Back to Table of Contents | June 2011

Clinical and Health Affairs

Children and Airplanes: Are We Having Fun Yet?

By Philip R. Fischer, M.D., and M. Rizwan Sohail, M.D.

■ Health care providers are often asked by parents whether it is safe for their child to fly and what they can do to make air travel more pleasant for the child and for their fellow passengers. This article provides answers to seven frequently asked questions about children and air travel.

Two million children leave the United States each year on international flights.¹ Millions more fly domestically. Whether in the clinic, at a party, or on the sidelines at a soccer game, physicians are often asked by parents how they can best manage common concerns related to traveling on airplanes with children.

Parents can do a number of things to make air travel more pleasant for their children and for everyone else on board the plane. Health care providers can help them by explaining how flying affects young bodies and teaching them to prepare for problems that might occur during flight. The following are seven questions parents frequently ask about taking children on airplanes.

Is my newborn old enough to fly?
It was once thought that infant alveoli required six weeks of post-gestational development before it could handle the low air pressure in an aircraft cabin. No evidence supports this hypothesis, however, and age is not in any way a predictor of one’s ability to tolerate low-pressure environments.

There has also been concern that the relative hypoxia experienced in an aircraft (the equivalent of breathing air with only 15% oxygen at sea-level instead of the normal 21%) might be risky for babies. Indeed, sleep studies conducted in a laboratory with conditions simulating those in an airplane cabin have shown that healthy 3-month-olds had lower oxygen saturation levels in the lab (SpO2 93%) than in a normal environment (SpO2 of 98%). The infants in the lab also had more respiratory pattern variations. However, they did not have any significantly prolonged episodes of hypoxia or apnea.² Similarly, there is little evidence that high altitude is associated with increased risk of sudden infant death syndrome.³

Babies who were born prematurely and have a history of neonatal lung disease are at increased risk for complications during air travel. In one investigation, 47 former prematurely born infants and toddlers with resolved lung disease, who no longer required oxygen supplementation, were subjected to 14% to 15% oxygen for 20 minutes. Eighty-one percent of those infants developed hypoxia (SpO2 less than 85%). All of the infants who developed hypoxia were younger than 12 months of age.⁴ Based on these data, it is reasonable to recommend that parents of babies who were born prematurely and have a history of neonatal lung disease postpone air travel until after their child’s first birthday.

Another consideration is the mother’s readiness for travel after giving birth. It is not easy physically or emotionally for a new mother to travel with a newborn. Having adequate time to rest and recover from delivery and to spend time with her child is very important for the health of both mother and child and for mother-child bonding. Elective travel would not be wise if it would compromise a mother’s mental or physical health.

What about earaches on planes?
Commercial aircraft are pressurized in a way that makes cabin air similar to ambient air at about 7,500 feet above sea level. During take-off and ascent, cabin pressure drops quickly. However, pressure in the middle ear, which is regulated and dependent on the opening of the Eustachian tubes, drops more slowly. This results in the volume of air in the middle of the ear expanding rapidly and causing pain. A similar but inverse process happens when the air pressure in the external ear canal increases during descent and landing, which also causes discomfort. Because infants and children have smaller Eustachian tubes that are readily obstructed by virus- or allergy-induced pharyngeal swelling, they frequently experience discomfort for a longer period than adults do. Up to 5% of young children have bothersome ear pain with ascent, and 13% have similar pain with descent.⁵

Parents of young children frequently ask if there is a medicine that they can give their child to prevent earaches during air travel. There is no known medication that can help. In one study, adults with recurrent air-travel-associated earaches found they had less pain when they took pseudoephedrine (2 mg/kg orally) 30 minutes prior to take-off.⁶ Children, on the other hand, had equal rates of ear pain whether they received preventive pseudoephedrine or placebo.⁵

Parents can, however, make food and drinks available during take-off and landing, so children (especially young infants) can suck and swallow in ways that manipulate the Eustachian tubes and facilitate pressure equalization. Is it all right for a child with middle-ear effusion or otitis media to travel?

It turns out that when there is fluid in the middle ear, changes in air pressure do not cause significant expansion or shrinkage of the middle ear space; thus, children with middle-ear effusion or otitis media do not often experience pain as a result of changes in altitude. Similarly, children with patent tympanostomy tubes should have no trouble with ear pain on flights.

Is it OK to sedate a child who will otherwise get fussy on a plane?
Most frequent flyers have stories about crying babies on planes, and some choose seats far from the bulkhead areas, where infants are preferentially seated. Because everything from earaches to interrupted schedules can make infants fussy during a flight, parents sometimes choose to sedate their children to decrease the chance that they’ll bother other travelers.

Most pediatric travel medicine specialists do not recommend sedatives for traveling children. However, there are no medical data that provide guidance on this issue. Over-the-counter diphenhydramine (1 mg/kg orally) is commonly used. It is usually safe, but parents should be warned that some infants have a paradoxical reaction and may become hyperactive or agitated after receiving a dose. If parents choose to sedate their child during air travel, they should try a test dose at home to make sure their child is not prone to these paradoxical reactions.

The real issue in deciding whether to sedate a child is the parents’ philosophy. Some parents want their children to learn to cope with the uncomfortable, dull, and unpleasant aspects of travel (and life in general). So they often use toys, books, video screens, and aisle walks to try to occupy their children during the “boring” hours of air travel. Other parents may want to make the trip seem less inconvenient and use a mild sedative. (On a related note, if parents use sleep aids when traveling across multiple time zones, at least one adult care provider should remain unsedated in order to be available to the children traveling with them.)

Does my baby need to use a car seat on the plane?
Although they are tragic and newsworthy, airplane crashes are rare. Mile per mile, air travel is much safer than road travel. Injuries associated with unexpected turbulence aboard planes are also uncommon. An approved child restraint system is the safest place for a young child during times of extreme turbulence or in an emergency. The physical forces that cause “rough air” and that are in play during crash landings, however, are very different from the physical forces that are generated during car crashes. Thus, families opting to place a child in a car seat on an airplane should make sure that the seat is also designed and certified for aircraft use.

Pediatricians are not yet convinced that the use of safety seats should be mandated for infants on commercial flights for several reasons.⁷ First, serious air-travel-associated injury is extremely uncommon, so uncommon that accurate risk-benefit calculations are impossible to make. Second, requiring families to purchase an extra ticket would prompt many to opt for road travel instead, which has a higher risk of serious injury and death than air travel. The Federal Aviation Administration and Travel Security Administration also offer advice for traveling safely with children.^8,9

Parents should know that there is more to airplane safety than using restraints, though. Passengers seated in aisle seats are more likely to have luggage from overhead bins and hot drinks spilled on them than are passengers in other seats; therefore, young children should not be placed in aisle seats.

Could my child with peanut allergies have a reaction to a nearby passenger’s food ?
Approximately 15% of the U.S. population has allergies of some sort. About 1% are allergic to peanuts. Fatal reactions are rare but possible, and very small quantities of peanut allergen can provoke a reaction. To avoid putting passengers at risk, some airlines have limited the availability of peanuts in their snack menu.

Data regarding peanut reactions in children during flights are very limited. In adults, however, approximately 9% of individuals with severe nut/seed allergies report food reactions on airplanes. Most peanut reactions occur because of aerosolized exposure, not ingestion. In one study, half of the affected people required epinephrine treatment during the flight. Most of them did not inform flight attendants, as they administered the product themselves.¹⁰ Whether in the air, at a restaurant, or at home, inadvertent allergen exposures are possible. Reviews of fatal food reactions indicate that most victims knew of their allergy, and that very few received epinephrine within 30 minutes of the onset of symptoms.^11,12 Consequently, the lesson is clear: Parents of children with peanut allergies should carry epinephrine with them, and affected children should receive an epinephrine injection soon after the onset of symptoms of a severe reaction.

Can my child get measles or influenza by flying?
The air on commercial planes is incredibly clean. It is recycled 20 to 30 times each hour, and the recirculated air is passed through particulate filters that remove microbes 0.3 to 1 micrometers in size, including mycobacteria, fungi, and some viruses.^13-15 In fact, a study in the 1990s found that the concentration of microorganisms in airline cabin air is much lower than that found in the air we breathe on a daily basis.¹⁶

Nonetheless, the close proximity of passengers on a plane does provide a significant risk for disease transmission. A simulation study revealed that when passengers coughed once and talked for 15 seconds, they dispersed droplets containing germs to passengers in the rows immediately surrounding them within 30 seconds and to passengers within seven rows of them within four minutes.¹⁷

Three recent cases of measles in Australia illustrate the potential for droplet spread of contagious germs.¹⁸ Two siblings were seated eight rows behind a coughing passenger (who developed a rash and was diagnosed with measles a few days later) during a 4½-hour flight. Each of the siblings had received two measles vaccines (at 1 year and at 4 to 5 years of age), and each went on to develop measles. Another traveler who was not completely immunized spent time in a departure lounge with the index patient and went on to develop measles. The case of the two siblings demonstrates that even vaccinated children seated fairly far from a coughing passenger can get measles from an aircraft-associated exposure.

Similarly, influenza can be spread in airplanes. The risk is greater in economy class cabins that are full than in those that are less full or in first-class cabins.¹⁹ Therefore, vaccination against influenza prior to travel is strongly advised.

There has also been concern about the spread of tuberculosis in airplanes, partly because of media coverage of contagious passengers. However, the risk of tuberculosis transmission on airplanes has proved to be quite low.²⁰ In one study of 131 aircraft passengers who potentially had contact with a patient with pulmonary tuberculosis, no cases of active disease were reported.²¹ Risk of acquiring the disease is somewhat higher for patients with cavitary lung disease who have positive sputum smears for mycobacteria at the time of travel. It should be noted that risk of tuberculosis exposure is generally limited to passengers seated two to three rows in front of and behind the index case, and most do not develop active tuberculosis even after exposure.

Conclusion
Air travel provides children with a wonderful opportunity to see new places and learn new things. There are potential hazards, however. Health care providers should educate parents about the risks of air travel to children and ways to minimize them. In most cases, they can reassure parents and offer tips to make travel safer and more comfortable for their children. MM

Philip Fischer is a professor of pediatrics and M. Rizwan Sohail is an assistant professor of medicine at the Mayo Clinic College of Medicine. They each care for air travelers in the Mayo Clinic Travel and Tropical Medicine Clinic. Between them, they have six children who have traveled tens of thousands of miles in airplanes.
 

References
1. Office of Travel and Tourism Industries. Profile of U.S. Resident Travelers Visiting Overseas Destinations: 2009 Outbound. U.S. Department of Commerce, International Trade Administration. Available at: http://tinet.ita.doc.gov/outreachpages/download_data_table/2009_Outbound_Profile.pdf. Accessed May 3, 2011.
2. Parkins KJ, Poets CF, O’Brien LM, Stebbens VA, Southall DP. Effect of exposure to 15% oxygen on breathing patterns and oxygen saturation in infants: interventional study. BMJ. 1998;316(7135):887-91.
3. Getts AG, Hill HF. Sudden infant death syndrome: incidence at various altitudes. Dev Med Child Neurol. 1982;24(1):61-8.
4. Udomittipong K, Stick SM, Verheggen M, Oostryck J, Sly PD, Hall GL. Pre-flight testing of preterm infants with neonatal lung disease: a retrospective review. Thorax. 2006;61(4):343-7.
5. Buchanan BJ, Hoagland J, Fischer PR. Pseudoephedrine and air travel-associated ear pain in children. Arch Pediatr Adolesc Med. 1999;153(5):466-8.
6. Csortan E, Jones J, Haan M, Brown M. Efficacy of pseudoephedrine for the prevention of barotrauma during air travel. Ann Emerg Med. 1994;23(6):1324-7.
7. Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):e1050-66.
8. Federal Aviation Administration. Child safety on airplanes. Available at: www.faa.gov/passengers/fly_children/crs/. Accessed May 3, 2011.
9. Transportation Security Administration. Traveling with kids. Available at: www.tsa.gov/travelers/airtravel/children/index.shtm. Accessed May 3, 2011.
10. Comstock SS, DeMera R, Vega LC, Boren EJ, Deane S, Haapanen LAD, Tueber SS. Allergic reactions to peanuts, tree nuts, and seeds aboard commercial airliners. Ann Allerg Asthma Immunol. 2008;101(1):51-6.
11. Sampson HA, Mendelson L, Rosen JP. Fatal and near-fatal anaphylactic reactions to food in children and adolescents. N Engl J Med. 1992;327(6):380-4.
12. Yunginger JW, Sweeney KG, Sturner WQ, et al. Fatal food-induced anaphylaxis. JAMA. 1988;260(10):1450-2.
13. Sohail MR, Fischer PR. Health risks to air travelers. Infect Dis Clin N Am. 2005;19(1):67-84.
14. Wenzel RP. Airline travel and infection. N Engl J Med. 1996;334(15):981-2.
15. Hocking MB. Passenger aircraft cabin air quality: trends, effects, societal costs, proposals. Chemosphere. 2000;41(4):603-15.
16. Wick RL Jr, Irvine LA. The microbiological composition of airliner cabin air. Aviat Space Environ Med. 1995;66(3):220-4.
17. Gupta JK, Lin CH, Chen Q. Transport of expiratory droplets in an aircraft cabin. Indoor Air. 2011;21(1):3-11.
18. Coleman KP, Markey PG. Measles transmission in immunized and partially immunized air travellers. Epidemiol Infect. 2010;138(7):1012-5.
19. Askling HH, Rombo L. Influenza in travellers. Curr Opin Infect Dis. 2010;23(5):421-5.
20. Abubakar I. Tuberculosis and air travel: a systematic review and analysis of policy. Lancet Infect Dis. 2010;10(3):176-83.
21. Marienau KJ, Burgess GW, Cramer E, et al. Tuberculosis investigations associated with air travel: U.S. Centers for Disease Control and Prevention, January 2007–June 2008. Trav Med Infect Dis. 2010;8(2):104-12.