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Travel Preparation Transcript

Preparation for travel abroad for an international adoption requires a discussion with a physician before you set foot on that plane. Dr. Aronson can help you understand how to handle simple medical problems while you are far away from home and also give you prescriptions for some simple medications. A preparation list is provided by Dr. Aronson below as part of her discussion of some of the most common pediatric medical problems and recommended management strategies. Prescriptions for antibiotics and other medications can be acquired from her even if you don't live in New York State. Please be aware that antibiotics will be prescribed to the child in-country, not to traveling adults. Dr. Aronson is also available for consultation by phone or e-mail while you are abroad.

You can contact Dr. Aronson by e-mail at: orphandoctor@gmail.com or through her office phone on Monday through Friday from 9am to 4pm 973-763-3762.

Call her cell phone 917-538-5217 after hours up until 10 pm. If you want on-site medical care while you are abroad, you can consult Dr. Aronson's website: www.orphandoctor.com. She has a section for international medical clinics listed by country and all hotels can direct you to expatriot medical clinics that are commonly used by Americans. You may want to get a Medex account before you travel so that you have access to medical care while you are away.

Antibiotics

Ear Infections and Respiratory Infections

Families traveling abroad for an international adoption should consider taking the antibiotic Zithromax (prescription) as a back-up for ear infections and respiratory infections. While many antibiotics are available overseas, it is wise to take an FDA-approved drug. Although 99 percent of colds do not become complicated, the typical course of respiratory infections in children begins with a cold. A cold virus in the nose or throat can affect the middle ear, where fluid can accumulate and become infected. That infected fluid in the middle ear, with an inflamed eardrum, is known commonly as an ear infection. The eardrum becomes red and swollen and is quite painful. The ear infection manifests itself in a number of ways. About 20 percent of children with ear infections actually grab their ears, and about 80 percent will not. Note, that sometimes children grab their ears for other reasons such as teething pain or sore throats. Some children grab their ears just because it is a fun activity! With an ear infection, though, the child becomes uncomfortable. Appetite, sleep, and mood are affected. In this setting, parents frequently call their pediatrician and say, "She's just not herself." An ear infection may or may not be accompanied by an elevated body temperature. A child can have a very low-grade temperature with little to no fever and still have an ear infection. Certainly, fever heralds underlying disease because it means the body is fighting infection, but generally, kids can have ear infections without displaying dramatic signs. Remember the subtle manifestations of disease in children: changes in mood, appetite, sleep patterns, and behavior.

Also Zithromax may be taken for respiratory infection, which may affect either the upper or lower respiratory tracts. When the virus moves into the lower aspect of the respiratory tract and causes inflammation of the airways, it is pneumonia. Symptoms include high fever, a productive-sounding cough, and fast breathing. As with an ear infection, the child usually starts off with a cold. After a few days, a high fever develops and breathing becomes very, very rapid. This combination undoubtedly disrupts sleep patterns and eating, and the child can be diagnosed with pneumonia. Upper respiratory infections are usually viral and do not require antibiotic therapy. The cough from a cold is most likely a postnasal drip and sounds worse than it really is. Children commonly pool secretions in the back of their throat. Saliva from teething can cause a little cough from time to time as well. It is very important to distinguish the difference between an upper and lower respiratory tract infection.

Parents should take Zithromax as a powder when traveling abroad. It is dosed once daily and does not require refrigeration. Do not reconstitute the powder until the antibiotic is needed. Directions for adding the appropriate amount of water are written on the bottle by the pharmacist. For ear infections, children take the medicine once a day for five days. The dosage is weight-dependent and should be determined by a physician before traveling. To ensure that the child receives a full dose of medicine, give the medicine from a medicine dropper, not in the feeding bottle. Some medicine applicators look just like a nipple, so the baby will suck the medicine down easily. Other medicine applicators resemble eyedroppers. A syringe without a needle may also be used. Do not use a teaspoon to measure medication.

Bronchiolitis (a coughing and wheezing condition in young children) is caused by an array of viruses and can mimic an asthma-like illness. Sometimes kids have colds and wheeze and they don't have bronchiolitis, but the treatment is the same. Pediatricians usually manage any wheezing for kids with medication like Albuterol (comes as a metered dose inhaler and is used with a spacer) which opens up the airways and decreases the constriction of the smooth muscle of the walls of the breathing tubes (bronchioles). Sometimes we use steroids as well (prednisone tablets daily in the morning for a week with a snack).

*Please note that if a child has a high fever, is breathing very fast, unable to eat, drink, or sleep, the child should be seen by a physician urgently or brought to an emergency department of a hospital.

Cuts and Scrapes

Physicians commonly recommend taking an antibiotic ointment such as Bacitracin, Neosporin or triple antibiotic ointment for cuts, scrapes, and scratches. Kids in orphanages frequently have dry eczematous skin, mosquito/insect bites, and get secondary bacterial infections.

Pink Eye or Conjunctivitis

A prescription for Tobramycin eye drops sufficiently treats pink eye, also known as conjunctivitis. The symptoms of an eye infection involve redness of the eye and/or a yellow discharge from one eye or both. Often times the eyes will be closed shut, practically glued together in the morning, and there may be intermittent discharge throughout the day. Use a cotton ball that is moistened with bottled water to wipe the eyes clean. In order to prevent the spread of eye infection, wash the child's hands and your hands frequently throughout the day. Apply Tobramycin drops simply by placing a drop near the inner corners of the eyes and moving the child's head slightly to that side. The drop will go in the direction the head is tilted by capillary action and it will end up in the conjunctival sac. Put two drops in each eye, three times a day, for one week even if only one eye is infected. Adults should each have their own prescription for Tobramycin eye drops, as conjunctivitis is highly contagious.

Little Red Bumps & Other Skin Problems

Eczema
Most children living in orphanages are not getting enough calories or the proper proportion of various nutrients. They may have Zinc deficiency, which can affect the immune system and/or the skin. Eczema is quite common and identified by very dry, rather scaly, red skin. Scabies, which will be discussed later, also may precipitate eczema. Bathing in very hot or cold water also contributes to very dry skin. Hydrocortisone 1% cream or ointment, Aquaphor, or Cetaphil cream may be used to treat eczematous skin. Use Aquaphor or Cetaphil twice a day as a maintenance regimen to keep the skin moist. Applying cream for dry skin is a nice way to introduce the child to tactile stimulation via massage. Steroid cream can be used judiciously to manage more angry and red areas of skin especially on those sweet little faces. You may substitute any emollient that you already have in your treasure trove of creams at home; avoid using perfumed creams. Unscented Dove soap is the least allergenic soap and good for all-purpose body washing for adults and children. Don't use a rough washcloth to wash the baby; a soft sponge will do. Most baby lotions, soaps, and creams are quite irritating to the skin of children who have poor nutrition.

Scalp
Malnutrition and poor hygiene may also affect the child's scalp. If a child is not bathed regularly, an excess amount of oil on the scalp may plug the pores of the skin, leading to an inability of the hair follicle to function normally. The result is severe seborrheic dermatitis or cradle cap, where the layer of oil that is on the scalp becomes brownish-yellow and then flakes off, looking similar to adult dandruff. The scalp may appear red in areas. A good way to treat cradle cap is with T-gel Shampoo made by Neutrogena. It is a coal tar extract, and a tiny amount can be used every other day to remove the scales and oil until the scalp looks cleaner. This will also improve the scalp's ability to grow hair. If you use baby shampoo, use it sparingly and not every day.

Diaper Rash

Two basic kinds of diaper rash will be discussed. Mechanical breakdown of the delicate skin around the genitals and anus is caused by frequent exposure to urine and stool. The skin may become red, dry, and wrinkled (prune-like). This is best handled by using bottom barriers discussed below. Occasionally, a child develops a fungal diaper rash, from yeast, which colonizes the bottom from the digestive tract. Yeast is commonly found in the stool. As it remains in contact with the skin, it causes a splitting of the cells of the skin and a very painful, fiery rash develops around the buttocks, genitals, the inner parts of the thighs, the grooves of the groin, and on the skin up to the belly button. For fungal diaper rash, apply Nystatin cream (100,000 U/gm; prescription) three times a day for seven days. Remove the diaper during naps and at bedtime and have the child sleep on a layer of towels instead of just a sheet in the crib. Exposure to air keeps the skin dry and aids significantly in the healing process.

Bottom Barriers (to prevent diaper rash)
Sometimes the skin around the genitals will appear a little red and maybe even prune-like, from repeated exposure to urine and stool. In this case, Desitin, A&D Ointment, or Balmex would work as a barrier to the moisture in the diaper. Any of these products works rapidly and facilitates healing. Apply product with each diaper change or as needed.

Any commercial baby wipe brand is fine as long as it is unscented and lacks alcohol. Since disposable diapers are ultra-absorbent, baby wipes are usually unnecessary after urination. Be careful not to overuse wipes, as their tendency is to strip the skin of its natural oils, increasing the risk of diaper rash.

Scabies (rash that itches beyond your wildest dreams)

Scabies are microscopic mites that burrow under the skin. Scabies exist in the United States and all over the world, but they are particularly common in a crowded setting like an orphanage or school. Approximately 5 percent of internationally adopted children come back with scabies. Frequently it is not diagnosed because when it becomes chronic, it may not look like the textbook description. It is often confused with eczema and is managed with steroids without much improvement. The scabies mites cause a reaction about 6 to 8 weeks after the mite has burrowed under the skin. It may be a local reaction where the burrowing occurred, or it might be a rash on the whole body. Scabies organisms tend to have a predilection for the soles of the feet and the palms of the hands, but may also be found around the armpits and belly button. Manifestations of this include little red papular lesions (red raised bumps) on the palms of the hands and the soles of the feet, with possible scaling, or even blister-like spots. It is recommended that each person traveling abroad as well as the baby have a prescription for Elimite cream 5%. The generic brand is fine. Elimite cream 5% is one brand of permithrin that is used to treat Scabies. It is not necessary to treat the child or yourselves preventively without a diagnosis of actual scabies. If scabies is diagnosed in the child, then everyone on the trip should be treated preventively. For older children and adults, apply the cream, which is odorless, to the skin, from the neck down, covering the whole body. Leave it on for 10 hours overnight and shower it off in the morning. For infants, apply some cream to the face as well; putting socks on the baby's hands will keep the baby from scratching the rash, rubbing the medication into the eyes, and eating the medication. Only one application is required, but it may take weeks or months for the skin to rejuvenate completely. Be sure to use a good moisturizer to aid in the skin's healing. Judicious use of Benadryl may be necessary for a few nights to keep the itching under control. Remember that adults will not manifest signs of scabies while in the orphanage because it takes 6 to 8 weeks. If a child has scabies, the scabies reaction may be avoided in the parents by using a single application of the Elimite cream. Change sheets and towels the morning after treatment. A second application of Elimite is sometimes needed for the patient, but this should be decided by you and your doctor.

A common complication of scabies is "acropustulosis" which looks like scabies and recurs for weeks and months after the initial diagnosis and treatment of scabies. It is an immune reaction to the scabies and does not require repeated applications of Permethrin, but rather maintenance moisturization.

Antipyretics (anti-fever), Analgesics (pain relief)

Acetaminophen
Acetaminophen (Tylenol is one brand) is a good product for the treatment of fever and pain. Infant acetaminophen comes in a variety of brands and fruity flavors and has a medicine applicator inside the bottle marked with 0.4 ml and 0.8 ml. It is best to take a couple of bottles overseas. It also comes as a children's concentration of 160 mg per 5 ml. Acetaminophen works great for relieving the pain of teething, which is commonly demonstrated by excessive drool, fingers or fists in the mouth, and/or fretful behavior. Teething is associated only with very low-grade temperatures of less than 100 degrees. If the baby has a cold or a viral infection, a dose of acetaminophen will relieve muscle aches and discomfort, which usually occur with a temperature of 101.5 degrees and above. Acetaminophen may also be used to relieve the painful inflammation of an ear infection for the first 48 hours after initiation of antibiotic therapy.

Note: ibuprofen which is an anti-inflammatory medication can be used for the same indications noted above; it can be irritating to the child's stomach and should be taken with food.

Acetaminophen (infant 80mg/0.8ml)

Acetaminophen (children's 160mg/5ml)

Dose: 10mg per kg of weight every 4 hours
i.e. child weights 8kg, multiply 8x10=80mg which is one infant dropper of infant acetaminophen or 2.5cc of children's acetaminophen

Ibuprofen (Motrin, Advil are brands)

Infant ibuprofen (1.25 ml/50 mg)

Children's ibuprofen (5 ml/100 mg)

Dose: 5mg per kg of weight every 6-8 hours

i.e. child weighs 10 kg; multiply 10 X 5 =50 mg, which 1.25 cc of infant ibuprofen or 2.5 cc of children's ibuprofen

To convert pounds to kilograms, divide the pounds by 2.2 i.e. 22 pounds divided by 2.2 equals 10 kilograms.

5 cc or 5ml equals one teaspoon.

Allergy and Itching Medication

Hives are recognized as red skin with an elevated, itchy, white area or welt. Benadryl (diphenhydramine is the generic) is usually found in a concentration of 12.5mg per 5cc and may be used to treat both hives from allergies and the itchy rash of scabies. It is available now as a clear, bubble gum-flavored liquid without dyes. The dose is 1 mg per kilogram of weight, given as often as every 6 to 8 hours. Thus, for a 6kg child: 6kg x 1mg per kg equals 6mg which equals 2.5ml (1/2 teaspoon) of Benadryl. Please remember that antihistamines commonly cause sleepiness. About 3 percent of children and adults do have an idiosyncratic reaction of hyperactivity. This reaction can occur even after the medication has been used and has caused no reaction at all. This medication is not recommended to control behavior on airplanes!

Coughs and Colds

Over-the-counter decongestants can cause infants and children to become either overly active or quite sleepy so they are recommended with caution for traveling kids. Since November 2007 the FDA has advised against the use of cough and cold preparations in children younger than 6 years of age. There is no scientific evidence that supports their effectiveness and there are many dangerous side effects.

Echinacea can very useful for the treatment of a cold especially as the cold first begins. A child's dose varies with age; consult a physician for proper dosing. Usually children under one year of age can take 5 drops twice a day and toddlers can take 10 drops twice a day. No particular brand is recommended over any other, but some products are flavored and are tastier for children. Echinacea is available at health food stores.

The mainstay of treating a cold is saline nose drops. They go in each nostril every few hours. Recommended brands include Ocean, Nasal, and Ayr. Saline gel (Little Noses brand) is also available and is quite comforting. After using the saline nose drops, a bulb aspirator effectively removes the mucus. Many types of bulb aspirators are available. They are available at local pharmacies. Saline nose drops are great for adults to avoid excessive drying of the nasal mucosae while flying on a very long trip.

Diarrhea & Vomiting (to prevent and/or treat dehydration)

Diarrhea and vomiting in childhood are not usually associated with fever. This illness is usually associated with viruses such as Rotavirus or Norwalk virus. Typically, the child becomes nauseous, vomits, and then the virus moves through the digestive tract and this leads to diarrhea, and the virus leaves the body. This is common and is known as viral acute gastroenteritis. Dehydration prevention is the key in this case. The best way to prevent dehydration is to monitor the child's urine production by making sure the baby has wet diapers and tears when the baby cries. If the child just has diarrhea but no vomiting, continue to feed formula in order to provide sufficient nourishment. Use electrolyte packets (you can order these on line) which are reconstituted with bottled water between feeds. Pedialyte is available in small containers for travel, but is less convenient. If the baby has nausea or vomiting, dispense with feedings for 4 to 8 hours and use the electrolyte solution every 5 to 10 minutes. Since the baby cannot tolerate large amounts of fluids, use an eyedropper to drop the electrolyte solution down the sides of the mouth. If the baby consumes too much fluid all at once, s/he will become nauseous and vomit back whatever was just consumed. So go slowly. If the diaper is too absorbent and the parent has difficulty checking whether or not the child has urinated, put tissues in the diaper. Babies sometimes urinate every 15-30 minutes; as a child matures into a toddler, urination may be less frequent and the child may urinate every hour. Other causes of gastrointestinal infections are bacteria and parasites. Bacterial infections of the intestines are not common, but may be accompanied by fever and blood in the stool. Seek on-site medical evaluation if this occurs. Parasites can wait until you get home to diagnose them. Decreased activity and poor urine production should also signal a need for urgent medical attention.

Teething

Teething begins about 4-6 months of age, but there may be no teeth until after one year! When a child's mood changes and they are inserting their fingers or fist, mouthing everything in their environment, or drooling to beat the band, think of teething. A dose of acetaminophen or ibuprofen at bedtime for the obviously teething infant is a gift to the baby. Remember that the fever of teething is low grade and is rarely above 100 degrees.

Constipation

This is the nightmare for new parents, especially those who go to China. The change in the diet usually causes a hard and painful bowel movement. Prevention of constipation is really a priority. Using more fluids and fiber in the diet and having that 6-pack of Sunsweet prune juice could save a baby a lot of discomfort. Fruits, vegetables, and diluted juices can prevent constipation. It is best to get a baby regulated from above and not from below. Many families rely on glycerin suppositories. In a pinch it is okay, but not as a long-term solution.

Plane Ride and Ear Pressure

Parents frequently ask about the management of ear pain from the changes of pressure in the airplane especially if a child has a cold or an ear infection. Having the child sucking on a bottle or a sippy cup on take off and landing can be helpful. A dose of acetaminophen or ibuprofen before the take off or before landing is also useful. Decongestants have not been proven to be effective. As mentioned above, it is not advisable to use antihistamines to control or prevent changes in behavior on an airplane. Good old-fashioned distraction with walking up and down the aisles, a visit to the bathroom, snacks, drinks, and play are in order. Some parents claim that inserts for the ear canals called "earplanes" are useful; they are available for adults and children.

Sleeping and Jet Lag

It is recommended that when you arrive home after a very long trip (greater than 8 hours time difference) that you and the baby just sleep as needed for a few days regardless of the time schedule. This will provide the needed rest after a very arduous trip. Then, sleep deprive a few hours at a time for the next few days until you are back in your time zone. Go out for walks and do simple errands, but keep the baby awake. Drink plenty of fluids and don't go back to work. It helps to have a select friend or family member to watch the baby so you can grab a nap here and there.

Feeding

This is probably the most controversial aspect of this preparation orientation. Babies under one year of age should be feeding formula with iron, either milk or soy. There are many opinions about whether babies from Asia should have soy or milk. Most babies living in orphanages in China are actually feeding on a very dilute version of milk-based formula with additional rice conge cereal, steamed eggs, and an occasional banana and orange. The controversy centers on lactose intolerance in Asian children; this condition actually does not appear to be a problem in infancy, but may develop over time and may become an issue in childhood, and usually develops in adults decades later. Lactose is the main sugar in milk-based formulas and the enzyme, lactase, which is necessary for its breakdown, may be missing from some individuals' intestinal tracts. Checking with the agency regarding what your baby has been eating is a good starting point. Most children are adopted late in the first year of life and can eat food in addition to their 28-32 ounces of formula each day. Baby food is heavy and inconvenient, but some families do like to take some along. Babies eat 3 meals and 2 snacks aside from their bottles. It is suggested that the infant can do fine just on the formula while you are traveling and food can be added on arrival at home. But…if the child has teeth and an appetite to match, table foods will be fine as long as you prepare the food as mashed or in small pieces. Any food will be fine, except for some obvious restrictions like nuts, chocolate, and peanut butter. As mentioned above, the formula should be iron containing. Development of intellect is based on good nutrition and iron is necessary for intellectual growth. Many people are convinced that iron causes constipation in infants; this may appear to be true for some infants although this has never been proven by medical studies. Introducing more fluids, fruits, and vegetables and having a handy supply of prune or fruit juice can prevent constipation.

Toddlers clearly can be fine on a regular assortment of table foods. Another controversy is how to transition babies from the formula in the country of origin to the formula in the U.S. There are as many ways to do this as there are parents adopting. As long as the baby appears to be getting enough calories, it doesn't matter how you transition the child. Most formulas from abroad are quite similar to American formulas. Nipples can differ so bring along a variety and you will find the magic nipple for your baby.

Oral Motor Dysfunction

Beyond the scope of this discussion is oral motor dysfunction, which is quite common in babies adopted from orphanage due to a complex set of circumstances including bottle propping, malnutrition, rickets, and under stimulation. Your baby may have difficulty sucking and swallowing so be patient and feed the child slowly with a lot of close holding and attention to the body language of the baby. When you get home, consult with Early Intervention Services through your local department of health which can provide a speech therapy evaluation to focus on feeding difficulties. Parents commonly report that the babies don't like water. This is a curiosity. It has been discussed that children with oral motor dysfunction cannot handle the slippery nature of water. Also some children appear to "know" instinctively, that drinking fluids like water, leads to increased urination and they don't want to be wet so they don't drink. They are used to not being changed for hours at a time in the orphanage so this is a practical response to a sad situation.

Checklist of Over the Counter Medications

• A & D ointment, Balmex, or Desitin
• Acetominophen or Ibuprofen
• Aquaphor or Cetaphil
• Hydrocortisone 1% ointment or cream
• Ayr, Nasal, Ocean saline nose drops; Little Noses saline gel
• Bacitracin, Neosporin, or triple antibiotic ointment
• Diphenhydramine (anti-histamine)
• Echinacea (flavored)
• Electrolyte packets or Pedialyte (travel bottles)
• K-Y Jelly
• T-Gel shampoo made by Neutrogena

Checklist of Prescription Drugs

• Elimite 5% Cream (permethrin generic ok) for scabies
• Nystatin cream for fungal diaper rash
• Tobramycin eye drops for pink eye
• Zithromax (azithromycin generic brand ok) antibiotic for possible ear infection and/or pneumonia
• Albuterol Metered Dose Inhaler and Prednisone tablets (for wheezing)
• Spacer (Aerochamber) or water bottle emptied and fashioned into a spacer

Checklist of Miscellaneous Paraphernalia

• Digital rectal thermometer (ear thermometers are useful for children over 4 yo)
• First aid kit: band aids, gauze, paper tape, alcohol pads, hydrogen peroxide
• Wash 'n' Dri packets or Baby wipes (unscented and without alcohol)
• Infant/child medicine dropper marked in ml or cc
• Formula as a powder (milk or soy) with iron in ready to feed packets or large cans
• Avent, Gerber, Dr. Brown or Playtex bottles (disposable inserts or drop-in bags)
• Rice cereal
• Thermos bottle for preparation of bottles
• Teething rings
• Bibs
• Baby carriers i.e. Ergo, Baby Bjorn, Snugli, Sara's Ride
• Cloth diapers for your shoulder
• Scissors for cutting fingernails or for enlarging nipple holes
• Diapers that are disposable (8-12 changes per day)
• Baby spoon and bowl (plastic)
• Sippy cups
• Activity blanket for young infants
• Prune juice for constipation (Sunsweet packs of 6)
• iPod to play music for bedtime
• Cotton garments all pre-washed before travel
• Sunscreen (#30 is enough) and hat for child
• Insect repellant to be applied to clothing only
• Umbrella stroller