Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Update on Poison Ivy: The Scourge of the Great Outdoors
Poison ivy is a good example for parents that if something is identified as “natural”, “organic”, “fresh” or “pure”, it is not necessarily “healthy” or “wholesome” — as advertisers and marketing people would have you believe. Poison ivy and its close cousins, poison oak and poison sumac, have no known redeeming qualities, except, perhaps, a subtle reminder from Mother Nature to watch your step, even when surrounded by nature.1. The “poisons” are a North American phenomenon. They exist only in the continental US and southern Canada. Visitors from overseas are generally unaware of the problem and baffled by the resulting rash. For them it is a traveler’s disease.
2. The plants are booby traps. The common saying about poison ivy “if the leaves are in three, let them be” helps identify only some of the plants. Many have more than three leaves and their shape, color and berries depends on the local environment and the season of the year. The same can be said for the less common poison oak and poison sumac. Moreover, many non-poisonous plants also fit these descriptions. For more detailed descriptions of these plants see http://www.webmd.com/skin-problems-and-treatments/poison-ivy-oak-and-sumac-leaves.
3. Know your poison.The chemical that causes the rash is urishiol, an oily, sticky substance. It is present in the leaves, stem and roots of the plants and remains active even in dead plants. Bruising any part of the plant releases urishiol. Susceptibility to the oil varies but few, if any, people are immune. Infants rarely get severe cases; likely it takes repeated exposure to become sensitized. Exposure to an amount of urishiol the weight of one grain of table salt causes rashes in 80 to 90 percent of adults.
4. Urishiol is rapidly absorbed into the skin.Within ten minutes, 50% of the oil is absorbed; by thirty minutes virtually all is absorbed. Wherever the oil touches the skin, a rash may appear. The more oil touching the skin, the sooner the rash appears and the more severe it will be. If you suspect exposure, wash the area immediately and thoroughly with soap and water or with rubbing alcohol. Rub the skin firmly with a washcloth. After about 30 minutes there is no reliable way of removing all of the oil.5. Urishiol can also be acquired indirectly. If shoes, clothing, toys, tools, or pets, for example, bruise plants, the oil is transferred to these objects/pets and remains viable for extended periods, sometimes (albeit rarely) years. Touching contaminated objects/pets is like touching the plant. Wear gloves to wash objects/pets. Avoid inhaling smoke from brush or wildfires; it may contain urishiol. The fumes may irritate exposed skin and, if much smoke is inhaled, damage the lungs.
6. The rashes of all three “poisons” are identical: It consists of pinhead-sized, fluid-containing blisters. The blisters are often in streaks, the result of oil-covered fingers touching the skin. Depending on the amount of oil present and the sensitivity of the victim, the rash may appear in about four hours to several days after contact and remain on the skin for several weeks.7. The rash is not contagious to others.The blister fluid is the body’s reaction to the plant. It contains no oil and cannot spread the rash to other parts of the body. Subsequent appearance of the rash on new areas of skin is the result of less urishiol having contacted that area or to a new exposure.
8. The poisons grow in forests, fields, and wetlands; along streams and roads; and in urban areas such as parks and backyards. Check playing areas for plants, especially along peripheries of sandlot baseball fields. Tell children not to touch vegetation unnecessarily. Report to authorities the presence of plants in recreational areas. Employ professional gardeners to remove plants from your property. Wearing long pants, long sleeves and high socks minimizes exposure.
9. The treatments for all three poisons is identical. However, the various home remedies reduce itching but do not substantially shorten the duration of the rash. Try cool water compresses or substances containing hydrocortisone or phenol and menthol. Not recommended are topical antihistamines or anesthetics (“caine” products, for example). These can cause rashes in some individuals. Oral antihistamines reduce itching but have side effects. Read directions. Severe cases require medical attention. Keep rashes clean with soap and water and apply antibiotic ointments to prevent secondary infections.10. Miscellaneous. Attempts to desensitize people against urishiol are ineffective. Urishiol blocking creams are not recommended for children. Such creams are applied to exposed skin before possible contact with the oil and act as a barrier, similarly to sunscreens.
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Diarrhea/Young Children/Travel
As far as young children are concerned, what does visiting equatorial Africa, attending day care/kindergarten, and swimming have in common?They increase the incidence of diarrhea in young children. However, even if your child(ren) do none of these and your house is compulsively clean you’ll still deal with several episodes a year. Are you aware that current treatment recommendations for most cases is to do nothing, that many traditional treatments worsen symptoms, and that only a small number of cases require prompt medical attention?
1. Virtually all cases are due to bacteria, viruses and other microorganisms. The organisms are ingested in contaminated food and water, drinking swimming water, and indirectly, from children placing previously contaminated hands in their mouths. Improving sanitation decreases the incidence. See related article.
2. More stools than usual or looser stools in otherwise healthy children is no reason to panic. If children have no other symptoms – are happy and active, drinking and eating normally, and not vomiting, bowel movements usually return to normal within a few days. No reason to even change diets.
3. Occasional vomiting and some stomach discomfort in otherwise healthy children calls for “watchful waiting.” In such cases, anti-vomiting medications are rarely effective or necessary. Generally, vomiting lasts only a few hours, rarely more than eight hours. A decrease in appetite is also of no concern. If occasional vomiting and diarrhea continue add more fluids to their diet. Encourage them to drink small amount at a time. Start with a tablespoon. If that is vomited, go to teaspoons. Offer liquids every ten to fifteen minutes.
4. Continue feeding breast milk, infant formula or cow’s milk. Withholding milk is unnecessary in otherwise healthy children. (Milk may worsen longstanding vomiting and diarrhea.) Diluting milk with water, another old custom, also serves no purpose.5. But avoid large amounts of plain water and very sweet fluids. Clear liquids – water, soda, tea, juice, and gelatin desserts, for example – lack salt and may slow recovery. Very sweet fluids can draw water from the body into the intestine, prolonging symptoms.
6. Resume feeding as soon as vomiting ceases.Withholding food is counterproductive. Food and liquids are essential to supply calories and may actually aid in protecting and restoring the 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 a child’s favorite food, whatever it is; children are more likely to eat and drink what they like. Less food intake is normal whenever children are ill.
7. Some traditional diarrheal remedies have serious side effects. Kaolin-pectate products (Kao-pectate) do reduce the number of stools. But they do so mostly by retaining stool in the intestine, giving false signs that diarrhea is improving. Bismuth-containing substances (Pepto-Bismol), loperamide (Imodium) and (atropine and diphenoxylate (Lomotil are not generally recommended for young children. Sports drinks (Gatorade) are designed to replace nutrients lost by perspiration, not specifically nutrients lost from the intestinal tract.8. If symptoms continue, start keeping records and get electrolyte solutions. Chart the frequency of vomiting, diarrhea and urination, and the amount of fluid intake. Electrolyte solutions, available in pharmacies and supermarkets, replace nutrients being lost. These solutions are available in liquid formulation or as powder in small packets. Mix with safe water. If electrolyte solutions are not immediately available, give clear fluids along with salty foods. pretzels, salted crackers or potato chips, for example.
9. Recognize impending dehydration. Seek immediate medical attention if vomiting or diarrhea become continuous; children refuse fluid or cannot retain it; are less active; run fever; complain of or show signs of severe abdominal pain; or there is blood/mucus in the stool.
10. Miscellaneous. While young children with moderate vomiting/diarrhea need no immediate treating, do isolate them from other children; keep them home from daycare and out of swimming pools so they do not infect others. Making your own rehydrating solution by mixing water, salt, sugar, and sometimes, other ingredients is no longer recommended; solutions are readily available and many parents prepare solutions incorrectly.
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Go Take a Hike: An Update
It’s all in the tone of your voice when you tell your children “Go take a hike. ” Are you telling them to leave you alone or are you recommending that they adopt a healthier lifestyle? (Hopefully it’s the latter.)1. Hiking benefits both adults and children. Hiking provides quality togetherness and helps prevents obesity, diabetes, hypertension, and a slew of other health issues. It requires little or no equipment, is a safe activity, and can be performed virtually anywhere, not only in the woods. You can “hike” in amusement parks, malls, and on city streets The earlier kids get acquainted with nature, the more likely they will continue their interest when they grow up.
2. Start kids hiking before they can hike.Carry them on your back, so you can hike and get them used to the outdoors. Start when they are about six months of age, a time when they can hold their heads up. Check that you have an infant carrier comfortable for you and appropriate for the infant’s age and size. (See infant carrier.) Outside, watch for branches and bushes. Protect their eyes from the sun, especially in snow country.3. Don’t bother trying to predict how far, how fast or for how long toddlers will walk.(Toddlers are defined as being between one and three years of age. Then they become preschoolers.) Medically speaking, let them walk as long as they like; no need to limit them. Let them set the pace and direction – which may be slow and in circles. The first few times you go “hiking,” stay close to your house or car. You may hear the “carry me” at any time and, possibly, many times. Don’t go further than you can easily carry kids back.
4. Most four year olds will walk one mile (1.6 kilometers). A rule of thumb: motivated kids will walk/hike one additional mile for each year over four, i.e. three miles (4.8 kilometers) for a six year old. Factor in physical fitness, difficulty of the terrain, and weather. Compliment them on their achievements.5. Keep them motivated. Let them help you pick out snacks for the walk/hike and tell them about what they will see on route. Call for rest stops when you see them dragging and losing interest. Do so before they complain. Let them lead the family. Alternate leaders if there is more than one child.
6. Choose routes interesting to young children. Kids are rarely impressed by historical sites and scenic landscapes and prefer picking flowers to viewing them. They tend to like waterfalls, lakes (especially ones with ducks in them) or into which they can throw stones, and rocks on which they can climb (safely). Ideally, choose routes with attractions close together so you can entice them on with something interesting just ahead. Point out animal tracks and burrowing holes, anthills, and birds’ nests, for example.
7. Provide young kids with backpacks. Wearing backpacks makes them feel part of the group. For toddlers, it doesn’t matter what they carry – a light toy, a small water bottle, their favorite snack, or nothing. For older children on serious hikes, backpacks should weigh no more than fifteen percent of body weight, less for tough terrain, first time hikers, and extremes in temperatures. (This holds for school backpacks too.)
8. Keep kids well hydrated and well fed.Loss of stamina occurs before thirst sets in. Encourage them to drink. Carry drinks they like. Drinking is especially important in hot and humid environments. For children of all ages, even on fairly strenuous hikes, plain water is adequate. Energy drinks and electrolyte solutions are unnecessary. “Trail mixes” consisting of dried fruits, nuts, grains and chocolate are very popular, and available everywhere. These mixtures provide energy, taste good, are lightweight, and are easy to carry, store, and eat.
9. Teach young children to “Hug-a-Tree” if they lose sight of you. If children feel lost they start running in the direction they happen to be facing, greatly complicating reuniting. Supply preschoolers with whistles, when appropriate. Check the many electronic gadgets now available to keep track of children.10. Miscellaneous. Allow kids to bring a friend along. (Adults are boring, friends are cool.) Expensive and sophisticated footwear and clothing add little to the kind of walking/hiking that children do. Have lists of supplies to carry: insect repellent, sunglasses, sunscreens, sun hats, extra clothing, a small first aid kit, and a cellular phone that works where you are hiking.
Necessary Do’s and Don’t’s to Keep Kids Healthy Outdoors
The headline on a recent article in the Wall Street Journal (WSJ) reads, “If You’re a Kid, the Experts Want You to Have a Fun-Free Summer.” To my surprise I am the main ogre (my word) in this article, one who leeches the fun out of kids’ summer pleasures. But, if truth be told, I like the article: the author, Lenore Skenazy, reads my newsletter, the WSJ editors saw fit to print it, and it brought about three thousand extra readers to my website, a record by far. Moreover, the criticism of me is good natured and balanced. What else could I ask for?Skenazy uses my recent article on children playing in the sand at the beach as her “punching bag” and takes issue with the many do’s and don’ts that I recommend to keep kids healthy and safe outdoors. It is her contention that my article is a prime example of how “experts” overemphasize the hazards of everyday childhood activities, in this case outdoor ones.
She quotes me (correctly): “Children playing in the sand are more likely to become ill than children walking on it and the risk of illness increases with digging in the sand, lying on it, and being ‘buried’ in it.” She believes that illnesses stemming from playing in sand, for example, are rare events, tend to be more annoying than alarming, and that the do’s and don’ts I recommend are not likely to eliminate all problems. Moreover, she believes that articles such as mine scare parents unnecessarily, makes parents overprotective, and causes parents to drive their kids crazy – sometimes literally so – with a litany of do’s and don’ts.Skenazy believes in raising “free range” children (what a great term) and writes and lectures extensively on that subject. (See her website here.) She believes parents should allow children to function as independently as possible, keep parental supervision to an age-appropriate minimum, and consciously accept reasonable amount of risks regarding their children’s wellbeing. She further believes that the psychological impact of overprotection is part of the equation on what to let children do/not do. There is no need to be helicopter parents (another great term), who hover over their children, refusing to cut the umbilical cord until kids are off to college – or later.
So it comes down to where parents should draw the line in the sand, (in this case, both literally and figuratively) between the free rangers and the do and don’ters. For me, the free rangers lean too far toward relying on their instincts to make decisions and are a bit uneasy with research and statistics. The free rangers believe that if they and their circle of friends have not encountered a particular issue then that issue occurs too infrequently to fret about.In fact, only recently have there been reliable statistics regarding illnesses and mishaps related to children’s outdoor activities. Problems occur far more frequently than generally believed. Emergency rooms (ERs) in the US record the reason for every visit, including those from children’s outdoor activities. The data are placed into computer databases where researchers, by keying in a few terms, can see how many children have had problems stemming from beach activities, falling out of infant carriers, skateboarding, or being forgotten in cars in hot weather, to name just a few examples.
I recommend that parents move that imaginary line in the sand a bit away from free range and toward the do’s and don’ts. Skenazy is correct that beach sand is not a source of a great number of ER visits, However playgrounds are, 200,000 yearly visits and amusement parks, 9,000 visits, for example. Trampolines alone are the cause of 100,000 visits.So read the litanies of warnings posted at outdoor recreational activities – and, of course, in my newsletter. Follow the advice. Kids will still be able to have fun.
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.
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