Dr. Rose Recommends for Healthy & Safe Travel
Health Guide Chapter 21
Traveling with Children
Children who travel should be up to date on their routine immunizations.
Hepatitis A vaccine can be administered to children as early as 2 months of age if immune globulin is not available.
The quinolone antibiotic ciprofloxacin is safe and effective for use in children.
Azithromycin is an effective alternative to ciprofloxacin for treating travelers' diarrhea.
The “BRAT” diet (bananas, rice, apple sauce, and toast) contains insufficient calories and nutrients.
Children who are fed a normal diet as soon as possible when dehydrated recover more quickly, and feel better,
The meningitis vaccine Menactra® is now approved for children 2 years and older.
Rotavirus vaccine is now available for infants. The first dose of the series must be administered between 6 and 12 weeks of age.
Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide.
The Rotavirus vaccine is not a travel vaccine, but can reduce the incidence of travelers' diarrhea in infants and children.
Petting zoos are a source of Salmonella (from baby chicks) and E. coli (from neonatal calves). Children should no touch these animals.
The summer of 2007 saw >400 cases of Cryptosporidium-associated vomiting and diarrhea from an outbreak around swimming pools in Philadelphia. Cryptosporidium species can also be transmitted in day care centers and from farm animal contacts. Treatment with 3 days of nitazoxanide is approved for children >1 year of age.
Atovaquone/proguanil (Malarone®) may now be used for prophylaxis for infants and children weighing at least 5 kg (11lbs).
A new website for kids who travel is here. It was started by Dr. Karl Neumann, a pediatrician who is a well-known expert and lecturer in the field of travel medicine.
Children make great travelers. They are inquisitive, fun, and, when they choose, inexhaustible. Taking them on trips exposes them to new experiences, cultivates family togetherness, and builds memories that last a lifetime. But traveling with children is never all fun and games. Parents must be aware of health and safety concerns, especially when traveling overseas, and even more so when visiting developing countries. Children may need immunizations even when adults do not. Children are susceptible to travelers' diarrhea, malaria, and other travel-related conditions. Children also acquire numerous “routine” illnesses whether or not they travel—for example, fevers, upper respiratory infections, and ear infections. If possible, parents should be familiar with the caliber of medical care in the area that they are visiting.
There are other issues to consider when traveling overseas. Infant car seats and seat belts are often not readily available. Toys bought overseas may not meet the same safety standards of those at home. Hiring local people to watch children may expose the children to infectious diseases (tuberculosis is a serious consideration). Children are vulnerable to severe sunburns during vacations in the tropics, and blistering sunburns are associated with an increased risk of skin cancer, such as melanoma, in later life. Swimming pools rarely have lifeguards. Teenagers often want to participate in potentially dangerous activities not available at home (e.g., parasailing and scuba diving).
Having alerted you to some of the health risks, the bottom line is that the benefits of traveling with children generally far outweigh the risks, provided that pre-travel preparation, and extra precautions are taken with respect to food, water, and insects, and common sense during travel.
Vaccinations for Overseas Travel
Vaccinating children for overseas travel involves two considerations: routine childhood vaccines and travel-related vaccines. For overseas travel, school-aged children are generally up-to-date with their routine vaccines and need no further injections. However, infants and preschool-aged children may need additional doses of such vaccines. “Childhood” diseases that no longer exist, or occur rarely, in this country are still prevalent in many developing countries and, sometimes, in developed countries. These diseases include diphtheria, pertussis (whooping cough), measles, mumps, and rubella (German measles), to mention the more common ones. Although children in the United States are routinely vaccinated against these diseases, the vaccines are administered at the age at which children respond with optimal, long-term protection. This is not necessarily the age at which children first become susceptible. Therefore, for travel, infants and children may need to be vaccinated at an earlier age than if they did not travel. However, when routine vaccinations are given at an earlier than usual age, or the intervals between doses of vaccines are shortened, the vaccines may give only partial immunity—which is better than no immunity at all—and the doses should be repeated at a later date. These additional doses cause no known untoward effects.
Up-to-date vaccination schedules are especially important for children who will have close contact with local children overseas. Parents should check their own immune status for childhood diseases. Traveling with children may increase parents' exposure to local children. Some childhood illnesses are more serious when contracted by an adult; for example, rubella and varicella (chickenpox) are especially serious for pregnant women.
Travel-Related Vaccines for Children
Cholera The cholera vaccine is no longer available in the United States. The risk of cholera to U.S. travelers of any age is extremely low. Breastfeeding is protective against cholera; careful preparation of formula and food from safe water and foodstuffs should protect non-breastfed infants.
Hepatitis A Hepatitis A is ubiquitous in countries with poor sanitation; children traveling to such countries should be protected. The disease in childhood rarely causes symptoms and, in fact, results in lifelong immunity. Infected children, especially those in diapers, can spread the disease to their caretakers. In the United States the hepatitis A vaccine (HAV) is approved for children 2 years of age and older (in Europe, 1 year and older).*
Note: Hepatitis A vaccine is safe in infants younger than 1 year of age, but is effective only after the disappearance of maternal antibodies. Infants vaccinated at ages 2, 4, and 6 months of age have shown 100% seroconversion, indicating that HAV (Havrix 360 ELISA units) is highly immunogenic in seronegative infants and could be included in the routine harmonized infant immunization schedule.
Japanese Encephalitis Japanese encephalitis (JE) is common throughout eastern Asia and is the leading cause of viral encephalitis worldwide. China, Japan, and other countries in the Far East vaccinate their children against this disease. However, this does not reduce the risk for travelers. Farm animals are the main reservoir for the virus, and mosquitoes spread the virus. Immunization is recommended for all children who will stay for several weeks or more in rural endemic areas, especially on or near farms, during transmission season. Reactions to the vaccination are common, possibly more so in children than in adults. JE vaccine is approved for children 1 year of age and older.
Meningococcal Meningitis This disease is rare among travelers. However, young children may be more susceptible than other age groups, and they should be vaccinated if going to an endemic area. The effectiveness of the meningococcal vaccine in children is dependent on the child's age when the vaccine is administered. Protection may not be completely effective in children vaccinated between 3 months and 2 years with the polysaccharide vaccine (Menomune). In January 2005 the Food and Drug Administration licensed Menactra, a quadrivalent conjugate vaccine which is more immunogenic (gives better protection). Currently, Menactra is recommended by the manufacturer only for ages 11 to 55 years, but there is no reason why the vaccine can't be administered “off-label” to younger travelers. Menactra, because it is a conjugate vaccine, may provide better protection in children under 2 years of age.
Rabies Pre-exposure rabies vaccine is indicated for prolonged stays in rural areas in developing countries where rabies is transmitted by domestic animals such as dogs and cats. The vaccine may be more important for children than for adults. In many areas, 40% of all cases of human rabies in local people occur in children younger than 14 years of age. Children tend to be fascinated by animals, use poor judgment around them, do not report minor bites, and, because of their height, may be more likely to suffer bites around the head and neck. Such wounds may be more likely to cause rabies. Pre-exposure rabies vaccination does not preclude proper wound care or post- exposure vaccination after an encounter with a possible rabid animal. But pre-exposure vaccination does eliminate the need for rabies immune globulin after an exposure, and it reduces the number of postexposure injections from five to two. Note: The newer preparations of rabies vaccine and rabies immune globulin may be difficult or impossible to find in developing countries.
Typhoid For typhoid fever, breastfeeding protects infants from contact with contaminated food and water. Careful preparation of formula and food from boiled, chlorinated, or filtered water can help protect non-breastfed infants and children up to 2 years of age. Because there is no vaccine currently available for use in children younger than 2 years of age, even more stringent preparation of formula, food, and water is necessary for those younger than 2 years of age to minimize their risk. The injectable TyphimVi typhoid vaccine is recommended for children more than 2 years of age traveling to areas where there is questionable sanitation.
Yellow Fever Yellow fever vaccine should not be administered to any infant less than 4 months of age, and children 4 to 6 months of age should be considered only under very unusual circumstances. Infants 6 to 9 months of age can receive the vaccine if they cannot avoid traveling to areas of risk and when a high level of protection against mosquito bites is not possible. Infants 9 months or older should be vaccinated as required or recommended for travel to South America or Africa. Unvaccinated children are at risk of acquiring the disease and should travel to infected areas only when travel is essential.
Tuberculosis Children should be tested for tuberculosis with the PPD skin test before and after travel to developing countries, especially when such travel is prolonged and closely exposes children to the local people. Tuberculosis vaccine (Bacille Calmette-Guérin, BCG) is almost never used in the United States. However, a recent review of the literature strongly suggests that BCG reduces, in children, both the incidence of serious TB infection and its spread to the central nervous system (brain and spinal cord coverings) and overwhelming infection. These latter complications are particularly common in young children who are newly infected. Most developing countries vaccinate all children at birth, and many European countries vaccinate children at risk, including those traveling to developing countries.
Health-care professionals who advise parents about overseas travel with children must thoroughly familiarize themselves with the contraindications, side effects, and interactions of the various vaccines, other injectables, and medications that they administer or prescribe.
Studies of diarrhea among travelers to developing countries show that children, especially children younger than the age of 3, have a higher incidence of travelers' diarrhea than do adults, have more severe symptoms, and have symptoms that last longer. Children place their fingers and other objects in their mouths, swallow water while bathing and swimming, wash their hands much less frequently than adults, make improper food and beverage selections, and may be cared for by local caretakers. Better parental supervision can reduce the incidence of travelers' diarrhea, but lack of immunity to diarrhea-causing organisms may also be a factor. Treatment of diarrhea in children can be problematic: small children often refuse fluids when they need them the most; some effective medications given to adults may not be appropriate; and reliable medical facilities may not be at hand. Also, infants in diapers can spread the disease to the people who change those diapers—the parents.
Fluid replacement and the prevention of dehydration historically have been considered the cornerstone of treatment of diarrhea in the pediatric traveler (although treatment with one of the newer antibiotics is now perhaps equally important). Correct treatment of diarrhea is imperative, starting after the first loose stool, but it is important to evaluate the seriousness of the situation. Is the diarrhea mild or copious? Is the child eating and drinking enough, despite having diarrhea? Children are not dehydrated if they take fluids well and are reasonably active and content, even if the diarrhea continues for a week. Not every episode of diarrhea calls for the administration of special formulas. Most of the time, just increasing the child's water intake, coupled with the regular intake of lightly salted food, takes care of the problem. Food increases the absorption of water, decreases the volume and frequency of stools, provides nutrients and calories, and speeds recovery. In other words, common sense treatment usually works.
However, what if the diarrhea is copious and severe, and the child isn't eating or drinking enough? Or the child has a fever and is generally quite sick? Symptoms of impending dehydration include continual vomiting and diarrhea, refusal to take or inability to retain fluids, and listlessness. Young children can dehydrate rapidly, sometimes in a matter of hours. In such cases, larger amounts of oral replacement fluids, or intravenous fluids, may become necessary, and hospitalization may be required. Parents traveling with small children should keep such eventualities in mind when choosing travel destinations. Fortunately, most cases of more severe diarrhea respond to the conscientious administration of an oral rehydration solution.
Some common treatments for diarrhea should be avoided, such as giving only clear fluids, and the BRAT* diet. These diets don't reduce stool volume, and are calorie deficient. Some other diets are also counterproductive. Soft drinks contain too much sugar and little or no sodium and potassium. Juice-like drinks are merely flavored sugar water. Gatorade and other sports drinks are intended to replace fluids lost by sweating and contain too low a concentration of sodium. Chicken broth contains much sodium but no glucose.
Treatment with Oral Rehydration Solutions Oral rehydration solutions (ORS solutions) contain the proper amounts of glucose (or starch), sodium, potassium, and base (citrate or bicarbonate) and are essential for keeping the body in metabolic balance when diarrhea is more severe. Premixed ORS solutions (PediaLyte, RiceLyte) are available at pharmacies in the United States and Canada, but these are bulky and are meant for home use, not for carrying abroad. For travel, there are small packets of ORS salts (WHO formula, CeraLyte) to which measured amounts of noncontaminated water are added. Travelers without these packets can easily prepare effective “homemade” ORS using table salt, sugar, and water. Instructions are found in Chapter 6.
Ideally, small children should take about 100 mL (about 3 ounces) of ORS with every loose stool or bout of vomiting. Solid food should be avoided as long as vomiting continues, which is rarely for more than 12 hours. If small children refuse to drink, they can be given smaller amounts every few minutes, by teaspoon or dropper. Amounts larger than 100 mL (3 ounces) should be avoided when children are vomiting; large amounts may induce vomiting. Unless vomiting occurs more frequently than every 45 minutes, water reaches the intestine and is absorbed. Infants should continue to breastfeed or drink formula and regular milk. Parents should watch for the return of urine output and improvement in the child's appearance and behavior, and restore a regular diet as soon as possible.
Cereal-based ORS (CB-ORS) is more effective than plain ORS. CB-ORS contains cooked starches (usually rice) in place of glucose. Starch causes more calories and water to be absorbed by the intestine. CB-ORS is available in the United States as a ready-to-drink solution (e.g., Ricelyte, available in most stores and pharmacies) and in packets (CeraLyte, available from Travel Medicine, Inc., at http://www.travmed.com). If RiceLyte is not available, children can be given plain water with one or more of the following: pretzels, salted crackers, mashed potatoes, rice cereal, or Cream of Wheat cereal. Drinks made with precooked infant rice cereal, unsweetened yogurt, or vegetable juices can also be used. Older children can be offered carbohydrates in the forms of rice, potatoes, cereal, pasta, and bread during the transition to their regular diet.
Anti-motility drugs are not considered first-line treatment for diarrhea in infants and children. Loperamide (Imodium-AD) can cause drowsiness, abdominal distention, and ileus (stoppage of intestinal motility), so follow label instructions carefully.* Diphenoxylate (Lomotil) gives unpredictable results in children, especially in those who are dehydrated, and may result in serious, delayed opiate-related toxicity. This drug should be avoided. In moderate and severe diarrhea, anti-diarrheal drugs such as kaolin-pectate (Kaopectate) may reduce the number of stools but may do so by retaining fluids in the intestine, worsening electrolyte imbalance.
Pepto-Bismol (bismuth subsalicylate)
Studies reported in the New England Journal of Medicine have shown the efficacy of bismuth subsalicylate (BSS-Pepto-Bismol) along with oral rehydration for the treatment of infantile diarrhea. Infants given 100 to 150 mg/kg/day of BSS had significant reductions in their total stool output, total intake of oral rehydration solution, and duration of hospitalization. (Measurements of bismuth and salicylate concentrations in blood were well below levels considered toxic.)
Children older than age 3: Repeat dose hourly, as needed, to a maximum of 8 doses in any 24-hour period. Temporary, harmless darkening of the stools may occur. Do not give this medication to a child who has chickenpox or the flu because of the slight risk of Reye syndrome. Note: Reye syndrome has never been reported in association with the use of nonaspirin salicylates such as has been found in bismuth subsalicylate.
Historically, oral rehydration therapy has been considered the cornerstone of treatment of diarrhea in children, with antibiotics relegated to a secondary role. This secondary status was because of questions of efficacy (because of antibiotic resistance) and/or safety (possibility of harmful side effects). Now, because of their remarkable effectiveness against almost all strains of bacteria that cause travelers' diarrhea and dysentery—and because of a re-evaluation of safety issues—the quinolone antibiotics have become accepted by many authorities as first-line therapy, especially in children with severe symptoms suggestive of enteroinvasive diarrhea.
The joint injuries observed in test animals have not been documented in infants and children given prolonged courses of quinolones for such disorders as cystic fibrosis, osteomyelitis, and chronic otitis media. It is now believed that the theoretical risk of joint damage does not justify arbitrarily withholding these antibiotics, especially for children with severe diarrhea or dysentery. A recent study in Israel of 210 cases of invasive diarrhea in children supports this conclusion. The children (35% were younger than 1 year of age) were treated with either oral liquid ciprofloxacin or intramuscular ceftriaxone. Clinical success was achieved in 99.5% of cases. Both drugs were equally effective. A clinical rheumatologist found no evidence of joint injury in patients given ciprofloxacin.
Although the issue is not entirely settled, most physicians now believe sick children deserve treatment with the most effective antibiotic. The antibiotics recommended for treating travelers' diarrhea, in order of effectiveness, are the following: Quinolones, Furazolidone or cefixime, Azithromycin, Trimethoprim/sulfamethoxazole (Bactrim, co-trimoxazole)
Quinolones Ciprofloxacin is available in both liquid and tablet forms. In cases where there is vomiting, ciprofloxacin, ofloxacin, or levofloxacin can be given intravenously.
Ciprofloxacin (Cipro)—Ciprofloxacin is the quinolone most often prescribed for children. It has excellent activity against Escherichia coli, shigella, salmonella, and Campylobacter, bacteria that cause most cases of travelers' diarrhea and dysentery. Dosage: 250 to 500 mg twice daily for 1 to 3 days.
Ofloxacin (Floxin)—Ofloxacin is as effective as ciprofloxacin but has better activity against chlamydia and gram-positive bacteria, such as staphylococcus, streptococcus, and pneumococcus. Dosage: 200 to 400 mg twice daily for 1 to 3 days for diarrhea.
Levofloxacin (Levaquin)—This antibiotic is the active component of ofloxacin. It is also a useful antibiotic for the treatment of other infections such as sinusitis, some pneumonias, bacterial bronchitis, urinary tract infections, typhoid fever, uncomplicated skin infections, and chlamydia. Dosage: 250 to 500 mg once daily for 1 to 3 days for diarrhea. For pneumonia and cellulitis: 250 to 500 mg daily for 5 days
Ceftriaxone This cephalosporin antibiotic is effective against enteroinvasive organisms such as E. coli, shigella, and salmonella, but must be administered by injection. It is an appropriated drug for use in a hospital setting. It is not effective against Campylobacter.
Azithromycin (Zithromax) This drug is effective, especially for the treatment of mild-to-moderate diarrhea. Azithromycin has activity against salmonella and shigella—as well as enteroinvasive, enteropathogenic, enterohemorrhagic, and enterotoxigenic E. coli, the most common cause of travelers' diarrhea. In Thailand, azithromycin has been shown to be more effective than ciprofloxacin against Campylobacter. Child dosage: 10 mg/kg/day for 3 days.
Cefixime (Suprax) This is a broad-spectrum cephalosporin with activity against the usual organisms causing travelers' diarrhea (except Campylobacter). There are reports of shigella resistance. Cefixime is also a useful drug for treating ear infections. Child dosage: 8 mg/kg once daily for 3 to 5 days for diarrhea.
Furazolidone (Furoxone) Although not as rapidly effective as the quinolones, furazolidone has excellent activity against the majority of gastrointestinal pathogens, including E. coli, salmonella, shigella, Campylobacter, and the Vibrio species (which cause cholera). Furazolidone is also effective against Giardia. Child dosage: Children 5 years and older should receive 25 to 50 mg (1/4 to 1/2 tablet) four times daily. Liquid furazolidone contains 50 mg per tbsp (15 mL). Side effects: Occasional nausea and vomiting. Not to be given to infants younger than 1 month of age.
Trimethoprim/Sulfamethoxazole (Co-trimoxazole, Bactrim) Most strains of E. coli, shigella, salmonella, and cholera bacteria are now resistant to TMP/SMX, and this antibiotic is now considered a last-choice drug. Note: TMP/SMX remains an effective treatment for cyclosporosis, a parasitic intestinal infection. Child dosage: Depending on the weight of the child, 1 to 4 tsp of pediatric suspension every 12 hours for 1 to 3 days. More than 88 lb, one double-strength (DS) tablet every 12 hours for 1 to 3 days. Side effects: GI upset, rash. TMP/SMX is safe for children older than age 2 months and can be taken by pregnant women.
Children, Insects, and the Tropics
In the tropics, protecting children from insect bites is the first line of defense against malaria, dengue fever, and numerous other vector-borne diseases. Protection includes the following:
Placing nets over baby carriages and cribs
Eliminating standing water around living quarters
Staying indoors at dusk and after dark
Dressing children, between dusk and dawn, in long-sleeved clothing that fits over the neck, wrists, and ankles
Not allowing children to go without shoes
Covering exposed skin with an insect repellent containing DEET
Spraying bed nets with a permethrin-containing insecticide
Using a pyrethroid flying-insect spray in living and sleeping areas during evening and nighttime hours
Sleeping in quarters that are air-conditioned, when possible
Use insect repellents containing 20% to 35% DEET. This is especially important in malarious areas. Products with higher concentrations are not much more effective and are more likely to produce skin rashes; neurologic symptoms are extremely rare and appear to be associated only with ingestion or extremely inappropriate overuse. DEET, when used correctly, is a safe product and carries no EPA or FDA warnings. Skin reactions to DEET can be minimized by applying it only to exposed skin, not using it on irritated skin, and washing it off when protection is no longer required. Permethrin insecticides, which are applied only to clothing or netting, have no known serious side effects.
The effectiveness of preventive medication against malaria depends on the region of the world visited and the risk of acquiring malaria, especially chloroquine-resistant falciparum malaria (CRFM).
Chloroquine Chloroquine is the drug of choice for chloroquine-sensitive malaria. In the United States, chloroquine is available only in bitter-tasting tablets. Dosage is calculated by body weight. Overseas, it is also available in syrup form. The concentration of chloroquine in syrup varies across countries. Chloroquine is generally well tolerated by children. Side effects are infrequent and tend to be mild. Reactions can be reduced by taking it with meals, or in divided, twice-weekly doses. Store chloroquine in a childproof container out of the reach of children. The overdose of only one to two tablets can be fatal to a small child. Note: When calculating a child's dose of chloroquine, formulas state the dosage in either “salt” or “base.”
Mefloquine Mefloquine is effective against most CRFM; however, mefloquine-resistant malaria is well documented in rural areas along the borders of Thailand. Doses of mefloquine for children are generally given as fractions of a tablet. No liquid preparation is available. Accurate dosing can be achieved by crushing tablets first and then dividing the powder. The powder can be given with apple sauce or a similar substance. Mefloquine was recently approved for children weighing as little as 5 kg, and most advisers would prescribe the drug even to a newborn who is traveling to a high-risk area of CRFM. Many small children vomit after taking mefloquine. The neuropsychological adverse effects of mefloquine that appear to be common among adults appear to be very rare among young children, or have not been reported.
Atovaquone/Proguanil (Malarone) This drug is the combination of atovaquone (250 mg) and proguanil (100 mg). Malarone is a welcome addition because it not only is 98% to 100% effective, but provides an alternative for persons intolerant of mefloquine or doxycycline, for children younger than 8 who cannot take doxycycline, and for those going on short trips (it is expensive), or are frequent travelers. Child dosage: In the United States a pediatric formulation is available and the prophylactic dosage is based on the weight of the child
Tablets should be taken with food or a milk-based drink at the same time each day. If vomiting occurs within 1 hour after dosing, a repeat dose should be taken. Side effects are minimal; they include stomach upset, cough, and skin rash.
Doxycycline Doxycycline is an alternative to mefloquine for the prophylaxis of CRFM. Doxycycline is contraindicated in children less than 8 years of age unless needed to treat a life-threatening illness, such as malaria. The drug can also exaggerate sunburn reactions; persons taking doxycycline should be instructed to avoid prolonged sun exposure and to use effective sunscreens that protect against UVA as well as UVB rays. Other side effects include yeast vaginitis (rare in children) and upset stomachs. The latter can be minimized by taking doxycycline with meals.
Lactating mothers taking anti-malarials secrete small amounts of the drug in their breast milk. The amount is insufficient to harm infants and insufficient to protect infants against malaria.
Parents should be made aware that any unexplained fever should be considered a symptom of malaria in areas where malaria exists and must be evaluated immediately, ideally by experts in the disease. The problem is that children frequently have fevers because of viral diseases, medical experts are often not at hand, and antimalarial medication can mask other important infections. Emergency treatment with atovaquone/ proguanil (Malarone), mefloquine (Lariam), or quinine, combined with doxycycline or clindamycin, should be administered when medical help is unavailable. Clear instructions for such eventualities must be provided for parents. See Chapter 7 for pediatric treatment doses of anti-malarial drugs.
The incidence of acute mountain sickness (AMS) in infants and young children is about the same as in adults, and, as in adults, the higher the altitude, the faster the ascent, the greater the incidence of AMS. Problems seem to develop more often in children who have had recent upper respiratory infections. Identifying AMS in young children can be problematic; children frequently become ill with vague viral illnesses that have symptoms similar to AMS—headaches (irritability), loss of appetite, inability to sleep, and fatigue, for example—and children cannot verbalize what is bothering them. Parents are advised that if children become ill, to assume that they are ill from altitude sickness and descend immediately. Acetazolamide (Diamox) may be helpful in reducing AMS when taken just before ascent.
Air travel appears to be safe for children with upper respiratory infections (URIs) and nasal allergies. Children do occasionally experience ear pain during flight, generally during descent, but less commonly than adults. Moreover, such pain does not cause permanent damage to the ear. The use of oral decongestants and nasal sprays for URIs and nasal allergies may help minimize pain, although some studies indicate that decongestants are not helpful in children. Nasal sprays may give some relief. Use sprays as directed and also at the onset of descent and then repeat 5 minutes later. Older children should blow their noses before using sprays.
Children with ear infections may have less risk of ear pain in flight than children without such infections. Ear infections often produce fluid in the middle ear. The fluid obliterates the middle ear space, and pressure differentials do not occur. Aerating tubes also prevent pressure differentials and pain.
Conventional wisdom recommends giving bottles or nursing infants who cry during flights. The conventional wisdom is that infants cry because they are experiencing barotrauma (pressure injury to the ear) or are dehydrated because of the low humidity aboard the aircraft, but barotrauma is rare and dehydration from low humidity alone does not occur. Low cabin humidity dries out the mucous membranes of the mouth and throat, creating a sensation of thirst. Giving frequent feedings may be counterproductive because at the cruising altitude of jet aircraft, the air in the intestine is already expanded 20% and feeding encourages air swallowing. Therefore, parents should not feed infants more often than they would at home.
Heavy toys, sharp objects, or unused car seats should not be left loose on the back seat or on the ledge of the back window. These may become projectiles in the event of sudden stops or accidents. Some experts recommend seat restraints for large pets. Older children should also use seat belts in the back seat. Seat belts minimize roughhousing. However, in many developing countries, seat belts are difficult to find or are not available. Unruly children distract drivers. Worse, sometimes children accidentally poke drivers or end up in the driver's lap. Parents should keep extra car keys in their pockets. Small children lock doors better than they open them, and sometimes parents accidentally lock small children in cars. Parents should remind children not to dart out of the door and into the street when the car comes to a stop.
Car Sickness Motion sickness during automobile travel is more common in children than in adults. For susceptible children, parents should not give them large meals just prior to and during trips but should give frequent drinks of fruit juice or soda. When necessary, anti-motion sickness medication such as Dramamine (dimenhydrinate) may be effective.
Reading or coloring in moving vehicles may bring on motion sickness. For small children, car seats should be placed at a level where children can see out the window. Cars should be kept cool and well ventilated and no one should smoke. If a child complains of feeling ill, it's best to distract the child with an activity such as singing and not to talk about motion sickness.
Parents should childproof rooms immediately by checking balconies and bathrooms, covering electrical outlets with furniture or tape, securing lamps and other objects that can be pulled off tables, and rearranging furniture with sharp edges. At night, a small light should be left on to help prevent injuries to children who get out of bed in unfamiliar surroundings. Keeping suitcases and clothes off the floor also helps prevent falls. Because poisonings often occur away from home, check that no medications or caustic substances are reachable. Avoid using syrup of ipecac—it is no longer recommended by poison control centers and may cause harm. Because hotel plumbing may be tricky, especially when the usual locations for hot and cold taps are reversed, children should be assisted with baths and showers. Even adults occasionally scald themselves by turning the wrong knob.
Outdoors and Wilderness
Parents should stop at tourist offices and visitor centers for suggestions about safe and enjoyable activities and to obtain material about local health and safety issues— dangerous undercurrents at beaches, animals and plants to stay away from, for example. Frequently, the most common sources of mishaps in the national parks are knives, axes, and campfires.
Teach children to sit down and stay put if they are separated from you. This facilitates your finding them. Have them carry a whistle for such emergencies; whistles are more effective for signaling than shouting.
Have children wear loosely fitting long-sleeved shirts, long pants, and shoes and socks to minimize insect bites, sunburn (use a sunscreen with an SPF of 30 or greater), scratches from bushes, and exposure to poison ivy. When possible, bathe or shower children after outings. Look daily for insects embedded in the skin. Using soap helps prevent poison ivy, cleans cuts and bruises, and removes insect repellents and sunscreens.
With the heat and humidity of the tropics, children need extra fluids and rest to avoid dehydration. The pace of travel should be slowed to accommodate the needs of children.
Many children who drown or nearly drown do so not while swimming. They sometimes trip, slip, or otherwise fall off boats, docks, and piers, while adults are distracted or taking pictures. When possible, children should wear an age- and size- appropriate personal floatation device when playing near water.
Shoes and socks protect feet against cuts, fungi, crawling insects, and the many insects that fly just above the ground. Clothing should be kept off the ground, but if it has been laid on the ground, it should be shaken vigorously to release insects. Insect bites can also occur when children strip leaves from trees and plants, shake bushes, kick logs, and turn over rocks. Use insect repellents when necessary, especially in wetlands in the spring.
Children should be instructed not to drink natural water. Even crystal clear water in streams and lakes far from civilization may contain diarrhea-causing organisms. Ask knowledgeable local people before using well water. Illness may occur weeks later. In case of illness, physicians should always be informed where children have traveled.
Animals often misinterpret the intentions of children who offer them food with outstretched hands, and especially when children make sudden moves as the animal nears. All animal bites and scratches should be reported to local game wardens and physicians.
If small children eat unknown berries and plants, samples should be taken to show experts.
Medical Kits Bring a small medical kit (e.g., the Adventure Medical Family Traveler Kit, available at www.travelinghealthy.com) for basic first-aid treatment. You can stock the kit with additional items, such as those listed subsequently. Choosing a destination where there is no ready way of communicating with competent medical professionals adds an element of risk to the trip.
A typical medical kit should include the following:
Medications that the child has used in the past year
Antiseptic wipes, thermometer, and gauze bandages
Insect repellent and sunscreen
Packets of oral rehydration salts
An antibiotic for general use or travelers' diarrhea (azithromycin or ciprofloxacin)
An antihistamine (e.g., Benadryl syrup)
Antibiotic and anti-fungal ointments
Acetaminophen or ibuprofen for pain or fever
Malaria prophylaxis or standby treatment, as required by itinerary