Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Helping young children adjust to the heat of summer
Outdoor temperatures are soaring this summer. Children less than four years of age adjust poorly to heat. So how do you keep the little ones hale and hearty?
1. Young children produce more heat per body mass, perspire less, and dehydrate more rapidly and more severely than older children and adults. Perspiring helps the body shed excessive heat. Moreover, hot environments tend to make children cranky, listless and reluctant to drink.
2. Start offering children extra drinks hours before exposure to heat occurs. Encourage them to drink but never force them; that may cause vomiting. If children are happy and active let them decide how much they want to drink. Offer fluids often; every fifteen minutes if necessary. No need to give them sports drinks or electrolyte solutions at this point; plain water is fine. Cold drinks do not appreciably cool children’s bodies.
3. Air conditioning (AC) to the rescue! Not only does AC lower indoor temperatures but, equally important, it decreases humidity. High humidity impedes perspiration. And forget the “new” old wives’ tales about AC: no one becomes sick from going in and out of AC or having cold air blow on them.
4. When AC is not available, cool kids using old-fashioned ways. Fans help cool bodies by reducing skin temperatures, which helps promote perspiration. Fans do not cool rooms and the higher the temperature the less effective fans become. Pools, sprinklers and lukewarm baths help lower body temperatures. Wrap children in lukewarm towels or sheets, if necessary. In some neighborhoods cooling centers open in hot weather.
5. Check the heat index (HI) before going outdoors. The HI calculates how the combination of air temperature and humidity on a given day affect our bodies. The data is placed into one of four categories: Caution, Extreme Caution, Danger and Extreme Danger. (See the table at the end of this article.) Readings are available daily for every zip code. See US National Weather Service at https://www.weather.gov/safety/heat-index A very high HI may be reason to stay indoors or shorten the time spent outside.
6. Young children tend to eat less in hot weather. But so do adults. This is not a problem. Neither is what type of food you give to children. Diet plays little role in staying cool. While fruits and vegetables contain more liquid than foods high in fats and protein, the difference is negligible, especially with the small portions young children eat.
7. Dress children in lightweight, light-colored, loose-fitting cotton garments. Loose-fitting shirts allow wind currents to remove heat from the skin and absorb perspiration. This helps cool the body and helps prevent heat-related rashes. Avoid sunburns. (See my article on sun-protective clothing at http://kidstraveldoc.com/sun-protective-clothing-has-gone-high-tech/)
8. In hot weather, assume that all signs of illness are heat-related. Regardless of the cause of the illness, the early treatment is the same: offer additional drinks and find air conditioning. If symptoms worsen, call your pediatrician or pediatric nurse practitioner. Ask whether it’s time to give electrolyte solutions or seek further medical assistance.
9. Choose tropical vacations with young children in mind. Consider avoiding extremely hot and humid destinations. Children may take a day or two to acclimatize. Increase fluids on arrival and limit time spent outdoors during this period. While serious problems are quite rare, check that your cellphone is operable and that there is a local, readily accessible medical facility, just in case.
10. Other considerations. Some baby carriers and car seats are made of heavy fabrics that increase the heat surrounding infants… Chronic illnesses and certain medications may make young children more susceptible to heat-related illnesses… Little is known about the benefits, if any, of “natural” cures (coconut water, for example).
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Why Do Parents Forget Their Infants in Cars?
New York. July 31, 2019. It happened again. A father, a social worker, was charged with manslaughter and criminally negligent homicide for leaving his one-year old twins strapped into the backseat of his car on a hot July day while he worked his eight-hour shift at a VA hospital. He forgot to drop them off at daycare. The twins are the 22nd and 23rd children to die such deaths in the US this year. And August, the commonest month for heat-related deaths, is yet to come.
Neighbors of the father are rallying to his support. They describe the circumstances surrounding the deaths as incomprehensible. They say he is a caring, loving, child-oriented person.
1. Surveys show that the vast majority of adults involved in these tragedies are responsible individuals. Like you. They simply forget that a child is in the car, or there is a mix-up between parents regarding who is to drive the child that day, or they leave the car “for a second” to mail a letter and become distracted by a friend or an event, for example.While it is a hassle to remove children from car seats for two-minute errands, leaving them can land you in jail – even if nothing happens. In some states it is a felony to leave children unattended in a car.
2. Be aware of your state of mind when driving with a child. Stress, emotional issues, lack of sleep, medications, and concerns over the weather, for example, can affect your judgment. Other contributing factors include mechanical problems with your car, or an impulse to stop for coffee. Combinations of factors further increase risk.
3. Parked cars can be killers. Last year, 51 American children died of heatstroke and dozens more suffered permanent brain damage due to heat. Fifty-two percent (52%) of these children were accidentally left in a car; 30% climbed into a car on their own, and 17% were left in a car on purpose and then forgotten. Many other children experienced “close calls.” Only 7% of the adults are believed to have been under the influence of alcohol or drugs at the time of the incident.
4. Temperatures inside cars rise fast. The temperature inside a car parked in the sun on a hot day can reach 160 degrees F (71 C). Windows rolled down a few inches (or centimeters) helps little. Even when outside temperatures are only 80 degrees F (27 C), the temperature inside the car can reach deadly levels in 20 minutes. In fact, children have suffered heat stroke in parked cars with outdoor temperatures in the fifties.
5. The younger the child, the greater the risk. In a hot vehicle, with no access to liquids, a young child’s body temperature increases rapidly, far faster than an adult’s in similar circumstances. Children are less able to sweat; sweating rids the body of heat. At 105 degrees F (40 C), the body’s temperature control systems become sluggish. At 107 degrees F (42 C), vital organs begin to shut down. Much of the damage is irreversible.
6. Look Before You Lock, says the National Highway Traffic Safety Commission. Train yourself to check the backseat before leaving cars. Place your briefcase, wallet, or work badge on the seat next to the child. One mother puts her shoes there. (She drives barefoot but wears shoes for walking.) Also, place one of the child’s toys or the diaper bag on the front seat.
7. Check your car immediately if your child is out of sight. Teach children that cars are not play areas. Lock cars when not in use. Young children find it easier to enter unlocked cars than exit them. And keep an eye on children when the trunk is open.
8. When you see a young child alone in a car, call 911. Don’t assume that an adult will be right back. Minutes count. If the door is unlocked, remove the child from the car if the child does not look right. In an emergency pour cold water over the child. If the child is responsive, also offer liquids.
9. The incidence of children left in cars rose sharply in the 1980s – the result of campaigns to improve safety. Until then most infants rode car seats placed in the front seat. But studies showed that infants are safest when their car seats are on the backseat and facing backwards, making sleeping infants practically invisible to the driver. But overall, placing infants on the backseat facing backward is safest.
10. Some new car models are equipped with various devices to alert drivers of an infant in the backseat. One system under study consists of sensors that are activated when the driver closes the driver’s car door. The sensors send off an audible alarm if it detects movement in the back seat. The problem: some healthy infants when sleeping move insufficiently and their breathing is too shallow to activate the alarm. In another system, an alarm sounds when the motor is turned off if the rear door was opened before or during the trip. This alerts the driver to check the back seat. This system is plagued with false alarms. No system is yet entirely reliable.
Bills are in front of both houses of Congress to mandate the use of such devices.
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Treating diarrhea in young children away from home: A primer
When packing for family trips, for overnight or overseas, include a pen, a paper pad and a cellphone. These come in handy if your child experiences diarrhea, a common health issue for young children away from home. The pad and pencil is to record symptoms. The cell phone is to call your pediatrician if symptoms worsen.
1. The vast majority of cases of diarrhea in young children need no treatment. Watchful waiting, doing nothing, is what you do when kids are happy and playful and eating and drinking normally – even when the number of daily stools double or triple and become loose. Rare vomiting and slight stomach aches can also be ignored under these conditions.
2. Watchful waiting stops when children’s dispositions and stool consistencies take a turn for the worse. Write down changes in activity, decreases in food and fluid intake, the presence of vomiting, the frequencies and description of stools and the frequency of urination. These findings become significant if symptoms continue to worsen.
3. Encourage children to drink. Never force them. If necessary, offer them fluids every 15 minutes and in small amounts. If they vomit, try a tablespoon or a teaspoon at a time. Record intake. Continue feeding breast milk, infant formula or cow’s milk. Restricting or diluting milk serves no purpose. Avoid giving copious amounts of plain water or sugary drinks; these can worsen diarrhea by pulling more fluids into the intestines. If your child does not get better promptly, it’s time to use your cellphone.
4. Continue offering food. Don’t force. Food is essential to supply calories and may actually help restore a damaged intestinal lining. The type of food is less important than previously believed. The BRAT diet (bananas, rice, applesauce, toast) is only marginally better than the child’s favorite food, whatever it is; children are more likely to eat and drink what they like.
5. Add electrolyte solution to the child’s diet if symptoms persist. These solutions reflect the makeup of fluids lost via vomiting and diarrhea and help avoid dehydration. Electrolytes are also available in pharmacies and most supermarkets as lollipops and small packets of powder. Mix powder with safe water in amounts directed on the product. Sports drinks (Gatorade) are less appropriate. They are designed to replace electrolytes lost by perspiration, not via vomiting and diarrhea.
6. Many customary treatments are outdated or controversial. Withholding food to “rest the intestine” is counterproductive. Probiotics are “good bacteria” to replace the “bad” microorganisms that cause most cases of diarrhea. Though probiotics are not harmful, there is no convincing evidence that they are effective. The same is true for substances that contain cow colostrum. Most natural, “chemical-free” and homeopathic remedies have not been studied scientifically.
7. Medicinal treatments can cause serious side effects in children. Use the following products only after speaking to your pediatrician: Kaopectate (kaolin-pectate), Pepto-Bismol (bismuth), Imodium (loperamide), and Lomotil (diphenoxylate and atropine). The same is true for anti-vomiting substances.
8. Recognize symptoms that require immediate medical care. Such symptoms include continuous vomiting or diarrhea; the refusal of fluids or the inability to retain them; reduced activity; presence of fever; complaints of or showing signs of severe abdominal pain; or blood/mucus in the stool. In such cases intravenous fluids may be necessary.
9. Improved sanitation reduces the incidence of diarrhea. The vast majority of cases are due to bacteria, viruses or other microorganisms. The organisms are ingested in contaminated food and water, by swallowing recreational water, and by children placing previously contaminated hands in their mouths. Frequent hand washing helps reduce the incidence. Remember to wash your hands after handling dirty diapers.
10. Miscellaneous. All children with diarrhea, even mild cases, should be isolated to prevent spread to others… Young children should be routinely vaccinated against rotavirus, the most common cause of diarrhea in this age group… Treat traveler’s diarrhea the same as other cases. However, some cases may be more severe and require professional intervention earlier… Check that your phone is operable wherever you travel.
Sun-protective clothing has gone high-tech
Sun-protective clothing has replaced sunscreens as the first line of defense for protecting your children (and yourself) from the harmful rays of the sun. However, rarely, excessive sun protection can itself lead to health issues.
1. The UV rays of the sun are as damaging to children’s skin as tobacco smoke is damaging to adult’s lungs. Estimates are that we get 50 to 75% of our lifetime sun exposure before we are 18 years old. Children’s skin is thinner and contains less melanin to block UV rays. Infants less than 6 months of age should be kept out of the sun entirely. Damage is cumulative for life. About 3.7 million skin cancers are diagnosed in the US annually, the vast majority sun-related.
2. Sunscreens have numerous shortcomings. Most parents apply too little and too infrequently for optimal protection. The degree and duration of protection is reduced by wind, water, towel drying, and excessive perspiration, to mention just a few. A recent report suggests that more sunscreen is absorbed into the body than previously thought, a finding that is under further study.
3. Sun-protective clothing has gone high-tech. Such garments consist of recently-developed, lightweight fabrics that absorb or reflect UV radiation. Fabrics are woven tightly, leaving practically no space for sun penetration. Many garments are dyed in colors, usually red or black, which also absorb or reflect UV rays. Garments should cover as much skin as possible (the back of the neck, for example) and fit loosely to allow air to circulate. Overly tight fits stretch fibers, allowing some sun through.
4. Familiarize yourself with the rating system for protective clothing. It’s called UPF (ultraviolet protection factor) and is somewhat similar to SPF (sun protection factor) for rating sunscreens. A UPF rating of 25 means that only 1/25th (4%) of UV radiation penetrates the fabric. The higher the UPF, the greater the protection. Fabrics rated below UPF 15 are not considered protective. UPFs of more than 50 add little additional protection.
5. Some sun protective clothing is pre-treated with solutions containing UV-inhibiting ingredients, further enhancing their effectiveness. See “UV blocking additives” on the Internet and check labels. These additives can also be purchased at stores or online and used at home on any garment, increasing the garment’s UPF. Protection withstands numerous washings. After using additives, light may shine through the garment when held up to the light. This does not mean that the fabric has lost its protective ability.
6. Hats should have brims at least three inches (7.5 centimeters) wide and extend around the head to shade the face, neck, and ears. Baseball-type and straw hats offer little protection. Brims of 6 or more inches (15 cm) are becoming popular. Every additional inch of brim reduces the lifetime skin-cancer risk by about 10 percent. Consider hats with attached drapes that hang over the back of the neck.
7. Sunscreens remain essential for uncovered skin. Ears are a common location for skin cancer in later life. The more clothing-covered skin, the less need for applying sunscreen. Follow the instructions that come with the sunscreen. For more information on applying sunscreen to children, see http://kidstraveldoc.com/protecting-infants-and-young-children-from-the-sun/ and https://www.aap.org/en-us/about-the-aap/aap-press-room/news-features-and-safety-tips/Pages/Sun-Safety-and-Protection.aspx
8. Sunglasses protect the skin around the eyes. Five to 10 percent of skin cancers occur on the eyelids. Sunglasses should block 99 to 100% of UV radiation and consist of large lenses that wrap around the face and have UV-protective side shields.
9. Rarely, children who receive maximum sun protection may need vitamin D supplements. The reasons: children require calcium to develop and maintain healthy bones. Simplistically, UV radiation activates vitamin D in the skin. Vitamin D then helps the intestines to absorb calcium from food. Maximum sun protection results in less sun radiation reaching the skin, and in turn, less vitamin D to absorb calcium. One solution: continue maximum sun protection to prevent skin cancer and supplement diets with vitamin D and calcium. Discuss the need for supplements with your pediatrician.
10. Miscellaneous: Sun-protective clothing is especially important for children with fair skin, for those spending much time at beaches and pools, and for children with sun-related medical conditions or who are taking medication that increases sun sensitivity. Sun-protective shades and umbrellas with high UPF numbers are available for strollers and for large umbrellas that create shade at the beach. Some high-tech fabrics may lose half their sun protection ability when wet. Check with manufacturers regarding how many washings protective clothing can undergo before losing its protective abilities.
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What are the chances of your child being bitten by a dog?
There are numerous benefits in raising young children with a dog in the family, says the American Academy of Child and Adolescent Psychiatry. However, hundreds of thousands of children are bitten by dogs every year, according to the US Centers for Disease Control.
1. Dogs are more than playmates for children. They help children develop self-esteem, compassion and empathy, decrease stress levels, and increase the amount of exercise children get. Moreover, having a pet dog may even reduce the incidence of respiratory infections.
2. Bites are a greater health problem for children than measles, mumps and pertussis (whooping cough) combined. Bites are also more common than injuries due to bike accidents or playground mishaps. Consider consulting a veterinarian before acquiring a dog. Some dogs are more child-friendly than others. Factors to be considered include the age, breed, and size of the dog, the age and temperament of the child, and whether there are allergies and immunodeficiency issues with children or other family members.
3. There are 50 to 60 million dogs in the US. More than one-third of households have dogs; many have more than one. About 4.2 million people of all ages are bitten yearly, with 800,000 requiring medical attention. While the vast majority of bites are minor and can be treated at home, it is important for parents to be able to recognize the occasional bites that require prompt visits to a medical facility.
4. Children are bitten more often than adults. Most commonly bitten are children between the ages of five and nine years; the most serious bites occur in infants. Most bites in children are inflicted by dogs known and liked by the children bitten. The majority of bites happen at home or at the home of a friend, and are inflicted by a dog with no history of aggressive behavior. And bites in children are twice as likely to require medical attention as those in adults. Because of their short size, children are more often bitten around the head and neck while adults tend to be bitten on the legs, causing less serious problems.
5. Most bites are provoked by children. A common scenario: toddlers meaning no harm rush up to dogs while making noises and flailing their arms, acts dogs interpret as threatening. Other scenarios: an older child or a group of children, also meaning no harm, rile up dogs “for the fun of it” and children accidentally step on or fall over dogs.
6. Never leave a child under five years of age alone with a dog. Young children don’t comprehend the difference between pulling the tail or hugging of stuffed animals versus real animals. Only after months of careful observation of how children and dogs interact can parents know if their children are ready to be left alone with dogs.
7. Children should approach dogs slowly and quietly. They should avoid eye contact, and stop every few steps to allow dogs to sniff and evaluate them.Children should not approach dogs that are feeding, sleeping, or showing signs of anger (growling, for example). They should ask owners before petting their dogs. When approached by an unfamiliar dog, children should stop, remain calm and quiet, and stand with the side of their body facing the dog. Facing dogs directly can appear aggressive. The dog may walk away. If not, children should walk away slowly and sideways.
8. Impress on children the importance of reporting bites and scratches inflicted by dogs — or other animals. Children may think that such injuries are too trivial to report, and most are. However, rarely such wounds can result in severe consequences.
9. Treat all animal-related wounds. This includes wounds inflicted by cats, squirrels, bats, skunks, and raccoons, to mention just a few. Wash wounds for several minutes with soap and water, apply an antibiotic ointment, and cover with a clean bandage. Consult an expert whether further treatment is necessary. Such experts can generally be found at large hospital-based ERs and local departments of health. They are familiar with the animal illnesses in specific neighborhoods and know if further treatments, anti-rabies vaccine most importantly, is indicated.
10. The necessity of giving anti-rabies vaccine depends on many factors. Nearly all cases of human rabies are fatal; there is no room for error. Fortunately, dog-transmitted rabies has virtually been eliminated in the US and other developed countries; nearly all dogs are immunized. Anti-rabies vaccine for humans is often not necessary. However, the vaccine is essential when the animal is unknown or the dog’s rabies vaccine status can’t be verified.
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An Rx for swimming is what doctors order to keep young children active
True or false? Newborns are natural born swimmers.
1. Alas, false. Young infants do make hand and feet movements that resemble swimming when placed in water. And they do hold their breath and open their eyes when their heads accidentally slip underwater. However, infants’ heads are heavy for the size and weight of their bodies. Until at least six months of age, they can’t keep their heads above water nor can they intentionally sustain breath-holding underwater.
2. In fact, “swimming” has little to do with swimming. Blame the English language. According to dictionaries, “swimming” is merely “bathing in a body of water.” This makes swimming an ideal family-oriented, wholesome activity, one that helps young children to be physically active. The US Centers for Disease Control (CDC) has designated May 20–26 as Healthy Swimming Week to acquaint parents with the benefits of swimming and help parents minimize associated mishaps and illnesses.
3. Placing infants in water at an early age accustoms them to water. Some pediatricians suggest starting by age two months to help them overcome fears (which few infants display) and prepare them for swimming lessons. Start with sprinklers. Avoid very warm or very cold water. In water, let them splash with their hands. Don’t rush progress. Stay within arm’s reach. Infants can go underwater in seconds, without making a sound.
4. There is no consensus as to the optimal age to start swimming lessons. Guidelines vary from six months, and sometimes even younger, to four years. The American Academy of Pediatrics suggests one year. Teaching infants to swim doesn’t “drown-proof” them. Generally, they swim only when adults hover over them, rarely when they fall into the water unseen. Also, starting lessons early does not create better swimmers.
5. Children (and adults) should shower before entering pools. Some disease-causing organisms found on skin may be resistant to the disinfectants in the water (usually chlorine). This allows organisms to remain infective for days. Moreover, other substances on skin – urine, stool particles, sweat, dirt, and personal care products, for example – combine with chlorine, reducing the chlorine’s effectiveness.
6. Skip swimming when children are ill. And hope other parents do so. Kids swallow water. The more crowded and the smaller the pool, the more likely the water is polluted. Some swimming facilities insist that infants wear special swim diapers, designed to keep stool from leaking out. However, such diapers merely slow leakage. Small, backyard “kiddie pools”, often filled with tap water, are especially vulnerable to contamination. Take kids on frequent bathroom breaks. Change diapers in diaper-changing areas.
7. Check the sanitation at public swimming facilities. Look up the latest inspection score. You can typically find them onsite or online. Do your own mini-inspection. Use test strips to check disinfectant levels before getting in the water. Test strips are available at most superstores, hardware stores, and pool-supply stores.
8. Proper flotation devices save lives. Use ones approved by the US Coast Guard. Many are designed to keep heads above the water. Devices must fit properly and comfortably; some are weight-specific. Have toddlers wear them when playing near water, not only in the water or on boats. Many air-filled swimming aids and air mattresses are toys; they may deflate suddenly, or children may slip off them.
9. Outdoor swimming significantly increases the risk of sunburn. Waterfront activities lengthen the amount of time kids stay in the sun. Most outdoor swimming facilities offer little or no shade. Water reflects the sun’s rays, adding to the direct radiation reaching skin. White, loosely woven T-shirts provide almost no sun protection. Water exposure shortens the time that sunscreens offer protection.
10. Miscellaneous. Sunburns of the back commonly occur to children (and adults) swimming in the sun. The sun’s burning rays penetrate several feet (half a meter) of water while the cooling effect of the water makes people less aware of the sun. Strong chlorine odors are not signs of well-chlorinated pools; it may mean that the chlorination system is malfunctioning.
For additional information, see:
CDC: Healthy swimming at https://www.cdc.gov/healthywater/observances/hss-week/index.html
KidsTravelDoc: Protecting young children from the sun at http://kidstraveldoc.com/protecting-infants-and-young-children-from-the-sun/
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