Distracted eating

We all do it sometimes. We grab a snack and plop down on the couch to watch a movie. Before we know it the whole thing is gone. We only meant to eat some of it, but downed it in one sitting.

That is distracted eating at it's finest. It exemplifies the problem of eating without intention. Not because of hunger. Not even healthy foods typically. Just eating because it's there.

What happened to sitting around the table and eating as a family without the tv or cell phones?

Photo source: Wikimedia

I see many kids who always have distracted eating.

The youngest might fit into another category all together, but they certainly aren't intentionally eating. These are the babies who parents "dream feed" - basically feed them while they're sleeping. This can be because they don't eat as parents think they should when they're awake or because parents want to get one more feed in before they go to bed so baby will let them sleep. I know many parents rely on it, but I will never recommend it for many reasons. It can disrupt their normal sleep cycles if you feed during periods of deep sleep.  Dream feeds also feed a baby who might not be hungry or need to eat, and it is hard to know when to stop. After the first few months most babies don't need to eat at night, but they are trained to eat at that time. Once they get teeth it can increase the risk of cavities if they eat without brushing teeth before returning to sleep. There are also risks of choking. And again, I firmly believe that we all need to eat when hungry and not just because there's food offered.

As kids move into the toddler years, they often become picky with foods and eat small volumes. This is normal. Parents need to offer healthy foods and feed small frequent meals. Think of snacks as mini meals so you will offer healthy foods - and no, goldfish crackers are not healthy foods. Young children tend to eat about six small meals a day. Each meal offer either a fruit or a vegetable and a protein to help insure your child gets enough of these food groups daily.

Unfortunately, some parents solve the "problem" of kids not eating a lot at meal times by allowing them to carry around food all hours of the day. This might be cereal, crackers, milk, or whatever the favorite food of the week is. This allows the child to snack all day, which means they are never hungry, so they don't eat at meal times. Parents will think it's better than eating nothing, and even think that since it's cereal or milk it's healthy. But it's not. These foods are usually highly processed and have little nutrition. Constantly nibbling doesn't allow the body to learn hunger cues. It also doesn't allow saliva to clean teeth between feedings, which increases the risk of cavities. If kids drink excessive milk they are at risk of severe malnutrition. Parents argue that milk is healthy, but they are thinking of mother's milk or formula for infants. Cow's milk has protein, calcium, and other nutrients, but it is not a complete meal substitute. I have seen children need blood transfusions due to severe iron deficiency anemia from excessive milk intake. Blood transfusions. It can be that bad. Yes, your child might like milk. And he might refuse to eat at meal time. But if you keep giving milk he will never get hungry enough to eat the food offered.

Other parents realize that kids will eat more if they feed the child, especially if the child is watching tv. This is wrong on many levels.

• Once kids are able to feed themselves, it is a great skill to use. They work on fine motor skills when self feeding. 
• Kids need to learn to pick (from healthy choices hopefully) which food they will eat next and to stop when full. When parents do the feeding, they keep pushing foods until the plate is empty. Many parents have an unrealistic appreciation of how much food a child should eat. 
• If a child is watching tv while eating, the focus is on the screen, not the food. Again, the child then doesn't listen to hunger and satiety cues.

I see several kids each year who will be going to full day school (kindergarten or 1st grade depending on the child) and parents worry that they won't be able to eat lunch because they never self feed. Many of these kids are overweight because they've been overfed for years but the parents often think the child doesn't eat enough.

If families eat while watching television or playing on smart phones or tablets, no one is connecting during the meal. No one is really enjoying the food or the conversation. There are many studies that show the more often families eat together (really together, not sitting at a table connected to a screen) the less likely kids will develop obesity, get depressed, do drugs, smoke, and consider suicide. Kids who eat with their families are more likely to eat healthy foods, do well in school, delay having sex, and have stronger family ties.

Help stop the habit of mindless eating. Encourage eating at the table as a family as much as possible. Offer healthy food choices and let everyone decide how much of each thing to eat. If you worry that your child isn't eating adequately, talk to your pediatrician.

For more, see my related blogs:

• Nutrition for the Picky Eater
• Taste a Bite Without a Fight
• Food Strike!
• Kid's Weight Is Weighing On My Mind
• Excessive Milk Can Cause Anemia? How?
• My Child Won't Eat... What Should I Do?

Resources:

MyPlate offers portion sizes for children, tips on healthy foods, activities for kids to learn about nutrition, and more.

If you're a Pinterest fan, check out my Nutritional Sites and Getting Kids to Eat Vegetables and Other Healthy Stuff

Stool colors & patterns in infants: What's normal & when should you worry?

Help! My baby is constipated. She hasn't pooped for days.

We hear versions of this all the time.

Constipation isn't defined by how often babies have a bowel movement. A breastfed baby might have a bowel movement every time he eats (and in between) or he might go less than once a week. (Watch out when it finally comes - it often escapes the diaper!) Most formula fed babies have a bowel movement 1-3 times a day. Babies who get some breast milk and some formula can have characteristics of each feeding type.

During the first few days of life the stool looks black and is thick. This is called meconium. It occurs in both breast fed and formula fed babies. If your baby doesn't have meconium within 24 hours of birth an evaluation to decide if there's a problem should be done. Be sure to talk with your baby's doctor if he doesn't poop within 24 hours of birth or if the meconium is formed like a plug. (See a photo on Stanford's newborn page.)

Meconium stool. Photo by Azoreg via Wikimedia Commons

After the first few days there is a period of transition stool. The stools become more green and sticky. This is the meconium mixed with breastmilk or formula stools. It happens earlier in formula babies and after mother's milk comes in for breast fed babies.

After the transitional stools, the stools will vary in color and consistency depending on if the baby gets breastmilk or formula. If breastmilk is the primary food, the stools can vary quite a bit. They often look like yellow cottage cheese, with a lot of liquid and chunks. It often becomes a bit thicker (like pudding) as a baby gets older. It is not diarrhea just because it is watery. Breast fed stools can vary in shades of yellow to brown or green, often changing depending on what the mother ate. Bright green and frothy stools can indicate a low fat diet in a breast fed baby. The fore milk has less fat than the hind milk, so if the baby consistently has frothy bright green stools we will monitor the baby's weight closely to ensure adequate growth and evaluate the amount of milk the mother is producing and baby is drinking.

If a baby is taking formula, the stools can look shades of yellow and brown and be the consistency of peanut butter, pudding, or thick oatmeal. Formula fed stools tend to smell more foul than breast milk stools, but even breast fed baby poops can stink.

Once a baby eats solids (or pureed foods) the stools can thicken a bit but should never be hard. They usually become more foul smelling at this time. Sometimes chunks of food (especially carrots, corn, and raisins) can be seen in the stool. This is normal.

If a baby takes an iron supplement the stools might turn dark green or black. This is normal and not a concern. This does not happen from the amount of iron in baby formula. All formula should have iron. It is an important nutrient for all babies and low iron formula is not recommended.

What's important?

• A term baby should gain about 15-30 grams per day after the first week of life.
• Blood in the stool can be from swallowed blood (often from a crack in mother's nipple), constipation, food allergy (usually cow's milk protein), or infection and should be evaluated.
• It is normal to have different shades of yellow, brown, and green stools.
• A baby with a swollen (distended) abdomen and discomfort or a change in feeding patterns should be examined.
• A baby should not have formed stools as long as they are on primarily breast milk or formula.
• Poop should never be a shade of white (liver concerns), red (blood), or black -if not on iron supplements (digested blood).
• Mucus in stool could be simply swallowed mucus but can be a sign of infection or food allergy.

Meningitis Risks and Preventions

Meningitis is thankfully uncommon, but when it happens it can be deadly. Meningitis is an inflammation in the membranes around the brain and spinal cord (meninges). It is usually caused by a virus, but many bacteria and fungi can also infect the meninges. Symptoms include headache, fever, and stiff neck and may include other symptoms depending on the organism causing the infection.

I wanted to write about meningitis because with the newest vaccine against meningitis, I am concerned that parents don't recognize what exactly their children are protected against and what risks remain after vaccination. I will break down meningitis by type of organism causing the inflammation, and include any vaccines and treatments available for that type within that grouping.

Bacterial Meningitis

Bacterial meningitis is a medical emergency. Even with early treatment with antibiotics, it can be devastating. If a person survives, many of the bacteria can cause permanent brain damage, hearing loss, learning disabilities, and loss of limbs. Anne Geddes, a photographer famous for her pictures of infants and children, has worked with Novartis Vaccines and the Confederation of Meningitis Organizations (CoMo) to create Protecting Our Tomorrows: Portraits of Meningococcal Disease, a book that is available for a free download on iTunes that shows people who have survived meningitis.

Photo by Mikael Häggström

The type of bacteria causing meningitis varies by age group. Fortunately the bacteria that cause meningitis are not as contagious as things we more commonly see, such as the common cold, but whenever there's a case of bacterial meningitis the health department will identify risks and help treat contacts at risk. The bacteria don't always lead to meningitis, but may be found in healthy people or cause other types of infections as well, such as ear infections, pneumonia, and urinary tract infections. 

• Newborns tend to be infected with bacteria that can be a part of the mother's urogenital tract. Group B Streptoccous (GBS), Escherichia coli, and Listeria monocytogenes are most common. Pregnant women are screened for GBS and treated with antibiotics prior to delivery if possible. Pregnant women should handle foods properly and avoid certain foods to protect against Listeria.
• Infants and children are most at risk from Streptococcus pneumoniae (pneumococcus), Neisseria meningitidis (meningococcal), Haemophilus influenzae type b (Hib). Thankfully starting at two months of age infants can get vaccines against Hib since 1985. A vaccine against 7 strains of pneumococcus became available in the year 2000, and it was improved to protect against 13 strains of pneumococcus since 2010. There are over 90 known strains of pneumococcus, but the vaccine covers the majority of strains that cause severe illnesses. Vaccination against N. meningitidis is not routinely given to infants at this time.
• Teens and young adults are at risk from Neisseria meningitidis and Streptococcus pneumoniae. Younger teens who are up to date on vaccines have been vaccinated against S pneumoniae, but since the vaccine was introduced in 2000, older teens might have missed this vaccine and it is not recommended to do catch up unless they are in a high risk group, such as if they are immune compromised or missing a spleen. 

• Vaccines are now available that help protect against all three serogroups (B, C, and Y) of meningococcal disease that are the most commonly seen meningococcal subtypes in the United States: 

• Meningococcal conjugate vaccine (Menactra®- which covers A, C, W, Y subtypes, Menveo®- which covers A, C, W, Y subtypes and MenHibrix®- which covers C, Y, and Hib) is recommended as part of the routine vaccine schedule at 11-12 years of age with a booster at 16 years. It is also recommended at younger ages for high risk people (immune compromise, spleen issues, and certain travel).

• Meningococcal polysaccharide vaccine (Menomune®- covers A, C, W, Y) is given to people over 55 years of age.

• Serogroup B meningococcal vaccine (Bexsero® and Trumenba®- both cover subtypeB). This is only recommended with a permissive use status, meaning it is not highly recommended for any age group, but it is allowed to be given to anyone over 16 years of age and is encouraged for high risk people, sometimes down to 10 years of age, depending on the risk. High risk people are those with known immune problems, specific chronic diseases, or who have no working spleen. High risk might include when there is a known outbreak, so if your college student hears of meningitis on campus don't let them think they don't need it due to vaccination with one of the vaccines that covers A, C, W, and Y. Some colleges require vaccination against meningitis B in addition to A, C, W and Y. 

Viral Meningitis

Viral meningitis is much more common but less deadly than bacterial meningitis. There are many types of viruses that cause meningitis, and usually there is no specific treatment for viral meningitis, just like other viral illnesses. Most people who get viral meningitis completely recover on their own within 7 to 10 days. People with meningitis caused by certain viruses such as herpesvirus and influenza may benefit from treatment with an antiviral medication. If there are symptoms of meningitis, it is important to quickly get the proper testing done to determine if treatment is needed or not. Prevention with standard hand washing and other measures to prevent the spread of viruses is important. Some vaccinations can protect against diseases that can cause meningitis, such as measles, mumps, chickenpox, and influenza. Since mosquitoes, other insects, and rodents can spread disease, avoiding bites can help prevent infection.

Fungal Meningitis 

Fungal meningitis is very rare and does not spread from person to person. It occurs when a person with a weak immune system is infected with a fungus that spreads to the brain or spinal cord.

What is a Bone Age?

Bone age is helpful in assessing a child who is shorter or taller than predicted based on parent heights or if a child has early or late pubertal changes. It is simply an x-ray of the child's hand and wrist. It involves minimal radiation and does not hurt. The bone age can help us approximate how much longer a child will grow and the expected height, but does not tell us why a child is shorter or taller than expected or hitting puberty at an unexpected age.

A delayed bone age means that the bones think they are younger than the child actually is. This can mean catch up growth after peers have stopped growing. A delayed bone age can happen for many reasons, but a common one is due to late puberty and can run in families. A history, physical exam and possibly labs can help asses the reason for delayed bone age.

If a child has an advanced bone age it means the bones appear older than the child's actual age. With this we expect them to stop growing earlier than most kids. This means that even if they are tall for their age, they could end up shorter than average. This is often associated with early puberty and childhood obesity. An advanced bone age needs further evaluation to identify the cause.

If the bone age equals the actual age, you can estimate the final height to be about the same percentage as the current height.

We often repeat bone ages to see if they are changing at a different rate than the child grows.

Radiologists and endocrinologists use books with x-rays of standard bones of various age groups to assess which age the child's x-ray most closely resembles. Since there are different bones that can develop at different rates, it is possible that two doctors will assign a different bone age. It is not an exact science, but can give a good estimate of how much longer a child may grow. 

The photo above is from Amazon's bookstore. You can see how the bones of the youngest hand on the left are very different from those in the hand on the right. The radiologist or endocrinologist finds the image that is most like the child's x-ray and call it that bone age. 

In the boy growth charts pictured below, the top set of lines is the height (stature) for age chart. The bottom set is the weight chart. The ages that are used to plot a height at a given time are listed at the top and bottom. The heights are listed on the right and left of the graph. The middle line is 50%, which reflects a height of 50% (taller than half/shorter than half of boys of the same age). The other lines are also labeled for their respective height percentiles on the far right. Hopefully this looks familiar because you've seen a graph like this at your child's doctor. If you haven't, be sure to ask to see it next time you're there.

There are many "normal" heights, usually determined by genetics. Tall parents tend to have tall kids, short parents have short kids. There is no "correct" height or "best" height, the percentiles simply give us a way to follow the growth over time and estimate final adult height if a child hits puberty at a typical age (early puberty stops the growth early, late puberty allows for later growth).

In Figure 1, I filled in a fictitious child's heights with blue dots. You can see that from 3 to 5 years this boy was at the 50th percentile for height. That means he was taller than half the boys his age and shorter than half. The fact that he's in the middle doesn't make it "normal" it just means that if his parents are average height, he is growing as expected because it's consistent year to year and he is of average height like his parents. At 6 years, he dropped to the 25th percentile, and at 8 years he fell to the 10th percentile. This consistent drop in growth often triggers a physician to look for reasons of the drop. Maybe the parents are both very short. Maybe there is a medical problem. Or maybe there is a family history of people having late growth spurts (something called "constitutional growth delay"). Treatment (if needed) varies depending on the cause.

Figure 1

The red arrow on the right marks the actual height at 8 years (blue) at about 47 inches (120cm). For this fictitious child, the bone age is 7 years, and if you plot 47 inches (the actual height at the time) at 7 years (the bone age), you will see this white dot is at the 50th percentile and marked by the red arrow on the left. A delay in bone age often coincides with a late growth spurt. I finished out the growth plots, and this kiddo actually fell more (down to the 5th percentile) before he hit a late puberty and grew into late teens/early 20s to hit a final height at the 50th percentile.

In Figure 2 below a fictitious boy is tall for his age early on. At 6 years old his height (black dot) is at the 97th percentile (he is taller than 97 out of 100 of boys his age) at about 49.5 inches (125.5cm). His bone age at the time (red dot) is 8 years 6 months, which is at the 25th percentile for height. A year later he is off the height chart, taller than over 97% of boys his age, but the bone age is 10 years 9 months, again at the 25th percentile. This chart shows an early growth spurt (as he looks taller than his peers) but an early puberty and a slowed growth faster than other boys. His final height is only at the 25th percentile, much shorter than his early heights would have predicted.

Many parents are super excited when their children are tall and can't comprehend when I talk about the possibility that it might not last. (I typically discuss this if both parents are short but the child is tall, if I see signs of early puberty, or if the child is obese - especially if parents are not as tall as the child's height predicts.) The bone age does not give a reason for the altered growth rate, but can help identify a need for further evaluation and treatment if indicated.

Figure 2

Bone age is difficult to understand, and I hope this helps parents understand with some pictures. I completely made up these growth charts. They do not reflect any real patient or any real diagnosis. They are solely to illustrate how we estimate the bone age on the growth chart to help assess final predicted height. The reasons behind altered growth patterns are many and might require further evaluation.

Take home point: At every well visit your child should have a height and weight measured. If the yearly growth accelerates too fast or slows, talk to your doctor about possible reasons. If a bone age is done, you can use a growth chart to put the bone age in at your child's height (instead of actual age) and see how tall the final height estimate would be. It isn't a guarantee, but can be helpful.

Staying healthy as an athlete

Many people assume that kids who are active in sports are automatically healthy, but that can be far from the truth. Sports do provide exercise, but not all kids participate at the same intensity level, some sports are more inherently challenging, many kids don't eat the needed foods to provide optimal nutrition, and many kids fall far short of the sleep they need to maintain healthy body and mind. There needs to be a balance: eat right, sleep adequately, and exercise daily. Kids also need time to be kids with unstructured time in addition to school, homework, and activities.

Not a typical team sport, but my kids don't do typical sports. This is from an office Bubble Soccer game. 

Eat right

First and foremost with nutrition, we all need to maintain hydration. Many kids avoid drinking at school so they don't have to use the restroom. This is of course not healthy. Talk to your kids about the importance of drinking throughout the day and troubleshoot toileting issues. When kids exercise, be sure they stay hydrated. The large majority of athletes need nothing more than water to stay hydrated. Water is by far the preferred drink of sports nutrition experts unless there is intense exercise longer than 60 - 90 minutes. This does not mean a child playing a baseball game for more than 60 minutes because they are not maintaining the level of intense exercise for the entire game. If a child is running a marathon, added electrolytes might be needed, but short of that type of intensity/duration, water is fine. Sports drinks add far too much sugar and unneeded salts to the diet. Encourage kids to take a sip or two of water every 15-20 minutes of exercise (more or less depending on how hot it is and the intensity of exercise).

As for foods, not all are equal and not all that are marketed as healthy really are healthy. Get in the habit of reading labels. The longer the ingredient list, the less healthy it probably is unless the ingredients are all foods themselves (such as a trail mix with a number of dried fruits and nuts). I've previously addressed the issues of kids getting too many calories. Far too many of our kids are overweight or obese. Many of them are active in sports, but they take in more calories than they use.

• Carbohydrates give quick energy for activity. Examples of healthy carbs are bananas, berries, oats, pasta, rice, and whole grain breads. These are recommended before exercise for energy (but kids don't usually need to carb load unless they are doing an endurance sport), and after exercise with a protein. 
• Protein is important for building and maintaining muscle. I like kids to eat foods with protein and to avoid protein shakes and powders, which are expensive and could possibly lead to too much protein. Examples of good protein sources include nuts and nut butters, eggs, lean meats and fish, yogurt (look for a brand without added sugar) and other dairy products. About 5 -15 g of protein (or about 0.5 to 0.8 grams of protein for every pound of body weight) is all that's needed after a workout, depending on age, size, and workout intensity. Many Americans get far more daily protein than is needed.
• Fat is not as bad as many people make it out to be. It is an important energy source for our bodies and helps us absorb fat-soluble vitamins. Healthy fats come from nuts, avacados, meats, dairy products, and eggs. 

Sleep

Many athletes (and teens in general) fail to get sufficient sleep for good health. They are torn between the demands of school, sports, clubs, volunteering, and making the time for sleep. The spiral typically has them staying up late to catch up on homework, only to be more tired the following day, which leads to poor focus at school - then everything takes longer to do. This encourages them to stay up even later to finish homework, which reinforces the problem. It is not uncommon for me to hear teens report anywhere between 4 and 8 hours of sleep. None of this is enough. Kids who are chronically sleep deprived suffer from more injuries, falling grades, general irritability and depression. I see many teens who want me to find a reason for their fatigue with labs, but it commonly is simply due to sleep debt.

Try to get kids to get enough sleep so they are easy to wake in the morning, stay alert all day, and aren't irritable or hyper in the evenings. If they have trouble sleeping, talk with their doctor.

From the National Sleep Foundation

I see far too many kids who claim to be very active and eat healthy, yet they have problems keeping up with other kids running or have BMIs that seem too high for the reported habits (not due to muscle mass). This could be due to an underlying problem, such as asthma, or habits that aren't as healthy as you think. Bring your child in for a yearly physical to review eating, sleeping, and exercise habits in addition to other health related issues. With most insurance companies there is no co pay for well care, so make the most of your insurance dollars and schedule a well visit! If there are any concerns, you can work with your child's doctor to find help.

Fever Phobia

My partner went to the American Academy of Pediatrics National Conference last Fall and came home with all kinds of new information. Most of it was great. But she also told us about a new product that would be coming to market that is not so great. I personally feel that this new product will be dangerous. Not in the "it will hurt your baby directly" category, but in the "will increase parental anxiety and overtreatment" department.

What's this product?

It's called FeverFrida. It has a sticker that goes under a baby's armpit that measures a baby's temperature every 4 seconds and sends information by bluetooth to the parent so the parent can know all the temperatures. It sends an alert if the temperature is over 99F.

Can you say anxiety inducing???

Fever is our friend, people! It helps fight infection. If we get a virus or bacteria, our body elevates the temperature to kill the infectious agent. I know a lot of people worry when their kids have a fever. I wrote about that in Fever is... because it is a very common fear. But we shouldn't feed that fear. This device will feed the fear with alerts for non-fevers and a reading every 4 seconds. That's 15 readings every minute. That means 21,600 readings in 24 hours. And they encourage you to bring all those readings to your pediatrician. Please don't. I won't even humor you by looking at them. That will encourage the fear. I can't do that.

Pediatricians don't usually consider a temperature a fever until it is at least 100.4F rectally (99F under the arm), so why this gizmo alerts you right at 99F is beyond me. The American Academy of Pediatrics doesn't recommend treating a temperature under 102F unless there is significant pain. (Note: This does not apply to babies less than 2 months, underimmunized kids, and those with immune problems.) In other words, you treat the pain, not the temperature in most kids. Let the fever do it's job! So what is the benefit of having a temperature taken every 4 seconds?

The FeverFrida is from a company that I have recommended for years because they make a wonderful product called Nosefrida. The Nosefrida can get mucus out of babies and helps them get through upper respiratory infections. I do love this product despite how gross it seems to suck the snot out of baby's nose. (We do a lot of gross things as parents if they help!)

I'm disappointed that the company is trying to play on parental fears with the fever monitor. Save your money and watch your baby for symptoms and treat based on these tips.

Travelling around the world? Stay safe and healthy!

Spring Break is around the corner, which means many of my patients will be travelling to various areas of the world for vacation or mission trips. Many of these areas require vaccines prior to travel, so plan ahead and schedule a travel appointment with your doctor (if they do them) or at a travel clinic. Many insurance companies do not cover the cost of travel medicine visits, medications, or vaccines, but they are important and are a small cost in comparison to getting sick when on your trip.

Vaccinate when you can!

Immunization records will need to be reviewed, so if you are going to a travel clinic outside your medical home (doctor's office) be sure to bring the records with you. Vaccines work best when they are given in advance, so do not schedule the pre-travel visit the week you leave! Some vaccines that are recommended are easily available at your medical office but others are not commonly given so might require a trip to a local health department, large medical center, or travel clinic. Check with your insurance company to see if the cost of the vaccine will be covered or not so you can include your cost in your travel budget if needed.

Watch the food and drinks

Many diseases are spread through eating and drinking contaminated foods. If in doubt: do not eat! Cooked foods are generally safer. Any fresh fruits or vegetables should be washed in clean water before eating. Be sure all dairy products are pasteurized. Avoid street vendors, undercooked foods (especially eggs, meats, and fish), salads and salsas made from fresh ingredients, unpeeled fruits, and wild game. Drink bottled water or water that has been boiled, filtered or treated in a way that is known to be reliable. Use the same water to brush teeth. Do not use ice unless you know it is from safe water because freezing does not kill the germs that cause illness. As always, wash hands often, use sanitizer as needed when washing is not available, and avoid touching the "T" zone of your face (eyes, nose, and mouth). Do not share utensils or foods. Avoid people who are obviously ill.

From: http://wwwnc.cdc.gov/travel/page/infographic-food-water-whats-safer

Many companies that schedule international travel recommend bringing antibiotics for prevention or treatment of diarrhea. This is not recommended by many experts due to the rise of "superbugs" with the use of unnecessary antibiotics. In general, the use of antibiotic prophylaxis is recommended only for high-risk travelers, and then only for short periods. The average duration of illness when untreated will be 4 to 5 days, with the worst of the symptoms usually lasting less than a day. Antibiotics might lead to yeast infections, allergic reactions, or even a chronic carrier state (colonization) or irritable bowel syndrome. Antibiotics should be reserved for the treatment of more serious illnesses that include fever and significant associated symptoms such as severe abdominal pain, bloody stools, cramping, and vomiting. Bismuth subsalicylate is available over the counter for adults and can reduce traveler’s diarrhea rates by approximately 65% if taken four times daily. Risks of bismuth products are that it can turn the tongue and stool black and they contain salicylate. Salicylate carries a theoretical risk of Reye syndrome in children, so should be avoided in children. Probiotics and prebiotics have been shown to help prevent and treat diarrheal illnesses safely in most people with intact immune systems.

Mosquitos...

Many diseases are spread by mosquitos. Contact with mosquitoes can be reduced by using mosquito netting and screens (preferably insecticide-treated nets), using an effective insecticide spray in living and sleeping areas during evening and nighttime hours, and wearing clothes that cover most of the body. Everyone at risk for mosquito bites should apply mosquito repellant.

Non-Infectious Risks

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page.

Learn local laws prior to travelling.

Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.

Remind everyone to stay in groups and to not venture out alone.

Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.

Wear sunscreen! It doesn't matter if you're on the beach or on the slopes, you need to wear sunscreen every time you're outside. Don't ruin a vacation with a sunburn.

For more safety tips, see this helpful brochure.

Keep records

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your family that is travelling. Save a copy so you can easily find it on any computer in case of emergency.

• your name, address, and phone number
• emergency contact name(s) and phone number(s)
• immunization record
• your doctor's name, address, and office and emergency phone numbers
• the name, address, and phone number of your health insurance carrier, including your policy number
• a list of any known health problems or recent illnesses
• a list of current medications and supplements you are taking and pharmacy name and phone number
• a list of allergies to medications, food, insects, and animals
• a prescription for glasses or contact lenses

Specific Diseases to Prevent

Risks of illness vary depending on where you will be travelling and what time of year it will be. I refer to the CDC's travel pages and the Yellow Book for information on recommendations. Some of the most common issues to address are discussed below in alphabetical order.

Dengue Fever

Dengue is a mosquito-borne viral illness. It is seen in parts of the Caribbean, Central and South America, Western Pacific Islands, Australia, Southeast Asia, and Africa. There is no vaccine or specific treatment. Mosquito bite prevention measures are important.

Hepatitis

Infants should begin vaccinations against Hepatitis B starting at birth and against Hepatitis A starting at a year of age. Be sure these vaccines are up to date. Hepatitis A is spread through food and water, so be sure to follow the above precautions even if vaccinated.

Malaria 

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be travelling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication.

• Atovaquone-proguanil should begin 1–2 days before travel, daily during travel, and 7 days after leaving the areas. Atovaquone-proguanil is well tolerated, and side effects are rare but include abdominal pain, nausea, vomiting, and headache. Atovaquone-proguanil is not recommended for prophylaxis in children weighing <5 kg (11 lb).
• Mefloquine prophylaxis should begin at least 2 weeks before travel. It should be continued once a week, on the same day of the week, during travel and for 4 weeks upon return. Mefloquine has been associated with rare but serious adverse reactions (such as psychoses or seizures) at prophylactic doses but are more frequent with the higher doses used for treatment. It should be used with caution in people with psychiatric disturbances or a history of depression. 
• Primaquine should be taken 1–2 days before travel, daily during travel, and daily for 7 days after leaving the areas. The most common side effect is gastrointestinal upset if primaquine is taken on an empty stomach. This problem is minimized if primaquine is taken with food. In G6PD-deficient people, primaquine can cause hemolysis that can be fatal. Before primaquine is used, G6PD deficiency MUST be ruled out by laboratory testing.
• Doxycycline prophylaxis should begin 1–2 days before travel to malarious areas. It should be continued once a day, at the same time each day, during travel in malarious areas and daily for 4 weeks after the traveler leaves such areas. Doxycycline can cause photosensitivity so sun protection is required.  It also is associated with an increased frequency of vaginal yeast infections. Gastrointestinal side effects (nausea or vomiting) may be minimized by taking the drug with a meal and it should be swallowed with a large amount of fluid and should not be taken before bed. Doxycycline is not used in children under 8 years. Vaccination with the oral typhoid vaccine should be delayed for 24 hours after taking a dose of doxycycline.
• Chloroquine phosphate or hydroxychloroquine sulfate can be used for prevention of malaria only in destinations where chloroquine resistance is not present. Prophylaxis should begin 1–2 weeks before travel to malarious areas. It should be continued by taking the drug once a week during travel and for 4 weeks after a traveler leaves these areas. Side effects include gastrointestinal disturbance, headache, dizziness, blurred vision, insomnia, and itching, but generally these effects do not require that the drug be discontinued.  

Measles

We routinely give the first vaccine against measles (MMR or MMRV) at 12-15 months of age, but the MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks. Under 6 months of age, an infant is considered protected from his mother's antibodies. These antibodies leave the baby between 6 and 12 months. The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday. Any vaccine dose given before the first birthday does not count toward the two doses required after the first birthday, but might help protect against exposure if the immunity from the mother is waning. It is safe for a child to get extra doses of the vaccine if needed for travel between 6 and 12 months.

Meningitis

Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States. In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but can be given as young as 9 months of age. MenACWY-CRM is newly approved for children 2 months and older. 

There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel. 

Meningitis vaccines should be given at least 7-10 days prior to potential exposure.

Travellers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. The vaccine is available for children 9 months and older in my office and a newer vaccine is approved for 2 months and up. Boosters for people travelling to these areas are recommended every 5 years. 

Tuberculosis

Tuberculosis (TB) occurs worldwide, but travelers who go to areas of sub-Saharan Africa, Asia, and parts of Central and South America are at greatest risk. Travelers should avoid exposure to TB in crowded and enclosed environments and avoid eating or drinking unpasteurized dairy products. The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States. Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure. It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body's immune system is compromised, as with old age or another illness. Appropriately treating the TB before it causes active disease is beneficial for the long term.

Typhoid

Typhoid fever is caused by a bacteria found in contaminated food and water. It is common in most parts of the world except in industrialized regions (United States, Canada, western Europe, Australia, and Japan) so travelers to the developing world should consider taking precautions. There are two vaccines to prevent typhoid.

• Children over 2 years of age can be vaccinated with the injectable form. It must be given at least 2 weeks prior to travel and lasts 2 years. 
• The oral vaccine for children over 5 years and adults is given in 4 doses over a week's time and should be completed at least a week prior to travel. The oral vaccine lasts 5 years. 
• Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Yellow Fever

Yellow fever is another mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Zika Virus

At this time it is advised that pregnant women and women who might become pregnant avoid areas in which the zika virus is found. For up to date travel advisories due to this virus, see the CDC's Zika page.