming traffic is also important.
6. Running across the street is counterproductive. Intuitively, to children, getting across as fast as possible seems to be the sensible way to go. However, running increases chances of stumbling, or dropping objects and stopping to pick them up. Also, running becomes a fun activity and a distraction from decision-making.
7. Children should wait until motorists do what they are supposed to do, like making complete stops at stop signs, red lights and before turning corners. Children should not start crossing when cars start slowing down. (Neither should adults.) And alert children to signs that drivers are about to move (drivers sitting in cars with motors running or headlights on, for example). And they should be extra careful when walking behind parked vehicles in parking lots. Use toy cars to demonstrate.8. Children are small and may be difficult for motorists to see. Consider dressing children in bright, reflective items during daylight, not only after dark, perhaps using vests such as those worn by highway workers.
9. Some new car/truck features complicate street safety, say experts. Eye contact with motorists is important. But inform children that tinted windows on cars and cabs of trucks far off the ground, for example, make eye contact between drivers and pedestrians more difficult. Also, new model cars make far less noise than older ones, making listening a less effective safety precaution.
10. Reinforce school bus safety. School bus-related tragedies occur in spite of repeated lectures on safety. Children often drop items getting on and off buses and the objects may roll under the bus. They should inform drivers before retrieving such objects. And to cross roads after getting off the bus, children should walk about ten feet in front of the bus, stop, and make eye contact with the driver. They should stop again after passing in front of the bus and look left and right before proceeding across the road.
Does your child know left from right? Ask them to make the letter “L” with their thumb and first finger on both hands. The correct “L” is on the left hand.Children/Travel/ADHD/Medication
For children who take medication for ADHD (attention deficit hyperactivity disorder) is discontinuing their medication for travel a sensible option?
Here are some thoughts:
1. You’re not alone in having to face the question. One in ten American children has been labeled as having ADHD. Four to five million take medication. And the numbers are climbing: children with ever milder behavioral issues are being classified as ADHD, more schools are recommending children be medicated, and there is less stigma about having ADHD and being on medication.2. Believe it. Human behavior is profoundly affected by drugs. The vast majority of health professionals, teachers, and parents believe that the correct medication, properly dosed, improves focusing and reduces activity, impulsivity, and inattention. This in turn, prevents children from developing anger and hopelessness, for example, due to repeatedly being disciplined for behavior that they are unable to control.
3. Why then even consider discontinuing ADHD medication for travel? Medicating children remains controversial, and rightly so. (See NY Times, December 15, 2013. The Selling of Attention Deficit Disorder.) Medications may have serious side effects. Discontinuance is the only reasonable way to judge if medication is still necessary. Medication is given mainly to control school behavior. Non-school periods may be less stressful – and may be the best time to judge if kids can function drug free.4. But travel may be just the time that ADHD children need medication. Travel eliminates the cornerstone of behavior modification: routine, routine, routine. Worse, it substitutes situations which trigger impulsive behavior – eating meals in restaurants, dealing with strangers, and sleeping in new surroundings, for example. If discontinuing medication does cause problems the problems are best handled at home. There is some evidence that continuous medication controls symptoms better than stopping and starting.
5. Discontinuing medication should be based on three considerations. One: the child’s chief issues. If it is lack of focusing with little or no hyperactivity or inappropriate behavior, “a drug holiday” may be reasonable. If the main issue is hyperactivity, impulsiveness, and fearlessness, discontinuance in new surroundings increases the risk of accidents, getting into trouble, and becoming lost. One positive sign for discontinuing is that the child has been well controlled with medications in recent months and did well on previous drug holidays.6. The 2nd consideration: practical issues. How much structure and discipline can you provide on the trip and are you prepared to deal with serious behavior issues should they occur? Does your upcoming trip involve features that could be troublesome, long car rides or overnight flights, for example. Will poor behavior adversely affect other children in your family or host families you will visit? Does the child want to stop medication; many will not. Does the child have other issues, anxiety or depression, for example? Consult your child’ health professionals.
7. The 3rd consideration: which ADHD medication is your child taking? More than a dozen drugs exist and fall into two categories, stimulants and non-stimulants. Stimulants – Adderall, Concerta, Ritalin, and Vyvanse, for example, lend themselves better to stopping. They become effective within hours of starting and stop working hours after stopping. Non-stimulants, chiefly, Strattera, require days to become effective, and remain active, with decreasing effectiveness, for many days perhaps weeks, after the last dose.8. Travel-related activities may change the desired effect of ADHD medication. Medications are dosed to control behavior at specific times of the day, when “meltdowns” tend to occur, school hours, late afternoon, and bedtime, but not interfere with sleeping. Travel can change meltdown hours and bedtime, especially if travel is through many time zones. Travel-related medications, anti-motion sickness substances, for example, may alter the desired effects of ADHD substances. Check with your prescriber.
9. Carrying certain ADHD medication may cause problems abroad. Keep items in their original, labeled containers, carry only a reasonable amount, and have a letter from the prescriber. Many ADHD drugs are derivatives of amphetamines, a substance tightly controlled or banned in some countries. However, reports of travelers having legal problems for carrying these drugs are extremely rare. If you carry a three months’ supply, for example, check with the consulate of the country you visit.
10. Should you stop medicating ADHD children for summer camp? Some parents do so without informing the camp. This can place the child and a whole group at risk. Camp activities require children to be focused, alert and cooperative. Making friends is often an issue. Camp directors are generally familiar with ADHD issues and should be included in discussions.Planning for your child to be a UM traveler?
What is a UM traveler, you ask? In airline talk, a UM (usually pronounced “U. M.” but sometimes “um”) is an Unaccompanied Minor traveling without an adult, with airline personnel providing some supervision. 1. Qualifications for UMs are surprisingly scant. On most major US and international airlines, if children have reached their fifth birthday (yes, fifth), you can ship them almost anywhere in the world. Visiting grandparents or a divorced parent living elsewhere are the most common reasons for UM travel. Some UMs are frequent flyers, making two or more trips a month. In the US, children take about 1.5 million such trips annually. Ideally, children should have flown accompanied by an adult before flying alone, but this is not a prerequisite. UMs are so numerous that some airlines have “UM Rooms” at major airports.
2. Rules for shipping UMs. There are no government regulations. Each airline has its own rules. Check websites. Typically, children between five and seven may fly on their own, but only on nonstop flights. Children between ages 8 and 11 can fly with connections on the same airline, but not on the last connection of the day. Children 12 years and older can fly alone, just like an adult. However, many airlines will provide services for 12- to 17-year-olds, when requested. 
3. Shipping UMs is not cheap – (certainly more expensive than shipping via FedEx or UPS). Most carriers charge adult ticket fees plus a surcharge of $50 to $100 each way, and sometimes for each leg of a trip. If siblings are traveling, there may be only one surcharge. 4. Planning the trip. Most important, decide if your child is sufficiently mature to handle the trip. Choose early morning nonstop flights when possible to minimize delays and avoid the need to make connections. Check the airline’s website for documents needed for dropping off and picking up children. Documents, often quite lengthy, must be filled out correctly and may involve photos. On departure day, check the weather locally, at connecting cities and at the destination. Airlines may not accept UMs if weather predictions are “iffy.”
5. Packing. Supply your UM with a small carry-on. Airline personnel will carry it, if necessary. Include snacks/meals of the child’s favorite foods. Drinks must conform to current airport security policies. For small children, supply an extra change of clothing in case of airsickness (not uncommon in this age group). Electronic games keep kids busy. (Coloring books and crayons typically end up on the floor.) Telephones are helpful for older children. Flight attendants can spot UMs returning home – they’re overloaded with too many presents. Tell grandparents and exes to reship UMs the way they arrived.
6. Dropping off your UM at the airport. Airline personnel will do so and introduce the child to flight attendants. Remain at the gate until the plane is airborne, lest it returns to the gate for mechanical or other reasons.
7. In-flight supervision. On boarding, flight attendants introduce themselves to UMs, make them comfortable, help unpack toys, and buckle seat belts. They monitor UMs periodically as other duties allow but are not baby sitters and are not obliged to take kids to the bathroom or feed them. (Take young children to the bathroom just before the flight.) 8. Retrieving UMs on arrival. Airline personnel deplane UMs after all other passengers and bring them to meet the pickup person at a prearranged location, at the arrival gate (security permitting) or in a common arrival area. The pickup person must have his or her documents in order, arrive at the airport early, know the child’s itinerary, and know how to contact you and the airline. Be available at a designated telephone number.
9. Shipping UMs out of the country. Surcharges are generally higher and there may be additional paperwork. Check with the consulate of the country you child is entering. An entry visa and an official letter from the child’s other parent may be necessary. The child may also have to pass through customs. Airline personnel will assist with customs.
10. Snafu procedures. If children are stranded by aircraft diversions or missed connections (rare occurrences, say airlines), you will be notified and kept current. If journeys cannot be completed that day, most airlines place children in hotels with an airline representative, sometimes with other UMs. If no one claims the child at the destination (usually due to miscommunications), you will be asked to contact the designated person. The airline will help you. The airline representative will remain with the child for a reasonable length of time. If no one appears, alternatives will be discussed with you, including shipping the child back to you – at your expense, of course.Kids/Winter/Sunglasses
Having your kids wear sunglasses when the ground is covered with snow is as important as having them wear them on a summer day at the beach – perhaps even more so. Wearing the right winter sunglasses prevents snow blindness and, more important, helps prevent cataracts in later life.
1. “Snow blindness” is not exactly a household term. And you need not be lost in the Arctic for it to occur. It happens to the unprotected eyes of infants being carried in backpacks or pushed in strollers, toddlers frolicking in the snow, and older kids out sledding. And while obvious cases are rare and you may never see one, such cases help understand what is happening.2. The sun’s rays burn the outer layers of the eyes just as the rays burn the skin. And, as with skin, eye damage occurs each and every time exposure occurs, burning during childhood is particularly injurious, and the damage is cumulative over a lifetime.
3. Snow reflects up to 80% of the sun’s rays. This is a far greater percentage than the reflection from water, sand, cement, grass or dirt. Reflected rays are additive with direct rays. Under the right (or wrong) conditions, snow blindness can occur in a matter of hours.
4. Outdoor winter activities increase risk. Many take place in snow-covered hilly terrain, allowing reflected rays to hit eyes from all angles. Altitude also increases radiation. Winter resorts tend to be located at higher elevations: the higher the elevation, the less atmosphere to filter out harmful rays. And cold weather, light clouds, and a sun low on the horizon offer little protection. Modern winter clothing allows kids to spend more time outdoors.5. Recognize the early symptoms of snow blindness. In preverbal kids not wearing sunglasses, beware of excessive blinking or unexplained crankiness. (Frostbite, feeling cold, and too-tight clothing are other possible causes.) Older children complain of eye discomfort, excessive brightness, irritation, dryness, and difficulty blinking. Eyes appear red and teary. These symptoms are often erroneously attributed to wind or cold. Symptoms may appear immediately or after 8 to 12 hours following exposure. Pain and temporary blindness can set in even later.
6. Ideally, buy sunglasses from eye professionals. Sunglasses are available in supermarkets and elsewhere and may be less expensive there. But in such locations no one helps you select the correct pair for your child. Most summer sunglasses allow too much light to enter the eyes for snow country. You want glasses that offer 100% protection against both UV-A and UV-B radiation,fit snugly, cover the entire area between the eyebrows and middle of the cheeks, and wrap around toward the ears. Wrap-around models prevent rays from entering from the side and help prevent irritation from wind. Large lenses protect from flying ice particles and dirt, and from branches, when skiing and snowmobiling.7. Hats, scarves and sunscreen complete protection. The sun is frequently overlooked as a cause of eyelid problems. The skin of the eyelids is sensitive, thin and burns easily. Hats with brims at least three inches wide help minimize sunrays from reaching the eyes and eyelids. Scarves help protect the neck. Apply sunscreen to any skin that remains exposed.
8. Insist that children wear sunglasses. Be firm. Make no exceptions. In fact, most infants and toddlers enjoy wearing them. Make it a treat for them to see their surroundings in different colors. Let them pick out styles. Set a good example by wearing sunglasses yourself.9. Know how to treat snow blindness. When symptoms occur outside, get out of the sun. If shelter is unavailable, place a loosely woven scarf, sweater or ski hat over the eyes. Relieve discomfort with cold compresses, ibuprofen (Motrin, Advil) or acetaminophen (Tylenol), a dark environment, and appropriate eye drops. Seek medical help, if necessary.
10. Virtually all cases of snow blindness heal spontaneously over a few days. And there are no immediate visible after effects – just as there are no immediate after affects from everyday sun exposure. But damage occurs and is permanent. It becomes apparent as reduced visibility decades later.
Travel/Children/Winter/Nutrition/Sports
Hi Kids! Good news regarding what’s good for you to eat on days when you spend time outdoors in cold weather. Tell your parents that there’s no need to make you eat yucky oatmeal or other ugh-tasting stuff while denying you a measly piece of candy, which is what you really want. Tell them that lots of snacks, especially chocolate-containing ones, are just what the doctor ordered for cold weather activities.Here’s what you have to teach your parents:
1. The colder the weather, the more calories you need to stay hearty. Calories provide the energy needed to maintain body temperature, warm the cold air you inhale, and supply fuel for muscles. Participating even in moderate sports – running around in the cold – requires about double the calories you need for sitting on the couch and watching TV.
2. Frequent eating helps maintain steady heat production. This seems especially important in kids. They become hungrier more often, and are more likely to become fatigued and feel chilled if there is not a fairly constant supply of ready-to-use calories.
3. “Trail food” mixes are ideal for rapid heat production.
Typically these consist of raisins, dried fruits, chocolateand nuts, foods most kids really like. Raisins and fruits supply carbohydrates. Nuts supply proteins and chocolate supplies fat.4. Cold weather also increases the need for fluids. The body loses fluids by deeper breathing, perspiring under clothing, and exertion. And the more exertion, the deeper you breathe, further increasing fluid requirements. However, in cold weather especially, the sensation of thirst may lag behind the need for fluids. Therefore kids need to be reminded to drink frequently, even when they are not thirsty.
5. The best fluids in cold weather are water and fruit juices. These are quickly absorbed. Juice supplies calories. But avoid very sweet drinks; they can upset stomachs and are absorbed more slowly. 
6. “Sports” drinks are not essential for children involved in everyday recreational activities. Water, fruit juices and trail mixes suffice. But sport drinks (Gatorade, for example) may be beneficial for teenagers involved in endurance sports such as cross-country skiing.7.Hot drinks in cold environments make you feel warmer but add little to body heat. The benefits are mostly psychological. A child would have to drink more than a quart (liter) of drinks at one time to generate significant amount of extra heat. In fact, cool fluids are absorbed somewhat faster and are more palatable in large amounts, though it takes a few calories to heat the fluids to body temperature.
8. Discourage children from eating snow and ice.Even pure white snow may contain pollutants from the air, including trace minerals like mercury, albeit in insignificant amounts. Snow can also contain windblown soils that can include animal fecal matter, which can cause diarrhea. Moreover, a mouthful of snow yields only a few drops of water while the body needs calories to melt the snow. Ice yields more water than snow but uses up more calories to melt.
9. Dietary nutrients do not appear to boost energy levels. There are thousands of such supplements available, mostly combinations of vitamins, minerals, herbs, and other so-called “natural” substances. These products are usually accompanied by glowing testimonials of their benefits in cold weather. Most products have never been tested scientifically, and the few that have, were found not to be beneficial.10. Do you feed a cold and starve a fever?Or do you feed a fever and starve a cold? In fact, neither is correct. While these illnesses are especially common in wintertime, they have nothing to do with outdoor weather or sport activities. And nutrition plays no role in preventing everyday fevers and colds. (The “correct” old wives’ tale is/was: feed a cold, starve a fever.)
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