GERM
00:00:09.040 – 00:00:11.400
Yutta Hey everyone, My name is Germ.

WORM
00:00:11.400 – 00:00:12.320
I’m Worm.

GERM
00:00:12.640 – 00:00:25.360
Welcome to the Germ and Worm Travel Health Podcast. Episode 70 Traveling Safely with Kids. I’m Dr. Paul Pottinger, also called Germ.

I’m a Professor of Infectious Diseases at the University of Washington in Seattle.

WORM
00:00:25.610 – 00:00:33.690
I’m Dr. Chris Sanford, also known as Worm, Associate Professor in the Departments of Family Medicine and Global Health, also at the University of Washington.

GERM
00:00:33.930 – 00:07:16.470
Chris, we’ve been looking forward to this episode for such a long time because we have a very special guest speaker, Dr. Sheila Mackell, a recognized expert in the field of pediatric travel medicine. I’m gonna have you give her a formal introduction in just a moment.

Today we’ll have her perspective on all kinds of important topics related to keeping kids safe, happy and healthy when they travel with their parents or otherwise overse seas. I’m really looking forward to this conversation. Our humble request for our listeners, of course.

Please visit us online to share with us your questions about travel health. The best way to reach us is online germandworm.com there you’ll find a portal to send us questions.

You can also search our previous content and binge our episodes to your heart’s content. We look forward to having you on our website.

Our Medical Disclaimer this podcast is designed to inform, inspire and entertain, but you should not use this podcast as clinical care before you or your family members travel. Please see a qualified healthcare professional for recommendations specific to you and your itinerary.

Now, Chris, we’ve also recently started a new section and I want to continue that tradition. It’s called why you should go. Last time you talked about Peru and all the great reasons to go to Peru.

Today it’s my turn and I want to talk about why you should go to Nepal. I’m lucky to have visited Nepal three times, and I’m looking forward to returning again soon.

This is a fascinating country for those who have not visited. A very rich history, a lot of natural beauty, and I do recommend that everyone at least consider a trip to Nepal.

The country of Nepal is a funny little place because it’s squeezed between two giants. A small country between India to the south and China to the north. It’s the world’s most mountainous nation.

The Himalayas are, well, literally squeezed up from the ground as two tectonic plates collide. And that’s why the mountain range continues to grow to this day at about the same rate as a human fingernail. Small, slow, but inexorably getting higher and higher.

But there’s more to Nepal than the mountains Actually, in terms of its natural beauty, you have jungles and plains down to the south to literally the highest heights in the world up farther to the north. And of course, that’s an important reason to go, isn’t it? To enjoy the natural beauty of the land of Nepal. And it is incredibly diverse.

If you plan to see the lowlands and the highlands, you’re going to need to prepare for different ecosystems. You can go from hot, sweaty jungle to what, literally some of the coldest places in the world, rice paddies down low.

And as you ascend on a trek, for example, you may go through several different ecozones in the same day.

Not unusual, for example, on a trek in the Annapurna circuit, to go from the rhododendron forest into a conifer situation, higher to alpine and even potentially glaciated terrain all in the same day. You could have that happen on an Annapurna trek or a trek to Everest base camp.

But of course, the main reason to visit Nepal, the people remarkably friendly, welcoming, and really curious about your perspective as an outsider visiting Nepal for the first time. Now, some Nepalese citizens have traveled the world, but many have not.

The economic poverty of Nepal is a very real factor and a real phenomenon, and that has limited international travel for many of the people who live there.

Regardless, they more than make up for that with their ethos of sincerity, warmth, and, of course, cultural riches that go far beyond whatever economic riches are there. Yes, there’s a good museum situation, but this goes well beyond that.

Just walking the street, you’d be exposed to religious iconography and this long history that surrounds you.

You cannot avoid it, even if you try, and I hope you wouldn’t try, because especially with the guidance of a skilled and trusted local guide, you’re going to get so much out of the experience, both in city life in the capital of Kathmandu and also in smaller villages as well. Now, Hinduism and Buddhism predominate in this nation of about 30 million people.

That makes it, by my count, about 1/10 the population of the United States, although its physical size is 1 67th that area. That means that there are some parts of Nepal that are very crowded, and I do include Kathmandu that way.

The greater Kathmandu area has about 4 million people there. Please spend time in Kathmandu. It’s incredibly interesting. It’s fascinating. It’s a busy, crowded city and all the good and potentially problematic things that come with that.

I would hope that visitors would also consider going to smaller communities outside of Kathmandu, where you might be able to spend quality time with people in their own family context and on their own land. So a lot of reasons to go to Nepal. Are there reasons not to go? Well, not really.

The reality is that they do have a difficult political situation and periodically there can be unrest in the general population because their political voice is not heard as much as it should be. That means that national strikes can happen. They’re called bandas. And if you do your homework ahead of time, please do.

You can understand whether there may be a banda coming. I recommend that everybody going to Nepal register with the embassy so that they know that you’re coming.

It’s not that they’re going to keep track of you, but rather you get onto an email list so that if there is some kind of a problem with the transit system, etc. You can get that heads up ahead of time and potentially move your trip.

A trip to Nepal, in my opinion really should have trip insurance because there can be some of these difficult to predict issues. Having said so, if you’re going to avoid traveling during a banda, are there other reasons not to travel? No, not really.

You should just understand that because it’s such a mountainous area and relatively close to the Bay of Bengal. Yeah, weather is a thing. In the summertime when Americans tend to be on holiday on vacation, that’s a popular time to leave our country.

But in the country of Nepal, beyond the month of May, that’s monsoon season. The monsoons are rains down low and snow up high. And it’s, it’s beautiful, it’s what keeps the land green. But it means that you might be hiking or trekking in the rain. So you need to figure out the season of your travel as well. That’s something that’s worth looking into.

Finally, in terms of staying safe from infections. Yeah, there’s infections there. You deal with it. Some of the lowland areas have malaria.

You can take a pill and use personal bug avoidance measures to be good with that. And in many parts of Nepal, there is an elevated risk of travelers diarrhea, foodborne illness. So please talk with your doctor about this.

Typhoid shot or pill is a great thing to do, but other simple things you can do to protect yourself from foodborne illness, that’s worth a conversation with your healthcare provider. If you do choose to visit Nepal, we’d love to hear from you. It’s one of my favorite places.

And if you’d consider dropping us a quick note, we would appreciate it. The best way to get us is online.

Germandworm.com Okay, now Chris, I’m going to pivot to you so you can give us an introduction to our speaker, Dr. Sheila Makell.

WORM
00:07:16.630 – 00:07:46.200
We’re delighted today to be talking with Dr. Sheila Mackell. Dr. Mackell is a pediatrician living in Flagstaff, Arizona.

Dr. Mackell is an international authority on travel health, specifically children’s travel health. She is the author of multiple journal articles and chapters in medical textbooks on pediatric travel medicine.

She’s also worked extensively abroad, really on all continents, doing medical work, which I’m curious to hear a little more about. Dr. Mackell, thank you much for joining us today.

Dr. Mackell
00:07:46.520 – 00:07:54.120
Thanks to you both. Really happy to sit and chat with you about what’s near and dear to me, and that’s pediatric travel medicine.

WORM
00:07:55.330 – 00:08:05.090
Thank you.

Before we get into some advice for traveling children to keep them healthy, first personal question or two in your personal life, where do you like to travel to?

Dr. Mackell
00:08:05.250 – 00:08:33.200
I actually I will tell everyone I like to go places I haven’t been before. And I like to go places where it’s kind of challenging to travel, recognizing that as I get older that those places might not be as accessible.

And I really like the outdoors and I love being on a river, as you might know. And so I have no one special place, but I like to explore all unexplored places.

WORM
00:08:33.760 – 00:08:37.600
And speaking of river travel, how many times have you floated the Grand Canyon?

Dr. Mackell
00:08:38.160 – 00:08:57.370
Well, I have a personal in on that, as I think, you know, in over 30 years, I think I’ve been probably 12 times, mostly thanks to my husband who guides there professionally and non. And so I’ve had a great opportunity to be on all kinds of river trips on the Colorado.

WORM
00:08:57.930 – 00:08:58.650
You married well!

GERM
00:08:58.650 – 00:09:07.570
Well, I really, really need to find out what his beverage of choice is and get him a case of it because I’ve never floated it. I need to set that up. That’s exciting, Sheila.

WORM
00:09:07.570 – 00:09:15.130
So I was going to ask too. Sheila, I know this. You could fill up the whole episode with this. But what are some of the places where you’ve done medical work overseas?

Dr. Mackell
00:09:15.690 – 00:10:23.290
Well, Chris, early in my career as a pediatrician, I got really interested in doing some international medicine. And so in the 90s, I traveled with various medical clinics, surgical clinics, public health groups.

And I sort of settled which fit in my schedule the best with my family to just do a couple weeks a year with one of the surgical teams somewhere else. So I have continued that through my career, usually once or twice a year.

And now that I’m not actively in the clinic, I go four or five, six times a year. It just depends how many times I’m offered. Most recently, I was in Morocco and Ghana, Madagascar.

I’ve had this incredible privilege to accompany these very skilled surgeons in treating and helping kids with surgical mostly cleft lip and palate, but also burns and other congenital issues. It’s been an amazing way to see the world because usually on one end or the other I can explore a little bit where I am.

WORM
00:10:24.050 – 00:10:25.970
Wow. Well, good for you for all your work abroad.

Dr. Mackell
00:10:27.010 – 00:10:27.810
Lucky me.

GERM
00:10:37.090 – 00:10:51.420
Thank you so much. Super inspiring. A question for you about the upsides and benefits to kids when they travel internationally. Not the threats, not the dangers, but the good things that you see as a pediatrician guiding people on international trips.

Dr. Mackell
00:10:51.420 – 00:11:56.550
That is a really great question. And so much of the time we spend talking about all these exotic travel related things.

But there’s so many positives that go along with travel and between resilience and independence are really important things for kids in life skills and from a young age to be able to go places, interact with people, diverse groups that you may not have in your own home. It really adds to the cognitive development of children and their cultural development.

Families just the positives that they enjoy with traveling with their kids are so big and it’s challenging and it’s inspiring to watch these families do this with their kids, very young kids to even more challenging sometimes taking your adolescents. But all of that adds to their own life experience that hopefully they can use as a, as a lesson, a learning lesson.

GERM
00:11:57.030 – 00:11:57.910
Thank you for that.

WORM
00:12:06.390 – 00:12:22.710
We’re seeing some interesting divergence now between CDC vaccine recommendations and recommendations from professional societies such as aap, American Academy of Pediatrics. Can you touch on some of these now diverging interesting recommendations?

Dr. Mackell
00:12:23.350 – 00:13:47.260
Well, as we know it’s a very evolving climate regarding immunizations.

The Academy of Pediatrics and Family Medicine and Internal Medicine and we are all working really hard to maintain our evidence base and activity in promoting vaccines that we know have been tested for safety and efficacy.

And many of us, and so we are working very diligently with all these organizations to promote this personally in our lives and in our professional lives.

The divergence is coming with some of the recommendations that are coming out and it’s extremely pertinent because we’re looking to expect some changes in the pediatric schedule that we may not actually feel are evidence based.

I would tell everyone to really please stay tuned, talk to your pediatrician and really understand that those of us who have been practicing for a while have seen many, many, many of these illnesses.

In fact, those of us who practice travel medicine probably have even seen more of them that we don’t often see in the US and those we feel the safety and necessity of vaccinations can’t be understated.

GERM
00:13:54.060 – 00:14:10.920
Well, along those lines, which I really appreciate that. And along those lines, let’s talk about malaria. Not currently vaccine preventable, but we do have medications to reduce the risk of malaria. What about kids, can and should kids use antimalarial preventative medicines?

Dr. Mackell
00:14:11.240 – 00:15:58.570
Absolutely, Paul, that’s a really fantastic point to bring up because malaria is, as we know from our travel, our travel world can be a deadly disease and it’s still a tremendous killer of children in Africa, particularly sub Saharan Africa. And the prevention measures we discuss with families are personal protection measures and physical measures.

And then medication measures and medications for malaria have been used and are safe to use in children all the way down to five kilos. You know that it’s, it’s there, there’s different options, it’s complicated.

And I won’t say, and this is not for the light hearted because if you have a group of children in your family, they may need different types of medicines, they may need different medications, different schedules and none of the medicines are actually very child friendly. They’re none of them come in a liquid form. So it involves crushing them up and hiding them something that’s palatable or mixing them in something.

Even for infants in breast milk, a breastfeeding mom unfortunately can’t take a medication that will transmit enough medication in the breast milk to protect the baby. Babies newborns also need anti malarials when they travel.

I might make a word about the malaria vaccine because some people may read about the malaria vaccine which has been deployed in a handful of countries in sub Saharan Africa with really excellent results. We don’t think that’s going to be part of our travel armamentarium.

But there is a vaccine that’s, that’s now available for folks who live in endemic countries who are at high risk in their childhood years for malaria.

GERM
00:15:58.890 – 00:16:01.130
It’s such an exciting time for that reason.

WORM
00:16:08.340 – 00:16:18.740
And on the same topic, a related topic, what about bug repellent in children? Can they use it? And what’s the, what’s the best one and how should they apply it?

Dr. Mackell
00:16:19.860 – 00:18:02.880
That’s another great question. Insect repellents are registered with the EPA and they are safe to use in the same repellents we use in adults.

DEET at a concentration of up to 35% is safe to use. The lower concentrations are also available. They just don’t last quite as long.

So they are, they are registered down for babies as young as two months of age. So DEET is definitely recommended as the primary repellent along with Picaridin.

The higher concentrations of Picaridin also are safe and effective against malaria in children. Other options A lot of people don’t want to put pesticides or DEED or anything on their children.

And you know, we respect that when you’re in your backyard.

But when you’re dealing with infections like malaria and dengue and all the other arboviral diseases, the using an effective, well tested and safe repellent is really what we recommend. The other things we want to do is maximize all the other things we can use.

We can treat the clothing, we can treat use insecticide treated nets over car seats, over cribs. And it’s really a great idea to make sure you’re using all the option the options that can be obtained today.

But insect repellents are fine and the insect repellents we recommend are the same DEET and Picaridin. The others have either not been tested or not tested and effective against the mosquitoes were worried about.

GERM
00:18:07.680 – 00:18:22.240
Sheila let’s talk about everyone’s favorite topic. Diarrhea, traveler’s diarrhea in kids. If a parent is traveling with their child and they notice the child develops diarrhea, how should they treat that patient, that child?

Dr. Mackell
00:18:23.520 – 00:20:44.990
Well, Paul, that is also parent kids and diarrhea that it happens. And we don’t need fancy definitions for pediatric travelers.

Diarrh families know it and unfortunately the focus of the literature has never been to really delineate what the parameters are in children. So we’ve gone clinically with the standard advice. It’s all about hydration.

It’s about getting your child to drink and have an adequate amount of urination, which is generally maybe every eight hours or so. Make sure that they’re able, that they’re drinking, that if they want to eat, they can eat some food. There’s no restriction.

There was the old, the old adage on the brat diet. Bananas, rice, applesauce, toast, really not recommended because it’s just so low in calorie and density.

But if they want to eat to keep them hydrated, to recognize that it’s sometimes a trip interrupter for families, you have to sort of work around this. And one of the unrecognized issues is how severe diaper dermatitis can get pretty quickly.

So understanding how to treat that have the things you need to treat it, some hydrocortisone, maybe an antifungal and discontinuing any irritant wipes just to be sure. Now if it gets severe, it really does dovetail into talking about how to get medical care. What would you do if you have fever? Blood in the stool?

Most of us would recommend a single dose of an antibiotic. We recommend azithromycin, as is recommended for adults. And the nice thing about that is that it comes as a powder that’s unreconstituted.

Families can use it if they need to use it. Most of us who are commonly prescribing that and urging don’t take it unless it’s super severe, as with adults, because it’s not going to fix it.

Lots of things that are going to run their course, but a lot of families want that in their back pocket just as a safety measure.

It also brings up some good discussions about medical care abroad and how you would access that and what you might need to think about in terms of if anybody gets ill in your family while you’re away.

GERM
00:20:45.470 – 00:20:47.470
It’s very helpful. Thank you so much.

WORM
00:20:53.290 – 00:21:06.570
In the US when we think about auto safety for children, we talk about things like booster seats and car seats and seat belts. When traveling abroad, what are considerations for auto safety for children?

Dr. Mackell
00:21:08.250 – 00:22:31.620
Pretty much the same thing. We always try to talk about safety because like I said in the beginning, we like to talk about all these fun, exotic things that we’re all interested in. But really safety with kids and all the safety aspects are worth spending some time on.

So urging families to take a car seat if they have a child whose car seat age, which is under two and even older, if they have a booster seat available cars in other countries, it’s important to do a little research and see what kind of transportation you’ll be taking if there’s a car to see if it has the latches or the seat belts. Understanding how to use it and just that a car seat matters is what we try to talk about.

A booster seat is nice because it’s a lot easier to travel with. There’s a lot of things now where you can get a stroller that turns into a car seat and it actually folds and goes into the overhead bin.

It’s super slick. And I’ve seen quite a few of those on airplanes. And I think that it’s, it’s great to talk about. And families don’t often think about it.

In fact, they’re like, well, nobody uses car seats where we’re going to.

And again, it’s an opportunity to just say, well, car safety, auto safety is probably as important as all the rest of the things we talk About Excellent.

WORM
00:22:31.620 – 00:22:31.980
Thank you.

Dr. Mackell
00:22:31.980 – 00:22:36.820
Yeah, trying to encourage that. And if there’s a seat belt for sure, put it on.

GERM
00:22:44.020 – 00:23:00.990
In a follow up to that. That not terribly different, but still super important. Water safety. If you have someone who’s planning to have some kind of water experience.

Sheila, I’m thinking the context of a swimming pool or a river or lake or the ocean. How do you advise those families, please?

Dr. Mackell
00:23:01.550 – 00:23:51.240
Well, the list of water safety points for families, it’s nice to hand it as, give it as a handout, but things like don’t assume the pool depth. You know, feed first entry only.

If you have young children, no matter what, look at the access to any body of water, be it a pool or a lake or an ocean. If it’s accessible.

You need to think about safety just like we have to here at home when with pool fences, swimming lessons, early PDFs for PFDs for kids. If you’re not sure you can get one, you should bring one or see if you can buy one where you’re going.

Just elevating the water safety during vacations is an important thing for parents to think about.

GERM
00:23:51.640 – 00:23:52.600
Thank you so much.

WORM
00:24:00.040 – 00:24:12.060
And you mentioned diaper dermatitis is not being a rare issue to deal with. What are some other both sun protection and skin issues that parents should be aware of during international travel?

Dr. Mackell
00:24:13.580 – 00:24:43.600
The common things are common.

So diaper dermatitis, other itchy skin rashes and heat rash from different climates and the other common things, they’re all sort of taken care of with the same component of creams and care. So caring for insect bites, let’s see, diaper dermatitis, insect bites and heat rash are really on my top three.

GERM
00:24:51.040 – 00:25:05.080
Could I ask a follow up question to that? For sun protection in let’s say a tropical sunny destination, do you have a preferred brand or formulation or kind of sunscreen that you recommend?

Dr. Mackell
00:25:05.560 – 00:25:57.720
There’s lots of baby formulated sunscreens which tend to be mineral based. And so we do tend, we do recommend the mineral based sunscreens of an SPF above 30, you know, 50 to 70 is adequate for sure.

But really thinking about the physical protection, there are really fantastic SPF clothing for kids that’s beach friendly and sun friendly and not too costly. So hats covering the skin, especially in the young babies who are, we don’t tend to recommend sunscreen in babies under six months.

We just recommend sun avoidance. So taking care of keeping that little tiny tender skin out of the sun to avoid the sunburn and sun damage.

WORM
00:26:06.920 – 00:26:27.320
Thank you.

And Sheila, I have a question on a different topic you mentioned before we started recording that you gave a presentation, an international presentation recently to Operation Smile.

Can you talk a little bit about your work with them and also for our healthcare providers in the audience, how they might get involved if they have interest?

Dr. Mackell
00:26:28.760 – 00:27:27.290
Sure, Chris. I’m really, really lucky to have worked with a number of organizations that do surgical care overseas.

And the push over the years is to teach everybody in the country to do this and sort of teach our way out of a job.

So we’re working with all the groups, all the different groups I work with to educate the folks that are actually giving the care in the country who may not have as extensive experience as some people who do this all the time in, in other countries to move that information forward.

And it’s really great to watch the evolution and it’s a real evolution of global health where you in 20, 30 years ago you just showed up and did it and left and now you are leaving it there and maybe working your way out of what you’re doing. And that’s really the goal.

WORM
00:27:36.580 – 00:27:55.620
Well, I wanted to thank Dr. Sheila Mackle for joining us today and sharing her expertise.

I suspect that in a year, Sheila, we’re going to be hitting you up for yet another interview because we continue to get questions about international travel and children. But for now thank you so much and and hope to see you soon.

Dr. Mackell
00:27:56.420 – 00:28:29.210
Thanks Chris.

And if I might just say to your the audience, if anyone in particular, all people are welcome to look at the International Society of Travel Medicine (ISTM).

The Pediatric Interest Group is putting out specific TIP information for each age group of travelers, helpful hints for all over the travel all across the globe, input from experts around the world on infant travel, toddler travel, adolescent travel. I’d really highly refer everybody to take a look at that.

WORM
00:28:29.690 – 00:28:39.690
Thank you. And you mentioned AAP American Academy of Pediatrics as being a reliable and evidence based source for recommendations for immunizations and other topics.

Dr. Mackell
00:28:40.410 – 00:28:43.370
Absolutely. Thanks for thanks for that plug too.

WORM
00:28:44.090 – 00:28:46.650
All right, Dr. Mackle, thank you again. All best.

GERM
00:29:03.640 – 00:29:39.540
Well that’s a wrap for episode 70 of Germ and Worm. Special thanks to our very special guest, Dr. Sheila Mackell. And thanks to all of you, our listeners for joining us. We appreciate having you here.

We’d love to hear from you.

Let us know if you have questions of your own about travel, health, travel, wellness or if there’s something you just want to hear from more about that we’ve already discussed.

Reach out to us by our website germandworm.com there you’ll find a communications portal to us and also all of our previous content that you can binge to your heart’s content. Please share your love of Germ and Worm with friends, family and on social media. That’s a great way to support our podcast. I’m Germ.

WORM
00:29:39.700 – 00:29:42.900
I’m Worm. It’s a big planet. See it in good health and we.

GERM
00:29:42.900 – 00:30:07.380
Look forward to seeing you all next time.

This podcast is is designed to inform, inspire and entertain, but it does not establish a doctor patient relationship and therefore it should not replace your conversation with a qualified healthcare professional. Please see one before your next adventure.

The opinions in this podcast are Dr. Mackell’s, Dr. Sanford’s, and Dr. Pottinger’s alone and do not necessarily represent the opinions of the University of Washington or UW Medicine.