Dr. Neumann’s 10 Tips: Preventing Vomiting/Diarrhea

May 13, 2012

Posted in Food & Water Precautions, Prevention Comments Off
Tags: airborn, alcohol-based sanitizers, bathroom, children, Diarrhea, diseases in stool, disinfected, flush toilet with seat down, hand washing, Infants, infected, kids, pathogens, poor hand washing techniques, potty chair, rubber gloves, sanitize, sinks, soap, stool, swimming, toilets, toothbrush, vomit, Vomiting

Just when you thought that you knew how to manage your kids’ vomiting/diarrhea, researchers come up with a slew of new findings that turn your management “skills” into old wives’ tales.

This is part one, Prevention, of a two-part series. Next posting: Treatment.

1. Most cases of vomiting and diarrhea in children are infectious. And person-to-person spread is more common than previously thought.  Until recently, it was believed that most cases resulted from ingesting the disease-causing viruses and bacteria (pathogens) in contaminated food and water. In fact, numerous cases are due to secondary spread: individuals infected by food and water spreading the pathogens to family members and other contacts who then spread them to others – and to others. “Contacts” can be total strangers.    

2. Infants and young children are ideal “spreaders.” Risk factors include being in diapers, attending daycare, touching objects and mouthing them, sucking on fingers, swallowing water while bathing/swimming, and poor hand washing techniques by older children – and often, by adults. Infectious vomitus and stool contain millions of pathogens and, for some diseases, less than a hundred suffice to cause infection. Moreover, children, more than adults, shed pathogens in stool for days after diarrhea ceases, therefore continuing to be infectious.      

3. Many pathogens are very hardy. They remain viable on people’s hands until hands are properly washed, and on objects such as doorknobs and toys for days. Pathogens survive on fabric toys such as stuffed animals for up to twelve days. Moreover, stuffed animals are difficult to sanitize.

4. Vomiting spreads pathogens far and wide. Infants and young children vomit more with intestinal illnesses than do older children and adults. Their vomiting is unexpected and uncontrolled, often propelling bits of vomit and the pathogens it contains into the air for distances up to six feet. The pathogens can be inhaled by others and contaminate nearby surfaces. Even vomiting into toilets and sinks can cause pathogens to become airborne. Close toilets before flushing. When possible, have children vomit into towels. Clean up promptly and disinfect surfaces, preferably while wearing disposable rubber gloves.

5.  Have a plan for changing diapers and disposing of them. Convenient sites for changing may not be sanitary ones. Choose sites that can be easily disinfected, not sofas, rugs or surfaces with minute cracks or crevices such as wood. Avoid excessive shaking and jarring of soiled diapers, clothing and linen; this can release pathogens into the air. Wash such items with detergent at the maximum available cycle length and then machine dry. If possible, have toddlers use regular toilets with special childrens’ seats rather than potty chairs. Ideally, such chairs should be cleaned in utility sinks, not present in most homes. Potty chairs should never be cleaned in sinks used for preparing food or for hand washing.

6. Make your bathroom child-friendly and simple to clean. Uncluttered bathrooms with non-slip stepstools and easily accessible soap and running water encourage children to wash their hands. Keep toothpaste and other bathroom paraphernalia in cabinets making it simpler to wipe surfaces. Have special containers for toothbrushes. Placing them on the sink is unsanitary.

7. Soap in itself does not kill disease-causing organisms. This makes hand washing technique important. It is the mechanical action of rubbing hands together with soap and water and then rinsing and drying that breaks down the tiny bits of grease, fat and dirt on hands that organisms cling to. Antibacterial soap is not significantly better than ordinary soap. Nor is liquid soap appreciably better than bar soap.

8. Hand washing is not child’s play.  Proper hand washing generally requires parental supervision.  Here’s the right way to do it: 

Remove rings and dangling bracelets. Wet hands with running water (warm is marginally more effective than cold). Apply soap.  Rub hands together to make lots of lather. Scrub between fingers and the back of hands and wrists. Keep nails short and wash under nails. Brushing nails is not essential. Rub hands for at least 20 seconds, the time it takes to sing “Happy Birthday” twice or “Twinkle, Twinkle Little Star” once. (Take your pick of songs.) 

9. Use alcohol-based sanitizers only when soap and water are unavailable.  Use ones containing at least 60% alcohol. While such sanitizers quickly reduce the number of organisms on the hands, they do not eliminate all types of organisms, and are less effective when hands are visibly dirty. Apply sanitizer to the palm of one hand, rub hands together, and make sure that the sanitizer covers all surfaces of hands and fingers. Continue until hands are dry. Sanitizers are toxic for children if ingested but taste so bad that ingestion rarely occurs.

10. Proper hand drying is essential. Wet hands transfer pathogens more readily than dry or unwashed hands. Ideally, each family member should have their own towel, especially when illness is present; damp towels in a humid bathroom abet the survival of organisms.

Place disposable paper towels plus a large foot-controlled trash can within easy reach of the sink. This allows children to dispose of towels without contaminating their just-washed hands. According to several studies, hot air dryers, common in public bathrooms, blow organisms from the hands into the air.  

Recommended hand drying methods and drying times

(Courtesy of the Centers for Disease Control)

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Dr. Neumann’s 10 Tips: Cruise ships/Children/Intestinal diseases/Norovirus

April 25, 2012

Posted in Destinations, Outdoor Recreation, Safe & Healthy Travel, Travel Comments Off
Tags: are cruises safe from norovirus, CDC, children, cruise, cruise ship, cruise ships norovirus, cruise with family, cruises with kids, family, Health, intestinal diseases, Intestinal illnesses, leafy greens norovirus, norovirus, norovirus cruise ship outbreak, norovirus lettuce, norovirus outbreak, norovirus outbreaks on cruise ships, shelffish norovirus, Vacation, viral infections

Cruise ships/Children/Intestinal diseases/Norovirus

Should the frequent outbreaks of intestinal illnesses aboard cruise ships deter you from taking your family on a vacation at sea?  Our thoughts at the end of the article.

(This is the second of a three-part series. Our previous posting: Children/Cruise ships/Health and safety. Our next posting: Intestinal diseases/Children/Treatment and preventing spread.)

1. The facts. Last year 14 million passengers including 1.3 million children sailed on cruises from American ports. And, as in previous years, and in spite of the best efforts of the U.S. Centers for Disease Control (CDC) and the cruise industry, many passengers became ill with intestinal illnesses, the vast majority of cases due to the norovirus.   

2. Norovirus is a hardy organism. Infection spreads rapidly, generally via contaminated food and water or from person to person; it may take fewer than 20 viruses to cause illness, far fewer than with most other viral infections. Viruses can also become airborne and inhaled when infected individuals vomit or by flushing toilets containing virus-contaminated vomit or stool. Close toilets before flushing.  Viruses continue to be shed after symptoms subside, sometimes for weeks. The virus may survive for 12 hours on hard surfaces, up to 12 days on contaminated fabrics, and several months in still water.

 3. Cruise ships are ideal places for outbreaks. Thousands of passengers and crew are confined in relatively close quarters for many days, eating food and drinking water coming from the same sources and stored aboard ship. One infected individual can spread the virus widely, especially if that person is a food handler. All aboard ship touch the same objects (doorknobs, for example) and passengers and crew eat at ports where sanitation may be less than ideal, and where they may become infected and bring the virus aboard.     

 4. Norovirus outbreaks are not limited to cruise ships. In the US, there are about 21 million cases of food-related intestinal illnesses each year, with norovirus accounting for more than half of the cases. The most common settings for outbreaks are restaurants and catered meals (36%), nursing homes (23%), schools (13%), and vacation settings, mostly cruise ships (10%). (In 2010, an outbreak involved 21 players and three staff from 13 National Basketball Association teams.) Norovirus is a factor in about 70,000 hospitalizations and 300 deaths annually, these occurring mostly in young infants, the elderly, and individuals with serious underlying illnesses.  

5. Outbreaks on cruise ships are widely reported. The medical staff on cruise ships docking at American ports must record and report to the CDC in Atlanta cases of intestinal disease involving passenger and crew; a “case” is someone who visits the ship’s infirmary with intestinal symptoms or who asks for medication for such illnesses. Because of the short incubation period of norovirus – a day or two from the time of infection until symptoms appear – most ill individuals are still aboard ship when they become ill. If the number of ill persons aboard ship surpasses 3%, special sanitizing programs are instituted aboard ship and the ship is inspected when it reaches port. Such events are posted on the CDC’s website and widely reported by the media.

6. Most outbreaks on land go unreported. When cases occur in restaurants, for example, victims scatter after meals, many do not see physicians or they see different physicians, and physicians are not required to report cases to health authorities. Outbreaks in schools, hospitals, prisons, and nursing homes for example are generally reported only if large numbers of individuals are involved or there are hospitalizations or deaths.  

7. Cruise ships are subject to stringent sanitary oversight.  CDC’s programs teach ship personnel sanitary practices and inspects ships (announced and unannounced) at least twice a year, has protocols for handling outbreaks at sea, investigates outbreaks, maintains electronic surveillance systems to track illnesses, and performs dozens of other functions to minimize illness. The CDC can prevent ships from sailing if conditions warrant more thorough sanitization.

8. Choosing ships with better sanitation ratings does not reduce the risk of becoming ill. Below is a list of the 14 cruise ships involved in major outbreaks of intestinal diseases in 2011. More recent outbreaks are listed at  http://www.cdc.gov/nceh/vsp/surv/gilist.htm .  A passing grade is 86. In February 2012, a ship with a perfect score, 100, a rare occurrence, was forced to return to port early due to an outbreak.

9. Avoiding certain foods is only minimally helpful. Studies show that foods that are most commonly involved in outbreaks include leafy greens (such as lettuce), fresh fruits, and shellfish, especially oysters. However, any food item that is served raw or handled after being cooked can become contaminated. Bottled water is only marginally safer than tap water.  

10. Should you avoid family cruises? The risk of intestinal illness is quite small, considering that 14 million passengers plus crew sail on thousands of cruises each year. (On most cruises the number of crew is at least half the number of passengers.)  And though there is no data, very likely, there is less risk of intestinal illness on cruises than on vacations in the tropics, and for young children, less risk than in daycare or preschool. All vacations and day outings involve some risk. 

In 2011, there were 14 major outbreaks involving several thousand passengers and crew. 
Here are the ships that were involved:

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Dr. Neumann’s 10 Tips: Keeping kids healthy and safe on cruises

March 27, 2012

Posted in Destinations, Outdoor Recreation, Safe & Healthy Travel, Sun, Travel Comments Off
Tags: cruise ship, Cruise ships, health insurance, immunization, influenza, Medical kit, medical services, norovirus intestinal disease, Vaccine

Of the 14 million passengers who sailed from American ports last year, 1.5 million were children. Families are the biggest growth segment for cruise ship companies. Every ship being designed has children in mind. Some ships are planned entirely for families. (Some adults without children are clamoring for adult-only voyages; children have overtaken ships, especially during school holidays.)

Here are some tips for smooth sailing:

1. Pack a medical kit.  A leading reason for parents visiting the ship’s infirmary is to obtain medications inadvertently left at home or ones you did not anticipate needing. Most common over-the-counter medications are available aboard. Some prescription items are stocked, but may be expensive, not covered by insurance and not identical to ones you use at home, possibly causing confusion. (See Medical Kit for tips on assembling a personalized kit.)

2. Does your health insurance cover shipboard medical expenses?  If not, buy travelers’ assistance insurance. Such insurance includes evacuation to a medical facility on land. This rarely becomes necessary but can cost tens of thousands of dollars. Policies are available through major credit card companies. Policies have exclusions – pre-travel conditions and hazardous activities, parasailing and diving, for example, sports popular at some ports.   

3. Update your children’s immunizations. Aboard ship there are passengers and crew from many countries; the crew are often from poor countries with lax immunization programs. Outbreaks of vaccine-preventable diseases have occurred aboard ship. Influenza vaccination is recommended for children six months and older (and adults). Shore excursions, even short ones, may require vaccines and preventative medications. Check with a travel medicine professional before your voyage.  

4. Shipboard medical care is expensive.  It is designed to treat routine illnesses and provide emergency care. Consultations can cost up to $100 for an initial visit. Most physicians are trained in emergency medicine. Injections, x-rays, lab work and “house” calls to cabins are extra. Fees may be waived for minor ship-related injuries. Most ships are equipped to electronically transmit x-rays, ECGs, digital pictures and other data to specialists on shore for immediate interpretation. If a family member has an ongoing medical problem or mobility issues, consult the cruise line’s medical department several weeks before sailing. In most cases, they can accommodate you.

5. Sunburns are common. Children burn easily. In the tropics, the sun is directly above, daylight is long, there is almost no haze to filter out rays, and rays reflect off water, increasing exposure. In temperate climates, don’t let cool weather and breezes lull you into complacency; neither reduces radiation. Taking ibuprofen immediately after excessive exposure and before burn symptoms occur may alleviate discomfort, but doesn’t reduce long-term skin damage.  Use sunscreen of SPF 15 or above. Reapply frequently.

6. Seasickness is uncommon. Weather data enables captains to change course to avoid bad storms. Ships are equipped with stabilizers. If children feel “queasy,” stay on deck and tell them to keep their eyes on the horizon. Or stay in air-conditioned areas, have them recline, keep their eyes closed and heads still. Avoid large meals and food odors. Sip fruit juices. Transderm-Scop, a patch placed behind the ear, is effective, but approved only for children older than 14 years of age. It requires a prescription and has side effects. Oral medications and injections are generally available aboard.  (See Motion Sickness.)

7. Most shipboard accidents are preventable. Leading causes are embarking and disembarking and the rolling of the ship. Inform children about risks related to steep stairs, wet decks, doorsills, and falling over items in the cabin. Leave a small light burning. Baby-proof cabins for toddlers. In many ports, ships remain at sea. Getting on and off launches, particularly in heavy seas or while holding young children, is dangerous. Allow crew to assist you.

8. Most serious cruise-associated accidents occur ashore. Riding motorbikes and parasailing are hazardous activities. In many ports there are no age restrictions. Tropical beaches have undertows and hazardous sea life. Lifeguards are rare. In developing countries, watch for broken sidewalks, exposed roots and unexpected steps.  Many ports of call have only rudimentary medical services.

9. Cruises are a learning experience for children. Most ten-year-olds can be left alone to find their way around the ship (usually better than their parents). They can sign themselves in and out of professionally supervised programs. Parents, if they wish, can track them via beepers, walkie-talkies and other electronic devices. Confined activities are available for younger children. Cameras manned by security personnel cover most public areas. On many ships children less than 12 years old must wear wristbands listing muster stations in case of emergencies when alone. Crew can read the bands and guide children accordingly.

10. But even cruise ships are not totally safe. Child molestation and problems with teenage troublemakers and drugs are rare occurrences. Observe children’s shipboard friends. Establish rules in advance. Set times and places to meet during the day. Set restrictions and curfews – just like at home. Warn children never to accompany unknown adults into non-public areas or into cabins.

Next issue: Norovirus intestinal diseases aboard cruise ships.

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Dr. Neumann’s 10 Tips: Infants in diapers/Swimming facilities/Illness

March 17, 2012

Posted in Food & Water Precautions, Prevention, Safe & Healthy Travel Comments Off
Tags: bacterium, bowel movements, CDC, chloramines, chlorine, cryptosporidium, Diarrhea, e. coli, eye irritation, giardia, hepatitis a, illness, infants in swim diapers, infants swimming, inflatable pools, intestinal illness, microorganisms, o157:h7, parasite, recreational water, septic, sewage, swim diapers, swimming facilities, urine, virus

Think twice before allowing your kids to swim in water where there are many infants.  The more infants in the water, the greater is the risk that the water is polluted with intestinal disease-causing microorganisms. 

Here is what you should know:

1. Recreational water is an underappreciated source of intestinal diseases. Such water includes swimming pools, hot tubs, water parks, lakes, beaches and oceans. In the past two decades, there has been a substantial increase in the number of cases of intestinal disease from such water. Many different types of organisms are involved.  In one recent year, one organisms,  cryptosporidum, which is resistant to chlorine,  caused 10,500 known case, says the Centers for Disease Control (CDC). And this is only the tip of the iceberg. No matter which organism is involved, only large outbreaks or outbreaks involving hospitalizations and deaths are reported.

2. Infants in recreational water are a fairly recent phenomenon. In the distant past, placing infants in water was just not done.  More recently, parents kept infants out of pools, believing that chlorine was bad for them. However, now there are water-based swimming and exercise classes for infants and infant-parent bonding programs, generally conducted in the same facilities used by others. And there are loads of accessories: swimming diapers, water toys and floating paraphernalia.

3. Do infants belong in recreational water? Exposing infants to water does not help them overcome a fear of water. Teaching them to swim does not “drown-proof” them; generally, they swim only when adults hover over them, not if they fall into water unseen, possibly giving parents a false sense of security. And infants don’t learn to swim in less time than older children or become more proficient than if they started lessons at a later age.

4. Infants in diapers are a major source of diarrhea-causing organisms. Infants are more likely to have intestinal illnesses than older children and adults, do not control their bowel movements, and tend to shed organisms for many days after symptoms have disappeared. Individuals with infectious diarrhea should not swim for two weeks after symptoms disappear.  

5. Infants are more likely to become ill from ingesting polluted water. Infants swallow water when their heads are dunked. Older children can be encouraged – with varying degrees of success – to keep water out of their mouths and, when ingested, to spit it out. Becoming ill is related to the number of organisms swallowed. Stomach acidity and immune mechanisms protect the body from some organisms, but the body is overwhelmed by too many. Because of infants’ small size and immature immune systems, it takes fewer organisms to make them ill, infants are often in the water with other infants, increasing the risk of exposure, and if illness does occurs, have more severe symptoms.   

6. Small inflatable, plastic pools increase the risk of spreading disease. The CDC recommends not using such pools. They are generally filled with tap water. While most tap water contains chlorine, the concentration is inadequate to kill many types of organisms. Yet CDC advises not to add additional disinfectant. The dose cannot be easily determined nor safely monitored, and the pools lack filters to remove particles that prevent disinfectants from working optimally.  

7. There is no way to prevent infants from urinating in the water. (But adults do this too. CNN reports that 16% of adults are guilty, including U.S. Olympic medalists.) Urine is sterile, but it emits a chemical odor, and causes mild eye irritation and coughs. Sweat and urine combine with chlorine, creating chloramines, hence the odor and symptoms. (It is a myth that a chemical exists that, when added to pool water, will combine with urine and turn the water around the perpetrator bright red. Apparently, some pools have such signs to scare swimmers!)

8. Swim diapers have limited effectiveness. These are designed to keep stool from leaking into the water. Swim diapers don’t disintegrate when immersed in water, fit snuggly around waist and thighs, and have a plastic outer lining. Some swim facilities insist that infants wear them. Most experts believe that, at best, swim diapers slow the leakage of stool into the water.  

9. There are problems with using chlorine in pools. While it is effective in killing most organisms in less than a minute, it does so only when present in adequate concentrations and if the water pH and temperature are within certain ranges. Moreover, there are important disease-causing organisms that are quite resistant to chlorine.

10. Pollution monitoring of natural water is haphazard.  Private or remote waterfronts are rarely tested. Public waterfronts may be randomly checked every few days or less, with results sometimes not available until days later, and with no efficient system of informing users of problems. Water quality at long stretches of beaches may vary substantially from place to place and change hourly, with the water tested at only a few locations. Sources of organisms include swimmers, animals, sewage runoffs, boating wastes, and malfunctioning septic systems in the area, to mention just a few.

Bottom line: Never swallow water when swimming.

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Dr. Neumann’s 10 Tips: Non-vaccinated children endanger the health of all children

March 1, 2012

Posted in Vaccinations Comments Off
Tags: africa, antibiotics, asia, chickenpox, chickenpox during pregnancy, child vaccinations, children vaccinated, college students, contagious, domestic flights, Europe, how do vaccines work, infant vaccination, infant vaccines, infected, measles vaccination, multi-dose vaccines, mumps vaccination, non-immunized Americans, non-vaccinated adults, non-vaccinated children, non-vaccine factors, overseas, parents who refuse vaccines, pertussis, polio vaccination, prevent diseases, refuse vaccinations, rubella during pregnancy, rubella vaccination, should I get my child vaccinated?, smallpox vaccination, unvaccinated infants, vaccinate, vaccinated, vaccinating programs, Vaccine, vaccine-preventable diseases, vaccines, vaccines during pregnancy, vaccines save lives

An important reason why some parents refuse to have their children vaccinated is that many of the vaccines routinely given are to prevent diseases no longer seen in this country.

Here’s what you should know:

1. Parents who refuse vaccinations for any reason are making a big mistake. The reason that these diseases are no longer seen in this country is because the vast majority of parents have their children vaccinated. Experience shows that if vaccine refusal increases sharply, or the vaccinating programs become lax – often because of the program’s success – the diseases return via travelers from countries where vaccination programs are less stringent, which is most of the world.   

2. Vaccines are the number one advancement in the history of medicine.  (The second is antibiotics.) Vaccines save millions of lives yearly, mostly those of children, and save countless children from crippling and disfiguring diseases – and do so with no known serious side effects. Parents who refuse vaccinations because of their conscientious beliefs place other children at risk, a dilemma difficult to unravel on ethical grounds.  

3. Crediting non-vaccine factors for the sharp decreases in vaccine-preventable diseases is erroneous. While better sanitation, less crowding, and healthier diets, for example, may be contributing factors, vaccines provide the knockout punch. Statistics bear this out. And while most vaccine-preventable diseases are no longer seen in this country, the causative organisms are present. Depending on the disease, the organisms continue to exist in soil, sewage, blood, and, sometimes, in perfectly healthy individuals.  Only vaccines keep them from surfacing.  

4. Non-vaccinated children benefit by others being vaccinated.  Parents of non-vaccinated children often cite the fact that their children do not become ill as proof that the vaccines are not necessary. Not so. These children are getting a free ride, so to speak. The more children vaccinated, the less chance that a non-vaccinated child will come in contact with someone who is infected. (You can’t have a forest fire where only a few, widely separated trees stand.)  

5. Non-vaccinated children delay the day that some vaccination programs can be terminated. Ironically, the only known method to permanently eliminate most childhood diseases is to eradicate the causative organisms. And the only known way to do this is to vaccinate virtually every person in the world. Eliminating measles, mumps, rubella, and polio, for example, is theoretically possible – it happened to smallpox. 

6. Even optimal vaccination programs are not 100% effective. For example, infants become susceptible to contracting pertussis (whooping cough) soon after birth, a time when the disease is particularly life-threatening. But available vaccines do not protect infants from pertussis until the infants are several months older, leaving a “window period” during which infants are susceptible.

Protecting infants from pertussis requires that individuals in contact with the infants be vaccinated. Likely, unvaccinated individuals caused the recent pertussis outbreak in California, resulting in several deaths.   

7. Compromising accepted vaccination schedules to please parents is counterproductive. Experience with tens of billions of doses of vaccines given to billions of children has delineated the earliest age that vaccines are effective and the optimum number of doses necessary to yield maximum long-term protection. Achieving immunity is delayed by waiting until children are older to vaccinate, increasing the time interval between doses, or giving one vaccine at a time. A single dose of many multi-dose vaccines gives little or no protection.

8. Non-vaccinated children become non-vaccinated adults. Many vaccine-preventable diseases – measles, mumps and rubella, for example – are far more serious for adults than for children. Before the age of vaccinations, children were infected at early ages, mainly because these diseases are so contagious. Now that most children are vaccinated, chances increase that non-vaccinated children reach adulthood without being infected.

Rubella and chickenpox are devastating to a fetus if a non-vaccinated woman contracts the disease during pregnancy.  In 1964-1965, before rubella immunization was standard in the U.S., an epidemic of rubella occurred. The epidemic resulted in about 20,000 infants born with the effects of the disease. Of these, 11,600 were deaf, 3,580 were blind, and 1,800 were mentally retarded. In addition, there were 11,250 miscarriages and 2,100 neonatal deaths.  

9. It is risky to take non-vaccinated children overseas.  It is risky for those children – and for your children if your children are not optimally vaccinated. Fully vaccinated American children by the age of 11 years have received 52 doses of vaccines against 14 diseases. Few other countries come close. As a result, the U.S. has the lowest incidence of vaccine-preventable diseases. Of the cases that do occur, many can be traced to overseas travel. Last year there were only 156 known cases of measles in the U.S., likely all imported, compared with thousands of cases in Europe, and millions in Africa and Asia.

10. Tens of millions of individuals enter the U.S. annually from overseas. They come from every country in the world. They are Americans (including children) returning home, tourists (including children) visiting the U.S., students studying at American colleges, parents bringing home children adopted overseas, immigrants, and others. No one is checked for disease; there is no way to do so. Travelers have spread vaccine-preventable diseases to non-immunized Americans on domestic flights, at colleges and other schools, at popular theme parks, everywhere.

Vaccination programs are the only way to prevent these diseases from returning to the U.S.

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Children/Outdoors/Good health

February 12, 2012

Posted in Outdoor Recreation, Sun Comments Off
Tags: AAP, archives of pediatric and adolescent medicine, children, children's dis-connect with the outdoors, exercise, good health, harvard health letter, how much television time should preschool children have, kids television, nature deficit syndrome, osteoporosis, outdoors, SAD, screen time, seasonal affective disorder, smart phones, sushine vitamin, tv watching, vitamin d, vitamin supplements, winter blues, winter sunlight

Do your kids a favor. Pry them away from their TV, video games, computers, and smart phones – forcefully, if necessary. Ignore their yelling and sarcasm. Then kick them out the door – literally, if need be. If they threaten to report you to child welfare services, inform them that merely being outdoors is the current cure-all for all that ails them and the preventative for virtually all that may ail them in the future.

While cure-alls come and go, this one is backed by impressive credentials – the Harvard Health Letter, the U.S. Department of Health and Human Services, and the American Academy of Pediatrics (AAP), for example. Their messages: “Letting your children ‘go alfresco’ helps them grow up healthy.” “Children’s ‘dis-connect’ with the outdoors is an important reason that so many children have physical and mental issues.” “Today’s children suffer from ‘nature-deficit’ syndrome.”

Do impressive credentials always get it right? Not necessarily. In fact, much of the support for equating the outdoors with heaven is not based on traditional evidence-based research. But the philosophy is worth listening to – while remembering that we tend to exuberantly embrace simple, safe and free cure-alls that promise better health for our children, especially cure-alls that have virtually no known downside. Only time and research may find kinks in the current adulation of alfresco.

Today’s children are “screen bound.”  “The nature of childhood has changed, and there isn’t much nature in it,” says one guru.  “Screen time” is higher than ever. Children between the ages of 8 and 18 spend half as much time outdoors as they did 20 years ago. On average, preschool children spend 32 hours a week with screen media. The AAP recommends that kids under age 2 years have no screen time, and those older than 2 watch 1 to 2 hours a day, preferably quality programming.

The worst sedentary activity is TV watching. Children who spend their indoor time watching TV have higher blood pressures than those playing  electronic games, on computers, or texting, according to the journal Archives of Pediatric and Adolescent Medicine. TV watching involves no movement on the part of the child and is often associated with eating, generally foods high in salt and calories.

Children are more active outdoors. While kids need not be outside to be active and being outside is no guarantee of activity, indoor living is associated with being sedentary. Time spent with electronic media is done mainly while sitting. The younger children start active outdoor recreational play, the more likely they will find ones they enjoy and will continue as adults.

“Green” outdoors is the best outdoors. Spending time surrounded by trees, grass and plants is superior to being amid buildings, concrete and artificial turf, with the wilderness the ultimate outdoors. Five minutes of green exercise a day results in improvements in self-esteem and mood. A window view of trees helps hospital patients recover faster than a view of brick walls.    

Activity should be sufficiently intense to increase heart rates. Brisk walking, biking, or “running around,” for example, have beneficial effects on muscle strength and endurance, bone and cardiovascular health, and concentration, memory, and classroom behavior. Children with attention deficit disorders scored higher on tests of concentration after walking through natural surroundings than those walking through residential neighborhoods or downtown areas. Children living in greener neighborhoods maintain lower average body weight.

Some children need coaxing to enjoy the outdoors. Others take to it “naturally.” Parents should expose children to various activities, ones appropriate for their ages. Look for activities provided by schools, park departments and other neighborhood organizations. Structured play times and activity-friendly environments are conducive to enjoyment. Ideally, children should spend at least one hour a day outdoors.

Though less well studied, some researchers believe that “nature time” helps family bonding. “The natural world seems to invite and facilitate parent-child connection and sensitive interactions,” says a former advisor on children’s health to the White House. “What better way to escape the constant, interrupting beeping of modern life, than spending concentrated time with your child during a walk in the woods.”

Vitamin D, the “sunshine vitamin,” is the vitamin presently in vogue.  It may have protective effects against future osteoporosis, cancer, depression, heart attacks, and stroke. Some kids have too little in their bodies. (It takes direct sunlight to activate the substances in the skin that produce vitamin D. Being in the shadow of a building with blue sky above is not sufficient.) Vitamin D can also be obtained from food and vitamin supplements. [Read KidsTravelDoc, Vitamin D.]

Winter sunlight helps minimize being sad and having SAD.  Sad (small letters) is having the “winter blues.”  SAD (capital letters) stands for Seasonal Affective Disorder, a more serious form of the winter blues. Sufferers have less energy, difficulty concentrating, become irritable more easily, need more sleep, and take longer to get up in the morning. In younger children, crankiness and crying spells may occur more often. [Read   KidsTravelDoc, SAD.]

Follow me on Twitter @KidsTravelDoc

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Family Travel/Airlines/“Baby discrimination”

January 15, 2012

Posted in Air Travel, Safe & Healthy Travel Comments Off
Tags: airline baggage fees, airlines, annoying children on airplane, babies on airplane, baby discrimination, baby ghettos, baby segregation, bulkhead seats, business travelers, child-free aircraft, child-free flights, child-friendly flights, family air travel, family boarding, family flights, family seating, family travel, frequent flyers, infants on airplanes, major airlines, middle seat airplane, non-collapsible strollers

Fasten your seatbelts – family air travel is heading for turbulence. Children are becoming persona non grata in the supposedly friendly skies.

London’s Daily Mail reports that several major airlines are considering child-free sections on aircraft and child-free flights. The Wall Street Journal asks, “Will new airline seating proposals create “baby ghettos” in the back of planes?”  Blogs talk about families being seated separately, sometimes leaving small children in middle seats among strangers, unless parents succeed in convincing passengers to swap seats – and middle seats are difficult to swap. Airline personnel may or may not assist in “seat swapping diplomacy.”

(Will infants have to stand up for their civil rights in Occupy Wall Street-type protests?  Of course, literally, infants cannot stand up. But they can raise their heads and wail to make their wills known. Will hordes of infants crawl into airports, creep beneath the crowds, and lie down blocking ticket counters and security check points? Will police dare to interfere?)

Here is what is happening:

• Airlines are flying low financially. Ever-increasing operating costs are shrinking profits. Some airlines are in bankruptcy. To increase revenue, they are scheduling fewer flights and eliminating scores of amenities, many of which affect families.
• Getting your family seated together is becoming a hassle. Fewer flights mean fewer available empty seats, giving reservation agents (or computers) less flexibility to find seats together. Worse, confirmed reservations can become void when sparsely filled planes are cancelled, sometimes days before flights. Passengers are then placed on other flights, ones already partially filled, and sometimes with different seat configurations, leaving few blocks of seats for families.
• Family amenities are being curtailed. Amenities cost airlines money. Cost saving measures already instituted on domestic U.S. flights include: discontinuing checking heavy, non-collapsible strollers at the gate; removing microwave ovens  (no longer needed since there is no hot food service) making bottle heating problematic; not storing milk; requiring parents to bring birth certificates to prove that a lap child is really younger than 2 years of age. And don’t count on pillows, blankets and snacks.
• Families may no longer board first. Several major airlines have discontinued this practice. One airline charges $10 a person to guarantee a spot in the first boarding group in coach. Family boarding now comes after first class and frequent fliers. The reasons given: parents and kids lugging car seats, diaper bags, videogames and other large toys clog the aisles and delay general boarding.
• Baggage allowances have been reduced. Don’t count on airline personnel to look the other way when you lug children’s travel paraphernalia aboard. Most airlines allow one or two items considered hand baggage, strictly enforce the rules, and charge hefty fees if more are carried.
• Choice seats are no longer available for families. Bulkhead seats at the front of coach cabins have space for airline cribs and for tending to infants. But many airlines now charge extra for such seats and reserve them for frequent flyers, people with disabilities and VIPs.  
• Make family reservations early and check on them frequently. Call ahead and ask whether the amenities you expect are available. If not, plan accordingly. If you can afford it, pay extra for bulkhead seats. U.S. airlines are more child-friendly on their overseas flights than on domestic flights. This is to compete with foreign airlines which tend to be very child- friendly.
• Business travelers are behind the movement to segregate children. Surveys of such travelers show that about 75% believe that children on planes are “irritating.” Business travelers fly frequently, do their work in flight, and request (sometimes, demand) seats away from children. And they have clout with the airlines. “Flights through hell” is how some describe long flights sitting near screaming infants or in front of a toddler who continuously kicks or pulls on that seat. An Australian airline recently settled a lawsuit by a passenger who said a screaming child caused her to lose some of her hearing.
• Parents are often unfairly blamed for unruly children. While some parents are oblivious to their misbehaving children, in fact, even well intentioned parents have limited means to soothe crying infants and calm rambunctious toddlers.  Air travel subjects young children to disrupted eating and sleeping schedules, limited and uncomfortable space, unfamiliar surroundings, and perhaps ear or stomach discomfort.  Parents should set rules for their children and enforce them as best as they can, and carry plenty of snacks and games. Sedating children is not recommended.
• Will airlines implement child-free sections and child-free flights? One major Asian airline already bars children from first class, and perhaps other airlines will also do so. But, likely, segregation in economy class, where most families sit, won’t “fly,” and raises questions. If family sections are full and seats available elsewhere, would families be barred from that flight? Must families with well-behaved children sit in the family section? Will adults traveling alone accept seats near children? Will soundproof partitions and separate toilets have to be installed to contain/accommodate children?

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Families/Overseas travel/Medications Part 2 of 2

January 4, 2012

Posted in Air Travel, Prevention, Safe & Healthy Travel, Travel Comments Off
Tags: Air Travel, airport, antibiotic, asia, breast pumps, children medication, codeine, doxycycline, families, hyperactivity, ill children, kids, Medications, nebulizers, overseas, pseudoephedrine

This is Part 2 of a two part series. To read Part 1, please click here.

You need not be under suspicion of possessing narcotics to be hassled by security and customs inspectors at airports. Families have been hassled for merely carrying everyday, over-the-counter medications, have had the medications confiscated, missed their flights and, very rarely, been detained to explain their “crime.” Moreover, once overseas, obtaining medication for your family is often a maze of confusion. When your children are ill, your treatment may be more problematic than the disease you are treating.

• Carry all your family’s medication in one kit for air travel. This makes it simpler for security personnel to check your kids and yourself. If you carry nebulizers, breast pumps and such, have letters from your doctor and get to the airport early. Security personnel must examine each item and call supervisors to look at unusual ones, and are under orders not to rush inspections because your flight is leaving.
• Pack more medications than you will need – but not much more. While you don’t want to run out, large supplies make security and customs inspectors edgy. Problems occur if you are staying abroad for prolonged periods and require a large supply. Keep medications in their original containers with intact labels and drug insert pamphlets. Inspectors are not fond of containers filled with a medley of pills and capsules.
• The amount of radiation emitted by airport radiation devices is insufficient to damage medications, even if you fly frequently with the same substances. X-rays do not make medications radioactive. Generally, you may request hand inspection of your carry-on bags, including medications. Leave extra time for this.
• Airport security regulations change frequently, especially regarding liquid items, the medications children generally take. Presently, in the U.S. and in many other countries, you may carry multiple liquids in quantities up to 3 ounces (90 ml) placed in a quart-size (liter-size), clear plastic, sealable bag.  Medications in volumes larger than 3 oz. are permissible if placed separately and declared verbally or in writing to security personnel. A doctor’s letter explaining the medical need for the substances helps but is not essential.  “Reasonable” quantities expedite security checks. 
• Many countries ban specific substances. It is illegal to enter Japan with many over-the-counter items commonly used elsewhere: inhalers and allergy/sinus substances containing the stimulant pseudoephedrine (Actifed, Sudafed, and Vicks inhalers), for example. Codeine-containing substances and medications to treat hyperactivity are banned by many countries in Asia and travelers have been detained for carrying such items. Check medications with the embassies of countries you plan to visit. Most have websites with complete information.
• Buying medications overseas is tricky. For example, the antibiotic doxycycline is known by 50 different names around the world, says Drugs.com. This database contains information on medications in 185 countries, listing 40,000 names. Also, many medications have very similar names, in spelling or pronunciation or both. Requesting such items is further complicated when dealing with people who speak other languages. Worse, there are cases where identical names are used for totally dissimilar substances in different countries.  
• Familiar items may have different strengths overseas. Even if your medications have the same name and similar packaging as items back home, they may be quite different. A teaspoon of a substance may contain more or less of the active ingredient(s) than you are accustomed to, measuring devices such as droppers may be calibrated differently, and letters at the end of the name may be in a language or alphabet you do not understand.  Such letters may stand for “extra strength” or “time released,” for example, and change potency significantly.
• Prescriptions may or may not be filled overseas. In most poor, developing countries prescriptions are generally not necessary for items that require ones at home. In developed countries, pharmacists may not fill foreign prescriptions, requiring that you see a local physician. Some countries (Germany, for example) prohibit the mailing or shipment of medications from overseas so you cannot legally have someone from home mail you what you need.
• Medications and herbal substances in developing countries may be suspect. A third or more of the medications bought in local pharmacies in such countries are fake, diluted, outdated, incorrectly labeled, improperly stored, and may even contain toxic substances. Natural and herbal cures are generally not properly tested or standardized (one batch rarely equals another in active ingredients) and are often stored in large open bins accessible to insects and vermin.
• Traveling or not, when children are ill, consider doing – nothing. Obviously, medications are essential for many illnesses. But not so for the vast majority of mild illnesses that children experience – colds and coughs, intestinal upsets, and low grade fevers, for example. Remedies for these generally do not shorten the duration of illness or prevent children from getting worse. When possible, speak to your health care professionals back home or reputable local professionals before treating.

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Children/Travel/Medication interactions/Adverse effects Part 1 of 2

December 11, 2011

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Tags: adverse effects of medication, antacids, blood test strips, children, children medications, children travel doctor, Dehydration, Diarrhea, dimenhydrinate, Dizziness, Dr. Karl Neumann, dramamine, exotic foods, insulin, Kids Travel Doc, kids travel doctor, medication, medication interactions, medications overseas, motion sickness, motion sickness-related nausea, over the counter medication for kids, Travel, travel-related, vitamins, Vomiting

Are you familiar with the harmful effects that may result from medications you give your children? That when you give more than one medication, the two may interact and cause adverse reactions not caused by one alone? That travel-related factors can cause additional interactions?

(This is Part 1, one of a two-part series. Watch for our next posting. Find out which over-the-counter medications may be confiscated by Customs in other countries and, albeit rarely, result in you being detained.) 

• Reactions to medications are common. Each year, more than half a million U.S. children have medication-related adverse reactions, some serious. Among children, those younger than 5 years are most affected; they metabolize certain substances poorly, allowing undesirable concentrations to accumulate.
• Food, food supplements and vitamins can interact with medications. Travel often means new and exotic foods, or familiar foods with different ingredients. Some foods combine with medications, neutralizing them; hence the warnings that certain substances should be taken on empty stomachs. Read drug inserts. Vitamins, food supplements, herbal medications and items marked “natural” or “organic” are often erroneously considered to be benign. Not so. These too can affect medications.
• Environmental factors affect medications. Expiration dates on medications are based on proper storage at room temperatures and away from excessive heat, cold, sun and humidity. Exposure to these factors “shortens” expiration dates, and sometimes, in a matter of days, can decompose them chemically into harmful substances. Certain antibiotics and antihistamines, for example, increase the effect of the sun, worsening sunburns.
• Travel-related medications can interact with medications. Dramamine (Dimenhydrinate) is commonly used to prevent and treat motion sickness-related nausea, vomiting and dizziness. One website, Drugs.com, lists 414 items that this drug can interact with: 16 major interactions, 390 moderate, and 8 minor. Dimenhydrinate requires no prescription.  Over-the-counter substances are almost as likely to cause adverse interactions as those requiring prescriptions.  
• Illness can affect the way medications perform. Intestinal upsets prevents certain medications from being properly absorbed.  Dehydration (from excessive heat) increases the concentration of substances in the body, producing symptoms resembling overdoses. Taking an antacid decreases stomach acidity. This acidity is important to destroy diarrhea-causing microorganisms sometimes found in foods, especially in developing countries. Antacids allow microorganisms to multiply more rapidly, sometimes resulting in illness.
• Heat may compromise the stability of capsules, tablets and powders.  Prolonged temperatures over 86 degrees F (30 degrees C) can dry out capsules, causing them to become brittle from heat and affecting how well the substance is absorbed from the intestines. Heat can cause antibiotics to lose their potency or make cortisone creams useless. But damage is difficult to detect. Clues include changes in color or consistency, odors and items sticking together. Often decisions on spoilage must be made on the basis of how items were stored.
• Most items marked “refrigerate” will maintain potency in a cool room overnight. While traveling, flight attendants usually will store medications in refrigerators if there is room. Cruise ships store medications; some provide refrigerators for staterooms. Battery-operated cooling travel bags are available at travel supply stores. Check the web. 
• Humidity adversely affects quickly-dissolving tablets. Many medications for children come in this form. Excess humidity may also have an adverse effect on capsules and give false readings on urine and blood test strips. (At home, humidity makes bathrooms poor choices for storing medications. Store elsewhere.)
• Medications may lose their effectiveness if they freeze. This is true for liquids, especially suspensions (items that require shaking before use). Insulin degrades if frozen or kept for prolonged periods in a very hot environment. Unopened bottles of insulin are best kept in the refrigerator. Open bottles can be kept at room temperature.
• Pharmacists tend to be your best sources for information. They can access websites which track most known drugs including their side effects, interactions and stability in different environments. And pharmacists can interpret the data for you. When possible, use the same pharmacy for all your family’s purchases enabling them to crosscheck your prescriptions on their computers. Tell them about your OTC purchases and your travel plans. Most large pharmacy chains have websites that you can check yourself. Or check specific medications on the web; most manufacturers have detailed information about their products. Make sure that you check recommendations for children.
• Consider medications when children display unusual symptoms.  Symptoms may appear immediately or days later. The most common symptoms include changes in behavior, skin manifestations and gastrointestinal upsets. Medications children take for hyperactivity and attention deficit conditions are prone to drug interactions. Consult your pediatrician regarding what to do if you must discontinue medications. Some should not be stopped abruptly. 

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Dr. Neumann’s 10 Tips: Children/Travel/Illness/Paying the medical bills

November 24, 2011

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Tags: Caribbean Island, child health care, children, co-pay, co-payment, copay, cruises, Destinations, domestic travel, family vacations, fever, healthy travel for kids, HMO, hospitalization, illness, in-network facility, insurance card, insurance coverage, kids health care, land excursions, medical bills, medical expenses, non-emergency visits, overseas, reimburse, scuba diving, skiing, Travel, travel plans, traveler's assistance insurance

There is an old saying that children always become ill at inopportune times. But are there opportune times? 

Especially exasperating is when they choose family vacations for their illnesses. Worse, you then discover that your insurance policy does not reimburse you for medical expenses incurred away from home, provides no assistance in finding medical care, and does not cover the cost of changing your travel plans.  

Here is what you have to know:

1. Young kids get sick often.  With preschool children, count on having about half a dozen illnesses a year with roughly half requiring a visit to the doctor. So if you are away from home two or three weeks a year, there is a fairly good chance that illness and travel will one day coincide.    

2. The good news. Studies show that travel is surprisingly safe and healthy for children. This is true for adventurous travel, going overseas, and even for infants. And when ill, the illnesses are usually minor and generally the same kind of illness they would have experienced had they stayed at home  But, unfortunately, there are exceptions.

3. Children can become ill even before you leave home.  Many family trips are planned – and paid for – long in advance. The more children, the greater the chances of one becoming ill, the more money down the drain if you must cancel. Increasingly, documentation of illness, doctor’s notes, for example, do not help in obtaining refunds from airlines, cruise lines, amusement parks, and ski resorts, for example. Check cancelation policies and consider cancellation insurance. (Ditto for non-medical reasons for cancellations; business-related, weather, or turmoil at your destination.)    

4. Check your insurance coverage.  An informal survey of dozens of parents planning major family trips showed that most did not know whether their children (or themselves) are covered for medical care while traveling. They had not read their policies – not even the large print.

5. Is your insurance accepted everywhere in the U.S.? Not necessarily. Your carrier or HMO may be a regional or statewide entity, one not automatically recognized in other parts of the country. Even large nationwide companies have limitation on coverage away from home.  Disputes often arise over non-emergency visits, for ongoing chronic conditions, asthma, for example. Some companies require pre authorization for such visits. Check with your carrier.  

6.  What is an emergency? Within the U.S. in case of an emergency, insurance companies advise you to go to the nearest medical facility, whether or not it is in your network, and pay the bill if necessary. If it is out of network, your company will reimburse you later – usually weeks later and, sometimes, only if the company says it was an emergency.  For example, reimbursement was denied for a late night emergency visit for an otherwise healthy 10 month old, cranky child with a fever of 101 degrees F (38.5 C). The bill came to several hundred dollars. (Medically, speaking, this case is a gray area.)

If hospitalization is recommended, companies strongly suggest you obtain pre-authorization in all cases other than dire emergencies.

7. Envision paying for medical bills. In-non-emergency situations look for urgent care clinics, emergency rooms or a doctor’s offices which accepts your insurance. If there is one, you will pay only your usual co-payment. (Carry your insurance card. Make copies, and have each adult carry one.) If no in-network facility is available, look for one that accepts your credit card. For major trips and long absences from home, assign a relative or friend who can help you in case health, financial or other problems arise. Keep receipts for all medical expenses to submit to your insurance for reimbursement later.    

8. Does your primary insurance carrier automatically pay for expenses incurred outside the US? Until recently, the answer was, no. And for most policies that still is the answer. But, recently, some companies have added coverage for health issues occurring overseas, sometimes at no additional cost. Check with your company.

When you travel, whether domestic or international, also check if your policy covers all destinations, all family members and all activities. For example, check categories such as: remote Caribbean island; cousin and grandparent; skiing and scuba diving accidents, for example.

9. Consider buying travelers’ assistance insurance. Such companies provide:  world-wide, 24-hour telephone “hotlines” manned by “assistance coordinators” who direct you to approved English-speaking physicians and hospitals, guarantee payments, and if necessary, arrange transportation to a facility that can provide the necessary treatment. Some companies offer such services within the U.S., if you live more than a certain distance from your home, usually a few hundred miles. However, the company decides whether, where, and what kind of hospital care is indicated. You may not be covered for pre-existing conditions. The companies may also reimburse you for changing non-refundable airline tickets, for example. Numerous companies advertise on the web.

10. Travel assistance insurance is expensive. But you may be eligible for reduced or even free insurance. Some companies insure children free when parents buy policies. Many corporations, universities, and other organizations cover their employees overseas.  Your credit card company provides such insurance, allegedly at reduced cost. Most cruise and package tour operators insist clients buy travel assistance insurance, and include it in the price of the trip. However, on cruises, for example, you may be covered only for ship-related incidences, not for air travel or land excursions you take on your own.

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