Glenbrook Pediatrics

We all use the term 'the flu' loosely, but the real flu is an infection with a specific virus called Influenza A which usually affects our hemisphere of the world after January. Symptoms include the sudden onset of fever, chills or rigors, headache, muscle aching, and nonproductive cough. It is spread from person to person by inhalation of particle aerosols, direct contact, or by contact with articles recently contaminated by someone's nasal secretions. A person is most infectious during the twenty four hours before the onset of symptoms and during the obvious sick period. The incubation period is one to three days.

There is a vaccine against Influenza A that is made each year in accordance with the yearly change in the virus. The flu can be no worse than a cold for some people but for others it can be very serious. This includes people with asthma, heart disease, kidney disease, diabetes, inflammatory bowel disease, and cancer as well as the elderly. We send postcards to all our patients that we think might benefit from the vaccine. There is not a general recommendation at this time for healthy children to receive the flu shot.

The best treatment for influenza is rest, plenty of fluids, and fever reduction with either acetaminophen or ibuprofen. Any symptoms that appear severe or are prolonged, especially in a younger child, require a visit to our office. We have a rapid influenza test, similar to a strep test, to check for this virus. We treat secondary infections such as pneumonia or an ear infection with antibiotics; otherwise treatment is to help symptoms only. You may see commercials on TV for Amantadine, Zanamivir, or Rimantadine to shorten the course of influenza infection. These drugs can be helpful but there are side effects so the risks and benefits of using them in your child should be discussed with your doctor. Call our office with any questions.

We are in the midst of this year’s influenza outbreak, and would like to address our patient’s commonly asked questions about influenza.

Influenza outbreaks occur yearly starting in the late fall or winter. Each year, the flu vaccine is manufactured based on a prediction of which flu virus will be circulating. This year the predominant circulating strain is somewhat different from the predicted strain. Because of this, the flu vaccine may not be as protective as usual. However, the vaccine can be expected to decrease the severity of illness in many children. We still consider the vaccine to be an effective way to help protect children from serious influenza illness.

Media reports about serious influenza illness in children have been frightening. It is important to remember that influenza occurs every year. Although we are seeing more flu than in some years, severe cases occur every year in children, so this is not a new phenomenon. Most children with influenza are sick for about a week with fever, sore throat, muscle aches, cough and poor appetite, and then recover uneventfully. We have had some parents ask if they should avoid all contact with others to prevent their children from becoming infected. We do not think it is necessary to take drastic measures to avoid this illness. The best way to protect your children is to get them the flu vaccine and to practice good handwashing. Children should wash hands before and after school, and after group activities. Children with fever or bad cough should not attend school or other group activities. Children should be encouraged to cover their mouths when they cough, and to use tissues. They should wash hands more frequently when they are ill.

Children with influenza should be seen in the office if their symptoms are severe or prolonged. We would like to see children who have severe headache, lethargy, trouble drinking, multiple episodes of vomiting, trouble breathing, or fever for longer than 3 or 4 days. Call our office if you are unsure whether your child needs to be seen.

We are having some difficulty keeping flu vaccine in stock because of increased demand. We are working hard to obtain sufficient supply of the vaccine for our patients. Beginning the week of December 8 we will have a voice mail message in our office with up to date information on our supply of vaccine. Please ask for the flu voice mail when calling our office to inquire about the vaccine.

We will provide updates on our website as more information becomes available about this influenza outbreak. The Centers for Disease Control website www.cdc.gov is also a good source of information.

2: HEAD LICE

What are lice? They are small insects (about the size of a sesame seed), which live only on humans, mostly on the scalp. They lay eggs along the hair shaft (commonly called “nits”). Each louse has an average lifespan of between 9-30 days and the eggs take about 7-10 days to hatch.

How did my child get this? Lice spread from person to person ONLY! THEY CAN’T FLY OR JUMP! It is possible for hats, combs, barrettes, pillows or headsets (e.g., Walkman) to carry lice from one person to another. However, lice can only survive for 24-48 hours off of a human. They need human blood. Pets do not carry lice, nor can children catch lice by being dirty.

How do we diagnose lice? Look in the hair above or just behind the ears for nits or live lice. The nits are difficult to remove from the hair shaft (unlike dandruff which is easy). The nits are silvery gray in color and less than a millimeter in length. As lice tend to be active at night, children may complain of trouble sleeping and itchiness. There may or may not be a mild rash on the scalp or even hives. If you are uncertain of the diagnosis, your doctor may check for other signs with a special lamp or examine for typical lymph node enlargement.

What can I do to treat my child? Prevention is the best! Remind your children not to share combs, hats, helmets, pillows and barrettes. Keep your child’s personal items in a cubbyhole or locker at school, separate from other children’s belongings. If your child has long hair, consider putting it into a ponytail or cutting it shorter. DO NOT USE anti-lice sprays or other chemicals (such as turpentine, kerosene or gasoline). You may vacuum carpeting, furniture and surfaces like car seats to clean up any stray live lice. Wash all stuffed animals, linens, and clothing in hot water (>130 F) or you can seal them into plastic bags for 2-3 weeks. Check the rest of the family and treat them only if lice are found on them too.

What about medicines? There are several medicated shampoos (such as Rid or Nix) available over the counter. Nix is the preferred treatment. Both products contain pesticides, which kill live bugs but only some of the eggs. These need to be manually removed. In addition retreatment with the shampoo is recommended in 7-8 days (when egg hatching takes place).

How do I remove the eggs? You can remove the nits by painstakingly combing through hair in sections under bright light. Use a fine-toothed comb like the Lice-meister, and comb through the whole length of the hair. Dipping the comb into white vinegar mixed with water (1:1 ratio) in between strokes will loosen the nit from the hair shaft. Wipe nits onto a towel so that you don’t reinfect the hair. This process may take many hours. You will need to comb daily until no live lice are discovered (about 10 days). You must remove the nits, as no product will kill one hundred percent of nits.

What else can I do? If you have followed the steps above and still have live lice, then your doctor may prescribe some other therapies. These may not be pleasant to use, in general, and likely are not much more effective than the over the counter shampoos, so do try the above treatment first.

When can my child return to school? After treatment with a medicated shampoo, a child may return to school. Some schools may require that your school nurse verify that the nits have also been removed.

What about natural therapies? Many advocate using petroleum jelly or full-fat mayonnaise to smother the lice on the hair. While this may work in some cases, studies show that the substances need to be applied for longer than 18 hours to work. They are also difficult to remove. We DO NOT advise using talcum powder to remove the creams or jelly as this poses a real risk of aspiration to young children.

Are there any long-term effects of lice infestation? This is the good news. No. The itching may persist for 2-3 weeks; however, no serious diseases have been associated with lice.

3: Constipation

Constipation means that bowel movements are difficult or painful to pass and less frequent than usual. A child with constipation feels an urge to have a bowel movement (BM), has discomfort in the anal area, and is unable to pass a BM after straining and pushing for more than 10 minutes. Going 3 or more days without a BM can be considered constipation, but can be normal in some children. Your child is only constipated if the infrequent BMs are associated with hard stools that are difficult to pass. Some children have infrequent stools that are soft; this is normal.

My infant grunts and seems to have a difficult time passing stool, is that constipation?

Babies less than 6 months of age commonly grunt, push, strain, draw up the legs, and become flushed in the face during the passage of bowel movements. However, the stool that they pass is soft. These behaviors are normal and should remind us that it is difficult to have a bowel movement while lying down.

Constipation is often due to a diet that does not include enough fiber. Drinking or eating too many milk products can cause constipation. It can also be caused by repeatedly waiting too long to go to the bathroom, holding it in until the stool is so large that it is painful to pass. The memory of painful passage of BMs can make young children hold in stool, worsening the problem.

Changes in the diet usually relieve constipation. When your child is better, be sure to continue the nonconstipating diet so that is doesn’t happen again. Occasionally changes in diet may not relieve the constipation, or children will not eat the foods needed to soften their stools. These children require a stool softener.

Stool softeners should be used every day as directed by your doctor. Continue these medications for at least 4-6 weeks, even if your child’s stools have softened and seem normal. Stopping too early usually results in recurrence of constipation. After 4-6 weeks of softener use every day, try giving them every other day and watch closely for signs of constipation. If your child has soft stools while taking the medications every other day, it is OK to try to stop them. If constipation recurs it may be necessary to restart the stool softeners and to continue them for a longer period of time.

Sometimes trauma to the anal canal during constipation causes an anal fissure (a small tear). If your child has an anal fissure, you may find small amounts of bright red blood on the toilet tissue or the stool surface. This tear will heal quickly on its own once the stool is soft and not re-injuring it on the way out.

Give prune or pear juice once or twice each day. If your child is over 4 months old, add strained foods with a high fiber content such as prunes, figs, dates, pears, plums, beans, or peas twice a day.

Sitting on the toilet (if your child is toilet trained)Encourage a regular bowel pattern by having your child sit on the toilet for 10 minutes after meals. If your child is resisting toilet training by holding in stool, stop the toilet training for a while.

If a change in diet does not relieve the constipation, or if your picky eater won’t allow for a change in diet, bring your child to our office for an appointment to discuss the use of a stool softener. Stool softeners are not habit forming. They stay in the gut to soften stool and are not absorbed into the body. Stool softeners work 8 to 12 hours after they are taken. If they do not work, the dose is usually too low. You can safely increase the dosage upward until your child has soft stools regularly. We will help you with this.

If your child has rectal pain requiring immediate relief, one of the following will usually provide quick relief: sitting in a warm bath to relax the anal sphincter, inserting a glycerine suppository through the anus, or gently putting a thermometer in the anus for 10 seconds to stimulate the rectal muscle. Do not use suppositories, enemas, or rectal stimulation regularly to remove stool. These can cause irritation or tears of the anus, resulting in pain and stool holding.

Call our office if your child develops severe rectal or abdominal pain, your child does not have a bowel movement after 3 days on this nonconstipating diet, or if you have other questions or concerns.

Adapted from Instructions for Pediatric Patients, 2^nd Edition, 1999 by WB Saunders Company.

Dosing Chart for Laxatives

¹ Adjust the dose of these laxatives to induce a daily bowel movement for 1-2 months, and then slowly wean. We will help you with this.

Adapted from Contemporary Pediatrics, Managing constipation: Evidence put to practice, December 2001, vol 18, no. 12, pg 63.

Recipe Ideas for Fighting Constipation

Mix all ingredients together and pour into an 8”x 8” square pan. Chill until set. More or less water may be needed to get a gelatin that sets. When firm, cut into 1”x1” cubes. Start serving two cubes per day and increase until soft stools are produces. Try using cookie cutters to make fun shapes for your child to eat.

Combine ingredients in large bowl; mix thoroughly. Press mixture into well-greased 8”x10” baking dish. Mark into 2” squares before baking. Bake 22 minutes at 375 degrees. Cut apart while still warm. Store in refrigerator or freezer.

Combine all ingredients except cheese in a 1-quart casserole dish. Bake uncovered at 350 degrees for 50 minutes. Sprinkle cheese over mixture. Bake until cheese melts.

Preheat oven to 350 degrees. Grease or line muffin pans. Recipe makes 22, 2” muffins.

Use whisk or egg beater to mix liquids well, then pour into the dry mixture. Stir quickly. Some lumps may remain. Bake about 25 minutes.

Adapted from Feeding and Nutrition for the Child with Special Needs, Klein and Delaney, 1994 by Therapy Skill Builders, a division of Communication Skill Builders.

Recipes Using Laxatives

¹ Should not be used in a child who is less than 1 year of age, has gastro-esophageal

reflux, a swallowing disorder, or severe respiratory problems. Do not give just before

4: Diaper Rash

A diaper rash is any rash on the skin area covered by a diaper. It is very common; almost every child will get a diaper rash at some point before they are toilet trained. The rash is caused by skin contact with ammonia, moisture, and bacteria from urine and stool in the diaper. Episodes of diarrhea can cause diaper rash in most children.

The most common type of diaper rash is red, and is located primarily in areas where the child’s skin touches the diaper. This is called an irritant diaper rash as it is caused by skin contact with irritants such as urine or stool. In general, this rash does not extend into the skin creases of the legs.

A yeast diaper rash is red and raw, extends into the skin creases of the legs, and is surrounded by small red dots. This is caused by infection with Candida albicans, a fungus. If you are treating your child for an irritant diaper rash and it is not improving, a yeast infection may be present.

If there is no rash present, most babies do not need diaper cream. However, if your child has diarrhea it is a good idea to apply a barrier cream with zinc oxide (such as Desitin or Balmex) with every diaper change to prevent rash.

5: West Nile Virus

Transmission of West Nile Virus to humans:

Spread to humans occurs by the bite of mosquitoes infected with West Nile Virus. You cannot get West Nile Virus from another person.

The likelihood of getting sick with West Nile Virus if you are bitten by a mosquito is very low:

Less than 1% of mosquitoes carry the virus. If a mosquito is infected, less than 1% of people who are bitten and become infected will become severely ill. The chance of becoming very ill from West Nile Virus after a mosquito bite, even in areas known to have infected birds and mosquitoes, is significantly less that 1 in 10,000.

Symptoms of West Nile Virus infection:

Most people (80%) who are infected with West Nile Virus will show no symptoms.
Approximately 20% of those infected develop a mild illness called West Nile Fever. Symptoms include fever, headache, body aches, skin rash, and swollen lymph glands. Symptoms generally last from 3-6 days and resolve on their own.
Severe disease is called West Nile encephalitis. This is very rare and occurs most often in the elderly. “Encephalitis” means an inflammation of the brain. Symptoms include severe headache, high fever, neck stiffness, disorientation, coma, stupor, convulsions, and muscle weakness.
Pregnant women are at increased risk of severe disease due to alterations in the immune system during pregnancy.
Children or adults on immunosuppressive medications are at increased risk of severe disease if infected with the West Nile Virus.

Treatment of West Nile Virus infection:

Research is currently aimed at developing a vaccine and anti-viral therapy to treat West Nile Virus infections. Currently, only supportive therapy is available including hospitalization, IV fluids, and respiratory support as needed.

The time from infection to onset of symptoms for West Nile Virus:

Usually 3-15 days.

If a person contracts West Nile Virus once, can they catch it again?

No, it is assumed that immunity will be lifelong.

How to reduce the risk of becoming infected with the West Nile Virus:

Use an insect repellant containing DEET (see below) whenever contact with mosquitoes is possible. No other insect repellant has been found to be as safe and effective as DEET in children.
Spray clothing with repellants containing DEET since mosquitoes may bite through thin clothing.
Stay indoors at dawn, dusk, and in the early evening. Wear long pants, long-sleeved shirts, socks, and shoes if you are outside during these hours.
Wear dark-colored clothing.
Do not wear perfume or scented body lotions.
Reduce local mosquito populations. The most effective way to do this is to eliminate sources of standing water such as old discarded tires, clogged gutters, bird baths, flower pots, wading pools or tree stump holes. Backyard bug “zappers” and ultrasonic devices are NOT effective in preventing mosquito bites.
Make sure that children do not touch dead birds. It is recommended that an adult wear gloves and double-bag the bird before disposal.

Recommendations regarding the use of insect repellants containing DEET in children:

The percentage of DEET in an insect repellant is important. A product that contains 5% DEET will protect against mosquitoes for approximately 1 hour, 10% for two hours, and so on. You must reapply repellant accordingly to have continuous protection.
Spray an insect repellant containing a high percentage of DEET (20%-40%) onto the clothing of children of all ages.
If your child is between the ages of 1 and 12 years apply a repellant containing 12% or less DEET to the skin. Reapply at least every 2 hours.
If your child is above age 11, apply a repellant containing between 20%-50% DEET to the skin.
Do not apply insect repellant under clothing, to children’s hands, near eyes, on lips, or to broken skin.
Once indoors, wash areas well with soap and water where DEET was applied.
Do not buy products that contain both DEET and sunscreen, as DEET may decrease the effectiveness of the sunscreen. Buy these products separately.

Insect Repellants (Reapply every two hours)

Product Name

Active Ingredient

To be used on the clothing of children of any age, and on the skin of children age 12 and up:

Off! Deep Woods

Sawyer Controlled Release

Ultra Muskol

Cutter Unscented Cream

Cutter Stick

DEET, 23.8%

DEET, 20%

DEET, 40%

DEET, 35%

DEET, 30%

To be used on the skin of children between 1-12 years of age:

Off! Skintastic

Off! Skintastic for Kids Unscented

DEET, 6.65%

DEET, 4.75%

Call our office if:

Your child experiences severe headache, neck pain, confusion, or disorientation.
Your child has fever for greater than 3 days.
Your child has a rash that you do not recognize.
You have any questions or concerns.

Where can I find out more?

Of course, feel free to ask your doctors at Glenbrook Pediatrics or feel free to check out the websites maintained by the National Pediculosis Association and the HarvardSchoolof Public Health: www.headlice.org or www.hsph.harvard.edu/headlice.html.

8: Travel Tips

Are you traveling this season? What will you do about motion sickness? Are you worried about flying with a baby? These and more are common questions plaguing families especially during high travel seasons.

Let’s start with Air Travel. Is it even safe to fly with a baby? The answer is yes, most of the time. Early on pediatricians worried about newborns flying in airplanes which hadn’t been pressurized well. These days, however, cabin pressures approximate what would be typical at 5000-8000 feet altitudes (similar to Denver, Colorado). Health babies should have no problem with these levels. However, any baby with severe anemia, congenital heart disease, abnormal lungs, or sickle cell disease may indeed have problems during a flight. If you have any concerns about your child feel free to ask one of your doctors at Glenbrook Pediatrics.

And what about the Ears? This is actually much less of a problem than is widely feared. Even children with active upper respiratory infections, allergy congestion or ear infections are safe to fly. In fact, ear pain in children during or after flying is fairly infrequent and doesn’t ever cause permanent damage. Studies have shown that decongestants and nasal sprays are not helpful in children even though they may provide some relief to adults.
It is also not necessary to feed a child during take-off and landing. The theory was that swallowing more would open Eustachian tubes (the tube that connects the middle ear with the posterior pharynx or throat) and allow less ear discomfort. While this may be true in small part, you have to remember that if the child is asleep, he or she is not feeling pain, nor will they later. In addition, feeding and sucking add more air to intestines. This may lead to bloating similar to what babies with colic may experience. Your best bet is to feed your baby or toddler on his or her own regular schedule. Avoid overfeeding and all will be happier…including the families traveling with you on the airplane.

What about germs on a plane? The risk of catching colds or other illness is low but possible given close quarters on planes. It is worthwhile in these days of airliner cutbacks to consider bringing your own pillow or blanket. These items are being changed over less frequently, which may allow for some germ transmission from previous passengers to you. Some viruses are able to survive on surfaces such as countertops and hand towels for hours. Frequent hand washing and avoiding sharing of sippy cups and water bottles will help you out as always.

What if My Child Experiences Motion Sickness? Great question. How do you even diagnose this problem in a child? Well, generally, motion sickness in a child looks pretty similar to an adult’s symptoms. The child may complain of dizziness, vomiting, pale or clammy skin, and even some lack of coordination. Most commonly this is seen between 4 and 10 years old and can be associated with air, car, or water travel as well as rides at an amusement park. It is cause by a mix-up in the brain receiving conflicting signals from our eyes and our vestibular system (which helps us to maintain our balance). One sense may be telling the brain that it is moving while the other feels like it is not moving.

How do I treat Motion Sickness? Prevention is usually the best tool for reducing this malady. What can you avoid?
*Cigarette smoke
*High fat foods
*Salty foods
*Crowded or poorly ventilated spaces
These factors are all known to increase one’s risk for travel sickness. Safe ways to treat motion sickness include the following:
*Ask for a center seat in a plane or boat…there tends to be less turbulence.
*Try to avoid any heavy or salty meals prior to travel. In fact, if your child can eat a light meal three hours prior to traveling that will be best. Try to serve only light meals during the trip, if possible.
*Focusing on outside objects (like the horizon) to diminish motion sickness. This means try to avoid letting them watch TV, play handheld videos or reading.
*Encourage older children to lay back or limit head bobbing. The head motion may well add to the mixed signals our brain is receiving from our senses.

Are there any medicines to try? A few are possible. Probably the safest drugs available are the antihistamines. No one knows exactly why they work but we do know they may help. Medicines like Dramamine or Benadryl are commonly used. Primarily they cause side effects such as drowsiness, dry mouth or eyes and constipation. However, some children may have the opposite effects and become irritable or agitated. Talk to your doctor about proper doses for these medicines. Other popular medicines such as Bonine or Antivert, Scopolamine (Hyoscine or transderm scop patch) have not been studied in children under 12 years old and thus cannot be recommended.

Are there any non-drug therapies to try? Yes. Ginger root, which comes in capsules, powders, or teas, is promising. It has already been approved in some European countries for the purpose of relieving motion sickness. It is available in the U.S. mainly in grocery stores and health food stores and has no known adverse reactions. The biggest downside is that these formulations of ginger do no fall under the F.D.A. regulations as far as quality control. Nevertheless, the doses for a 3-6 year is 250 mg per day taken one hour prior to traveling, 6-12 yr is 500 mg/day taken one hour prior to travel and greater than 12 year olds would take 1000 mg/day.

Alternatively, acupressure has been shown in scientific studies to have some benefit. Many believe that stimulation of points on the wrist can produce an anti-nausea effect. Many studies show that this effective for preventing vomiting prior and after surgery in adults. One study showed benefit in controlling seasickness. There are many commercially available wristbands, which make use of this principle. Again, there are no known adverse effects. Lastly enjoy your trip. Have a safe and happy traveling season from Glenbrook Pediatrics.

9: International Travel Tips

International travel is a wonderful opportunity to learn about other cultures, and is certain to be a memorable family experience. Here are a few suggestions to help ensure a healthy trip as well.

The first step in preparing for the trip is to assure that everyone in the family is up to date on the usual immunizations. Immunization coverage is low in some developing countries, so the risk of acquiring illnesses such as pertussis and measles is higher. A physician visit at least 4-6 weeks before the trip is recommended to review health records and update standard immunizations.

The most common illnesses seen in travelers are those we see here at home, such as colds, stomach flu and sore throats. The crowding in airports and fatigue associated with travel may make you and your children more susceptible to these illnesses. Wash hands frequently, drink plenty of fluids and rest as much as possible. We are happy to speak with you by phone to discuss questions about your child’s illness. As when you are at home, we will recommend that you see a physician if your child seems very ill, or if a prescription medication may be needed.

The risk of infectious illness varies depending on the region to which you are traveling. Travelers to Canada, Western Europe and Australia are likely to encounter only the same illnesses seen in the United States. This is also true of many urban areas in Asia and South America. In areas with crowded living conditions and poor standards of water sanitation, and in rural areas, the risk is higher.

Hepatitis A is a common foodborne illness in developing countries. An effective vaccine for Hepatitis A is available for adults and children >2 years old. It is given in 2 doses 6 months apart, but partial protection is provided within 2-4 weeks after the first dose. Children less than 2 years old should receive immune globulin to protect them from hepatitis A. They are protected immediately after the injection, and the effect lasts for 3-5 months.

Travelers’ diarrhea(TD) occurs commonly in travelers to Latin America, Africa, the
Middle East and Asia. It is acquired by eating food contaminated with bacteria.
Symptoms include loose stools, bloating, nausea, abdominal cramping and fever.
Most affected travelers have 4-5 watery stools per day, and the illness usually lasts
3-4 days.

The best way to prevent TD is careful food preparation. Eat only well cooked food, and fruits and vegetables that you have peeled yourself. Drink only bottled or boiled water. Avoid tap water and ice cubes. Avoid dairy products unless you know they have been pasteurized. We do not recommend giving your child preventive antibiotics, since it is impossible to predict which germs he or she might contract. Pepto-Bismol is sometimes used to prevent TD in adults. We do not recommend giving Pepto-Bismol to children, because it contains aspirin. We also do not recommend giving your child anti-diarrhea medications such as Lomotil, as these may actually make the illness worse.

Children with travelers’ diarrhea usually have a short illness lasting 3-4 days. The best treatment is simply replacement of the fluids and salts lost in the stools. Thiscan be accomplished with oral reydration salts (ORS), which come in packets and can be purchased here to bring along on the trip. The packets are also widely available in stores in most developing countries. The powder is added to boiled water according to the instructions on the packet, and the child drinks the fluid to prevent or treat dehydration. As long as your child is not vomiting, he should continue to eat his normal diet, in addition to the ORS. We recommend that you seek medical attention if your child is lethargic, has decreased urine output, bloody stools, fever >102 or persistent vomiting.

Insect borne illnesses are prevalent in some tropical countries. The most well known of these is malaria. The Centers for Disease Control website (www.cdc.gov/travell) is an excellent source of information regarding malaria risk in different areas of a given country. If you are traveling to a malaria infested area, you will need to take a medication to prevent malaria infection. We will refer you to a travel clinic to determine which anti-malaria drug is appropriate for that region. Even if you are not traveling to a malaria infested area, it is important to avoid insect bites. Bring along an insect repellant that contains DEET, and apply it daily to exposed skin. It is saf& to use DEET in children >2 months of age, but children should use repellants containing <10% DEET. Wear long sleeves and long pants, especially in the evening. Wear shoes at all times. If you return from a malaria infested area and your child has an unexplained high fever, please call us. We will do the appropriate testing to determine whether malaria is the cause of the illness.

Be cautious of dogs in developing countries, as rabies is more common than it is in this country.

You may want to bring along a Traveler’s Health Kit with useful first-aid items. This should include:

We can immunize your child against Hepatitis A in our office. If other vaccines or malaria prophylaxis are required, we will refer you to a travel clinic. Nearby clinics include:

For additional general information about travel, see our Travel Tips handout, or the CDC website at www.cdc.gov.

1: INFLUENZA