Dr. Karl Neumann's KidsTravelDoc
A pediatrician's guide to travel and outdoor recreational activities
“Mom – I think I’m gonna throw up!”
Motion sickness/ Children/ Prevention/ Treatment – An Update
If no one in your family has ever been motion-sick, it’s only because they haven’t yet encountered the right (or is it the wrong?) situation. It may be a storm at sea, an “amusement” park roller coaster that spins in three dimensions simultaneously while you are strapped in upside down, a ride atop a camel or elephant, or space travel. Motion sickness happens on camels and elephants because they sway from side to side as they walk. Astronauts experience it in spite of being screened, trained and medicated to deal with it. (A new source of motion sickness-like symptoms, virtual reality headsets, doesn’t even require motion.)
1. Children two to twelve years of age are especially susceptible. A test is to have children read, draw or play video games in the back seat of a moving car. If that does not make them sick, chances are they will tolerate rides in boats in moderate waves, airplane turbulence, “merry”-go-rounds, and roller coasters. In children, once motion sick, always motion sick. It’s rarely outgrown but may become milder with age. Children are more likely to be susceptible when a parent has it.
2. Motion sickness is rare in infants. Most actually fall asleep with motion. However, consider motion sickness when infants are unusually fussy in moving cars, boats and planes. In cars it may be because infants often face backwards for safety reasons, a position known to increase motion issues. When possible, wait until they are asleep before starting the car.
3. Recognize early symptoms. Children will lose interest in their activities and lie down or curl up in their seat. Next comes “queasiness” – dizziness, paleness, stomachache, sweating, headaches, yawning, and rapid breathing. Take immediate action to avoid the ultimate disaster, vomiting. Symptoms usually disappear promptly when motion stops.
4. Prevent vomiting. Distract kids with singing and word puzzles. Expose them to fresh air, well-ventilated areas, or air conditioning. Have older children breathe slowly and deeply. Tell them to close their eyes and keep their heads still. Separate them from people who are already sick. Avoid sights and odors of food.
A mid-1800 British medical journal states that diets are an unpredictable feature. ‘Cold pork and chutney (a spicy Indian sauce) or corned beef and pickles will sometimes stay down when the daintiest substances the pantry can prepare are promptly rejected.”
5. Air travel. The larger the plane, the smoother the ride. Avoid propeller planes if possible. Opt for window seats; looking out at the horizon helps minimize symptoms. Sitting over the wings or in the middle of the plane (as is often suggested) is not particularly helpful. Recline seats, when possible, and aim air vents, when available, at the child’s face. A cold cloth to the forehead may help.
6. Sea travel. Take cruises on large ships with stabilizers, opt for itineraries and seasons when seas tend to be calm, and choose ships that pull up to docks at ports of call. At some ports, ships anchor outside the harbor and use small boats likely to cause motion sickness to ferry you ashore. Choosing cabins at the center of ships is not very helpful.
7. Carsickness. If possible, raise car seats so that children can see out of windows. Tell older children to focus on distant scenery. Stop frequently and expose children to fresh air. Also stop if children show early symptoms. Keep the car cool and well ventilated. Avoid strong odors. If possible, avoid winding roads and frequent traffic stops. Expert opinion is divided as to whether watching DVDs increases, decreases, or has no effect.
Several thousand years ago, the Chinese observed that children were particularly susceptible to motion sickness. They called it cart-sickness – for obvious reasons.
8. Amusement park rides. Generally, moderate roller coasters are better tolerated than merry-go-round-type rides. Outdoor rides are better than indoor ones. Rides simulating space travel are prone to causing illness; some supply motion sickness bags. Sit facing forward. Ask ride operators if many children become ill. (Generally, they prefer losing a fare than having to clean up a mess.)
9. Preventative medications are generally not recommended for children. Antihistamines – dimenhydrinate (Dramamine) and diphenhydramine (Benadryl), for example – may reduce the incidence and severity of motion sickness but may cause side effects (agitation, drowsiness, and dry mouth for example). Read labels regarding lower age limits, dosage and frequency of administration. Medication by injection is available on cruise ships. Transderm Scop, the most frequently used medication for adults, is not approved for children under the age of 12 years.
10. Other preventative treatments are available – with little scientific evidence of effectiveness. These include small, light carbohydrate snacks along with frequent sips of water, juice or soda before and during travel; doses of ginger; and applying acupuncture or acupressure just above the wrist.
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How to navigate children through a COVID summer
There is more to coping than masking, distancing, and handwashing.
Yes. It’s a dilemma. What’s best for your family? Choose (a) or (b):
(a) The safest place in a COVID pandemic is indoors. Venture out only when absolutely necessary, says the US Center for Disease Control and Prevention.
(b) Spending time outdoors is especially important for children as the COVID pandemic disrupts the structure traditionally supplied by summer activities, says the American Academy of Pediatrics.
My choice? (b).
1. It’s time to consider lifting some restrictions. As of this writing (mid-July 2020), relatively few children have been tested for COVID 19. Therefore, there are few definitive answers. However, evidence is mounting that when compared to adults, children are far less likely to become ill when exposed to the virus, have milder cases, are less likely to transmit the disease to others and are less likely to be asymptomatic carriers. Children appear less likely than adults to be the first case within a household. Little is known as to whether children with underlying, ongoing illnesses need specific protection.
2. Keeping kids shut in for indeterminate lengths of time is unrealistic. No one knows how long this pandemic will last. Optimal quarantining — no visitors, no going to work, no school, no shopping and for young children, not receiving essential immunizations — is almost impossible to maintain.
3. Vaccines and medications to treat COVID-19 may not be “around the corner.” Vaccine development requires numerous steps of testing, and every step can (and often does) lead into a cul-de-sac. Moreover, many vaccines require two or three doses, sometimes given a month or two apart, to yield meaningful immunity. And most medications on the horizon reduce the severity of the illness, but are not cures.
4. Social isolation of children tends to cause family friction. (Physical isolation would be a better term for isolation. Social isolation is what you do not want.
The absence of playmates often results in moody and argumentative children with frequent angry outbursts. Children fear that adults close to them may die. Parents become short-tempered. Parents begin arguing among themselves, worsening the cycle. Adult disputes are best kept from children.
5. Structuring children’s daily routines helps alleviate their anxieties. Arrange rather strict waking, meal and bed times. Assign chores to be done. Plan for age-appropriate reading, exercising, and screen time. Some children enjoy phone conversations with favorite relatives and friends; Zoom-type contacts may work even better.
6. Get children out of the house. Children need physical and mental activity to stay in shape. Most indoor activities are eventually “boring,” involve little or no movement and are often associated with eating – generally foods high in salt and calories. Children are more active outdoors and less likely to dwell on the predicaments that COVID has brought them. Plan moderately strenuous activities — brisk walking, biking, sports that allow for distancing or just “running around.”
7. “Green” outdoors may be the most therapeutic outdoors. Spending time surrounded by trees, grass and plants seems to be superior to being amid buildings, concrete and traffic, with wilderness the ultimate outdoors. Family picnics may be the perfect antidotes for a COVID-spoiled summer: getting outdoors, having fun, exercising, distancing from other people, and bonding the family.
8. Swimming is another reasonably safe outdoor activity. The virus doesn’t spread through water in properly maintained pools, sprinklers, hot tubs or water parks; chemicals kill the virus. Lakes and oceans should be safe; the large volume of water dilutes the virus and respiratory viruses survive poorly in water. Avoid crowding in and around swimming areas. Masks may be removed for short periods in the water if strict distancing is maintained. Discourage yelling and screaming; it increases the emitting of viruses, if present.
9. To hug or not to hug young children? Hugging has benefits beyond expressing affection. It may physically lower levels of anxiety and promote feelings that people care for you. Young children accustomed to being hugged, especially by grandparents, may interpret the absence of hugs as abandonment or punishment. Under ideal conditions the risk of infection from a hug are minimal. Ideal conditions include short hugs, wearing masks, no obvious COVID infection-type symptoms, no chronic illnesses, and not living in a COVID “hot spot.” Children under two years of age should not wear masks but almost never become infected. Kissing is a no-no.
10. Playdates may be a beneficial first step in “opening up” social integration. “Opening up” society and the economy are key words today. It’s being done with restaurants, nail salons and gyms. Is it 100% safe? Probably not. But neither are trips to the playground (US emergency rooms annually treat about 200,000 children ages 14 and younger with playground-related injuries, some serious). Outdoor play dates are safer than indoor ones. And schedule playdates with one other child at a time. Choose a child from a family whose lifestyle you are familiar and comfortable with.
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At what age can your child be left home alone?
A timely issue.The coronavirus pandemic has closed most organized children’s activities for this summer. Concurrently, many parents are resuming work schedules away from home.
1. An unforeseen event should never be the reason for a child’ first time home alone. Often it is. Advanced planning and correctly judging your child’s age-appropriate maturity should be the deciding factors, as maturity varies from child to child. There is no magic age when a child suddenly becomes responsible and mature. (Below you will see how widely recommendations from professionals vary.) A good time to start planning for children to be left home alone is when children are about six years old, even if you have no immediate plans to do so.
2. In the US, some states have minimum age laws for leaving children alone. The laws vary from state to state. In the case where an underaged child experiences a serious mishap in your absence, you could be charged with neglect or abandonment, and prosecuted by the authorities. Punishment may include monetary fines and imprisonment. Many other countries have similar laws.
3. Most eleven- or twelve-year olds can stay alone during the day for up to three hours provided it is a safe neighborhood and there are friendly neighbors to contact for assistance. So says the American Academy of Pediatrics. However, some children are able to remain alone at younger ages, and for longer periods in the evening.
4. Many states have guidelines for parents. The guidelines are mostly formulated by government child welfare agencies. Recommendations vary widely, based mainly on the child’s maturity. The consensus: Some 6-9 years olds can be left alone for very short periods. Some children can get off school buses at age nine without an adult present. Some 11-year-olds can supervise younger siblings for several hours.
5. A survey of child mental health experts makes these recommendations:
- 8 years and under: Should not be left alone for any period of time. This includes leaving children unattended in cars, playgrounds and yards.
- 9 to 10 years: Should not be left alone for more than 1 ½ hours and only during daylight and early evening hours.
- 11 to 12 years: May be left alone for up to 3 hours, but not late at night or in circumstances requiring adult supervision.
- 13 to 15 years: May be left unsupervised, but not overnight.
- 16 to 17 years: May be left unsupervised for up to two consecutive overnight periods.
6. Children should never be coerced, bribed or otherwise talked into staying alone. Children who show anxiety when left alone are more likely to misinterpret situations that are likely harmless and react irrationally. For example, the telephone rings, the child answers, no one is there, and there is a click as the call is ended. This occurs in TV crime shows. A child already uneasy with being alone may react by running outside, for example.
7. Children’s self-sufficiency may provide clues to their readiness. Does he get himself up in the morning and ready for school with minimal parental involvement? Does she remember to do her homework and reasonable chores by herself? Asking age-appropriate “what if” questions and role-playing scenarios can also give you insights. What if the power goes out? The toilet floods? The dog needs to be walked unexpectedly? Can they use the elevator? Can they have other children visit?
8. Provide children with three telephone numbers to call if a problem arises. Your number may be busy, making children uneasy. Post numbers and telephone-related information near an easily accessible telephone. Ideally, choose persons that your child knows well and is comfortable with, live nearby, and are aware that such calls may be coming.
9. Some children become anxious when home alone. A common reason for their anxiety is that you, their parent, may never show up again. (This explains many cases of school phobia.) Children seem to be reassured when you give them a short summary of your day’s activities. Ideally, take children and show them where you go and what you do when you leave home, where you eat lunch, and, importantly, where you park the car or take a bus or train to return home.
10. Call children to assure yourself that they’re OK and to assure them you’re OK. Calls should become less frequent with time as children adjust to being alone. Frequent calls from children about “nonsense” may indicate that they are still apprehensive alone and you should have a talk with them about their concerns. Call children if you will be delayed returning home; some watch the clock for your return. The best scenario: children become annoyed that you are calling them too often. They are comfortable alone.
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Why the rush to teach infants how to swim?
1. Infants don’t have to know how to swim to go swimming. Blame the English language for the confusion. “Swimming” also means “bathing in a body of water.” Do place infants in water soon after birth, if you wish, to acquaint them with it and help them to overcome fears, if any. Start with sprinkling water on them. Choose lukewarm water. Let them splash with their hands. Stay within arm’s reach; infants can go under in split seconds, without making a sound. Try to keep them from swallowing water. For infants, there is a perfect place for all this: your bathtub.
2. Formal swimming lessons for infants younger than one year of age are available – but controversial. Some programs have websites showing infants a few months of age performing aquatic stunts with no adult in sight. The programs claim that the younger the infants, the greater their affinity for water, a “throwback” to their existence in the womb. They will “roll onto their backs, float, rest, and breathe.” In fact, most infants do make hand and feet movements that resemble swimming and do hold their breath underwater for a few moments However, most cannot reliably sustain keeping their head above water or holding their breath if their head slips under the surface.
3. Early swimming lessons do not “drown-proof” infants. They may swim like fish when an adult hovers over them but usually panic when they fall into water unseen. Moreover, their ability to swim may give parents a false sense of security, making parents less vigilant, perhaps increasing the risk of drowning. Also, check that adults hovering over infants are themselves swimmers. Can you, grandma or the nanny swim?
4. A time to start thinking about starting lessons is when your child reaches the “ripe old age” of one year. So says the American Academy of Pediatrics. The Academy once recommended four years. Lowering that age was based on a small study that suggested that an infant’s ability to swim may help survival rates, but very slightly.
5. One-year-olds do not learn to swim in less time than three- or four-year-olds. Nor do they necessarily become more proficient later on. Early lessons do not increase intelligence, concentration or alertness, as some programs claim. Nor is there a relationship between early walking and the ability to swim. Early lessons are fine if they emphasize water safety for parents and provide water-related fun for both parents and infants/toddlers. However, parents rarely make good swimming instructors for their own children. Better to use experienced, certified, child-friendly instructors. The American Red Cross, YMCA and other organizations train and certify instructors. Check the web.
6. Swimming lessons should not be your primary strategy in preventing drownings. True, in recent decades more infants and toddlers had lessons and fewer drowned. However, according to experts, the decrease was mostly due to adults becoming more aware about water-related safety measures: fences around pools, appointing designated “child-watchers” at picnics near bodies of water, and wearing flotation devices, for example.
7. Children should take swimming lessons at ages five or six, even if they already swim. By this age children can be taught basic water survival skills such as floating, treading water, surfacing from under water, propelling themselves at least 25 yards, and getting out of the water. Lessons should include realistic scenarios such as falling into water while wearing clothes.
8. Appropriate, US Coast Guard-approved flotation devices save lives. Numerous types are available. Check the web. Many are designed to keep young children’s heads above water. Devices should fit properly and comfortably; some are weight-specific. Toddlers should wear flotation devices when they play anywhere near the water. Most children who drown were not supposed to be in the water. Many air-filled swimming aids on the market are toys, not flotation devices. They may deflate suddenly, the child may slip off them, or they may blow away in a strong wind.
9. Swimming presents health issues. Ironically, a main risk factor for infants becoming ill while swimming is the number of other infants in the water. Skip swimming when your child is ill – and encourage other parents do the same. Even in optimally maintained pools, infants who place their heads in the water have stomach upsets more often than infants who do not. The cause is diarrhea-causing organisms – often shed by infants. Chlorine and other disinfectants kill most but not all of these organisms.
10. Children who are not toilet trained should wear swim diapers when in public swim facilities. So says the US Centers for Disease Control. Many public swim facilities insist on it. So should you. Swim diapers retain stool and urine. However, some leakage occurs, especially if diapers are not changed promptly. Check diapers frequently and change them a distance away for the swimming water.
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KidsTravelDoc Newsletter
Dr. Neumann, August 2019 photo by Michael Perlman 
Dr. Neumann examines medical facilities for travelers in Uganda circa 2014. 
Dr. Neumann greets Taiwan President Lee Teng-hui, president from 1988 to 2000 while giving a lecture on travel medicine. 
Dr. Neumann is the recipient of an honorary doctorate degree in travel medicine in Glasgow in 2010. 
Banner photo: Dr. Neumann observed the vaccination program to eradicate polio in Cameroon in 1998 at the Ministry of Health. Sunglasses for young children: there is a lot for you to know
Consider making your next baby gift a pair of sunglasses – a gift that is thoughtful, unique, practical, a gentle reminder for new parents to start sun protection early, and, hopefully, a trendsetter that others will follow.
1. Infants’ eyes absorb more harmful ultraviolet (UV) rays than adults. Infants have relatively large pupils, allowing more light to enter. And their lenses contain less pigment to absorb radiation. Moreover, infants tend to look directly into the sun – though reflexes quickly make them blink and look away. Children with fair complexions are especially vulnerable.
2. Children spend more time outdoors than adults. We get a large percentage of our lifetime sun exposure by the time we are eighteen years old. While about 80% of parents acknowledge the importance of wearing sunglasses, more than half of children seldom or never wear them. Damage is cumulative over a lifetime, causing cataracts and other eye problems later in life.
3. Sunglasses and certain hats protect eyelids and skin around the eyes. These areas have delicate skin and burn easily. Using sunscreens is impractical: children won’t hold still for you to apply it, and spray products are not recommended for the face due to risk of inhalation. Sweat, tears, and water can cause sunscreens to seep into eyes, causing burning. Use sunglasses with large lenses and that wrap around toward the ears. This prevents rays from coming in around the glasses. Dress children in sun-protective hats with brims at least three inches (7.5 centimeters) wide and that extend around the head.
4. Sunglasses also protect eyes from injury. Choose ones that are impact-resistant, made of shatterproof polycarbonate, not glass, and have flexible frames. Such frames are less likely to be damaged when children play with them or leave them where they can be stepped or sat on. Impact-resistant glasses are recommended for sports.
5. Be aware of unusual sun exposure. This can occur in cars, for example. Side and back windows may not protect against all radiation. Ask your car dealership about the option of installing transparent UV-blocking window film. Note that the sun may come from different directions as you drive. Check where the sun is when you carry an infant on your shoulder or back. Sunshields are available for strollers and carriages. (Skin- and eye-damaging UV rays may also penetrate window glass in homes, trains, buses and planes.) Infants less than six months should have no sun exposure.
6. Buy sunglasses from reputable stores that sell eyeglasses. Beware of “fun” or “novelty” sunglasses. These are mainly marketed for children’s entertainment or “self-esteem,” or so they can make a “fashion statement.” Such sunglasses are widely available on the web and at variety stores at beaches; they offer little or no UV protection. Rarely such glasses, especially ones with wide frames, may contain lead.
7. Special features to look for. All sunglasses should block 99 to 100 % of UV rays. Children’s sunglasses come in various sizes. (One size fits all adults.) Labels generally state the age range for the glasses. Comfortable fit on the nose and around ears makes children less inclined to remove them. Straps help keep glasses in place – and help prevent loss. Dark lenses are no more protective than light ones; protection results from treatment of lenses. Replace glasses when they become scratched. Good sunglasses need not be expensive. Cost mostly reflects frames, not protection. Polarized lenses reduce glare making wearing them more comfortable. Avoid heavy frames to minimize possible discomfort.
8. Being in the shade of a building while having blue sky directly overhead offers little protection. This is also true of fluffy clouds. Being under a beach umbrella protects from direct sunlight but allows considerable radiation reflected from water and sand. Dirt, grass and concrete reflect comparatively little radiation. Minimize outdoor activities between 10 AM and 2 PM when radiation is most intense.
9. Winter days in snow country are as harmful for eyes as summer days at the beach. Snow reflects up to 85% of direct sunlight; this is additive to the direct sunlight. Many winter activities take place in snow-covered hilly terrain, adding radiation from different angles. Modern winter clothing allows more time spent outdoors. Altitude increases radiation; the higher the elevation, the less atmosphere to filter out harmful rays. Cold weather and the sun low on the horizon offer little protection. Many experts recommend wearing sunglasses year-round when spending extended periods outdoors.
10. Getting young children to wear sunglasses can be a hassle. Most young children seem to enjoy them; they make everything appear more colorful. Other children are hesitant. Try various doses of age-appropriate patience, coaxing, compliments, flattery, rewards/bribery and firmness (e.g., a “no going out without them” rule). Have periods daily when all family members wear sunglasses. Point out other children wearing them. Let older children pick out their own pair. Some children, especially children with special needs (ADHD or autism, for example) may be fearful of sunglasses. Check the websites of organizations devoted to such conditions for tips to help you manage.
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