Will she remember this when she grows up?

Chasing Daddy around temple in Shanghai

This was a question that many friends and coworkers asked me when I told them what I was planning for my 3 month sabbatical last year. We were about to embark on a multi-country, “around the world”  trip with a toddler in tow.  I knew it wasn’t going to be easy with a 3 year old but I was willing to risk it for the sake of having these once in a lifetime experiences.  But was she going to remember the places we would visit or the people we would meet?

Traveling with young children requires you to slow down and prepare for the unexpected.  Children love routines and traveling takes them out of their comfort zone.  A different bed, place, and time zone throws off their sleep routines. It takes longer for children to adjust to a different time zone.  I tell families to expect it to take up to a week for their child to start sleeping well again.  Unfamiliar foods can also be difficult for young children to eat.  Overtired and hungry is a formula for toddler meltdowns.  We sure had our fair share of these tantrums towards the beginning of our travels.

What always surprises me about kids though is their RESILIENCE.  Children deserve more credit than what they are given.  When one of our flights in the Phillippines was delayed for 3 hours, we had to sit in a 90 degree room with no air-conditioning in a tiny airport.  My 3 year old daughter just had fun visiting the tiny gift shop 20 times and looking at the pictures and videos we had taken on our ipad.  Then, when we were told that our flight was cancelled because of “lack of sunlight” and that we would have to spend the night in a nearby hotel, she again was happy just with the thought of going swimming again.  As long as children are fed and rested, they can handle more than you could imagine.

What I realized through my travels is that my daughter relished just BEING with us and having our FULL attention.  When we are home, we are constantly distracted by work and house chores.  Technology also takes our attention away from the people we love most.  When we are away from home, we play games, explore new playgrounds, hold hands, and just simply talk to each other more.   I also saw my husband develop a stronger connection with my daughter that has continued to last, even 6 months after our return.  She no longer demands that I be the one to put her to bed every night or that I be the one to help give her a bath.

Taking a child on an international trip has its pros and cons.  We were not able to stay out past 9 pm or do any adventurous activities.  However, my daughter did get a chance to pet an Australian koala, float (while we snorkeled) in the water on the Great Barrier Reef, ride on a donkey up a volcano in the Phillippines, sit on a bamboo raft going down the Li River in Guilin, and see clownfishes swimming in sea anemones.  She was also able to give food to homeless Filipino street children, see a tarsier, the world’s smallest monkey, and taste the sweetest mangoes and lychees we’ve ever had.  She missed 3 months of school and we spent a lot of our savings.  But she was able to learn and experience things she could never learn in a classroom or at home.  And our connection as a family has deepened as a result. This is what I find most valuable about traveling with children .

Mosquitoes, a love hate relationship

They love me.  I hate them.  I seem to attract mosquitoes every time I go on a vacation to a warm place.  When I get a mosquito bite, my skin swells up like a giant tennis ball and itches like crazy for a week.  My husband never seems to get bitten. And if he does, the mosquito bites disappear after a few hours.  I don’t know why I am so unlucky.  Unfortunately, my 3 year old daughter appears to have inherited my genes in this respect.  The mosquitoes also love her.

Mosquito bites are incredibly annoying.  In many developing countries in Asia, Middle East, South America, and Africa, mosquitoes also carry deadly diseases, such as malaria, dengue fever, chikungunya, yellow fever, and Japanese encephalitis.  We are lucky not to have to worry about these diseases in the U.S.  However, I fear that travelers often forget about how common and dangerous these diseases are in other countries and don’t take the necessary precautions.

In my practice, I have many families who travel to India to visit friends or relatives and stay for many weeks at a time.  Malaria is endemic in ALL of India, rural and urban areas.  The disease is more common during the wet monsoon season, which is roughly June through September.  This coincides perfectly with our summer break, when most families take the time to take long international trips.  Parents will often tell me how they knew of someone who got malaria in India.

Getting malaria can be very scary.  Malaria usually presents as high fevers, chills, and flu-like symptoms, such as body aches and fatigue.  Malaria can also cause severe anemia, jaundice (yellowing of the skin), seizures, kidney failure, coma, mental confusion, acute respiratory distress syndrome, and death.  Children under age 5 are particularly vulnerable to these severe complications of malaria.  There are 4 different types of malaria, with Plasmodium Falciparum being the  worst type.  Infection with this species is known to cause rapid and severe illness.  In fact, infection with this type of malaria is considered a medical emergency!  Over the last 2 decades, the rates of Plasmodium falciparum infection is increasing in India with an estimated incidence of >40% of all malaria infections in that country.

The good news is that malaria is PREVENTABLE.  There is no anti-malaria vaccine yet but there are exciting new treatments in the horizon.  The Bill and Melinda Gates Foundation are developing some exciting new anti-malaria drugs. For now, the best way to prevent malaria is to take medications to prevent malaria called chemoprophylaxis and use insect repellants, such as DEET.  Most of these malaria prophylactic medications are safe, well-tolerated, and effective for people of all ages.  In addition, I recommend travelers use repellants with 20-30% DEET, even on infants as young as 2 months.  Use mosquito nets when your accommodation does not have window screens or air conditioning. Permethrin can also be applied to clothing and bed nets.  The type of mosquito that carries the malaria parasite tends to bite during the twilight hours, between dusk and dawn. Be careful when you’re visiting those night markets or having dinner at sunset.

How do you know if there is a risk for malaria at your trip destination?  Check the   CDC website.  If there is a risk, visit your doctor or a travel medicine specialist at least 2 weeks before your trip since some medications need to be started a couple weeks before you leave.  Since nausea or vomiting is the most common side effect with these prophylactic medications, take it with food and water.  You can also call your doctor and switch your medication if you get an unwanted side effect before you leave on your trip. Many parents are reluctant to give medications to their children.  I get it.  I usually don’t like giving unnecessary medications to children either.  But when I weigh the risk of my child getting a deadly disease, like malaria, with the possible side effects  of the medication, I would choose to give the prophylactic medication every time.

Malaria symptoms can develop as early as 7 days after initial exposure and as late as several months after departure.  If you have visited a malaria endemic area and come down with high fevers, don’t forget to mention your recent travel to your doctor.  Prompt diagnosis and treatment of malaria is life-saving.

Now what about the other bad diseases that mosquitoes can transmit? Like dengue fever or Japanese encephalitis?  Tune in for future posts on these mean and smart bugs!

Is the orphanage you are supporting a fake one?

Something I’ve learned about recently has made me very upset and concerned. Many well-intentioned people travel to developing countries to volunteer their time and donate their money to orphanages.   I completely understand this desire to help those less fortunate, especially children.  I am a pediatrician and seeing pictures of poor orphans make me sad. I have joined short-term medical missions to Mexico and Nepal in the past and have found these experiences to be profoundly rewarding.  But I am now discovering that these experiences have rewarded me much more than they have rewarded those I was serving.

Traveling to far-away places to help another community has become increasingly popular and a very lucrative business. However, I have learned that this business has also become another way to dupe tourists.  Fake orphanages have been fueled by the rise in voluntourism.  In Cambodia, a country that suffered tremendously 30 years ago by the Khmer Rouge, UNICEF discovered that the number of orphanages increased by 75% from 2005-2010.  What was shocking was that 77% of these orphans were not actually true orphans! Most of them had a living parent.  Many of these children are from poor families who give up their children in return for money or promise for a better future for their children.  Many poor Cambodian parents falsely believe that if they send their children to orphanages, they will have a better education, better access to medical care, and better nutrition.  These children are often asked to dance and sing for tourists.  They are asked to show a sad face and wear dirty clothes to seek more donations from tourists.  In Cambodia, this has become a multi-million dollar business. Most of the money are not going to the children, but to the orphanage directors.  And more and more children are being abandoned by their families and exploited as a result.  Some children are even being sold to adoptive parents from rich countries.  Cambodia is not the only country where this is happening.  Nepal has seen a surge in fake orphanages, especially in the aftermath of the recent earthquake. Indonesian orphanages are deliberately kept in poor condition to get more money from tourists.

Children, who are true orphans, are much better off in a foster care system and not in a residential care facility.  We all know this is true.  Why then do we continue to give money or volunteer at orphanages in other countries?  Many people who volunteer also have no experience and no background check.  This makes more children more vulnerable to sexual exploitation as well.  Is it VOLUNtourism or volunTOURISM?  There are some legitimate orphanages out there but it is difficult for the tourist to figure that out.  Asking a local NGO would be a first step.  Organizations that require a background criminal check and have strong supporting staff is also a plus.  Tourists love spending time with children.  But then leaving after a few days will continue the cycle of abandonment for orphans. I favor organizations that require a minimum time commitments of several weeks in order to truly make a positive impact on orphans.  I would also look for organizations that actively promote family reunification. Help poor families take care of their children, not take the children away from them.

Is this safe to eat?

Street food in Chinafrogs in singapore

One of my favorite things about traveling internationally is eating good food.  Our friends know that we love to eat street food.  The street food in Asia is delicious, cheap, and convenient.  In China, the street vendors sell juicy pork buns and meat skewers.  In Bali, bicyclists sell noodle soup with fish balls.  In Thailand, they sell fruit skewers with spiced pineapple and fresh mango pieces.  Most of our memories and pictures of our international trips are of the delicious food we eat there.   Much to my husband’s dismay, this all changed after our daughter was born and started coming with us on our trips.

When we brought our three year old to Asia, one of my main concerns was how to keep her from getting sick.  Like most mothers, I was more concerned about my child’s health than my own.  Most people who were born or grew up in a developing country know about the risks of eating street food but do it anyway.    I was raised in the U.S. while my husband grew up in the Philippines.   He has fond memories of the food he ate as a child. Bangus, fish balls, halo halo, to name a few.  Every time we passed a food stall in Asia, he would stop and buy a small bite to eat, even if the food looked a little sketchy and unhygienic.  And I would often give in and taste it as well.  I can never resist trying a new ethnic food.   Perhaps this is why I got “Bali Belly” mid-way through our trip.   Perhaps this is why the incidence of traveler’s diarrhea is very high in developing countries, roughly  30-70%, depending on where and when you go.  Along with respiratory illnesses, traveler’s diarrhea is by far one of the most common illnesses tourists get while abroad.

Bali belly.  Montezuma’s revenge.  Delhi belly.  Turkey trots.  Whatever you call it, traveler’s diarrhea is no fun when you are on vacation in a foreign land, where the bathrooms are places you try as much as you can to avoid.  Traveler’s diarrhea (TD) can be mild in some people or can be quite severe in others.  TD can often cause fever, bloody stools, vomiting, abdominal pain, and dehydration.  Young children are more likely to get dehydrated due to TD.  Young children are also more likely to get hospitalized due to traveler’s diarrhea.  Getting traveler’s diarrhea can more than ruin your trip.

The good news is that traveler’s diarrhea is preventable and treatable.  Most people have heard the popular saying, “boil, peel it, or forget it.”  This rule is a good one to follow with regards to food safety but there is more to know for travelers.  The CDC also has a helpful free app for travelers called “Can I Eat This?”

1.  Choose foods that are freshly cooked and piping hot.  Those meat skewers I saw in China may have been sitting around all day. Avoid raw meats or seafood.  Avoid raw vegetables.

2. Choose fruits that you can peel yourself or wash in clean, disinfected water.   The fruit skewers in Thailand are peeled but could still be contaminated by unclean water.  The fresh tomatoes in salsa in Mexico are probably not washed in clean water or peeled.

3. Avoid food from street vendors since their level of hygiene is generally poor.

4.  Drink only disinfected or bottled water.  Boiling water for 1 minute will  make it safe to drink.  Some water  bottles in Asia may have teen tampered with so always check the cap to make sure it is sealed.  When I was in China, I bought a carton of milk from a grocery store.  When I got back to our hotel, I discovered that it had already been opened.  Filtered water is also not clean water. Also, use disinfected water for brushing teeth.

5.  Avoid ice in drinks at restaurants as it may have been made with unclean water.

6.  Avoid unpasteurized dairy products and juices.  Be wary of ice cream prepared in contaminated containers.

7. Always wash your hands with soap and water before you eat and after you go to the restroom.  One thing I had a hard time finding in public restrooms in Asia was soap.  Hand sanitizer helps but does not kill Norovirus.  You may want to carry around a little bottle of soap when you are traveling.

Now, even if you follow all of these food and drink safety rules, there are no guarantees.  You can still get traveler’s diarrhea.  You cannot control the hygiene of the restaurants you eat at. For people going to developing countries with young children, I advise them to bring ORS (oral rehydration solution) salts.  If your child gets diarrhea, start ORS salts right away as this could prevent dehydration.  In the U.S., we use pedialyte electrolyte solution.  However, in other countries, the equivalent is ORS salts, commonly sold in pharmacies.  You can buy it online to have in your travel health kit before you go on your trip.  Sports drinks or soda have too much sugar and not the right amount of electrolytes that young children need.  If your child is vomiting, you can give a teaspoon every 5 minutes.   Once your child can keep down liquids, you can give him/her food.  But avoid food that is sugary or fatty while your child is still recovering as those foods can sometimes make the diarrhea worse.

In developing countries, 80-90% of traveler’s diarrhea is due to a bacteria.  The most common culprit is enterotoxigenic E.coli, followed by campylobacter, shigella, and salmonella species.  Conversely, diarrhea in the U.S. is predominantly due to a virus.  Traveler’s diarrhea can be severe and cause dehydration, especially in children.  This is why I recommend bringing a prescription antibiotic, like Azithromycin, with you if you are going to a developing country.  This antibiotic should be used for severe diarrhea, not just mild or moderate diarrhea.  Taking it early can help you feel better faster and prevent complications.  Imodium and pepto-bismol is not recommended for kids under 12 due to possible serious side effects.  When I developed bloody diarrhea in Bali, I was so glad that I had brought Azithromycin.   I still spent 3 days lying in bed in my hotel room, but it could have been much worse. At least my daughter did not get it.

But what about antibiotic resistance?  It’s been shown recently in a study that travelers who have taken antibiotics have a higher risk of being colonized with ESBL (extended spectrum beta-lactamase) producing bacteria.  And we already know that most TD causing bacteria in South and Southeast Asia are now resistant to Cipro.   The trends of antibiotic resistance are scary.  This is why people should reserve using antibiotics only for severe diarrhea.  What about probiotics? Will they help?  As of now, there is not enough data to show that probiotics help treat traveler’s diarrhea. Many people with TD who seek medical care overseas are also very likely to get intravenous antibiotics, not just oral antibiotics.  Then, there is also new evidence that treating traveler’s diarrhea with antibiotics will lessen the risk of developing a potential chronic problem, such as irritable bowel syndrome (IBS).  The debate is ongoing.

Remember that antibiotics do not kill viruses or parasites, which are also common pathogens in developing countries.  If your child’s diarrhea does not improve within 3 days, or if he/she develops high fevers, dehydration, or severe bloody stools, you will need to seek medical care.  Getting a stool sample tested may be recommended.

Don’t feed the cute monkeys or puppies!

Macaques at the Sacred Monkey Forest in Ubud, Bali

adorable puppies in Chengdu, China

When we went to Ubud, Bali, one of the main attractions was seeing the monkeys at the Sacred Monkey Forest.  My three year old daughter was thrilled to see them walk around us and eat the food that people brought for them.  I remember that our biggest concern was to make sure the monkeys didn’t swipe our hats, drinks, and sunglasses.  There were signs everywhere warning people to keep your valuables safe from the monkeys.  In fact, I witnessed a monkey take off with an elderly tourist’s eyeglasses and promptly broke them in several pieces.  I felt really sorry for this woman since I knew it would be impossible for her to find a replacement for the rest of her trip.  We felt lucky to take some good photos of the monkeys, feed them some bananas, and leave with all of our belongings.  In retrospect, we were also very lucky not to get scratched or bitten by any monkeys.  I learned recently that about 40% of workers at this temple have reported getting bitten by these monkeys.

One of the many informative seminars I attended at a recent travel medicine conference was on the deadly diseases that wild animals can spread to humans.  I learned that monkeys, dogs, bats, and other wild animals in developing countries can harbor terrible viruses, like rabies, which is extremely fatal without treatment.  Bites from macaques can transmit another deadly virus, called herpesvirus B, which is just as terrible.  About 50,000-55,000 people die from rabies worldwide each year.  And about half of these deaths are in India alone.  Mostly all were bitten by a rabid dog.  In the United States, rabies is only a concern with bites from animals such as bats, skunks, foxes, coyotes, and raccoons.  Dog and cat bites in the U.S.  almost never carry rabies.  I consider this yet another huge success story of vaccinations, this time in pets.

Children under age 5 are particularly high risk for animal bites since they are smaller and usually love animals.  Bites to the face and neck, which are higher risk bites, are more common in children.  Children may also not tell the parent that a dog scratched or bit them.  About 40% of all human rabies occur in kids younger than 14 years of age.  Animal bites are the 7th most common health problem in travelers, with children 3-4x higher risk.  There is an approximately 1.3% chance of a dog bite in travelers who stay in an endemic country for a month or more.

The full treatment of animal bites to prevent rabies can be difficult to obtain in some developing countries.   It is important to wash the wound thoroughly with soap and water and apply a povidone-iodine solution directly to the wound.   But more importantly, the post-exposure treatment involves getting human rabies immunoglobulin (HRIG)and starting a series of 4 rabies vaccine shots as soon as possible, preferably within 72 hours, after an animal bite or scratch.  Since most rural areas do not carry HRIG, an animal bite or scratch would mean that you would have to scrap your entire trip, go to the nearest hospital or clinic that actually has this life-saving treatment, or go home ASAP!  This is an important reason why I recommend all families traveling to developing countries AVOID touching or feeding wild or stray animals, no matter how cute or harmless they look.  This is why I will never let my child go near a wild animal again the next time we travel to a developing country.

In the U.S. there is a vaccine against rabies that people can get before the trip to help prevent rabies in case they get an animal bite.  The CDC recommends the rabies vaccine for people who will be outdoors a lot like campers or cavers, those who have occupations like veterinarians, long-term travelers (>1 month), and young children get this vaccine series.  However, the rabies vaccine series involve  3 separate doses over the course of 21-28 days.  The timing of this vaccine series is difficult since most patients are not seeking pre-travel advice until the week or two before their trip.  Also, each of these 3 vaccines  is extremely expensive, about $200-300 each!  In addition, getting this pre-exposure rabies vaccine series does not mean that you don’t need treatment after an animal bite.  You won’t need the difficult to find HRIG shot, but you would still need an additional 4th dose of rabies vaccine.  Most developing countries have a good supply of rabies vaccine, even rural areas.  So getting the 3 rabies vaccines before your trip would not completely ruin your trip, which you probably have waited all year for.

When I discuss the rabies issue with families, it is a difficult decision for families to make.  Rabies is a scary and deadly disease.  Luckily, travelers rarely come down with rabies (1 study reported 22 cases over 10 years).  Perhaps this is because travelers tend to seek medical advice after an animal bite.  My recommendation is that if you choose not to get the rabies vaccine series before your trip and you are traveling to a highly endemic area, like Asia or Africa, with a small child, be sure to BUY travel health insurance and medical evacuation insurance.  This could save you a tremendous amount of money, time, and worry!