Air Travel for Newborns and Infants

Karl Neumann, MD, FAAP

Healthy newborn infants are physiologically fit to fly. Most major world airlines have removed all restrictions that formerly banned such travel in the first few weeks of life. The restrictions stemmed from the early days of aviation and were based on the facts that the aircraft of that day were not pressurized, that oxygen was sometimes required during flights, and that little was known about newborn physiology and how infants would fare in flight. The old regulations are still often cited in the travel medicine and pediatric literature and in the lay press.

A telephone survey of the 7 largest U.S. airlines and the 4 largest foreign airlines that serve the U.S. shows that none of them have a lower age restrictions for infants to travel by air. Four of the U.S. airlines suggest that parents of infants less than a week old "check with their doctor," or "have a note from a doctor" that says the infant is in good health. However, such a note is rarely, if ever, asked for by check-in and boarding gate attendants. Other information in airline computers include: only one infant per row because of oxygen mask considerations; parents should consider using an infants’ safety seat; and exposure to infection aboard the aircraft could be a problem for infants of this age. One airline requires that all infants be accompanied by an adult!

Modern commercial jet airliners generally cruise at altitudes between 9,000 and 12,000 meters (30,000 and 40,000 feet). The aircraft are not totally pressurized, resulting in a simulated cabin atmospheric pressure between 1,500 and 2,400 meters (5,000 and 8,000 feet). At this atmospheric pressure the arterial blood oxygen saturation of healthy passengers of all ages decreases from near 100% at sea level to about 90 to 92%, a saturation level that is well tolerated by healthy newborns and infants. The oxygen dissociation curve is very helpful in maintaining oxygen saturation at a high level at all ages. Healthy newborns have well developed lungs and usually have high hemoglobin levels, which may be an additional safety factor.

Air travel may NOT be safe for infants with severe anemia, congenital heart disease (especially abnormalities of the right side of the heart), and poorly or abnormally developed lungs. It is important to note that some of these conditions may not be present or recognized at birth, and may become symptomatic during flight or while the family is visiting high altitude destinations. There are no known reports of an infant having cardiopulmonary problems as a result of an airplane flight, though such problems have been reported for infants born at or near sea level who subsequently were taken to elevations over 1800 meters (6,000 feet). Children (and adults) with sickle cell disease, for example, often do poorly at the atmospheric pressure existing at cruising altitudes, but infants with this condition are generally not symptomatic in the first few months of life. In spite of one recent article in a major medical journal stating that a history of recent air travel is a risk factor for SIDS, the consensus of experts is that there is no such association.

There are no data to determine whether or not newborns and infants are at increased risk of infectious diseases during air travel. Many adult frequent flyers claim that they experience more URI’s after flights than at other times. Speculation implicates prolonged and close togetherness in an enclosed space, recirculating cabin air, exposure to travelers from distant parts of the world where different strains of organisms circulate, changes in the immune system due to the stresses of travel, and the extreme dryness in the cabin air. Dry air results in a lack of moisture in the nasal passages. This may facilitate organisms passing through. Saline nose drops may alleviate this.

There are several documented cases of adults acquiring tuberculosis during long flights, and acquiring influenza in an aircraft standing on the tarmac for many hours with no operational ventilation system. In the tuberculosis incident, the passengers who acquired the disease were all sitting near an infected, heavily-coughing passenger. The U.S. Centers for Disease Control believes that such incidents occur extremely rarely.

Currently there is much debate about air quality in the aircraft cabin. In recent years, to save fuel, airlines have changed the method of supplying air to aircraft in flight. Under the old system, air was exchanged every few minutes. Under the new system, half the air in the cabin is passed through sophisticated systems and re-circulated. The result is that the air that passengers breathe is about half re-circulated air.

Fresh air is taken in from the outside and is virtually sterile; there are no microorganisms in the air at cruising altitudes. Moreover, the outside air passes through the very hot engines killing any organisms, and is then cooled. This is a very expensive process. Re-circulated air passes through sophisticated filters, making it virtually as microorganism-free as fresh air. But some experts question whether or not the filters in use eliminate all viruses. The consensus appears to be that the risk of acquiring infection in-flight is small but that it does exist.

Parents have few options for protecting their infants from risks of exposure to microorganisms in flight and that these options are largely unproven and impractical: flying at off-hours when there tend to be fewer passengers; traveling first class where there is less crowding and, therefore, more air per passenger; flying early in the day when aircraft are cleaner; changing seats when a nearby passenger coughs and sneezes; frequent hand washing; and bringing ones’ own pillow nad blankets. Aircraft are cleaned thoroughly only before the first flight of the day. Presumably, the air in the morning is cleaner. On most airlines, pillows and blankets are replaced only at the time of that cleaning. Lately, many major airlines exchange pillows and blankets only when they are visibly soiled – sometimes once every several weeks.

(Karl is the Editor of NewsShare and writes extensively about travel and wilderness medicine for professional and lay audiences. He is a practicing pediatrician and associate clinical professor/attending pediatrician at the New York Weill Cornell Medical Center in New York City.)