Babies and young children are especially vulnerable to the effects of food poisoning so it is essential that great care be taken to protect them from risk. What won't affect your stomach may prove to be disastrous to your child's less hardened digestive system.

Contaminated food (rather than polluted water) is the commonest route to acquire traveller's diarrhoea.

The maxim, which will protect you and your children, is:

PEEL IT - BOIL IT - COOK IT - OR FORGET IT

Diarrhoea is not one disease but a large group caused by viruses, bacteria or parasites; it is convenient to call them the diarrhoeal diseases which also include dysentery, typhoid, and all other infections of the bowel. The commonest diarrhoeal diseases in less hygienic environments are the filth-to-mouth pathogens, especially variants of the normal bacteria colonising everyone's bowel.

Most people (doctors and public-health engineers included) believe that diarrhoea gets to you by way of contaminated water. While water-bourne outbreaks of diarrhoeal disease do occur, they are exceptional. Foreign water is nowhere near as hazardous as most travellers believe; most travellers' diarrhoea comes from dirty hands or unhygienic preparation of food.

Dr David Shlim who runs a travellers' clinic in Kathmandu found in a pre-monsoon survey at the airport that 68% of travellers leaving Nepal had been hit. It is crucial to know how to avoid travellers' diarrhoea, particularly since these same precautions will also protect you from other, more serious, filth-to-mouth diseases including typhoid, dysentery, hepatitis and cholera. Hand Sanitizer

It is important to be meticulous about hygiene while travelling; wash your hands before touching food or feeding children and make sure they wash their hands properly before eating. If children's nails are kept short, they are less likely to carry bacteria and pinworm eggs under their fingernails. Dummies or pacifiers should be sterilised frequently, pack several.

It can be surprisingly difficult to define diarrhoea in babies, but you will know what is abnormal for your child. Don't be concerned about on loose stool; but, if you think your baby has diarrhoea, look to see if he remains bright-eyes, moist-mouthed, interested and happy to feed, in which case you need only worry about the mess. Large quantities of watery diarrhoea are obviously always abnormal.

Diarrhoea can be dangerious because of the out-pouring of water that it provokes. The smaller the baby the less fluid he can afford to lose. The four important rules are:-

1.keep offering the baby breast-milk at frequent intervals and seek help if he does not want to feed. Bottle-fed babies should be given clear fluids.
2.assess whether the baby is dry/dehydrated.
3.if the baby is dry/dehydrated give oral rehydration solution
4.assess every few hours whether he is getting dry

Dehydration Checklist

Do the inside of the mouth and tongue look dry? Does the mouth lack the usual glistening layer of saliva? This is the easiest sign to assess and it is also a very good indicator of the beginnings of dehydration; it is also present in severe dehydration.

Does the child seem thirstier than normal? If he is thirsty, offer her more to drink. And always check the other items below.

DANGER SIGNS

Drowsiness; the child is listless, unresponsive and unable to drink. This is the worst of the danger signs - GO TO HOSPITAL IMMEDIATELY.

If the child has any of the next three signs he is seriously dehydrated and needs medical attention as soon as possible.

The child is passing less urine than normal. Normally a child will pass urine very frequently, at least every four hours. Children who are becoming significantly dehydrated pass less urine and it is dark or tea-coloured. (Watery diarrhoea can be hard to distinguish from urine - if in doubt smell it)

The eyes look sunken within the surrounding bony ridge and there are dark rings.

The child's skin loses its natural elasticity. Pinch a fold of skin on the belly. When released the skin should immediately spring back to the normal smooth surface of the belly. If it continues to stand proud after two seconds this is a serious danger sign. GO TO HOSPITAL IMMEDIATELY.

When diarrhoea and water are pouring out of the baby's bottom, fluid needs to be poured in at the top to keep up with losses. But when a baby has diarrhoea the gut cannot absorb food and water well. Mixing water with a little sugar and salt improves absorption efficiency enormously; put two heaped teaspoons or sugar or glucose plus a thumb and two-finger pinch of salt (less than a quarter-teaspoon) of salt into a glass of safe water, and mix.

Commercial oral rehydration solutions (ORS) are slighty improved sugar and salt mixtures. ORS is not a medicine but a means of preventing dehydration, so that you must give enough to compensate for all the fluids leaving from the baby's bottom for as long as he has diarrhoea. ORS is widely available and the powder should be made up in boiled and cooled water.

If you are giving ORS to a baby under two months of age, use twice the standard amount of water for each sachet; this half-strength ORS will prevent too much salt overwhelming immature kidneys. Small babies with diarrhoea should also be heading for a doctor, since they can get into trouble very easily.

Giving ORS early will generally avoid severe and dangerous dehydration, so if in doubt, give it. Offer (50-100ml) of ORS after each loose poo. If the child is thirsty and wants more, give more. You cannot give too much ORS. Encourage your baby to drink and drink until those early signs of dehydration disappear. If the baby vomits, wait ten minutes, and continue offering ORS more slowly- perhaps as slowly as one dessertspoon every five minutes. Breast-milk is therapeutic so also ensure this is given first, followed by ORS with a cup and spoon. Drinking too much too fast may induce vomit. This doesn't matter; slow down, but continue offering ORS by spoon.

The commonest cause of blood with the stools is constipation; smears of blood will then be on the outside of the stool. True bloody diarrhoea (which means blood mixed in with loose or watery faeces) should always be taken seriously and medical opinion sought.

In any kind of diarrhoea, if the child loses interest in drinking he will need hospital or clinic treatment perhaps with intravenous fluids. Young children are not only more likely to suffer travellers' diarrhoea (some conservative doctors would even say don't travel to unsanitary countries with children under three!) but they are more likely to suffer difficulties and complications, so seek a doctor's help sooner rather than later in this age group.

When to seek help

If you are worried about the baby or if he refuses feeds, or if you don't feel confident about managing, seek medical advice. If you are happy that the infant is only mildly dehydrated, that he is taking ORS nicely and that any signs of dehydration are getting better, than carry on. Always seek help if he has any of the signs of serious dehydration above.

Drugs to avoid in diarrhoea

Drugs which stop diarrhoea work by paralysing the bowel. These are dangerous in babies for three reasons: a slight overdose can also paralyse the breathing muscles and kill the child; if the child has dysentery the bowel may rupture; paralysing the bowel keeps toxins inside and does not stop crucial fluids leaking from where they are needed.

The main villain-drug is loperamide hydrochloride (marketed as Loperamide or Imodium), but codeine and Lomotil are also dangerous. Unfortunately these drugs are still prescribed in some developing countries especially India and Pakistan. Don't give them to your baby even if they are prescribed.

Getting back to normal

Once the diarrhoea is drying up and you are happy that the baby is well hydrated, you can stop the ORS. Breast-fed babies continue as normal. In the infant who has started solids be sensible at first. Avoid wheat-based foods and very greasy heavy foods. Bananas, stewed apple and rice-based weaning foods are perfect for rehabilitation. Recovering children will have huge appetites and should be fed as often as they ask. Offer foods at least five times a day, plus extras like bananas, toast, chicken and biscuits.

If the diarrhoea doesn't settle down?

If the baby continues to be unwell with diarrhoea for more than two or three days, go to a clinic. There may be persisting infection and tests are worthwhile.

Forget good manners and get children to drink from the original container using a sanitary straw. In most developed European countries, tap water is perfectly safe. In areas with poor sanitation and hygiene assume that only canned, cartons or bottled carbonated drinks and tea and coffee made with boiling water are safe.

Individual boxes of fruit juices are often incredibly sweet but this means that they can be good bribes for flagging children and the sugar content improves energy levels and enthusiasm.

To prevent locals refilling bottles of water from their restaurant sinks only drink carbonated water and as above use a sanitary straw. Bottled water may be just treated tap water; tests in India, Nepal and Pakistan have found that even bottles with an intact seal contain faecal bacteria and there is on guarantee that bottled water is safe. It is expensive and can taste of plastic. It may contain unsuitable levels of minerals or sodium for very young children, it's best to use one with less than 20mg of sodium per litre.

Boiling is the most effective method of purifying water. If preparing baby bottles start boiling long enough in advance for the water too cool before baby is screaming for his milk. Boil it for 10 minutes, this is sufficient to kill everything including cysts. Make sure that you will have the facility to do this at your destination. It's a good idea to ask as a special request, at the time of booking that your hotel room comes equipped with a kettle. Or take your own travel kettle, checking that it will work using your overseas accommodation voltage. If at a hotel ask that they give you water boiled as above rather than just heated water. Bottle fed babies may need sips of cooled boiled water as formula is not so thirst quenching.

Other methods of purifying water, such as chemical sterilisation using iodine or chlorine are not suitable for pregnant women or children under 12. Various filters are available but these too use iodine so the answer is:-

Tap water or bottled water - either boiled is the safest option.

Disposable Steriliser Bags are a safe and convenient way to sterilise baby's utensils when travelling. They eliminate the problem of transporting bulky, plastic sterilising systems, microwave units or steam sterilisers that may not operate on foreign voltages and are economical to use with each bag of solution lasting for 24 hours

Ice cream - unless you are absolutely sure it has been made from pasteurised milk and it has been stored correctly at the right temperature - wrapped ice-lollies should be fine.

Cream.

Unboiled milk.

Lettuce and other leafy uncooked vegetables and salads If you have the facilities available carefully washed and peeled cucumber is reasonably safe. Smooth shiny-skinned fruits and vegetables are pretty safe if they have been washed properly and are not punctured or scarred. When peeling take care not to contaminate the inside.

Strawberries - are particularly dangerous as they grow so low to the ground and are impossible to clean.

Cooked food and moist grains, which have been allowed to go cold (e.g. quiche, cold pizza and rice salads).

Cooked food that has been inadequately reheated.

Dishes containing meat, which are more hazardous than vegetarian food.

Fried rice (gracefully called cow-pat in Thai) is often made from inadequately reheated leftovers.

Drinks like yogurt, ice and fruit mixtures e.g. Indian lassi with ingredients, which are likely to have been handled during preparation.

Milk and other dairy products are not eaten widely outside the western world although you may find tins of cheese in some countries. Yogurt is however widely available even where milk is not. Yogurt is often safe since it is usually boiled and lactobacilli discourage colonisation with most harmful bacteria; indeed in a stomach mildly upset by antibiotics or infection yogurt will help settle symptoms.

If your child is still drinking cows milk and this forms a significant part of his diet, ensure it is pasteurised before you serve it and if in doubt boil it and allow cooling before serving. In southern Europe milk is usually homogenised which alters the flavour and therefore, puts some children off drinking it. You could take with you or buy once there UHT milk cartons. Get your children used to the slightly unusual taste of UHT however before you load up your suitcase.

To protect against any attempts by the locals to stretch pasteurised milk by adding water or unpasteurised milk bottles, stick to canned milk, but never from a can which has ballooned since there is a risk of botulism.

Children eat when they are hungry. Having made the effort to find things that they can eat and should like, you can't do anymore than that. Sometimes when we are travelling I think Rory is living on air, but then he does that at home some days too, so don't worry yourself that by the end of your trip your child will be starving. Cereals are always a good stand by to have around.

Strange new foods

If your child is a fussy eater play it safe with familiar items until his natural curiosity takes over and don't bother insisting that he try just one bite of something new - it won't work. For the time being it is a good idea to give in to the demands for familiar food from your child otherwise you will find yourself with a rebellious child whose determination is usually greater than yours.

Children are great mimics, however, and will be affected by adult attitudes to eating. If parents refuse to try new dishes, children are likely to copy their conservative eating habits, however, if you gobble down foreign foods with obvious relish they will think it's something special and eventually try it for themselves.

Perhaps surprisingly those rather unpleasant looking street side snacks that are freshly fried in smelly dark-yellow oil are safe from microbes. Busy little cafes and hotels which are popular with locals often have such a rapid turnover that their food never has a chance to get stale and is far safer than international cuisine cooked in pretentious hotels.

You will soon learn where to eat, restaurants that are popular and crowded with locals are usually ok, and no restaurant that poisons its patrons lasts long. Avoid places which only allow well-behaved children, to day may be the day that your angel grows horns ! Instead look out for restaurants that offer children's menus where you can eat out of doors. This way at least your little ones can use up some energy before the food arrives and whilst you finish yours, beware of waiters etc carrying hot food etc a safe area for them to play away from the actual tables would be perfect.

Investing in an easy wash harness and reins for your little one keeps them safe whilst walking and in 'foreign' highchairs where the anchor straps can be used to secure your child safely. To save 'highchair hassle' we take a Travel Highchair on our travels which is extremely useful both home and away.

A telephone reservation can be helpful to check if the restaurant times will coincide with your child's meal times, whether they have highchairs or whether there will be room for you to use buggy at the table. In the United States you can often phone ahead to order before arriving so that your meals will be ready the moment you walk in the door. Lunch times are the best times for eating out as a family when children are less tired and restaurants are more relaxed. Make it clear when you arrive that you want to order straight away, are happy to wait to be seated until the food is ready and that your Childs meal should be served first. Order everything cooked to be well done and piping hot.

Barbecues can also pose problems. About 1,000 people have barbecue injuries during a hot summer every year in the UK- some suffer serious burns. Children must be supervised near barbecues at all times - even when the cooking is completed. Make sure the barbecue is stable and on a level surface. Never pour petrol or methelated spirit onto the barbecue and use thick gloves when handling skewers and metal trays.