Air Travel Regulation,

Jet Lag, and Motion Sickness

dr. Ari Prayitno, Sp.A (K)
 INFORMASI UMUM

• Presentasi ini disampaikan pada kegiatan

SEMINAR DAN PELATIHAN TRAVEL MEDICINE DAN TRAVEL

TRAVEL VACCINATION IN CHILDREN

• Hari/Tanggal : Minggu/ 26 Januari 2020

• Tempat : RS Univ. Indonesia

• Narasumber : Ari Prayitno

IDAI
• Semua isi dan materi presentasi adalah hak cipta dari UKK
Tropik dan Infeksi Anak IDAI, digunakan untuk kalangan
terbatas dalam kepentingan edukasi kesehatan di bidang terkait

2
3
 Outline
Introduction

Air Travel for Paediatric

Flight Medical Consideration

Jet Lag

Motion Sickness

Take Home Message

 KASUS 1
Seorang ibu beserta keluarganya datang berkonsultasi ke anda. Ibu
tersebut dan keluarganya berencana melakukan perjalanan liburan ke
luar negeri dengan menggunakan pesawat 5 hari lagi. Ibu tersebut baru
saja melahirkan seorang bayi perempuan, 10 hari yang lalu.
Beliau bertanya kepada anda, bolehkah bayinya dibawa terbang dengan
menggunakan pesawat ?
Anda sebagai dokter akan ?
A. Melarang keras bayi tersebut dibawa terbang
B. Menganjurkan sebaiknya bayi ditunda untuk di bawa terbang
C. Memberikan surat keterangan bayi bisa dibawa terbang
D. Mengijinkan ibu tersebut membawa terbang bayinya
 Introduction
The number of people travelling internationally continues to grow
WTO (2017): 1.33 billion worldwide tourist arrivals à ↑88% since 2015
CDC (2016): 2.81 million international travelers from US were children
or adults traveling with children
Risk of becoming ill or injured à many factors Data about the
• the region of the world visited incidence of pediatric
• a traveler's age and health status illnesses associated with
• the length of the trip international travel are
• the diversity of planned activities limited,
Travelers may serve as a conduit for disease from one the risks that children
country to another face are likely similar to
e.g: Ebola, Chikungunya, Zika those their parents face.
Kozarsky PE, Henry R. Introduction to travel health & the CDC yellow book [Internet]. 2019 June 21[cited 2019 December 9]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/introduction/introduction-to-travel-health-and-the-cdc-yellow-book
Weinberg MS, Weinberg N, Maloney SA. Traveling safely with infants and children [Internet]. 2019 June 24 [cited 2019 December 19]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/family-travel/traveling-safely-with-infants-and-children
 Air Travel for Paediatric
Air travel is safe for most newborns, infants, and children.
Pretravel care: visit travel medicine provider 4-6 weeks before trip

Preparation Pre-travel Consultation

• Collect information about destination • Past medical history
as much as possible • Detail itinerary (country, duration,
• Study the itinerary weather, specific activity,
accommodation, hygiene) à
• Discuss with children about this trip family’s risk of illness or injury
• Travel document (identity, vaccine during travel
card, insurance) • Recommended vaccination &
• Medicine & Food medical supplies
Weinberg MS, Weinberg N, Maloney SA. Traveling safely with infants and children [Internet]. 2019 June 24 [cited 2019 December 10]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/family-travel/traveling-safely-with-infants-and-children
Flying with children [Internet]. 2019 December 05 [cited 2019 December 10]. Available from: https://www.faa.gov/travelers/fly_children/
 Air Travel for Paediatric
Before travel
1. Enough rest
2. Small frequent meals before fly
3. Backpack preparations
4. Notify kids about screening
procedure in airport
1. On-board activity à paper,
coloring pencil, cards, books
2. Bottled-water
3. On-board meals & snacks
4. Medicine
Avoid too heavy
Weinberg MS, Weinberg N, Maloney SA. Traveling safely with infants and children [Internet]. 2019 June 24 [cited 2019 December 10]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/family-travel/traveling-safely-with-infants-and-children
Prayitno A, Kesehatan Wisata. In: IDAI. Buku Ajar Infeksi dan Pediatri Tropis. Jakarta: IDAI; 2018. p. 736-48
Air Travel for Paediatric
Formula, breast milk,
juice > 3.4 ounces
(100ml) are allowed in
carry-on baggage and
do not need to fit
within a quart-sized
bag.

Inform officers at the

beginning of screening
TSA. Traveling with children [Internet]. Available from: https://www.tsa.gov/travel/special-procedures/traveling-children
 FEDERAL AVIATION ADMINISTRATION
Child Safety Recommendation
• Secure child seat with Child Restraint Systems (CRS): hard-
backed child safety seat
• Government approved and has “This restraint is certified for use in
motor vehicles and aircraft" printed on it.
• Use during all phases of flight
• FAA-Approved Child Harness Device (CARES) for child 10-20 kg
Children need to have
their own seats

Weinberg MS, Weinberg N, Maloney SA. Traveling safely with infants and children [Internet]. 2019 June 24 [cited 2019 December 10]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/family-travel/traveling-safely-with-infants-and-children
Flying with children [Internet]. 2019 December 05 [cited 2019 December 10]. Available from: https://www.faa.gov/travelers/fly_children/
Rear-Facing CRS Forward-Facing CRS

The Cares Safety Harness

 Medical Clearance
IATA (2018): Every airline should have a medical clearance procedure
Required if*:
• Suffers actively contagious and communicable disease
• Cause discomfort to other passengers because of physical or behavioral
condition
• Potential risk to safety or punctuality of flight
• Requires special assistance
• Medical condition which may be adversely affected by flight environment
o If a passenger wants to carry a medical device, it has to be approved by the airline
o Special services may be provided by the airlines if given sufficient advance notice.

*other than these depend on airplane

International Air Transport Association. Medical Manual. 11th ed. Geneva: 2018 June
 Example of Medical Time Frame

The MEDIF is the name given to the forms used by airlines to manage
passengers requiring special assistance and medical clearance.
International Air Transport Association. Medical Manual. 11th ed. Geneva: 2018 June
 Contraindications to Air Travel
• Newborn baby < 48 h old
• Pregnant women >36th week of pregnancy (32nd week for multiple
pregnancies).
• Those suffering from:
• angina pectoris
• active communicable disease
• decompression sickness after diving
• increased intracranial pressure à haemorrhage, trauma or infection
• infections of the sinuses or of the ear and nose à Eustachian tube is blocked
• recent myocardial infarction and stroke
• recent surgery or injury where trapped air or gas may be present
• severe chronic respiratory disease, breathlessness at rest, or unresolved
pneumothorax
• sickle-cell anaemia
• psychotic illness, except when fully controlled
WHO. International travel health: contraindications to air travel [Internet]. https://www.who.int/ith/mode_of_travel/contraindications/en/
 Airlines Infant Policy
• Not to carry infants <7
days-old
• Not to carry infants <2 days-old
• Number of infants not
• Infant 3-7 days require medical
exceed 10% of aircraft
certificate (issued 72hrs before standard
capacity
departure time) à fit to travel

• 0-6 days-old: not to carry

• 7-21 days-old: require • Allowed infants: • Allowed infants:
formal written letter >9 days old >7 days old
• >21 days-old: allow
 Kapan bayi bisa dibawa terbang ?
• Usia 0 - 48 jam : dilarang membawa bayi naik pesawat
terbang
• Usia 2 - 7 hari : dianjurkan tidak dibawa naik pesawat
• Usia >7 - 21 hari : ada surat keterangan dokter (medical
certificate)
• Usia >3 minggu : diperkenankan untuk terbang
 Aerotoxic syndrome
• Sick plane syndrome, sick aircraft syndrome
• by Chris Winder and Jean-Christophe Balouet in 2000
• to describe short- and long-term ill-health effects caused by breathing airliner
cabin air which was alleged to have been contaminated to toxic levels with
atomized engine oils or other chemicals
• Possible sources of poor-quality cabin air include exposures related to normal
operations of the aircraft:
• Ozone (O3)
• Fluorohydrocarbons (aircon systems)
• Carbon dioxide (passengers exhaling CO2)
• Carbon monoxide (CO from jet exhaust fumes or ambient airport air)
• Temperature
• Relative humidity
• Off-gassing from interior material and cleaning agents
• Personal-care products
• Allergens
• Infectious or inflammatory agents no significant new evidence
• Cabin pressure/partial pressure of oxygen, etc
Eddington, I, editor. Towards a safe and Civil Society. Proceedings of the International Congress on Occupational Health Conference, held in Brisbane, Australuia, 4-6 September 2000
Eddington, I, editor. Towards a safe and Civil Society. Proceedings of the International Congress on Occupational Health Conference, held in Brisbane, Australuia, 4-6 September 2000
 KASUS 2
Suami dari ibu pada Kasus 1 tersebut mengatakan bahwa mereka
sekeluarga akan berlibur ke Toronto, Kanada (UTC -5). Mereka akan
terbang menggunakan pesawat Cathay Pacific dari Jakarta (UTC +7) jam
01.00 malam dan akan transit di Hongkong
Beliau bertanya kepada anda, persiapan apa yang harus dilakukan agar
mereka tidak jet lag setibanya di Toronto?

Persiapan apa yang akan anda anjurkan kepada keluarga tersebut?

 Jet Lag
• Jet lag results from a mismatch between a person’s circadian (24-hour)
rhythms and the time of day in the new time zone.
• Key: how many time zones have crossed and the discrepancy between time
of day at home and at the destination
• The first few days after a flight to a new time zone :
• a person’s circadian rhythms are still “anchored” to time of day at home. Rhythms
then adjust gradually to the new time zone
• If ≤3 time zones are being crossed, any symptoms such as tiredness are
likely due to travel fatigue and will soon abate
• If >3 time zones away for
• a vacation : jet lag as a transient and mild inconvenience
• traveling on business or to compete in athletic events very uncomfortable
• If ≤2 days are spent in the new time zone : anchor their sleep-wake
schedule to time of day at home as much as is practical.

Atkinson G, Henry R, Batterham AM, Thompson A. Jet lag [Internet]. 2019 June 24 [cited 2019 December 9]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/jet-lag
https://www.timeanddate.com/time/map/
 Clinical Presentation
Varies between people
Typically experience ≥ 1 after a flight across > 3
time zones:
• Poor sleep à difficulty initiating sleep, early
awakening, fractionated sleep
• Poor performance in physical and mental tasks
during the new daytime
• Negative feelings à fatigue, headache, irritability,
anxiety, inability to concentrate, depression
• Gastrointestinal disturbances and decreased
interest in, and enjoyment of, meals

Atkinson G, Henry R, Batterham AM, Thompson A. Jet lag [Internet]. 2019 June 24 [cited 2019 December 9]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/jet-lag
 Treatment
Should try to follow the local people’s sleep-wake habits
as much as possible and as quickly as possible
± 1-1.5 days
Light
• Exposure to bright light à can advance or delay
human circadian rhythms
• Schedules for “good” and “bad” times exposure
Diet & Physical Activity
• Smaller meals before and during flight
• Caffeine and physical activity in daytime to ameliorate
daytime sleepiness
Atkinson G, Henry R, Batterham AM, Thompson A. Jet lag [Internet]. 2019 June 24 [cited 2019 December 9]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/jet-lag
Jet Lag [Internet]. https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Health-information-for-passengers/Jet-lag/
 Treatment
Hypnotic Medications
• Temazepam, zolpidem, or zopiclone à help reduce
sleep loss, but no resynchronize circadian rhythms or
improve jet lag symptoms
Melatonin & Melatonin-Receptor Analogs
• Secreted by night
• Delays circadian rhythms when taken during rising
phase of body temp (morning) à opposite bright
• Ramelteon 1 mg, a melatonin-receptor agonist before
nocturnal sleep in the new time zone
In conclusion, there is still no “cure” for jet lag.
Atkinson G, Henry R, Batterham AM, Thompson A. Jet lag [Internet]. 2019 June 24 [cited 2019 December 9]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/jet-lag
Jet Lag [Internet]. https://www.caa.co.uk/Passengers/Before-you-fly/Am-I-fit-to-fly/Health-information-for-passengers/Jet-lag/
 Prevention
Before Travel During Travel After Arrive
• Exercise, eat a • Avoid large meals, • Eat meals at the
healthful diet, get alcohol, caffeine appropriate local time
plenty of rest • Drink plenty of water • Spend time in the sun
• A few days before: • On long flights: get up • Drink plenty of water
going bed 1-2 hr later and walk around
than usual (before • If sleepy during the
periodically day, take short naps
traveling west) or
earlier than usual • Sleep (20-30 mins)
(before traveling east) • Take medicine at night
if needed

CDC. Jet lag [Internet]. 2013 April 21 [cited 2019 December 11]. Available from: https://wwwnc.cdc.gov/travel/page/jet-lag
 KASUS 3
Salah seorang anggota keluarga yang melakukan perjalanan ke Toronto
tersebut (Kasus 2), mudah sekali muntah bila di ajak bepergian dengan
mobil atau kereta. Bergoyangnya kendaraan yang dinaiki oleh orang
tersebut, akan langsung membuatnya muntah.
Ayahnya khawatir bila anggota keluarga ini saat di pesawat akan
muntah-muntah.

Orang tersebut akhirnya bertanya kepada anda, apa yang harus

dilakukan agar tidak mengalami mabuk perjalanan ?
 Motion Sickness
Vomiting/
Nausea Sweating
physiologic responses to travel by retching

sea, car, train, air.

Clinical Presentation
Excessive
Cold sweats Apathy
salivation
Risk Factors: Increased
Hyperventil Loss of
• Children 2-12 yrs ation
sensitivity
appetite
to odors
• Women (especially when pregnant,
menstruating, hormones) Headache Drowsiness
Warm
• Migraines sensation

• Medication
General
discomfort

Erskine SK. Motion Sickness [Internet]. 2019 June 24 [cited 2019 December 10]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/motion-sickness
 Treatment
Drugs Dosage
Over The Counter Drugs
Diphenhydramine 5 mg/kg/day (PO) High sedative
Dimenhydrinate 2-6 yrs: 12,5-25 mg (PO) max 75 mg/day 1 hr before travel and
6-12 yrs: 25-50 mg (PO) max 150 mg/day every 6 hrs during
>12 yrs: 50 mg (PO) trip. Do test dose.
Meclizine >12 yrs: 25-50 mg (PO) single dose Chew
Prescription Drugs
Scopolamine >12 yrs: 0,5 mg (patch behind ear) 4 hrs before
Promethazine >2 yrs: 0,5 mg/kgW/times (PO) For severe symptoms
Prayitno A, Kesehatan Wisata. In: IDAI. Buku Ajar Infeksi dan Pediatri Tropis. Jakarta: IDAI; 2018. p. 736-48
Erskine SK. Motion Sickness [Internet]. 2019 June 24 [cited 2019 December 10]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/motion-sickness
 Prevention
DO DON’T
• Reduce motion or motion perception à • Don’t encourage
choosing window seats, sitting over the wing of reading/focusing on
an aircraft (less bumpy) games while traveling
• Reduce sensory input à lying prone, shutting • Avoid alcohol/caffeine
eyes, sleeping, looking at the horizon • Avoid heavy, greasy
• Drink water, eat small meals frequently meals
• Adding distractions à listening to music, using • Avoid unnecessary
aromatherapy, eat lozenges, controlling head movements by
breathing using pillow/headrest
Erskine SK. Motion Sickness [Internet]. 2019 June 24 [cited 2019 December 10]. Available from: https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-by-air-land-sea/motion-sickness
Graudins LV. Preventing motion sickness in children [Internet]. 2009 June 1 [dited 2019 December 11]. Available from: https://www.nps.org.au/australian-prescriber/articles/preventing-motion-sickness-in-children
THANK YOU