Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
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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Car Seats / Safety / Kids
Installing children’s safety seats into cars is not child’s play. More than ninety percent of first-time parents make at least a minor error in installing seats, in positioning infants in seats, or in transitioning children to advanced seats as the children grow. An appropriate seat – optimally installed and correctly used – reduces the risk of serious mishaps by more than 70 percent.
1. Choosing the safest car seat is easy. While there are literally hundreds of makes and models available, with all kinds of special features, and some seats costing ten times as much as others, no seat is safer than others. All seats sold in the US have passed the same crash tests. Differences in seats are largely based on the ease of placing and removing seats from cars and transforming seats to accommodate infants as they grow. For a list of seats types available, see https://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Product-Listing.aspx.
2. Consult an expert seat installer unless you are 100% sure that you can do it yourself. Manufacturers supply manuals and, sometimes, videos, to guide you but even with directions car seats can be tricky to install. If you need help, the National Highway Transportation Safety Administration (NHTSA), a government agency, lists by zip codes the location of seat safety inspection stations all over the country. Chances are there is one near you. Go to https://www.nhtsa.gov/equipment/car-seats-and-booster-seats.
In Canada: for more information, go to https://www.caringforkids.cps.ca/handouts/car_seat_safety
3. Register seats with the manufacturer at purchase time so they can contact you when necessary. Recalls of seats for safety issues occur from time to time. Notify them if your address changes. You can also check for recalls and register online to be notified of future recalls at https://www.odi.nhtsa.dot.gov/owners/SearchSafetyIssues?prodType=C. (Similar information is available from the NHTSA for other child-related products such as cribs, highchairs, and carriers.)
4. When traveling by car, children must be in their safety seats at all times. Even for the shortest rides. Most car accidents occur close to home, where most miles are driven. Make no exceptions for older kids; exceptions make it more difficult to enforce rules. For infants, stop the car when they need attention for soothing, feeding or diaper changing, for example. The safest place for children is in the center of the back seat.
5. Know (1) the appropriate seat for your children’s current height and weight, and (2) when to transition them to the next stage seat.
> Infants and toddlers should ride in rear-facing seats as long as possible, until they reach the highest weight or height allowed. These limits appear in the instruction manual and are inscribed on the seat. Most seats allow children to ride rear-facing for 2 years or more.
> Once children have outgrown rear-facing seats, they should ride in front-facing seats that have harnesses. They should use such seats as long as possible, until they reach the height and weight limits for that seat. Many such seats can accommodate children up to 65 pounds (29 kilos).
> When children reach these limits, they should transition to belt-positioning booster seats. Such booster seats should be used until children fit properly into the car’s lap and shoulder belts.
> Children are generally ready for adult seat belts when they have reached 4 feet 9 inches (1.4 meters) in height and are 8 to 12 years old. Belts should fits low across the upper thighs and across the middle of the chest.
6. Delay transitioning children to the next stage as long as possible. Each transitioning step reduces protection. When rear-facing, the car seat absorbs most of forces in a crash, When riding forward-facing, their bodies are restrained by the harness straps, but their heads – which for toddlers are disproportionately large and heavy – are thrown forward, possibly resulting in injuries.
7. Safety trumps comfort. Some children appear uncomfortable in the seats that studies show to be the safest, preferring to face forward or seemingly not knowing where to place their legs, for example. However, they do accommodate to the safest seat and position without adverse effects, if you insist.
8. New seats are expensive, old ones are not. However, old seats may lack the latest safety features, be missing installation instructions, have been recalled, or be past the seats’ expiration date (usually six years). Most seats are made mostly of plastic, a material that becomes brittle with age. Expiration date are usually stamped somewhere on the seat.
9. Children should never sit in the front seat of a car equipped with passenger-side air bags. In crashes, kids are propelled forward and get hit by airbags that are not fully inflated. Because children are lighter, an airbag can lift them off the seat and cause them to hit their heads on the car’s ceiling, resulting in serious injuries. Some cars are now equipped with cut-off switches, allowing drivers to turn them off.
10. Many car seats are unstable when standing alone. They can be tipped over accidentally by adults or older children. Older infants can wiggle sufficiently – even when properly strapped in – to topple the seat over themselves. Some parents neglect to strap infants in when seats are not in cars. If young infants turn seats over onto couches they may land with their mouths on soft fabric and have difficulty breathing.
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Locking the door on measles!
Your family no longer has to travel overseas to come home with one souvenir you didn’t bargain for, a vaccine-preventable disease. Such “souvenirs” may be coming to visit you. Currently, measles is the prime example.
1. Measles, which had become a rarity in this country, is popping up all over. As of mid-April 2019, cases have been reported in 19 states. Virtually all originate overseas. They are brought here by American travelers who became infected overseas and by infected foreigners coming to the US as tourists and students. The virus then spreads, mostly to people who were not or were incompletely vaccinated against measles.
2. Measles was once a common childhood disease, an expected part of growing up. Most children recovered completely. However, one or two in a thousand died, usually from measles complications such as pneumonia or encephalitis, and some others were left with serious permanent disabilities. An average of 450 deaths occurred annually, mostly in previously healthy children.
3. Measles is one of the most infectious diseases. The virus is transmitted through the air: an infected person coughs or sneezes and someone in close proximity then inhales the droplets. Transmission also occurs by touching objects and surfaces contaminated with infected nose or mouth fluids. The virus can remain infectious for up to two hours. Brief exposures suffice to become infected.
4. Aspects of measles help delay diagnosis and subsequent isolation of patients, abetting the spread. Infected individuals begin exhaling the virus about three days prior to showing symptoms of being ill. The earliest symptoms, fever and cough, are not specific to having the disease. Even the eventual rash is not necessarily diagnostic; it resembles other rashes. Moreover, the vast majority of American healthcare providers have never seen a case, further delaying diagnosis. Tell providers about your recent trips if they do not ask you.
5. In the US, since 2000, the percentage of children under two years of age not optimally vaccinated has quadrupled. While this percentage remains small, the trend is troublesome, especially for infants less than six months of age. Measles vaccines are not very effective under this age while many infants are susceptible and tend to experience complications. The best way to protect young infants is to make sure all individuals in contact with them are vaccinated.
6. There are many reasons why parents refuse to vaccinate their children. Ironically, one reason is the success of vaccination programs. Most parents have never seen cases of vaccine-preventable diseases and erroneously conclude that vaccines are no longer important. Some parents believe vaccines cause the diseases that the vaccines are designed to prevent, or cause other adverse reactions. (In fact, the achiness following some vaccines is due to the immune system “revving up” to boost protection.) Other parents believe that vaccines cause autism although there is no evidence to support this. Still others refuse vaccines for ethical or religious reasons.
7. Don’t ask healthcare providers to alter accepted vaccination schedules. Parents ask providers to delay starting vaccinations until children are older, to increase the interval between doses, to dilute doses, or to give one vaccine at a time rather than many. Some providers acquiesce, reasoning that some protection is better than none. This is not a good idea. Accepted schedules are prepared by recognized experts, are based on the latest data, and change from time to time. Altering schedules results in confusion: unknown immunization status, ultimately more doses to correct the situation, and turmoil in record keeping.
8. The risk of acquiring vaccine-preventable diseases increases substantially when traveling outside the US. Most countries have less comprehensive vaccination programs than the US. Some governments cannot afford the costs, vaccination protocols are haphazard with poor record keeping, and children are immunized against fewer diseases. The result: diseases remain common, even in developed countries. Moreover, traveling with children likely increases your family’s odds of interacting with local children, the primary source of such diseases.
9. Consult your healthcare provider if a family member may have been exposed to measles. The time between exposure and the appearance of symptoms varies between seven and fourteen days. A dose of measles vaccine given within three days of exposure will usually prevent or ameliorate the disease. A dose of gamma globulin may help to ameliorate the disease after the three-day period. When making the appointment, notify providers of a possible measles exposure. They may want to see you when there are no other patients in the office.
10. Inform healthcare providers of upcoming foreign travel as soon as you finalize your plans. Family members may require additional vaccines (and preventive medications), especially when visiting developing countries. Some destinations require vaccines that require multiple doses over a period of a several months. Attending large gatherings and staying at the homes of friends and relatives are common ways people are exposed to infection.
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Eating outdoors/ food safety / kids
Eating meals outdoors – at picnics, barbecues, tailgating parties and buffets – substantially increases your risk of getting an intestinal illness, says the US Centers for Disease Control. Moreover, infants and young children, due to their immature immune systems, are especially susceptible to such illnesses.
1. Pack a hand sanitizer. Soap and water are somewhat more effective than hand sanitizers to cleanse hands but are often not available outdoors. Clean your kids and your own hands before eating, and before and after handling food, especially raw meat, poultry, or seafood.
2. Wicker picnic baskets may be quaint but are outdated. High tech, relatively inexpensive coolers help keep foods safe for prolonged periods. When filling, use large pieces of ice or frozen chemical gel, not ice cubes, which melt quickly. Transport coolers inside cars; car trunks can become very hot. Place coolers in the shade, leave closed, and open as infrequently as possible. Leave food items in the cooler until you need them.
3. Proper refrigeration is essential. Even optimally stored meat, fish, and dairy products frequently contain disease-causing organisms. Refrigeration keeps the number at levels sufficiently low to prevent illness. Refrigeration does not kill organisms, it merely prevents them from multiplying. Interruptions in refrigeration – as often happens when meals are moved outdoors – allow organisms to multiply rapidly. Subsequent re-refrigeration preserves the number of organisms at the new higher level, a level that may be sufficient to cause illness. In young children, this level is lower than in adults.
4. Disease-causing organisms are most often found on the surface of foods. When meats and fish thaw, those organisms mix with moisture from the food. The “juices” then drip onto other food items, food-preparing surfaces and peoples’ hands. Transport meats and fish in sealed plastic bags. Carry tin foil to cover surfaces. Never use the same plate or surface for both raw food and prepared food.
5. Keep all foods cool and clean. Wash fruits and vegetables before leaving home. Organisms can be transferred from the skins of melons and other fruits and vegetables to the inside by the knife. Scrub skins and cut them with a clean knife. Keep them cool after cutting.
6. Keep a food thermometer in the cooler. Bacterial count can double in fifteen minutes at high air temperatures. Temperature-sensitive foods should remain at about 40 °F. (4 °C). Such food items may no longer be safe to eat if exposed to higher air temperatures for more than two hours; one hour, if outdoor temperatures are above 90 °F (32° C).
7. Use a food thermometer for outdoor cooking. Items made of ground meat (hamburgers and meatballs, for example) have surface meat mixed throughout. Grilling browns the outside rapidly – sometimes, before critical temperatures are reached at the center. Even centers may turn brown before critical temperatures are reached. Familiarize yourself with food thermometers and how to use and clean them between uses. See https://www.cdc.gov/foodsafety/keep-food-safe.html for critical temperatures for various meat and fish products.
8. Cook eggs well. Organisms may be present inside raw eggs; they enter while the egg is formed in the hen. The organisms can pass through cracks in shell and even the pores in an intact shell. Raw eggs have a coating that prevents organisms to penetrate the shell. Boiling destroys the coating. Keep eggs clean after boiling.
9. Plan to keep insects away. Most insects are merely annoying. But some – flies, for example – can carry disease-causing organisms. Choose picnic sites away from refuse and rotting fruit. Spray your site before unpacking the food – though most outdoor liquid sprays, candles and coils are of questionable efficacy. Bring tablecloths and food hoods to cover food.
10. Be near the front of the line at outdoor buffets. Such meals contain large numbers of different food items. Some foods need to be kept warm, others cold. Generally, all items are placed on the serving table at the same time and may remain there for prolonged periods. The food may be exposed to the sun, insects, peoples’ hands and people breathing on it. Many desserts, some especially prone to spoilage, may remain on the table the longest.
Miscellaneous. Don’t drink untreated natural water; even when crystal clear such water may contain disease-causing organisms. Children may be especially sensitive to certain organisms. Clean work surfaces, utensils, and grills before and after cooking. Bring sunscreens, sunglasses, first aid kits and trash bags.
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Should children miss school for vacations?
You find a package to Disney World that seems almost perfect for your family: working parents with little leisure time for their children, one child in sixth grade, one in third. The package: off-season, reasonably priced, a good fit for your work schedules. But it means that your kids will miss three school days.
To go or not to go? It’s an issue of family bonding versus teaching kids priorities.
And it’s a common question. Search “Missing school for vacations” on Google and you’ll see 169 million entries, likely with almost as many shades of opinion! Obviously, no one can read them all. I browsed a large number and selected some pertinent comments from parents, educators, child psychologists and pediatricians, below.
> In most school districts, keeping children out of school for other than medical reasons or family emergencies is illegal and can result in parents being summoned to court by attendance officers and facing child welfare authorities. Some districts do allow four or fewer days absences per school year for “personal reasons.” In fact, absences of less than ten days per school year are rarely, if ever, investigated. “Chronic” absenteeism, or truancy, is a serious offense and parents may be investigated and punished. Children are never disciplined when parents keep them out of school.
> A majority of school districts are funded by states on the basis of daily attendance. Absenteeism for any reason costs schools large amounts of badly needed money.
> In Britain and the Netherlands, truant officers are posted at airports and train stations before school holidays to ensure that families don’t start vacations early.
> No studies exist on the effects of occasional absenteeism on a child’s school performance. However, numerous studies show that the more absences, the poorer the child’s academic and social performance.
> Decisions to take a child out of school should be based on the grade the child is in, the child’s scholastic abilities, whether essential lessons will be missed, the child’s feelings about missing school, the philosophy of the teacher(s) on the subject, and the school’s policy. Likely, children in lower grades will miss little essential work.
> A child being absent from school disrupts the class and increases teachers’ workloads. Some children are out for a week or two for travel. For the family, a child out of school is one absence. For the teacher of a class of 20 or 30, there may be numerous absences. This means repeating lessons and assigning and checking makeup work, slowing learning for everyone. Classes should not be held back for non-essential absences.
> Travel should be an integral part of a child’s education. A semester overseas is becoming the norm at colleges. Younger children should be encouraged to travel, obviously during vacation time, if possible. However, meaningful, short trips – to historical places or to provide exposure to a different culture, for example – trumps missing a few days of school.
> When you take children out of school for unauthorized reasons, do you level with the teachers or do you make up excuses – a family emergency, for example? Once you start on the road of deceit with the school, and worse, if your kids are old enough to understand what you are doing, what appears to be merely a few days of unauthorized absences becomes a big lie.
> When I was in junior high school my father took me along to attend his conference in Athens, Greece. I missed a week of school. When I think of joys in my youth, Athens comes first to mind.
> Our school administration is supportive of short trips during school time. On returning, children are expected to give a “show and tell” performance about their trip. Possible negative fallout from this is that other children are envious. Remarks heard – probably emanating from parents – are that kids who travel are rich and spoiled.
> The advantage of home-schooling children – an option that seems to becoming increasingly popular – is that you take your children anywhere at any time. Their education travels with them.
> What are you teaching children when you swap a week of school for a sunny beach? They learn that attendance, and by extension, education, isn’t a priority. Schooling comes first.
> I teach in an affluent community. I am appalled by how often parents tell me (they don’t ask) that the student will be absent for an upcoming trip. They say that trips are “educational” when they are not. The lies show a lack of respect for teachers and education.
> My family is poor. It’s vacationing when prices are low or staying home. Missing a few days of school is no big deal.
> Teachers work hard to create dynamic learning experiences that build deep conceptual understanding. These experiences, especially in math, cannot be “made up.” Absences are like when buttoning a shirt and missing one, the whole series is off-kilter.
> Parents erroneously believe that homework assignments in advance of taking kids out of school cover all bases. These students miss classroom discussions, partnering in group, and other activities. Is getting to Disney a day before the masses that important?
> A profession that compresses their work life into 9 months of the year has little standing to be offering criticism of how the rest of us balance schooling and family life.
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