Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Lyme disease: The ticks are awaiting your children
The US Centers for Disease Control (CDC) recommends that children who spend time in tick-inhabited parks, woods and forests be checked from head to toe for ticks embedded in their skin. Prompt removal of such insects prevents Lyme Disease. If you live in a particularly heavily infested area, check children after they spend time in your yard. In the US, in recent years, about 30,000 cases of Lyme disease were reported annually with many more cases going unreported.1. 2017 may produce a bumper crop of ticks. A relatively warm winter allowed more ticks to survive from the previous season. Changing rainfall patterns permit ticks (and other insects) to thrive, enlarge their geographic habitat, and extend their biting season. Mice populations may also be increasing and for similar reasons. Global warming may be a factor
2. Ticks are not the cause Lyme disease. However, Lyme disease would not exist without ticks. The cause is a bacteria which is found on animals, mostly deer and mice. Ticks transmit the bacteria from animals to humans. Only some animals are able to harbor the bacteria and only some ticks can transmit the bacteria. Ticks differ from most biting insects in that when they bite a person they embed themselves into the skin and remain there for prolonged period3. Know when and where ticks are active. Lyme disease occurs most commonly in rural areas of the northeastern US from Virginia to Maine, northern California, and in the northern Midwest. However, occasional cases are occurring in many new locations in the US and Canada. About 80% of cases occur in May through July. Most state or local health department can provide current information.
4. Ticks thrive in moist, bushy areas with high grass and leaf litter. Teach children not to lie on the ground in such areas and to walk in the middle of paths and trails. Ticks are less common in dry, sandy environments. Ticks attach to people when people brush up against ticks on grass or twigs. Ticks cannot fly or jump. Once on human skin they can crawl anywhere on the body. Dress children in “anti-tick” attire. Light-colored apparel makes it easier to spot ticks crawling on clothing. Long sleeve shirts and long pants tucked into socks helps avoid skin contact.
5. Mosquito repellents are effective against ticks. See our recent posting for applying repellents to young children. http://kidstraveldoc.com/an-update-applying-mosquito-repellents-to-young-children-is-no-fun-and-games-for-parent-or-child/ The repellent most often recommended for this age group is DEET in 20 to 30% concentration. DEET is safe for infants aged two months and older. Wash off when no longer needed. In highly infested areas, apply permethrin 0.5% to clothing. Permethrin is a safe substance that kills ticks on contact and remains on clothing for extended periods, even after laundering.
6. Check children for ticks.Ticks require at least 36 hours to embed themselves into skin to be able to transmit the bacteria into the skin. Have children bathe or shower soon after coming indoors. This helps wash away ticks not yet embedded. Ticks are difficult to see. Some are the size of a pinhead. Use a magnifying glass, if necessary. Check scalps carefully. Lyme disease is never transmitted from person to person.
7. Know how to remove ticks. Use fine-tipped tweezers. Grasp the tick at the skin surface. Pull straight, in a continuous motion. Don’t twist – this can cause the mouth parts to break off and remain in the skin. Never use hot matches, nail polish, or petroleum jelly to remove ticks. Visit a medical facility if part of the tick remains in the skin.8. Save ticks that you remove. Place the tick in a sealable, transparent envelope or jar. Bring it to a medical facility. Experts can determine if a tick is the kind that can transmit the causative bacteria. If yes, a short course of a commonly used antibiotic prevents Lyme disease. If not, there is no reason to treat.
9. Recognize early Lyme disease symptoms. Even thorough examinations can overlook tiny embedded ticks, especially in an uncooperative child. Fortunately, Lyme disease can still be effectively treated when early symptoms appear. Be suspicious of reddish discolorations of the skin that grow to several inches in diameter and then begin clearing at the center, giving the rash a “bull’s eye” appearance. The redness usually develops 3 to 14 days after the bite and at the bite site. Medical treatment is essential. Other symptoms of Lyme disease include fatigue, chills, fever, headaches, and muscle and joint pain. If left untreated, Lyme disease can involve joints, the heart, and the nervous system.
10. Miscellaneous. If children have been in tick-infested areas, wash and dry their clothing at a high temperature to kill any ticks that remain. An informative, illustrated 12-page booklet on Lyme disease is available at http://www.cdc.gov/lyme/resources/brochure/lymediseasebrochure.pdf
Digging in the sand at the beach is no longer fun.
Remember when digging in the sand at the beach was a fun activity for young children, an activity with almost no do’s and don’ts attached to it. Children could dig holes trying to reach China while parents could laze nearby. Sorry. No more. Based on recent findings, only with lots of do’s and don’ts is frolicking in the sand a healthy activity, says the US Environmental Protective Agency (EPA).
1. Call it sand pollution. In fact, digging in the sand was never healthy. In the past, sand pollution was largely overlooked. While health departments monitored water at public beaches and banned swimming when problems became excessive, beach sand was rarely tested, and access to the sand virtually never restricted. Now studies show that children playing in the sand are more likely to become ill than children merely walking on it. And the risk of illness increases with digging in the sand, being “buried” in it, and digging in wet sand.2. Fortunately, most sand-related illnesses are merely annoying. The most common ones are stomach upsets, often with diarrhea, from ingesting bacteria or other microorganisms present in beach sand. Less common are skin rashes, and eye, ear and nose problems. Most illnesses are mild. If medical care becomes necessary tell the staff that your children were at the beach. This helps diagnosis.
3. Younger children are especially likely to become ill. They spend more time digging in the sand, are more likely to get sand in their mouths (eating food items dropped into the sand), less likely to wash their hands, and more susceptible to intestinal illnesses. Teach children to keep their hands away from their mouths. Carry hand sanitizers and use it freely.4. Most beach related illnesses are preventable. For example, when beach water is polluted, keep children out of the sand. The action of tides and waves spreads pollution from the water unto the sand. Information about beach water is often posted on the site or available from local health officials. Also, keep children with open sores and cuts out of the sand. Organisms in the sand can infect wounds. Have them shower after playing at the beach. Keep their fingernails short and brush them often.
5. Look for clues that the sand may be polluted. Sand contamination is highly variable over short distances. Stay away from dirty-looking water, places where water from surrounding hills or streets run across the sand, and where birds and dogs congregate. Be aware that wet sand, the kind best for digging, contains nutrients that enable microorganisms to multiply and survive for longer periods of time.
6. Sand pollution tends to be especially high after heavy rains. Sewage treatment plants “scrub” wastewater before dumping it into the sea. But heavy rainstorms can overwhelm the plant’s ability to treat wastewater; there are no facilities to store it. This results in raw sewage flowing into the water and sand. Wait 72 hours after storms to use the beach.7. Beaches popular with parents of young children are frequently polluted. Parents opt for sheltered water and sand for safety reasons, where there is no high surf or undercurrents. This eliminates waves and other forces which agitate the sand and help flush it clean. This requires closer oversight by parents to avoid illnesses.
8. Dry sand presents problems, too. Children like burying their legs and feet and occasionally, burying their friends up to their necks. Dry sand frequently contains fungi which cause skin rashes. Discourage children from lying directly on the sand. Have them use beach chairs or, at least, a towel or blanket. Have them shower and dry them vigorously after lying in the sand.
9. Walking barefooted is another “don’t”. Have children wear lightweight, ventilated, hard-soled footwear that covers the toes. This helps prevent stubbed toes, lacerations, puncture wounds, and burns from hot sand. Ideally, footwear should be worn for wading in the water.10. Appropriate footwear is especially important at tropical beaches. Sand, on the beach and in the water, may conceal poisonous sea life that may have tentacles, fangs, barbs or spines, for example. Some are able to inject venom into children’s’ (and adult’s) skin or burrow under their skin. Teach children not to touch objects in the sand and water. Poisonous sea life can resemble rocks or seaweed. Jellyfish blend into their background and their tentacles can extend many feet. Coral is a live organism with sharp edges that can lacerate skin. Treating tropical beach injuries requires expertise. Injuries caused by different forms of sea life call for different treatments. Seek medical assistance, when in doubt.
An Update: Applying mosquito repellents to young children is no fun and games – for parent or child
Applying repellents correctly is uncomfortable, messy, time consuming, expensive, and if not done correctly, can result in health issues. Prepare yourself for lots of frowns and complaints.
Before reading this posting, you may want to go to our previous one of this two part series: Can you outsmart mosquitoes? Your kids health depends on it. Please see: http://kidstraveldoc.com/can-you-outsmart-insects-your-kids-health-depends-on-it/
1. The US Centers for Disease Control (CDC) recommends only repellents containing one of the following active ingredients:
- DEET
- Picaridin (known as Icaridin outside the US.
- Oil of lemon eucalyptus (OLE) or PMD. Note: “pure” oil of lemon eucalyptus is NOT recommended. It has not undergone validated testing for safety and efficacy.
- IR3535.
- Para-menthane-diol. These products provide longer-lasting protection.
No repellent bears the name of these ingredients. You must search for the name on the label, says the US Centers of Disease Control.
2. These repellents have been scientifically tested. They are safe for young children when used correctly and are effective against a wide variety of biting insects, including most disease-causing species of mosquitoes, ticks, fleas, and chiggers. They are not effective against bees, wasps and hornets, for example.3. Little is known about the safety and effectiveness of the hundreds of products on the market that do not contain the above ingredients. In the US and in many other countries repellents are not government-regulated. Anyone can concoct a product and call it an insect repellent. Few are tested for safety and effectiveness.
4. And don’t be fooled by terms such as “natural” and “chemical free” on repellents. While they sound child-friendly, in fact, the terms are virtually meaningless. All substances are chemicals. There are good chemicals and bad chemicals. Oil of lemon eucalyptus, for example, is “natural.” However, this doesn’t make it safer/better than repellents formulated in laboratories. (Poison ivy and deadly mushrooms are 100% natural.)
5. Check the lower age limitations and recommended concentrations of approved repellents. DEET, for example, should not be used on infants less than two months of age; oil of lemon eucalyptus, not on infants under 3 years. The skin of young children is especially permeable. DEET is the only CDC-approved repellent that comes in various concentrations; for children, use ones that contain between 20 and 30% DEET.6. Apply repellants correctly. Place the substance on your hands and then rub it on your child’s skin. A thin coat suffices; a thicker coat does not increase protection. No need to place it under clothing; long pants and sleeves reduce the amount of repellent needed. Wash off when no longer needed. Avoid eyes, mouth, wounds or rashes. If accidentally applied to such areas, rinse with soap and water. Apply outdoors or in well-ventilated indoor areas.
7. Use permethrin on clothing. Permethrin helps prevent insects from crawling under or biting through clothing. Once correctly applied, permethrin remains effective on clothing through many washings. Permethrin can also be sprayed on camping gear such as tents.8. Avoid products that combine repellents and sunscreens. While many situations call for both, the intervals of applications, for example, make combination products impractical. Generally, apply the sunscreen at least twenty minutes before sun exposure. Repellents can be applied just before going outside. Repellents may reduce the effectiveness of sunscreens. If both are needed, consider using a stronger sunscreen.
9. Avoid non-repellent items that claim to provide protection. Wristbands are ineffective. Taking vitamin B allegedly reduces itching from bites, causing people to think they are being bitten less. Sound and light devices attract insects to the devices, but then attack people near the devices, possibly increasing risk of being bitten. Products that emit vapors may be harmful if inhaled indoors over prolonged periods of time, especially by children. Outdoors, vapor effectiveness varies depending on wind direction and other factors.
10. Familiarize yourself with one or two repellents. Products come in the form of lotions, creams, gels, aerosols, sticks and towelettes. Read instructions. Contact manufacturers, if necessary; most have websites. Know how long protection lasts; hot weather, perspiration, swimming and other factors tend to shorten duration of effectiveness. Read storage advice. Most products have expiration dates. Using extremely old repellent can cause skin irritation and rashes.Excellent additional information is available at :
- Repellents: Use and Effectiveness (Environmental Protection Agency)
http://cfpub.epa.gov/oppref/insect/
- Insect Repellent Use and Safety (CDC)
www.cdc.gov/westnile/faq/repellent.html
- Choosing and Using Insect Repellents (National Pesticide Information Center)
http://npic.orst.edu/ingred/ptype/repel.html
Can you outsmart insects? Your kids’ health depends on it.
Part l: An update on zapping mosquitoes
You no longer have to visit the Amazon rain forest or equatorial Africa to pick up an exotic tropical disease. Nowadays, Zika, West Nile, Chikungunya, dengue and similar diseases can come to visit your family – at your home. Blame global warming. Believe it! Climate change has arrived! Prepare your defenses. There are no vaccines or medications to prevent these diseases. And there are no medications to cure them.1. These diseases are caused by mosquitoes. Mosquitoes wallow in warmth. A warmer environment enables them to multiply more rapidly, enlarge their habitat, and lengthen their breeding and biting seasons. Milder winters allow more of them to survive to bite you again next year.
2. But it’s not the mosquitoes that are your nemesis. Most mosquito bites are merely annoying. It is the viruses that mosquitoes can harbor that are worrisome. Many mosquitoes that spread diseases in the tropics already exist in North America, Europe and in other temperate climates – but are not (yet?) carrying these viruses. If an infected traveler – even one without symptoms – is bitten by a local mosquito after returning home, that mosquito can spread the disease to subsequent persons the mosquito bites. Rarely, diseases can arrive in this country by an infected mosquito that hitched a ride on a plane or ship.
3. Ridding your neighborhood of mosquitoes is your first line of defense. Repellents are secondary. While repellents are important, applying them correctly and safely, especially on infants and young children, is time-consuming, expensive, messy, not foolproof and may raise health issues. (Our next posting will discuss the use of repellents on children.)4. Know your local mosquitoes. Ask your local health department. Different species of mosquitoes transmit specific diseases. Generally, seasonal biting begins soon after trees begin to bloom and ends with the first frost. Each species has a different time of day for peak biting activity, but it is usually around sunrise and sunset. Stay indoors at such times if a mosquito-borne disease alert is in effect.
5. Check that local authorities eliminate standing water in your neighborhood. Notify them about standing water in empty lots and near uninhabited houses. Generally, insecticides are sprayed to kill larvae in ponds, reflecting pools and other bodies of still water. Sometimes fish are placed in water to eat larvae.6. Insecticides are safe for infants and children. According to the US Environmental Protection Agency, “The chemicals used in approved insecticides, when used correctly, do not pose unreasonable risk to public health and the environment. Insecticides do not cause asthma. Rarely they may cause mild, temporary eye irritation.” Some experts suggest you keep family members with serious respiratory issues indoors during sprayings. Health departments will supply dates and times.
7. Eliminate standing water on your property. Mosquitoes breed in poorly maintained swimming pools and in standing water on tarpaulins covering pools. Empty children’s wading pools at least once a week. Check for standing water in backyard toys, abandoned tires, flowerpots, trashcans, and even bottle caps.8. “Bug proof” your house/apartment. Cover gaps in walls. Use weather stripping under doors. Check bathroom exhausts. Make sure windows and chimneys are properly screened and repair any holes. Remove piles of wet leaves from yards and roof eaves. Air conditioning and fans are effective deterrents; mosquitoes prefer still air. Fans are effective on porches and terraces. Observe similar mosquito precautions when away from home.
9. Be leery of devices that claim to repel mosquitoes. Products that emit vapors may be harmful if inhaled indoors over prolonged periods of time, especially by children. Outdoors, vapor effectiveness varies depending on wind direction and other factors. Sound devices worn around the neck or wrist to scare away mosquitoes are not effective. “Bug lights” are not repellents but do not attract mosquitoes as many ordinary lights do.
10. Miscellaneous. Taking vitamin B or antihistamines may reduce itching from bites, making people think they are being bitten less. Avoid scented soaps, perfumes, and hair spray; these may attract biting insects. Do mosquitoes prefer biting infants? (Maybe they taste sweeter?) In fact, no one knows if infants are bitten more often. If so, it may be because infants are unable to swat them away. Place nets over strollers and playpens outdoors.For the latest information, see https://www.cdc.gov/zika/prevention/controlling-mosquitoes-at-home.html
Are cruise ships healthy for young children?
You’re considering taking your kids on a cruise but then you hear about yet another outbreak of intestinal disease aboard a large ship. Do you go? It’s your decision. Here are the facts. My recommendation is below.
1. About 14 million passengers, including 1.5 million children, sailed from American ports last year. And, as in previous years and in spite of the best efforts of the U.S. Centers for Disease Control (CDC) and the cruise industry, some passengers became ill with intestinal illnesses, mostly due to the norovirus. Young children appear more susceptible to this virus than adults.2. On cruise ships, most cases of norovirus result from placing your fingers/hands in your mouth after touching virus-contaminated objects – other people’s hands and doorknobs, for example. A less likely source of norovirus on cruise ships is ingesting virus-contaminated food and water. The virus can survive for 12 hours on most surfaces and up to 12 days on contaminated fabrics. It takes relatively few viruses to make people ill, far fewer than for other intestinal illnesses.
3. Cruise ships are ideal places for outbreaks.Thousands of passengers and crew are confined in relatively close quarters for many days. They touch the same objects and eat food and drink water from the same sources. One infected individual can spread the virus widely. The virus is often brought aboard unwittingly by passengers or crew, often at ports where sanitation is poor and the virus more common. Once aboard ship, it is difficult to eradicate.
4. Outbreaks on cruise ships are widely reported. The medical staff must document passengers and crew who visit the ship’s infirmary with intestinal symptoms or who ask for medication for such illnesses. Since the symptoms of norovirus generally occur within two to three days of infection, most victims are still aboard ship when symptoms appear. If the number of ill individuals surpasses 3%, the outbreak is reported to the CDC immediately, special sanitizing programs are instituted on the ship, and the ship is inspected when it reaches port. Ships are also inspected twice yearly (often unannounced) and are barred from sailing if they receive a failing sanitary score. Outbreaks and scores are posted on the CDC’s website (see below) and often widely publicized by the media.5. Cases of norovirus are far more common on land. Last year, in the U.S., there were 21 million reported cases of food-related intestinal illnesses. Of these, norovirus accounted for more than half. However, far more cases go unreported. Physicians need not report cases to health authorities, and almost never do. Moreover, when outbreaks occur at restaurants, diners scatter after meals, and the outbreak goes unreported.
6. The majority of norovirus cases are merely annoying. Symptoms generally include mild diarrhea and stomach discomfort for a day or two. Vomiting occurs occasionally, especially in children. Children who drink and eat normally and are happy and playful need not be treated, even when symptoms last a few days. But these children should be isolated to avoid spread. No swimming. No playgroups. Seek medical care if children have frequent vomiting and diarrhea, are cranky and listless, and refuse liquids.
7. Proper and frequent hand washing greatly reduces the chances of illness. The CDC recommends the following:Wet hands with clean, running water (warm or cold). Turn off tap. Apply soap. Lather by rubbing hands together. Lather back of hands, between fingers, and under nails. Scrub for at least 20 seconds. (Hum “Happy Birthday” twice.) Rinse under clean, running water. Dry with clean towel or air dry.
8. Use soap and water if possible, not hand sanitizer, to clean hands. When soap and water are not available, use alcohol-based hand sanitizers that contain at least 60% alcohol. Compared to soap, sanitizers remove fewer types of disease-causing organisms, are less effective when hands are visibly dirty, and can cause alcohol poisoning when swallowed. Read instructions.
9. Choosing cruise ships by their sanitary score is not helpful in avoiding illness. Ships’ current and past sanitation scores are available at http://www.cdc.gov/nceh/vsp/surv/gilist.htm. However, there is little correlation between scores and risk of illness; outbreaks occur on ships with perfect scores. The same is true for avoiding leafy salads and shellfish, for example, foods associated with norovirus outbreaks on land.
10. My opinion: Most types of travel and many outdoor recreational activities – camping and swimming, for example – increase the incidence of intestinal diseases. Chances of illness aboard cruise ships are small and in most cases of illness, symptoms are mild. And there is “in-house” medical care available on ships. Even staying home has its pitfalls. Young children average two episodes of intestinal diseases yearly, more if they attend daycare or nursery school. So taking children on cruises is a reasonable travel decision. Bon voyage.Is air travel safe for young children with bad colds and ear issues?
If a decade ago you’d asked your doctor if young children should fly with ear infections, nasal allergies or bad colds the likely answer was an emphatic no, that flying with these conditions could damage the ears. Today, if you asked, the likely answer is a conditional yes.1. No studies exist to help 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 is feverish, or an older child has an earache. They are seen at a medical facility, a diagnosis of ear infection is made, medication is prescribed, and delay in flying is recommended. That delay may be until the pain/fever subside, or until a course of antibiotics is completed, which may be five to ten days.
2. Ear infections are greatly over diagnosed. Especially in emergency care clinics, the kind often found in resorts. 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 an infection is present. Not to miss an infection, treatment is prescribed, “to be on the safe side.”
3. Air travel does cause earaches. And possibly more so in young children than in adults. However, millions of children fly each year, many with the conditions described above. Yet my asking hundreds of pediatricians, pediatric ear specialists and physicians in aviation medicine I have yet to find one who has seen a case of permanent damage to a child’s ear from air travel. And no case of such damage is described in the medical literature. If it does occur, it is an extremely rare event.4. Earaches associated with flying are caused by changes in atmospheric pressure plus the presence of mucus in the nose. As airplanes ascend and descend the changes in altitude also change the air pressure in the ears. Normally, there is no pain; a tube, the Eustachian tube, which connects the middle ear to the upper nose allows air to flow freely back and forth, equalizing pressure. However, if the tube(s) are clogged, with mucus from colds or allergies, the changing pressure may cause pain.
5. Young children who already have ear infections can fly. In fact, they are generally less likely to have pain than children with no infection. The reason: infection generally produces fluid in the middle ear. The fluid replaces the air. No air, no change in air pressure. No pain. Children who have 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, equalizing pressure.
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 likely to be disturbed.
7. Conventional “wisdom” says to feed infants during ascent and descent, and often during flight. Allegedly, this prevents both dehydration and earaches. However, dehydration is a myth. And, at cruising altitudes, due to the changes in air pressure, the air in the stomach and intestine is already expanded by 20% (giving adults a bloated feeling.) For infants, sucking adds air and food to the stomach, which may cause fussiness and crying. On the other hand, the sucking motion may help keep the Eustachian tubes open. Feed infants no more often in flight than at home.8. Commonly used remedies given children are of questionable usefulness. Oral antihistamines to reduce nasal secretions/congestion are no longer recommended under any circumstances. Saline nose drops/sprays and drinking lots of fluids to unplug the tubes are ineffective.
9. Preventing ear pain. Pain most commonly occurs during descent. 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 indicated.10. Treating ear pain. Administer acetaminophen or ibuprofen. Teach older 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 try chewing gum, sucking on hard candies, yawning, and moving their jaws from side to side, maneuvers that may open the tubes.
Hi Readers:
You may reproduce this article for your organization. (Many pediatric groups do so.) Two issues per month. We are non-commercial. Our goal: to help parents keep kids healthy/safe for travel/outdoor recreation. Recently quoted in NY Times, USA Today, Travel & Leisure. Author: retired pediatrician, travel medicine expert, journalist.
Karl
Karl Neumann MD FAAP CTH
www.kidstraveldoc.com
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