Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Can infants and young children travel by air? Answers to frequently asked questions. An update.
1. Can healthy newborns travel by air? Healthy newborns, yes. However, two groups of infants require medical evaluation prior to flying: those born significantly premature and those having heart and lung issues at or soon after birth. Such infants should be evaluated by pediatricians until they reach their first birthday, even if they show no symptoms. Rarely, they have difficulty compensating for lower oxygen levels in aircraft cabins at cruising altitudes.2. How soon after giving birth can mothers safely travel by air? The general rule: one week after uncomplicated routine deliveries, three weeks after uncomplicated C. sections. Likely, you can fly sooner. However, “What’s the rush?” Discuss your plans with your healthcare provider. How important is your trip? Air travel worsens fatigue. Are you breast-feeding? Is it going well? Are there medical facilities at your destination? In flight, drink lots of fluids, exercise your legs frequently, and walk when possible. This helps prevent blood clots from forming in your legs. Clots are rare, the result of prolonged sitting in confined spaces.
3. Is cosmic radiation a threat to infants? The increased amount of radiation at cruising altitudes compared to exposure on the ground is negligible, even on ultra-long flights, and should cause no problems. Such exposure also appears to be safe for the fetuses of women who fly occasionally. (Curtailing flight hours is recommended for pregnant flight crewmembers.)
4. Do airlines have lower age limits for infants? Only a few airlines still ask for letters from a physician stating that an infant less than two weeks of age is in good health. (The recommendation is rarely enforced.) Check your airline’s webpage (see “Infants”) or call the airline’s reservation number.5. Are aircraft equipped to handle infant-related in-flight health issues? Problems occur extremely rarely. Flight attendants are trained in first aid and aircraft carry kits with common medications and basic lifesaving equipment. However, the equipment and medications are not infant-oriented and may be used only by licensed physicians – if one happens to be aboard and volunteers to treat. Few physicians are trained in emergency medicine, let alone treating infants in flight. In emergencies, the crew can contact specialists on the ground for advice.
6. What kind of problems occur during flight? Mostly accidents, rarely illnesses. Most accidents are preventable: infants rolling off adults’ laps; adults holding infants and tripping while walking in aisles; burns due to hot beverage spills; luggage falling from overhead bins, for example. Place infants in window seats to minimize risks. Most illnesses are ones that occur at home. Carry appropriate medication. For on-going conditions, consult the child’s health care provider prior to travel.7. Are infants likely to contract infectious diseases? Unlikely. Infants are partially protected by immunity obtained from their mothers. Most contagious diseases spread through the air. Cabin air is replaced every few minutes with mostly sterile air. Air circulates from ceiling to floor, not through the entire aircraft, making passengers susceptible only to illnesses from those sitting nearby. Infants should be up-to-date with their immunizations. Saline (salt water) nose drops restore moisture to nasal membranes and may help warding off cold-causing germs. Washing infants’ hands frequently and wiping down tray tables and toilet lavatory surfaces with disinfectants may help prevent intestinal illnesses.
8. Do infants need extra drinks to prevent dehydration? No. In-flight dehydration is a myth. Feed no more than at home. Adults erroneously interpret parched mouths/throats as dehydration. This dry feeling results from air conditioning removing moisture from the cabin air. Extra feedings are counterproductive. At cruising altitudes the air in the stomach and intestine is already expanded by 20%, the result of lower atmospheric pressure. (This gives adult bloated feelings.) For infants, excessive liquids and solids and the act of sucking add unnecessary bulk and air and may cause fussiness.
9. Is it OK to sedate infants for long flights? No. Surprisingly few infants cry, considering that air travel disrupts their sleep and feeding schedules, they rest in unfamiliar and sometimes uncomfortable positions and, if on an adult’s lap, are disturbed every time the adult moves. No studies show which medications are effective and how much and when to give. Sedating medications (antihistamines, for example) make some infants more active. Herbal supplements and melatonin (a hormone that controls the body’s day/night circadian rhythm) are inappropriate for sedation.10. Should infants with colds, nasal congestion or ear problems travel by air? Discomfort may occur, most commonly during descent. However, serious or permanent damage to ears does not seem to happen. Child-sized earplugs that claim to lessen ear pain are not very effective. Noise-cancelling headphones are safe but of questionable necessity. Decongestants and nose drops are not effective at this age. Allowing children to briefly breastfeed or suck on a bottle or pacifier may avoid or relieve symptoms. Carry acetaminophen to treat pain.
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Backpacks / Children / Safety / Health
Backpacks here. Backpacks there. Backpacks everywhere, and for almost every reason. Toddlers wear them for the sake of wearing them, often empty and in the shape of cartoon characters. Elementary school-age kids pile everything they have into them. High school kids use them as fashion statements, often slung over one shoulder, a style that tends to cause backaches. (And now, there are bulletproof ones for children to use as shields in case of a school gun shooting incident! See the web.)Here what you should know.
1. Loads on backs should not exceed 15% of a child’s body weight. Lesser loads, about 10 % or less, are recommended for very young children, backpack beginners, long trips, going uphill, climbing stairs, walking on tough terrain, and in hot weather. If your child’s backpack is too heavy, discuss with school staff if loads can be lightened.
2. Backpacks that are too heavy or worn incorrectly often lead to bad posture and back problems. In the US, about 14,000 backpack-related injuries occur yearly. Approximately half of the cases are in children and teenagers. Improperly used backpacks can strain muscle and joints, causing upper and lower back pain and neck and shoulder pain, sometimes severe. (However, there is no evidence that these problems will result in scoliosis or other permanent deformities.)
3. Choose function before fashion. Buy backpacks with shoulder straps that are wide, contoured, and padded to prevent straps from digging into the shoulders. Straps should be adjustable so that the backpack rests snuggly against the back, can be put on and taken off easily, and doesn’t interfere with arm movement. Backpacks should be no wider than the child’s body.4. Waist straps help keep backpacks in place and transfer some of the weight from the shoulders to the back and hips. When straps are too loose, backpacks dangle uncomfortably. Ideally, the backpack should rest two inches below the waist. Padding in the back of backpacks protect wearers from objects, especially ones with protruding edges, increasing comfort. The lighter the backpack, the more weight can safely be placed in it.
5. Discourage children from wearing backpacks on one shoulder. This fad is now in vogue – and even young children are surprisingly fashion-conscious. Weight should be distributed equally. Numerous compartments simplify weight distribution. Place heavier objects at the bottom, near the center, and up against the back.
6. Tuck in straps. Some backpacks, especially ones designed for young children, have long straps to fit children of various sizes. Long straps may cause tripping, become entangled in branches or get caught in doors.7. Watch your child for backpack “dysfunction.” The aches and pains resulting from wearing new backpacks are not symptoms of a necessary adjustment period. Investigate before they become worse. Look for red marks on children’ shoulders and ask about tingling or numbness in their arms. Backpacks are too heavy when children have difficulty putting them on, lean to one side while wearing them, or bend forward with their heads down for balance. Doing so can cause children to topple over, especially on stairs. Consider showing your children exercises to build up the muscles used to carry backpacks.
8. Put backpacks on correctly. Children should bend at the knees, not at the waist, while keeping the trunk of the body straight and stable. They should push up using their leg muscles and keep the backpack close to the body. Excessive twisting and turning may indicate that the backpack is too heavy or the wrong model. Some children find it advantageous to place backpacks on a chair or table (depending on the child’s height), before placing them on their backs.
9. Avoid injuring others. Fully loaded backpacks protrude more than a foot (30 centimeters). Bystanders, in the aisles of school buses or on airplanes, for example, have been pushed over when a backpack wearer suddenly turns around. Remind children not to leave backpacks on the ground or floor. In one survey, 28% of backpack-related injuries were the result of someone tripping over a backpack.
10. Consider rolling backpacks. Wheels allow children to roll backpacks where feasible. Handles on wheeled backpacks should be sufficiently long so that children can stand fully upright when pulling them. (Some schools ban wheeled backpacks as being dangerous on stairs and not fitting into lockers.)
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Strollers
If your infant’s stroller is recalled because of a safety issue, will the manufacturer be able to contact you?
1. Strollers help keep your infants and toddlers safe and healthy but only if (1) the stroller is structurally sound and (2) you use it correctly. Recalls of basic child-related items occur frequently, says the US Consumer Product Safety Commission (USCPSC). Such items also include carrying slings, carriages, cribs, highchairs and changing tables. Among these products, strollers are the leading cause of injuries, accounting for about 14,000 US emergency rooms visits each year. This year, 800 strollers were recalled. In 2013, 200,000 were recalled due to a potential strangling hazard.2. Staying in contact with the manufacturer is your responsibility. You must register your stroller (or other items) with the manufacturer at the time of purchase, notify them each time you change your contact information (email, telephone number and postal address, for example), and read and respond to messages they send you – which many people fail to do. You can also check for recalls. USCPSC maintains a registry of recalls involving children-related items. See saferproducts.gov or call UPCPSC at 1-800-638-2772. The name of the manufacturer and model and serial numbers of the item you are checking are provided somewhere on the product.
3. Seventy-five percent of stroller-related injuries result from children falling out of them. In most mishaps, infants are improperly strapped in. “I just turned my back to turn off the water” is a typical scenario. Infants slide down between the hand tray and the bottom of the seat. While the body fits through this space, the head becomes entrapped, compromising the infant’s ability to breathe. Other recent recalls involved children seriously injuring fingers in the mechanisms of fold-up strollers and falling out when handlebars became disengaged. Other mishaps include “tip-overs,” “collapses,” and “runaways” (see #4 below).4. Umbrella strollers cause the majority of stroller-related injuries. They are lightweight, simple to set up and maneuverable. However, these features make them prone to tipping over, often due to heavy objects hanging on the handlebars or overloading storage areas. Strollers with wide bases are less likely to tip over. Keep infants away from the stroller as you open and fold it; their fingers can get caught in the hinges. Make sure that umbrella strollers are “clicked in” when opened. If not, the stroller may collapse while you push it. Engage the brakes whenever you take your hands off the handlebar. Umbrella strollers’ lightness enables them to roll down slopes so slight that you may be unaware that a slope exists.
5. Most umbrella strollers are not designed for young infants. Younger infants must lie flat on their backs; popular models of umbrella strollers do not provide the head support that infants require. Umbrella strollers are safe to use once infants can hold their heads up while sitting with support (usually by five to six months).6. Other safety recommendations. Read the product manual. Check that infants’ fingers cannot reach the wheels. Strollers left in the sun in hot weather can cause plastic and metal pieces to become sufficiently hot to cause burns. A sun shade for the stroller is a helpful accessory. In strollers that allow an older child to sit or stand in the rear, keep in mind weight guidelines and keep children from becoming too rambunctious lest they tip the stroller over.
7. Hand-me-down strollers are rarely bargains. (Ditto for the other products mentioned above.) Injuries have occurred because fabric covering hardware is torn, exposing bolts and screws, for example. In most cases, the newer the model, the safer it is. Newer models benefit from improved technology, more stringent government regulations, feedback from users, and no wear and tear from usage.
8. How long is too long to allow infants to sleep in car seats/strollers? “Travel systems” allow parents to transfer sleeping infants from car seats to stroller bases without waking, an appealing feature for parents. Ideally, young infants should sleep flat on the backs. Sitting semi-upright for lengthy periods can contribute to developing flat spots on the back of infants’ heads, worsen reflux, if present, and affect breathing. Generally, infants should sleep in strollers/car seats no longer than two hours, with regular monitoring.9. Infants in strollers do not belong on stairs/escalators. Use elevators when available, have someone carry the stroller or infant while you carry the other, or if you are by yourself, carry the infant and stroller separately (not an easy task). Stroller/escalator accidents are especially common at airports. You may be rammed by people pushing luggage or your stroller may not be positioned correctly for escalator stairs to rise or fall. At airports, elevators are available where there are escalators or stairs, but they are frequently out of sight. Ask.
10. Miscellaneous. When purchasing a stroller, check that the handlebars are at waist level or slightly lower and that you can steer it in a straight line when pushing with one hand. It is unsafe for young children to push a stroller while an infant is seated in it. Infants gain weight and grow rapidly; check your manual from time to time to see if your infant has outgrown your stroller. In parking lots, drivers can have difficulty seeing strollers. Keep the stroller close to your car and stand next to it.
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Swimmer’s Ear
On a summer vacation at the beach, five hours from home, your 3-year-old announces that dreaded complaint, “My ear hurts!”
What to do?
1. Chances are you dealing with a swimmer’s ear. Also, think ‘swimmer’s ear’ in younger preverbal children who poke their fingers into their ears or are unusually cranky. Swimmer’s ear is quite common. Symptoms generally begin two or three days after swimming.2. Swimmer’s ear is an infection of the outer ear canal.The canal extends inward for about an inch (2.5 cm) and ends at the eardrum. Tugging or pressing on the earlobe increases pain significantly if a swimmer’s ear is present. (Children also experience earaches with middle ear infections. However, such infections are far more common in cold weather, are unrelated to swimming, and pulling or pressing on the earlobe does not increase pain.)
3. Swimmer’s ear is caused by bacteria and fungi. These are most commonly found in non-chlorinated recreational water such as lakes and streams, particularly polluted ones, and in inadequately chlorinated swimming pools, hot tubs and whirlpools. Backyard kiddie pools are common culprits; such pools are rarely adequately chlorinated. Swimmer’s ear is uncommon in ocean water; salt water retards growth of these organisms. High summer humidity helps these organisms to flourish in the ear canal.
4. “The only object to insert into a child’s ear is your elbow.” This old adage helps prevent many swimmer’s ears. Instruct children not to try to remove wax or relieve ear discomfort with cotton swabs, paper clips, hairpins, fingernails or similar objects. These can damage the delicate skin lining the canal. Abraded skin is prone to become infected. Moreover, trying to remove wax tends to drive the wax deeper into the canal and removes the layer of wax that helps protect the skin from moisture. Clumps of wax can solidify and develop sharp edges capable of damaging the skin.
5. Dry the ear canal as soon as symptoms occur. Use equal parts of rubbing alcohol and acetic acid (vinegar). Mix half and half. Fill the canal. Do it several times a day. Such drops are also available at pharmacies; no prescription is necessary. Hair dryers aimed at the ears are also effective. Keep dryers about a foot (30 centimeters) from ears.6. Apply drops correctly. Have the child lie on their side and pour the alcohol/acetic acid solution into the ear until the canal is full. Have them lie there for five minutes. Do the other side, if necessary. Do this several times a day. Continue for several days after the pain is gone. Note: do not use eardrops if a child has serious, ongoing ear problems. Consult a physician.
7. Preventing swimmer’s ear. Choose swimming venues where the water is salty or likely to be well chlorinated. Instruct children to keep their heads out of the water where water quality is questionable. Children who have a history of swimmer’s ear are subject to repeat infections. Use drying drops routinely before and after they go into the water.
8. The use of earplugs is controversial. If they fit well, earplugs help keep ear canals dry. However, poorly fitting ones – which most are – allow moisture in, keep the moisture in, and may abrade the skin. Competitive swimmers wear earplugs specifically molded for their ears. Wearing bathing caps for prolonged periods and placing cotton in the ears can also interfere with drying.9. Seek medical help if pain is severe, there is a discharge from the ear, or symptoms continue. Occasionally, cases of swimmer’s ear require eardrops containing other substances, oral medication, an anesthetic for pain, or steroids to promote healing and decrease swelling. Sometimes debris (such as wax) must be cleaned by a physician in order to allow drops to reach the damaged skin.
10. Miscellaneous. Children with swimmer’s ear can go in the water. They are not contagious to others. However, they should keep their heads out of the water… The frequent wearing of headphones may bring on swimmer’s ear. Headphones increase the temperature and humidity of the canal, create skin abrasions and may introduce organisms… Children who have eczema and other conditions associated with flaky, scaling skin are prone to swimmer’s ear.
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Family Vacations in National Parks – Health and safety is up to you. An update
(Editor’s note: A reader writes, “You are an old fuddy-duddy who leaches the pleasure out of family vacations by over-emphasizing the health and safety hazards to children of travel and recreational activities.” Even the Wall Street Journal has chastised me. I was the ogre (my word) in a somewhat tongue-in-cheek article, “If You’re a Kid, the Experts Want You to Have a Fun-Free Summer.” I am the “expert leacher.” Nice publicity for me.
True, I am old, but a fuddy-duddy?
Medicine is becoming more evidence-based. For example, ERs record the reason for every visit, including those occurring from mishaps and illnesses that occur in places like national parks, the subject of today’s article. The facts are placed into databases. It is where I get much information. I’m all for kids taking trips – except trips to the ER. Does that make me a fuddy-duddy?
Family Vacations in National Parks – Health and safety is up to you. An update
The National Park Service (NPS) has two sometimes-conflicting missions: maintaining a pristine wilderness and minimizing problems for visitors. All large parks have experts to monitor safety conditions. But the wilderness, by its very nature, has inherent dangers, with wild animals roaming free and its “in the rough” character.
1. Go prepared. All parks have websites. Conditions in parks may be quite different from those where you live. And each park is different. Check weather, altitude, pollen counts and whether pets are allowed, for example. Summertime temperatures at many parks in the Western US reach more than 100 degrees F (38C) degrees. The Grand Canyon (Arizona) is hot, dry and has elevations in excess of 6,000 feet (1,880m). Large parts of Yellowstone (Wyoming) are at 8,000 feet (2,440m). Altitude sickness is possible at higher elevations (see below). Insects are a big nuisance in the Everglades (Florida); covering up with clothing and using insect repellents are essential.
2. Stop at Visitors’ Centers. Check the literature and bulletin boards for safety information and ask rangers about fun, age-appropriate, seasonal- and weather-permitting activities for children. Ask if cell phones are operative. Cell phones have been controversial with on-going debates about whether phones are appropriate in the wilderness – nuisances due to phones ringing in campsites, people speaking loudly on phones and antennas ruining the scenery versus lifesavers in cases of emergency.3. Know your family’s limitations. However far you walk, you must walk back. Leave more time for the return trip, due to heat, fatigue and other factors. Most four-year-olds can walk a mile or so, rest thirty minutes, and then walk back. Six-year-olds can walk two or three miles each way. At some places (the Grand Canyon, for example), the outward hike is downhill into the Canyon, making the return uphill. How far can you carry your child?
4. Backpacks. Children’s backpacks should not exceed 10% of a child’s body weight for backpack beginners going up and down hills, walking on tough terrain, and in hot weather. Backpacks that are too heavy or worn incorrectly can cause temporary aches and pains. Some backpacks, especially ones designed for small children, have long straps to fit children of various sizes. Long straps may cause tripping and become entangled in branches. Tuck them in.5. Supervise children closely in sensitive areas. Obey signs. At higher altitudes, for example, snowfields persist all summer and are irresistible to children. However, the snow may conceal hidden cavities underneath and collapse under the weight of a child. And falling off walkways over hot geothermal water may expose children to scalding water.
6. Keep your distance from large animals. Stay at least 100 yards (90 meters) from bears and wolves and at least 25 yards (23 m) from all other large animals – bison, elk, bighorn sheep, deer, moose, and coyotes. It’s best to hold children’s hands. Discourage children from playfully flailing their arms at animals; animals may interpret flailing as aggressive moves.7. Cars, not animals, are the chief cause of most serious mishaps. When driving, be prepared for a child in your car to shout, “I see a bear.” Roads in parks are heavily traveled, hilly, often narrow and winding, and often there are families walking alongside. Expect cars in front of you to make sudden stops and children to dart into the road when they see a large animal.
8. Other mishaps involving children. Children fall (especially when walking on slippery rocks in streams), are bitten by small animals while feeding them, and drink unsafe water from lakes and streams. Feeding animals is prohibited. Report bites to park personnel. Persons bitten may require rabies vaccine. Untreated water from lakes and streams may contain organisms that cause diarrhea days or weeks later. In case of illness soon after travel, tell health care personnel where you have been.9. Take pictures from a distance. Many children have their own cameras and are overly zealous in taking pictures. Don’t open car windows to take pictures when animals are nearby. Leaning out is even worse. Camera-related accidents can also occur from going too close to thermal pools or cliffs to get better views.
10. Altitudes higher than 6,000 feet may cause altitude sickness. Symptoms include headaches, loss of appetite, nausea, inability to sleep, excessive shortness of breath with exercise, and, in young children, irritability. Generally, at the altitudes of National Parks, symptoms are mild and disappear after a day or two. Treatment is rarely necessary. However, young children with significant heart and lung problems should be medically cleared before traveling to higher elevations.With your family’s health and safety in mind, find a park to visit at http://www.nps.gov.
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Young Children Flying Alone: An update
Did you know that five-year old children may fly unaccompanied on major US airlines?
1. In airline parlance these children are “UMs”: unaccompanied minors. Each airline has its own rules for transporting UMs. The rules are outlined on each airline’s webpage. There are no government regulations. In Canada and the United Kingdom, children must be eight years old to fly unaccompanied.2. Typically, children between five and seven may fly alone but only on nonstop or direct flights. Children between ages 8 and 11 can fly with connections. Children 12 years and older can fly alone, just like an adult. However, many airlines will provide UM services (for a fee) for 12- to 17-year-olds, when requested. Some airlines bar UMs from “red-eye” flights (flights that depart before 5:30AM (0530) or arrive after 10PM (2200)), and small aircraft with no flight attendant aboard. Visiting grandparents or a divorced parent are common reasons for UM travel. In the US, estimates are that UMs take several million flights annually. Some UMs qualify as frequent flyers.
3. Is your child ready to be an UM? Ideally, young children should have flown accompanied by an adult before flying alone. Ask yourself if he or she is sufficiently mature to be alone, among strangers, sitting strapped in for hours in new surroundings and having to use the toilets on his or her own. (Ask flight attendants how UMs manage and they tell you that virtually all, even the youngest, “ace” the flights.) Prepare your UM for in-flight noises from engine reversal and bumps from turbulence and landings, for example; these can be scary. Make them aware that takeoff and descent can make one’s ears hurt, that swallowing or yawning several times, or chewing gum may help.
4. Planning the trip. 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 accompanying photos may be required. On departure day, check the local weather at connecting cities and at the destination. Airlines may not accept UMs if weather predictions are “iffy.”5. Transporting UMs is not cheap. Many carriers charge adult fares plus a surcharge of $50 to $150 each way, and sometimes for each leg of a trip. If siblings are traveling, there may be only one surcharge. Overseas trips may be more expensive and require more paperwork. Check with the consulate of the country your child is entering. An entry visa and documents signed by both parents may be necessary. Airline personnel generally assist children through security and customs.
6. 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. Electronic games keep kids busy. (Crayons for coloring books 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. Ask grandparents and exes to send UMs home similarly to the way they arrived.
7. Dropping off UMs at the airport. Generally, you will get a special pass to accompany your child to the gate, sometimes even aboard the plane. Airline personnel will take your child onto the plane and introduce him or her to the flight attendants. Remain at the gate until about thirty minutes after takeoff in case the plane returns to the gate for mechanical or other reasons.
8. In-flight supervision is basic. Upon boarding, flight attendants introduce themselves to UMs, make them comfortable, help unpack toys, buckle seat belts and point out call buttons. They monitor UMs periodically but are not baby sitters and are not required to help feed them or take them to the toilet. (Take them to the toilet just before the flight.) One airline suggests you pack an extra set of clothing – some children vomit during turbulence – but says nothing about whether or not flight attendants will help the child change clothing. Warn children to report inappropriate advances from strangers; several such incidences have been reported.
9. Retrieving UMs on arrival. Airline personnel deplane UMs before or after other passengers and bring them to prearranged locations. The pickup persons must have their documents in order. They should make sure they go to the correct airport in areas where there is more than one and leave plenty of time for delays due to traffic and becoming lost within airports. Children scheduled for additional flights are taken to a common holding area or the gate of the next flight and assigned to a new flight attendant.10. Stranded children. If children are stranded by aircraft diversions, missed connections or failure to be picked up (usually due to misunderstandings), the airline will notify you. Such scenarios are extremely rare. 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 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 transporting the child back to you.
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