Kids Travel Doc
A Pediatrician's Guide to Travel and Outdoor Recreational Activities
Can you outsmart insects? Your kids’ health depends on it.
Part l: An update on zapping insects.
May 1, 2018. The number of diseases caused by insects, mostly mosquitoes, has tripled in recent years, and children may be especially at risk, warns the Centers for Disease Control (CDC) in a special report. No longer must you visit tropical rain forests or other faraway places to pick up Zika, West Nile, Chikungunya, dengue and other mosquito-transmitted diseases. Nowadays they may come and visit you at your home. (Your neighborhood may already be the residence of disease-causing ticks, says the CDC. We’ll discuss protection against ticks in future postings.) There are no vaccines or medications to prevent these diseases. And there are no medications to cure them.
1. Global warming is believed to be a significant factor in increasing the number of such illnesses. Mosquitoes especially wallow in warmth. A warmer environment enables them to multiply more rapidly, enlarges their habitat, and lengthens their breeding and biting seasons. Milder winters allow more of them to survive to breed and bite again next summer.2. But insects are only the messengers, so to speak. Most bites are merely annoying. It is the microorganisms that insects can harbor that are the nemeses. Many of the mosquitoes, for example, that spread disease in the tropics already exist in North America, Europe and in other temperate climates – but are not (yet?) carrying these organisms. However, if an infected traveler from the tropics – even one without symptoms – after returning home is bitten by mosquitoes capable of carrying dengue fever virus, for example, those mosquitoes can then infect subsequent persons with dengue fever. Another route of infection is an infected mosquito hitching a ride on a plane from the tropics.
3. Ridding your neighborhood of mosquitoes is your first line of defense.Repellents are secondary. While repellents are important, applying them correctly and frequently, 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 transmit specific diseases. Generally, seasonal biting begins soon after trees begin to bloom and ends with the first frost. Many species have specific times of day for peak biting activity. These vary from all day to 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 appear to be 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 residence.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.
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
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Children/Travel/Tootbrush/Illness. Are they related?
Can your children’s toothbrushes make them sick? Many dentists think so. And they think it’s more likely to happen on trips and vacations.1. Germs that cause upper respiratory and intestinal illnesses thrive on toothbrushes. Moisture from saliva, food particles, cellular matter derived from gums, and high humidity in bathrooms create a favorable culture medium for organisms to grow. Storing toothbrushes in toilet kits, some airtight, impedes drying, allowing organisms to multiply even more rapidly.
2. Microorganisms encountered during travel are potentially more harmful than the ones at home. As a general rule, the poorer the area you visit, the worse the sanitation, and the more likely the local organisms are different and more virulent than the ones at home. Discard toothbrushes after returning home from such trips.3. Children tend to place their toothbrushes on sink counters. Unless counters are optimally disinfected they are hotbeds for organisms, contaminated from water splattered by washing oneself or from unsanitary objects placed there, possibly even dirty diapers. Keep sink surfaces clean and dry; bathroom humidity keeps counters wet for prolonged periods. Toothbrushes should be placed on a clean washcloth or on tissue until rinsed and dry.
4. Toothbrushes and sink countertops may be contaminated from toilets. Flushing propels organisms into the air. Close toilet lid before flushing. Hand washing before and after brushing teeth further increases the level of cleanliness.5. Show children how to rinse toothbrushes under hot water and air dry them. Rinsing removes toothpaste and other debris from the toothbrush. Air dry by standing them in a holder with bristles upwards. The bristles should not touch any object, especially another toothbrush. Soaking toothbrushes in three percent hydrogen peroxide or alcohol-containing mouthwash may make them more sanitary, says the American Dental Association (ADA). And clean toothbrush holders regularly.
6. Young children tend to use the toothbrush easiest to reach, often not their own. Away from home it may be a new toothbrush, making it more difficult for children to identify which one is theirs. Have children choose a toothbrush in their favorite color for the trip.
7. Some dentists suggest that each child have their own tube of toothpaste. It’s possible for organisms on toothbrushes to be transferred to the toothpaste around the opening of the tube and then to the toothbrush of the next user. (Whether this actually happens is debatable.) The optimal way to apply toothpaste to a toothbrush is to lay the toothbrush on a clean surface. Then apply the paste from above without touching the toothbrush.8. Children tend to swallow considerable amounts of water while brushing. Adults generally do not. In areas of extremely poor sanitation tap water may be contaminated with disease-causing organisms. Use bottled water for brushing and rinsing toothbrushes in such areas.
9. Replace toothbrushes when bristles become frayed. Routinely, toothbrushes should be replaced about every three to four months, more often if they show signs of wear or after being used inappropriately – dropping them on a wet bathroom floor, for example. Worn bristles do not penetrate between the teeth.10. The ADA recommends the following:
- Use toothbrushes with soft bristles.
- Brush for about two minutes.
- Manual or powered (electric) toothbrushes are equally effective. Many children find powered toothbrushes easier to use.
- Microwaving toothbrushes or placing them in dishwashers to sanitize them may damage the bristles and is not recommended.
- Ultraviolet light, antibacterial-treated bristles and other products available to reduce organisms on toothbrushes do not appear to reduce the risk of illness.
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How long is too long to allow infants to sleep in car seats?
Infant car seats present dilemmas for parents.
1. A car seat is practically part of your family. Chances are you had a car seat delivered to you before you delivered your baby; hospitals won’t discharge you without one. The seats are mandatory to take your baby for a car ride. Once home, with a car seat, you can do your chores and have your baby constantly at your side. Many babies sleep better in car seats than elsewhere.2. Car seats first appeared in the early 1960s. Until then little thought was given to the need for car safety specifically tailored to young children. And parent behavior often increased the hazards of car rides. Parents purchased platforms that eliminated the backseat well space designed for people’s legs, creating a sort of playpen made up of the platform and the back seat in which toddlers could bounce around. No restraints. No padding. Toys scattered about. Sometimes a big dog added to the “fun.” Kids were sometimes tossed about dangerously by the car merely turning a corner.
3. Safer cars, sophisticated car seats, and a greater awareness of safety issues have greatly reduced the incidence of serious mishaps. However, further lowering this number is proving elusive. The tougher safety problems remain. Many of the recommendations to solve the remaining issues are complicated to follow, expensive, and impractical for parents to carry out.4. A car seat is not a safe sleep environment for an infant. “If your baby falls asleep in a car seat you should move him or her to a firm sleep surface on his or her back as soon as possible,” says the American Academy of Pediatrics. (The same rule applies for infants falling asleep in strollers, swings, infant carriers, or slings.)
5. Infant car seats are lifesavers. The importance of car seats for preventing injuries/fatalities is well established, decreasing fatal injuries by an estimated 70%. But they are lifesavers only when they are correctly installed in cars and babies are correctly placed in their seats. Too often, neither is properly done. According to the US Centers for Disease Control, 72% of 3,500 observed car and booster seats were incorrectly used in such a way that they actually increased the risk of injury to a child. In many countries, there are experts to check whether your car seat is correctly installed. Check the web. In the US: http://www.safercar.gov/cpsApp/cps/map/findfitting.htm?q. In most cases there is no charge for the inspection.6. Car seats are unstable when standing alone. About 10,000 infants, most of them younger than four months of age, are treated in US ERs each year because of car seat-related injuries unrelated to car accidents: falling out of a seat because they were not properly strapped in; falling with the seat from an elevated surface such as a kitchen counter; seats accidentally tipped over by an adult or older child; older infants wiggling sufficiently – even when properly strapped in – to topple the seat over. If young infants fall from seats and land face down on a couch or other soft surface they may have difficulty breathing. (For more information on car seat issues away from cars, please see: http://kidstraveldoc.com/health-alert-infantscar-seatshazardous-away-from-cars/.)
7. Infants sitting in car seats are at risk of suffocation. Many infants spend more than five hours a day resting or sleeping in such seats, much of the time in a semi-reclining position. The longer they sit semi-reclined, the greater the risk of their heads flopping forward, compressing their airways and compromising the amount of air reaching their lungs. Rarely, infants suffocate by strangulation from improperly adjusted straps.8. How long is too long to allow infants to sleep in car seats? There is no precise answer. Ideally, all infants under the age of six months should be in the sight of an adult while they sit semi-reclined – having an (awake) adult sitting with the infant in the back seat, for example. Infants over the age of six months whose heads still flop over even occasionally should be similarly observed. On long car rides infants should be observed at least every 30 minutes and taken out of the car seat every hour or two.
9. Be leery of used car seats. New seats are expensive, old ones are not. But 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 largely of plastic, a material that becomes brittle with age. Expiration dates are usually stamped somewhere on the seat.10. Infants should never be placed for sleep on their sides until one year of age. The fact that some infants sleep better on their sides is not a reason to allow them to do so. “Side sleeping” is almost as hazardous as “stomach sleeping”; both may increase the rebreathing of oxygen-poor exhaled air. Also, infants sleeping on their sides sometimes roll over to their stomachs. Moreover, a “poor sleeper” may be annoying for parents but frequent awakening may, in fact, be a safety mechanism that protects against breathing issues.
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Will family vacations ever be all fun and games?
Poor parental planning spoils more family vacations than lousy food, miserable weather, no-star accommodations – or cranky children. While a family vacation will rarely be all fun and games, savvy planning can keep the inevitable misadventures down to a manageable few.1. Successful family vacations are primarily kids’ vacations. This means getting away from daily routines and regimentation, declaring a moratorium on non-essential talk of behavioral issues and school problems, and being wholly involved with the child(ren). Let them choose age-appropriate activities. Playing ring-around-the-rosy, tag or soccer builds family unity far better than watching TV together.
2. “Indulgence” does not mean “anything goes.” Establish ground rules before leaving home. Vacation spirit makes it difficult for many parents to say no. Explain to kids that they will see situations and activities that may be unhealthy, age-inappropriate, or hazardous for them, even though others participate. Example: eating food from street vendors in areas of poor sanitation, snowmobiling alone, or going on seemingly unsafe amusement park rides. Plan rotations for who will sit where in cars and who will decide which DVD to play first. Set limits on the amount of money to be spent on souvenirs.
3. Include children in planning. Participation gives kids a sense of inclusion and accomplishment, helps motivate them, and minimizes apprehension of the unknown. Show older children maps and brochures of hotels and national parks, for example. Talk about how you will be getting there and let them choose among reasonable alternatives. Allow younger children to participate in seat selection on airplanes. Let toddlers mail letters concerning the trip, open replies or press buttons on the computer.4. Opt for the most spacious accommodations your budget allows. Skimp on scenic views, fancy restaurants and other non-essentials; generally, these are unimportant to kids. Vacations usually crowd families into single rooms. This eliminates accepted “escape valves” from too much togetherness at home, multiple TV sets and visiting friends, for example.
5. Allow children to stake out their territory. At home, children are most at ease in a specific chair for TV watching and particular floor area for playing. New surroundings remove these comfort zones. Hence, children run into hotel rooms to lay claim to new territory. Go along with reasonable claims. Anticipate squabbles if children are close in age. Territoriality is a reason children prefer returning to places previously visited.6. Staying with friends and relatives is risky. Are your hosts accustomed to having children around 24/7? Will you be crowding them or will you feel confined there? Are there children’s activities available? One scenario: You become friendly with neighbors. Their kids are friends with your kids. They move away. You go to stay with them. You discover living next door to people is totally different than staying under one roof.
7. Consider the optimum length of time to be away. Start off with short vacations. Longer is not necessarily better. Some toddlers sleep poorly in new surroundings. Bringing your own crib may be helpful. Adults can become anxious about missing work. Children may miss friends. Homesickness causes moodiness. Think twice (or three times) before planning long family trips to solve serious marital rifts.
8. Have a “Plan B.” Check weather and other variables to minimize needing Plan B. Camping and rain are generally mutually exclusive. Are there activities available at the beach or ski resort in case of inclement weather? Children fare poorly spending the day in a hotel room – and so will parents.9. Set realistic ratios between swimming and visiting museums. Don’t fret if children find cultural activities “boring.” Such visits usually do have lasting positive impressions, as can be heard when children later tell (or boast to) friends and teachers about where they have been and what they saw.
10. More tips. Allow children to bring a comfort item, even oversized stuffed animals, torn blankets – or a human friend. A compatible friend is like having one child less to take care of. Prepare children for reentry into the real world: reestablish bedtimes, homework, and chores. And on the way home, discuss the good and the bad of your trip and start brainstorming about where your family should take their next vacation.
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Warning: Escalators are hazardous for young children
There is more to protecting your young children from injuries on escalators than just holding their hands, says the Consumer Product Safety Commission (CPSC). Each year, for several thousand children, most of them under the age of five years, an escalator ride is the first leg of a trip to the ER. Injuries most commonly involve fingers and toes, some injuries resulting in permanent impairment.1. Most accidents occurred while children were under direct supervision of an adult. Many occurred while the adult was holding the child’s hand. (Very few accidents were due to mechanical problems.) Factors increasing the risk of accidents include adults accompanied by more than one child, carrying packages, wheeling a stroller or cart, and holdings a pet on a leash.
2. Consciously keep your full attention on your child. Don’t be distracted by your surroundings – even though your escalator and what you see were specifically designed to distract you. Many escalators are located in shopping malls, amusement parks, airports and other public places and are situated to draw your attention to eye-catching architecture or multicolored, animated advertisements, for example.3. Lift toddlers on and off. Most four-year-olds lack the skills to coordinate stepping on and off moving platforms at the right moment. They tend to jump on and off and may lose their balance, are unaware where steps will rise or fall, and slide their feet over the “combs.” The combs are the teeth-like projections where steps emerge and disappear at the beginning and end of the ride. The combs produce a space where fingers and toes can become entrapped.
4. Place children in the middle of the steps. Avoid placing them near the narrow gap between the sides of the step and the sides of the escalator. This gap can entangle shoelaces, pants bottoms, scarves, drawstrings, long skirts and flexible plastic, sandal-type shoes. Sliding such shoes against the side of the escalator causes friction. The friction further softens the plastic and increases the risk of the shoes becoming wedged into side gaps or the combs.5. Look around before getting on. Adults absentmindedly step on escalators coming toward them, causing falls. (Older children do it on purpose.) Leave several steps empty before getting on. You can’t stop escalators when you are in the middle of the ride. Emergency shutoff buttons are usually located only at the top and bottom of the escalator, generally on the right as you enter.
6. The risk of injury increases when children misbehave. Sitting down on the steps and facing backwards is extremely hazardous, as is picking up objects that were dropped, especially near the end of the ride.7. Never loiter after stepping off. Walk away from the escalator and then stop to get your bearings, as people may be right behind you. Children have been injured when adults or luggage fell on them.
8. Airport escalators require special attention. Accidents occur frequently and are more hazardous. Risk factors include distractions, carts, heavy luggage, unfamiliar surroundings and, perhaps, passenger fatigue. Obey signs banning luggage carts on escalators. Large and heavy luggage is treacherous; it may not fit on a step and can go tumbling onto riders below.9. Stay alert on moving walkways. Walkways are safer than escalators. However, similar to escalators, walkways have spaces along the sides and combs at the end. The length of some walkways and distractions along the way cause some people to forget to step off. Train yourself to react to voice warnings, flashing lights and palpable “bumps.”
10. Use an elevator. Where there is an escalator there is virtually always an elevator nearby. Elevators are safer. However, elevators are slower, often out of sight, with no signs to direct you and no one around to ask directions. It may take a few minutes to find the elevator but they’re minutes well spent.
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Influenza/Children Repost
Hi reader: This article “Children/Influenza/Travel) is a repeat. It first appeared several weeks ago. Some clinics asked us to repost it. Karl Neumann MD
This winter, keep influenza (“flu”) in mind when planning travel for your family.
1. The winter of 2018 will be a significant flu season. The disease has already spread to virtually all parts of the country. The flu virus currently circulating has a history of causing severe illness in infants, and this year’s vaccine is not particularly effective, says the US Centers for Disease Control (CDC).2. Travel increases the risk of your family acquiring the flu. Example: On airplanes and cruise ships and in amusement parks your family may come in close contact with families from near and far. Some were not vaccinated against the flu. Some parents refuse vaccination or they come from countries where flu vaccination is not universally given. Children infected with the flu cough up and sneeze out flu viruses days before showing signs of being ill – and rarely cover their noses and mouths. The viruses can travel six feet (two meters) through the air and infect others.
3. Flu is a more serious illness in young children than most parents realize. During outbreaks, more children than adults percentage-wise are stricken. Most affected children require medical care. In the U.S., each year about 20,000 children under the age of five years are hospitalized with flu, many of them under the age of two. Infected children shed viruses for a longer period of time than do adults.
4. Vaccinate! Vaccinate! Vaccinate! Children as young as six months can safely receive flu vaccine. Children younger than six months cannot. This younger age group is particularly susceptible to severe cases. All adults and older children in contact with infants should be vaccinated. For infants with health problems, consider delaying nonessential travel until after flu season or until infants reach six month of age.
5. The effectiveness of flu vaccine varies from year to year. The vaccine must be prepared months before the flu season. There are innumerable strains of the virus. Only a limited number of strains can be included in the vaccine. And new strains emerge frequently. Experts make educated guesses about which strains to include in the vaccine, based on recent flu activity around the world and other data.6. Vaccination with a less than optimum vaccine is better than no vaccination. Partially effective vaccines can prevent some cases and reduce the severity and duration of others. Regardless of effectiveness, children receiving flu vaccine for the first time need two doses, given at least one month apart. Significant immunity does not begin until two weeks after the second dose. Children (and adults) previously vaccinated require only one dose, with full immunity also taking two weeks to develop.
7. Acquiring flu from the vaccine is a myth. Years ago flu vaccines were less refined and sometimes caused flu-like side reactions such as aches and pain and fever, but never the flu. Now vaccines are more sophisticated and side effects are rare and mild. Another reason for the myth: flu season is also upper respiratory infection (URI) season. Severe URIs (colds) are common in children. Bad URIs closely resemble flu but the two illnesses are unrelated. Bad URIs soon after vaccination are erroneously interpreted as vaccine failure or cause by the vaccine.8. Wearing facemasks decreases the transmission of flu but is impractical. Masks reduce the number of flu viruses exhaled by sick individuals and reduce the number of such viruses inhaled by susceptible people when the virus is in the air. However, many children find masks uncomfortable and only certain types of masks are effective. Masks must fit properly, be worn constantly, and be changed frequently.
9. The risk of acquiring flu during air travel is small. Cabin air is replaced every few minutes with air from outside (air at high altitudes is sterile) or recycled through sophisticated filters. But flu organisms can survive for many hours on seats and armrests. Washing your and your infant’s hands and wiping surfaces with appropriate disinfectants may reduce risk. If possible, change seats if a nearby passenger coughs and sneezes.10. Go to a urgent care facility or ER if your child develops flu-like symptoms. (See list of symptoms.) Such facilities can test for flu. Testing takes minutes. If tests are positive, and if treatment is warranted (all cases need not be treated), medication can reduce the severity and duration of the disease. If your child is well but was exposed to someone with proven flu, treatment may prevent symptoms from surfacing. Flu testing and necessary medications are generally available on large cruise ships. (On such ships, physicians can confine confirmed flu cases to their cabins.)
Common symptoms of flu in children:
- A high-grade fever up to 104 degrees F / 40 degrees C.
- Chills and shakes with the fever.
- Extreme tiredness.
- Headache and body aches.
- Dry, hacking cough.
- Sore throat.
- Vomiting and belly pain.
Check the current flu activity at your travel destinations
US: https://www.cdc.gov/flu/travelers/travelersfacts.htm
United Kingdom: https://www.google.com/search?q=UK+flu+activity&tbm=nws&source=univ&tbo=u&sa=X&ved=0ahUKEwj49ruG3_vYAhVR0VMKHRDBCLUQt8YBCDgoAQ&biw=1050&bih=567
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