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Traveling With Children

Fortunately for us modern moms and dads, anywhere we want to go is just a plane, train, or automobile ride away. Despite the conveniences of modern transit, traveling with children can be a difficult endeavor if you’re not prepared. So here are a few tips to make your journey smoother:

1) Know your rights.

This sounds funny, but a lot has recently changed in U.S.A. airport security rules. For example children under 12 do not need to remove their shoes during screening. According to the TSA’s website, you may carry as much juice and milk for toddlers as you “need until you reach your destination”. The precise definition of how much you need varies by who is screening you at security.  During one trip with my then 1 year old, the security agent at LAX insisted that 3 small juice boxes was too much for a 5 hour flight, and threw all of our drinks away. I did not know enough to argue and instead I spent $$$ buying some non-dilute juice for my child at the airport 🙁 This also brings up the point to remember to be flexible, and give yourself extra time for the unexpected.

For the latest information, check out the TSA website. For information on car seat travel rights, see this post by TheCarSeatLady.

2) Know your company.

Certain airlines and hotel chains are better at hosting children than others. Conversely, some airlines have recently banned children from first class on their flights, so don’t expect an upgrade (or even friendly service) on those airlines. In general, European and Asian companies are considered friendlier to children on flights than North American airlines, often providing coloring books, special snacks, small toys, and other treats for families.

Some airlines offer pre-boarding for families with infants and toddlers, while others have none. This may be more annoying than you think. When traveling with our then 2 year old, we had to wait until first class, business class, and everyone with a silver/gold card from the airline boarded (more than half of the passengers) before we were allowed to get on with a toddler, car seat, and hand luggage. Trying to get past the tiny aisle with people everywhere and a large car seat was not fun, and I think it disturbed the other passengers as well. Allowing us to board early, install the carseat and settle in would have prevented a lot of hassle for everyone. However, when we got to our destination we stayed at a hotel that provided us with squeaky bath toys and other amenities in the room that made us feel like family.

Check out this article on the most family friendly airlines.

 

3) More tips just for flying with children:

– Try and book a flight with as few stops as possible, as take-off, landing, and boarding are the toughest times.

– Make sure you have assigned seats together in advance. Many companies have been separating families on flights, and then you rely on your fellow passengers to switch seats so you can sit together, or charge extra money to seat families together (but a July 2016 ruling by Congress outlawed this for kids under 13 years old). This LA Times article gives tips on how to stay together.

– I take our car seat when flying with my son, to make sure he is strapped in securely during our flight (even turbulence can be dangerous to a lap child). This also ensures that he has a safe seat for automobile travel when we arrive at our destination. It is also easier for him to fall asleep during the flight in his car seat, and more difficult for him to annoy other passengers by kicking them or climbing on the chairs. We use a GoGo Kidz Travelmate to turn the car seat into a stroller at the airport. Booster seats are not necessary (or allowed) on flights, since there are no chest straps.

excited by the stuff he sees through the window
My son sitting in his carseat happily staring out the plane window

– To avoid pain from the changes in pressure in the ear during flights, teenagers and adults can chew gum or drink water to encourage swallowing, and thereby open up the eustachian tubes in their ears to relieve the pressure. For babies the best way to do this is breast or formula feeding. Breast or formula feeding has the added bonus of being a natural pain reliever. For toddlers, diluted juice in a straw cup works well. Older children can suck on lollipops to get them swallowing (and happy and distracted by candy). Nasal sprays can also help relieve congestion and prevent pain during the flight, but speak to your pediatrician about this (salt water sprays can help babies with stuffy noses, while kids with ear infections or sinus problems may need a prescription nasal spray). If all this ear tube talk is confusing, check out the ear anatomy pics on my pinterest page.

– I recommend waiting as long as possible before flying with infants. The younger an infant is, the less developed their immune system, and the more likely they are to get sick. The air on airplanes is re-circulated so it is very easy to pick up germs from other travelers, even ones who are seated far away from you. Infants younger than 2 months old who catch an illness with fever may have to undergo extensive testing, including blood, urine, and spinal fluid exams if they get sick. I know this is not possible for many families, but waiting until your infant is 9 months or older can save you a lot of hassle.

I advise checking the CDC travel web page, and making an appointment with your pediatrician at least 2 months before any foreign travel, so you can get any needed vaccinations or medications for your trip. You can also check out travel clinics in Los Angeles.

4) Have your bags packed with items that will keep your child calm, quiet and comfortable. 

I prefer small, light items. If you are used to distracting your child with your phone or other electronic items, keep in mind that you will not be able to use them on take-off or landing, and they might run out of batteries on long car trips, so make sure to pack low-tech items as well. I recommend packing a carry-on or car bag with:

  • baby wipes (good for cleaning up messes for kids of all ages, cleaning up yourself, and cleaning up icky surfaces)
  • snacks
  • your own sippy cups or bottles
  • more diapers than you think you need
  • several different sizes of ziplock bags (for messes, soiled clothes, soiled diapers, and they are just generally handy to have)
  • a medical bag (children’s acetaminophen, children’s ibuprofen, children’s benadryl, disinfectant, bandaids)
  • sunscreen (the sun through a car’s windows can burn a child, and then sun through a plane’s window has more radiation than down on the ground, so slather yourself and your child with sunscreen to avoid sunburns and -much later- skin cancer)
  • lollipops for older kids
  • extra clothes (even for older children, as it’s easy to get spilled-on during a flight or car trip, and you never know if, when or where you’ll get stuck)
  • books
  • re-usable stickers
  • dry-erase crayons/markers and board
  • a soft blanket
  • your child’s lovey (favorite blankey, stuffed animal, or other comfort item).

I’ve linked to a few of these items, as well as book suggestions, on pinterest.

Eat Pack Go has many more great travel tips, and the link is for a funny story illustrating why you shouldn’t feel bad about that huge carry on with extra supplies.

Traveling with children can be more stressful than traveling alone, but with patience, planning, and a large bag it can be a fabulous adventure.

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Stomach bugs: what to do if your child is throwing up or having diarrhea

Vomiting and diarrhea viruses are not fun for anyone. Doctors refer to the most common cause of these symptoms as “viral gastroenteritis”. Some kids just vomit, some kids just have diarrhea, and the most unlucky have both. 

Most of these illnesses do not need to be treated with medications (antibiotics can make it worse, since they also kill the good bacteria in your tummy), and anti-diarrheal medicines (like Imodium) can be harmful to children. The most important thing is to keep your child HYDRATED (more on that below). If you suspect your child has vomiting or diarrhea from food poisoning or any other type of foreign ingestion, please call poison control 1-800-222-1222, who are free and staffed with physicians 24-7!

How can you tell if your child is starting to get dehydrated?

– their mouth/lips are very dry

– they are peeing less than usual

– they are thirsty

Now what?

You need to keep your child hydrated!

– A baby can continue to breast feed or take infant formula, if they are just a little dehydrated. If they vomit after every feeding, or are refusing the breast/bottle, then try to hydrate them with an Oral Rehydration Solution, like Pedialyte. Warning: the plain ones taste like salt water, so I suggest getting a few flavored ones and trying them out, to see which ones they will take. If they refuse the bottle completely, you can try feeding them via a syringe or spoon, giving small amounts every 15 minutes.

– A child who is getting electrolytes from food (such as chicken soup, or crackers, even if it’s just a little bit) can hydrate with water. If they are not taking in any food, or if they are throwing up the food, please hydrate them with an ELECTROLYTE solution (aka Oral Rehydration Solution, aka ORS). You can buy them at most USA markets (under brand name Pedialyte, or generic versions), you can make your own by mixing 1 liter (5 cups) clean water with 6 level teaspoons (=2 tablespoons) sugar and 1/2 teaspoon salt. You can add a little bit of orange juice or a banana for potassium. Common substitutions are rice water, congee, green coconut water, or mixing gatorade with water (although I do not recommend doing this, since it is hard to get the right balance of electrolytes this way). If your child does not want to drink, try giving them sips every 15-30 minutes, or giving them the ORS/Pedialyte in frozen popsicle form.

– For every age, and everybody in the house, WASH YOUR HANDS A LOT to prevent spread/transmission of the stuff that gets you sick. Teach everyone to wash their hands in warm water, scrubbing for at least 20 seconds (2 rounds of the Happy Birthday song). Try and use real soap and water, instead of no-rinse hand sanitizers, since they do a better job at killing the tummy microbes.

But what if they keep vomiting?

– Let their tummy rest.

– Call your pediatrician, or go to the hospital, if they have signs of dehydration tat are not resolved by giving fluids by mouth (see more below).

– Ask your pediatrician if your child is old enough and healthy enough for a medication against nausea/vomiting.

– Start with no food, but still give an electrolyte fluid (like pedialyte or ORS above), for the first 12 hours.

– When they are ready/want to eat, give bland foods (e.g. the popular rice, toast, soup broth, apple sauce) and avoid foods that are fried, acidic, oily, or contain milk.

But what if they have icky diarrhea?

– Change the diaper or bring them to the toilet frequently. Use a LOT of diaper cream to keep the area from getting chapped/sore. Put on a zinc cream (like the purple desitin) as if you are icing a cake – this acts as a barrier layer, to prevent acidic poop from sitting on the skin.

– Feed them binding foods, like rice.

– Sometimes the microbes that cause diarrhea, also cause a temporary lactose (the sugar in cow’s milk) intolerance, so avoid lactose-containing stuff, like cow’s milk and cheese. You usually have to do this for 2-4 weeks after the onset of the illness, until their GI system is back to normal.

– Try a children’s probiotic with lactobacillus once per day, such as children’s culturelle.

When my patients get sick this way, I often refer them to the great patient resources at UpToDate, such as this one on nausea and vomiting in children:

http://www.uptodate.com/contents/nausea-and-vomiting-in-infants-and-children-beyond-the-basics?detectedLanguage=en&source=search_result&search=patient+information&selectedTitle=7~150&provider=noProvider

or this one on diarrhea in children:

http://www.uptodate.com/contents/acute-diarrhea-in-children-beyond-the-basics?source=see_link

How can you tell if your child is dehydrated enough to warrant intervention (like an urgent care or ER), or at least a call to your pediatrician?

– they are not urinating (peeing)  often enough (every 4-6 hours for a baby, every 6-8 hours for a toddler/child, every 8-12 hours for an older child/teenager)

– they are crying, but can not make tears

– they are an infant whose fontanel (soft spot on top of the head) is more sunken than usual

– eyes look very sunken

What are some other signs that I should call my pediatrician about, or head over to the local urgent care/ER?

– persistent high fever (above 102.5 F)

– any fever in an baby younger than 3 months old

– severe abdominal (tummy) pain

– abdominal pain that moves to the lower right side

– lethargy or decreased responsiveness

– bloody (red or black) or bright green (like pea soup) vomit or diarrhea

– diarrhea not improving after 1 week

 

The good news is that most of these illnesses pass quickly without any medications, so hang in there, and keep washing your hands with soap and warm water!

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Coughs, Colds and Croup

Even though it’s a beautiful Spring here in Southern California, we are still seeing some coughs, colds and croup, so here are my tips to help keep your family comfortable as they clear their viruses:

Helping a child with nose congestion:

–          Use a nasal saline mist (the kind that comes in a metal can, not drops) to spray moisture into each nostril and help clear her out. I like the mists more than the drops because you can hold the canister right below her nose and spray it in, without touching the canister to the actual nose, and without sticking anything directly up the nose. These are also sterile, so you don’t have to worry about the water source. The mist is gentle and cleans out the nose better than the drops.

–          Use a humidifier. Only put distilled or sterile water into it (not tap water). Clean it at least every 3 days. Do NOT use the menthol or eucalyptus discs/drops that come with some humidifiers.

–          If your child suffers from allergies and is over age 4, you can use an over the counter antihistamine to help dry her up (e.g. children’s Benadryl). Under age 4: ask your pediatrician about these. Do NOT use the over the counter medications known as “decongestants” or “medicated cough syrups”, as these have been shown to have more risks than benefits in children under age 6 years old.

–          If your child is very congested you can steam up your bathroom and sit in the bathroom with your child. Make sure the air is okay and the child does not have any access to the hot water. Never leave a child alone in the steam!

–    If you want to, you can use a vapor rub on the feet or chest of a child. It has not been proven to help or hurt. However, do not let the rub get near her nose or mouth! Vapor rub placed under the nose has been reported to cause wheezing in some children, and it is dangerous to ingest. Call poison control if your child eats any of this, or gets it in their eye 1-800-222-1222 (an important number to keep in your cell phone for emergencies).

–          Children under age 2 years usually can not blow their noses, so help decongest them (e.g. get the boogies out) by using a snot sucker device such as the Nose Frida (http://www.fridababy.com/) -you put in the nostril and use to literally suck the snot out. Sounds gross, but there is a filter (which needs to be changed every day) which prevents you from getting any snot in your mouth. You can do this before feeds and before sleep, or just as needed to clear out the mucus in your baby’s nose. I like this better than traditional nasal aspirators because it’s much easier to clean, is difficult to put it too far into the baby’s nose, and it gets a lot more of the snot out. The key to good suction is to hold the other nostril closed, when you suck out boogers from the first nostril (should take less than 1 second).

Helping a child with a “wet” or “phlegmy” cough:

Do all of the above for nasal congestion plus the following:

–          Have your child sleep propped up at 30 degrees so the mucus drains easily.

–          Give children over age 1 year a big spoonful of honey twice a day. The honey has been shown to help relieve cough symptoms in kids & help them sleep, in published randomized control trials (scientific studies). The honey they used was NOT “raw”, which can have dangerous bacteria in it. nor was it Menuka. Just plain pasteurized honey from the store works.

–     Warm liquids, such as chamomile (caffeine-free) tea and lemon, or chicken soup, can help people feel better.

–          Zinc may help shorten colds and soothe sore throats, but this has not been proven conclusively. You can get this in some non-medicated cough syrups, such as Zarbees (for over age 1 since it also contains honey), or in zinc lollipops (over age 2, observing child while they eat them). If your child is over age 6 years you can give him the zinc cough drops that are available at all pharmacies, but please supervise to prevent choking.

Helping a child with a dry, barking, or croupy cough:

Do all of the above for nasal congestion & wet coughs plus the following:

–          Use a cool-mist humidifier. Use distilled/sterile water in it. Clean it at least every 3 days by rinsing out the water tank with distilled vinegar and then washing that out. Do not put oils in the water.

–          If the child is having a coughing fit, or breathing like Darth Vader, take him/her for a walk outside in the cool air, or hold him/her in front of an open freezer for a few minutes, to reduce the swelling in the throat. If that is not helping, call your pediatrician for immediate medical advice, take the child to the office or ann ER. Please call 911 if (s)he is actually having trouble breathing.

Check out other mom pediatrician blogs on the topic, such as this one from Dr. Stuppy:

http://pediatricpartners.blogspot.com/2013/12/but-snot-is-green-or-how-can-we-treat.html

Other Important Stuff:

–          If your child is wheezing, noisy breathing, breathing hard, breathing quickly, breathing with flared nostrils, or other signs/symptoms not mentioned, please call your pediatrician or 911, or take them to the ER immediately. This information is not intended to act as a substitution for speaking to your physician or using common sense!

–          If your child is breathing so hard that they have trouble walking or talking, or if their lips or fingernails turn blue, please call 911 for immediate medical assistance.

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Wheezing: Tips for Kids Using Inhalers

There are different kinds of metered dose inhalers (“MDI”):

1)      A “rescue inhaler” contains Albuterol or Levalbuterol, which opens up the lungs and reduces inflammation for quick relief. Brand names include Ventolin, ProAir, Proventil, or Xopenex. 6 puffs of these are equivalent to putting 1 vial of Albuterol or Xopenex in a nebulizer and sitting with the mask on your child for 15 minutes. These are usually used on an as-needed basis, up to every 4 hours. If your child needs to use this every 4 hours for more than 24 hours, needs it more often than every 4 hours, or needs this more than twice every week, please call your pediatrician.

2)      Some inhalers are used to prevent asthma, wheezing, and breathing trouble. These are only effective when used every day on a continuous basis. They are not used for fast-acting relief of an acute breathing difficulty, but may help when used during cold or allergy season, or if started right at the beginning of an asthma exacerbation or when a child is exposed to known triggers. Brand names of some of these medicines include Flovent, Qvar, Symbicort, Dullera or Advair. Flovent and Qvar are like using the Pulmicort/Budesonide in the nebulizer. Symbicort, Dulera and Advair also have other medicines in them for stronger asthma prevention. Please discuss if and when you should use these with your physician.

3)      There are also inhalers that contain powder or are not used with a spacer. Some brand names are: Maxair autohaler, Proair RespiClick, Asmanex Twisthaler, or Pulmicort Flexhaler. None of these need a spacer to work effectively, but these are only for older children who can control breathing in the medication and not breathing out into the device.

Please see the “Asthma Education For Kids” playlist from BoosterShotComics on YouTube, especially episode #1: “Iggy & The Inhalers” to better understand the roles of different medications used for wheezing or asthma. Episode 4 explains how to use a spacer with mouthpiece.

There are 4 main brands of spacers. They may be cheaper online than from a pharmacy, but always require a prescription.

1)      Aerochamber with flow-vu. This brand is a clear tube with colored ends and teddy bears on the side. It has a two-way valve (to get the medicine in and air out) and is anti-static (so the kid can inhale all of the medicine and it won’t stick to the sides). The flow-vu allows you to see when a child gets a breath with a good seal. There is a small orange one for infants, yellow medium one for age 1-5 years old, blue one with mask for older children that still need a mask, and blue one with mouth-piece for older kids that can seal their lips around it instead of having to use a mask (more comfortable, kids can usually start doing this around age 6).

2)      Vortex Non-Electrostatic Valved Holding Chamber. This device also has a two-way valve and is anti-static. It is metal, so it is more durable and machine-washable. It comes in 1 size with different sized masks that fit on the end. This has the advantage of only needing one device as the child grows older (you just switch the mask on the end, not the whole device).

3)      Optichamber. The original device is a plastic tube with 1-way valve that most pharmacies try to give our patients. Some versions are NOT anti-static, therefore much of the medicine sticks to the plastic, instead of being inhaled by the child. The single valve can make some children feel suffocated when breathing into the mask. I do NOT recommend this device. However, there is now an Optichamber Diamond version, which is anti-static, has a 2-way valve, and can be used comfortably. It comes with different size masks or a mouth piece, all clear, and very soft.

4)      InspiraChamber. This is a clear, anti-static, valved chamber, with purple ends. It offers very soft masks with a special place in the small mask to fit a pacifier, to calm the child while they inhale. It also has a flap that moves, so you can see if the child is taking a breath with a good seal and getting the medicine.

How to Use Your Inhaler:

Before using a new inhaler for the first time, shake it up, then put it into the spacer and press it 10-15 times to prime the device (e.g. makes sure the medicine is coming out in an even dose, and not just the propellent). The next time you use it, shake it first, but you do not need to prime it.

My son playing with his inhaler and spacer to get used to it

To use a spacer with a mask:

  • Shake the inhaler before each use.
  • Put the inhaler mouthpiece into the spacer.
  • Hold the mask over your child’s nose and mouth and create a good seal. Holding your fingers like the letter C can help. If you’re using a device with flow view, you should see the flap move with each breath the child takes. Otherwise look at the child’s chest to count breaths.
  • Press the inhaler.
  • Have your child breath in and out six times (about 30 seconds).
  • Remove the mask and let your child breath normally for a minute.
  • Repeat if more than one puff was prescribed (most inhalers need 2 puffs per dose, but some use more or less).

While your younger child may not like the spacer and mask being held over his mouth and nose, it will go much quicker than using a nebulizer. Let the child play with it and practice putting it on stuffed animals or family members to make them comfortable. Some children will allow you to use it if they get to be the ones to hold it or press the inhaler (just make sure the seal is tight over their face so they get all of the medicine).

To use a spacer with mouthpiece (older children and adults):

  • Shake the inhaler before each use.
  • Put the inhaler into the spacer.
  • Have your child seal their lips around the mouthpiece and exhale.
  • Press the inhaler.
  • Have your child breath the medicine in and hold their breath for about 30 seconds. If they can’t hold their breath, they can take another breath or 2 in to get more medicine from that puff (any extra medicine should be sitting in the chamber).
  • Take the spacer out of their mouth and have the child breath normally for a minute.
  • Repeat if more than one puff was prescribed.

Keep in mind that while many experts believe that an MDI with a spacer is as good as, or better than, a nebulized treatment, some parents prefer a nebulizer, and that is okay.

If you are not sure if your child is actually wheezing, or what they have, this blog from Dr. Stuppy can help, with descriptions of different kinds of coughs and breathing, along with youtube video links.

If your child does NOT have asthma, reactive airway disease, wheezing, bronchospasm, or difficulty breathing, my post on Coughs, Colds and Croup may be more helpful.

Please note that this guide is NOT intended to diagnose or treat any illness or condition. Always speak to your own physician for advice. 

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Fun In the Sun

Sunscreen Tips and Links

Before going out to have fun in the sun, you should apply sunscreen to yourself and your child. Reapply sunscreen every 2 hours, and after every time you get wet or sandy (rubbing the sunscreen off). Harmful UV rays come through clouds, so a cloudy day is no excuse to skip the screen.

SPF 30-50 are best. SPFs that are higher than that do not add significantly more protection.

The safest sunscreens are barrier sunscreens. These are sunscreens that use zinc oxide or titanium dioxide as the active ingredient, which sit on the skin to provide a shield from the sun. Since they are not absorbed systemically, I recommend using only these types of sunscreens* on infants (in addition to shielding clothing and hats).

Chemical sunscreens are those that contain chemicals which are absorbed into the skin to provide protection. These are newer, but still safe when used correctly. Some of the active ingredients in chemical sunscreens include, but are not limited to, octinoxate, octocryleme, oxybenzone. Most sunscreens on the market today use these, and there are many more options that kids like with these formulations, such as sprays, colors, and different textures. The best sunscreen is the one you can actually get on your child everyday. The aerosol spray sunscreen versions should only be used outside, in well ventilated areas, and below the neck, because they are meant to be sprayed evenly on the skin (you should see a layer of sunscreen forming), and not breathed in. They are a quick way to reapply sunscreen on kids at the beach or park, but can be avoided at home.

A lot of people are wondering about vitamin D. Although our skin can make vitamin D by being exposed to UVB light from the sun, the amount of sun it takes is variable by region and skin type, and enough sun to make enough vitamin D will also increase skin aging/wrinkles and cancer risks, so I still recommend using sunscreen, then getting vitamin D in your diet. For more information, see

http://www.vitamindcouncil.org/about-vitamin-d/how-do-i-get-the-vitamin-d-my-body-needs/


Do not use combination insect-repellent and sunscreen mixes. Insect repellents should not be applied more than once per day, and should not be applied to babies. For more information on insect repellents see here and here.

I used to link to the Environmental Working Group’s sunscreen ratings, but their methodology has been ignoring science, and based on fear-mongering lately, so I stopped. For more information on that, see here and here.

EWG also warned against “nano particles” with no scientific basis. For information on them see this article from cancer.org.

*Here are some examples of sunscreens that use barrier (mineral) ingredients, in alphabetical order:

Aveeno Mineral Block

BabyGanics Cover-Up Baby Pure Mineral Sunscreen Stick

Banana Boat Natural Reflect Sunscreen

Burt’s Bees Baby Bee Sunscreen

California Baby Sunscreen

Mustela Sun Cream and Sun Lotion

Neutrogena Baby Pure and Free

Here my son demonstrates proper beach attire with sunscreen (c) 2011