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Children at High Altitude – Managing the Risks
There are many opportunities for children to travel to areas of high altitude (>2500m) for tourism, for skiing, and for racing and training. This short summary focuses on some of the hazards that may affect children at altitude, and identifies ways in which the risks can be managed, notably by careful planning, awareness and rapid and effective treatment. It is intended primarily for those with no specialist medical knowledge; some references for further reading are listed.
Careful assessment and management of the risks will facilitate safe enjoyment of some of the most
beautiful places in the world (Pollard, Murdoch, 1996).
Factors which affect the safety and physical well being of children high in the
mountains include:

• Mountain/environmental/climatic hazards, including terrain, snow conditions, crevasses, rock/ice fal s, avalanches, changeable weather, wind, visibility (not covered in this short risk management • Individual responses to altitude, and the various forms of altitude sickness Cold exposure
Smal children are particularly vulnerable to the effects of cold because of their large surface area to volume
ratio. Adequate clothing is essential to prevent misery, hypothermia, and frostbite. Physical exercise wil al ow the children to generate heat through muscle activity, and the risk of hypothermia wil be lessened. Younger children may become susceptible to hypothermia on long slow chairlifts at any altitude; T-bar or Poma alternatives should be used in preference. Remember to make particular al owance for the added Sun exposure
Reflection from snow and a thinner atmospheric layer at high altitude make the risk of solar ultraviolet radiation burns more likely than at sea level. Children are more likely to burn than adults if exposed to excess sun. Snow blindness results from solar damage to the cornea and conjunctiva. Appropriate sun-block creams (protection from UVA and UVB, SPF at least 30, applied before sun exposure), hats, long sleeves and goggles are required to prevent sunburn or snow blindness. Dehydration
Since minute ventilation is about 20% higher at an altitude of 2500m and each breath must be humidified, relative dehydration is a frequent issue. Adequate fluid intake should be encouraged, and sports drinks should be available for ‘resuscitation’.
Children with pre-existing il nesses
Children with certain underlying chronic medical conditions may be at increased risk of developing either an
exacerbation of their chronic il ness or an il ness directly related to altitude.
Risk factors include a history of high-altitude il ness, residence at an altitude below 900m, exertion, and certain pre-existing cardiopulmonary conditions.
N.B. Don’t travel on cable cars or any aircraft with sick children – the pressure changes are too rapid
Dr Jenny Shute, MA, BM, BCh. Member FIS Medical Committee Individual responses to altitude, and the various forms of altitude sickness
The major categories of altitude il ness are acute mountain sickness (AMS), high altitude pulmonary oedema (HAPE), and high altitude cerebral oedema (HACE). The two latter more serious conditions are usual y preceded by AMS. The mainstay of treatment for each of these conditions is DESCENT.
The incidence of acute mountain sickness (AMS), the most common form of altitude il ness, is high – approximately 1 in 4 visitors to Colorado ski resorts develop AMS symptoms.
Acute mountain sickness (AMS)
• An acute il ness characterized by headache, anorexia, nausea, vomiting, fatigue, weakness, dizziness, light-headedness, and sleep disorder. The symptoms typical y develop within 6 to 10 hours after ascent, but sometimes as early as 1 hour. • Children are no more susceptible than adults; being fit doesn’t help. • Previous history may indicate susceptibility High altitude pulmonary oedema (HAPE)
• Acute pulmonary oedema caused by altitude hypoxia, presenting as dyspnoea (breathing difficulty), reduced exercise tolerance, cough, haemoptysis (coughing up blood), tachycardia (fast pulse), tachypnoea (fast breathing), cyanosis (blueness of fingers, lips etc), fever • Conditions that predispose a child to HAPE include recent inflammatory processes, such as viral infection, and conditions linked with underlying pulmonary hypertension.
High altitude cerebral oedema (HACE)
• HACE consists of headache, ataxia (disturbances of balance), behavioural changes, hal ucinations, confusion, disorientation, decreased level of consciousness, focal neurological signs, and coma. • There is no published information about the incidence of HACE in children.
Sleeping Altitude
• Most mountain tourist sites and ski resorts are located at or below about 3200m, and the majority of travel ers to these sites wil sleep at 2000m or below. • Ascents with sleeping altitudes at or below 3000m carry a low risk of serious altitude il ness. Sleeping altitude is more important than ‘active altitude’, perhaps because with wakefulness and activity the ventilation rate is higher and therefore oxygen saturations are higher. • Staying even one night at lower elevation significantly mitigates the incidence of AMS • Remember, wherever possible ‘climb high, sleep low’. Risk Management re Altitude il nesses:
Planning
• Plans should include sleeping at lower altitude wherever possible • Drug prophylaxis (usual y acetazolamide*) may be used in adults but is not indicated in children • Management of group size, provision for adequate supervision at al times on the hil • Prepare an evacuation strategy in case urgent descent is necessary • Be flexible – if one child becomes sick the group plan may need to be adjusted Awareness
• Ful awareness by al responsible adults re signs and symptoms • Be aware that non-specific signs (e.g. fussiness) may present in younger children • Care – upper respiratory infections are a predisposing factor for HAPE; URTI may also lead to problems of equalising pressure on rapid ascent in lifts, perforated eardrums Dr Jenny Shute, MA, BM, BCh. Member FIS Medical Committee Treatment
• DESCENT (a descent of only 500 to 1000m usual y leads to resolution of AMS) • Descent, when possible, should involve minimal exertion (exertion is likely to exacerbate the symptoms); the child should be carried where practical during descent.
• If HAPE is suspected, the patient should remain sitting upright.
• Cal for urgent medical assistance if HAPE or HACE are suspected *NB acetazolamide (used in the prophylaxis and treatment of altitude il ness) is on the WADA list of In short, the keys to management of the risks of altitude illness are careful planning, full awareness of the
risks and of the signs and symptoms, flexibility and rapid treatment – most notably descent.
Acknowledgements
Thanks to Larry Gaul M. D. FACC /USSA, fellow member of the FIS Medical Committee, for his helpful and
expert advice.

This short summary has been gleaned from the literature, in particular from the publications listed below.
References
For those who would like to read more, and for medical personnel requiring more detailed information Children at High Altitude: An International Consensus Statement by an Ad Hoc Committee of the
International Society for Mountain Medicine, March 12, 2001 – Pollard et al, published in HIGH ALTITUDE
MEDICINE & BIOLOGY, Volume 2, Number 3, 2001; Mary Ann Liebert, Inc.
High Altitude Illness – Peter H Hackett, MD, & Robert C Roach, PhD; published New England Journal of
Medicine, Vol. 345, No. 2, July 12, 2001
The High Altitude Medicine Handbook – Andrew Pollard & David Murdoch (Third Edition 2003); published by
The Radcliffe Medical Press, Oxford
Travel to High Altitude with Young Children: An Approach for Clinicians - Michael Yaron and Susan
Niermeyer; published in HIGH ALTITUDE MEDICINE & BIOLOGY, Volume 9, Number 4, 2008
Children at Altitude – 2008 Consensus Statement of the UIAA Medical Commission, Meijer, H.J. & Jean, D
Dr Jenny Shute, MA, BM, BCh. Member FIS Medical Committee

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A Primal-Dual Bicriteria Distributed Algorithm for Capacitated Abstract In this paper we consider the capacitated vertex cover problem which is the variant of vertex coverwhere each node is allowed to cover a limited number of edges. We present an efficient, deterministic,distributed approximation algorithm for the problem. Our algorithm computes a (2 + ǫ)-approximatesolution which violates th

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