REVIEW

CURRENT
OPINION High-altitude illness in the pediatric population:
a review of the literature on prevention
and treatment
Vanessa Garlick a, Anne O’Connor b, and Catherine D. Shubkin c

Purpose of review
Increasing numbers of children are now traveling to high-altitude destinations, and pediatricians often see
these children prior to and immediately following their travels. Thus, pediatricians have the opportunity to
provide guidance for the prevention of altitude illness and must treat high-altitude illness (HAI) in some
circumstances. This review will examine guidelines for prevention and management of HAI in the pediatric
population.
Recent findings
Recent research has examined children’s short-term cardiorespiratory adaptation to high altitude, incidence
of acute mountain sickness, hypoxic ventilator response, and maximal exercise capacity. Overall, studies
indicate that children and adults are largely similar in these variables. Furthermore, studies suggest that
heritability seems to be a component of response to altitude and development of altitude illness – a finding
that may have implications for family vacation planning.
Summary
Increasing numbers of children are visiting high altitude destinations. Whereas most of these child travelers
will only experience mild to moderate symptoms of HAI, a small percentage, particularly those with
predisposing health conditions, may experience severe disease. Pediatricians should encourage preventive
measures with an emphasis on gradual ascent and vigilance for onset of symptoms that should prompt
immediate transport to medical care.
Keywords
acute mountain sickness, children at altitude, high-altitude cerebral edema, high-altitude illness, high-altitude
pulmonary edema

INTRODUCTION some circumstances, must treat high-altitude illness

Family ski vacations to the Rockies (10 000 ft.),
youth trips to hike the Inca Trail (14 000 ft.), and
school excursions to view the Grand Canyon
(8 000 ft.) were once only undertaken by a fortu-
nate few; however, these trips are now becoming
increasingly frequent (Fig. 1) [1]. For example, Rocky
Mountain National Park had its highest annual
visitation in 2016 with 4.5 million people, a 40%
&
increase from 2012 [2 ]. Increasingly popular tourist
destinations, such as Rocky Mountain National
Park, are at significant altitudes, placing which
places children, particularly those with existing
susceptibilities, at risk of developing altitude illness.
Pediatricians are in a unique position to see these
children prior to and immediately following travel.
Thus, they have the opportunity to provide guid-
ance for the prevention of altitude sickness, and, in
(HAI).
EFFECTS OF ALTITUDE
As altitude increases, atmospheric barometric pres-
sure decreases, leading to a proportional decrease in
a
Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock,
b
Department of Emergency Medicine, Dartmouth-Hitchcock Medical
Center and cChildren’s Hospital at Dartmouth-Hitchcock, Geisel School
of Medicine, Lebanon, New Hampshire, USA
Correspondence to Catherine D. Shubkin, MD, Children’s Hospital at
Dartmouth-Hitchcock, Geisel School of Medicine, 1 Medical Center
Drive, Lebanon, NH 03765, USA. Tel: +1 603 653 9663;
fax: +1 603 727 7998; e-mail: Catherine.d.shubkin@dartmouth.edu
Curr Opin Pediatr 2017, 29:503–509
DOI:10.1097/MOP.0000000000000519

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Office pediatrics

alkalosis. In contrast, long-term compensatory

KEY POINTS mechanisms, such as an increase in red blood cell
 High-altitude illness in the pediatric population should mass and increased excretion of bicarbonate by the
&&

mainly be treated through graded ascent. kidney, take several days [5 ].

 Parents should be educated about signs and symptoms

of high-altitude illness prior to traveling with
young children.
 Children with predisposing conditions are at increased
risk of high-altitude illness, particularly high-altitude
pulmonary edema.
the partial pressure of oxygen. At sea level there is a
large pressure gradient for oxygen to flow from
inspired air to tissue. However, this gradient is
reduced at increased altitudes, leading to a type
of tissue hypoxia known as hypobaric hypoxia.
Hypobaric hypoxia drives physiologic changes
and, in some individuals, the initial development
&
of HAI [3 ].
The effects of altitude are typically first noted
upon ascent above 1500 m (5000 ft.). At this
elevation, the carotid bodies sense the low PO2 in
arterial blood through a process mediated by a her-
itable transcription factor known as the hypoxia-
inducible factor (HIF); the rate and depth of breath-
&&
ing increase in response [4 ,5 ]. This hyperventi-
&&
lation is almost immediate and leads to a respiratory
ACUTE MOUNTAIN SICKNESS
Acute mountain sickness (AMS) is by far the most
common form of altitude sickness in both children
and adults. Symptoms of AMS develop after 6–48 h
at altitudes of 2500 m (8000 ft.) and higher. The
cardinal and defining symptom of AMS is headache,
which is characteristically bilateral and is worsened
by Valsalva maneuver. The diagnosis of AMS
requires headache in an unacclimmatized individ-
ual who has recently traveled to an altitude above
2500 m, in addition to the presence of one or more
of the following symptoms: insomnia, dizziness,
lassitude, fatigue or gastrointestinal symptoms
&&
(nausea, vomiting, anorexia) [5 ].
The severity and diagnosis of AMS is frequently
assessed by a questionnaire known as the Lake
Louise Scoring System (Fig. 2) [6]. This tool is rela-
tively easy to use in all verbal and school-aged
children; however, it has obvious limitations in
the nonverbal pediatric population. Therefore, the
Children’s Lake Louise Score (CLLS) consisting of a
‘Pediatric Symptom Score’ and a ‘Fussiness Score’
has been developed to assess preverbal children [7].

300000 Mt. Everest (29,029 feet/8848m)

9000m 29000

28000

27000

8000m 26000

25000

24000

7000m 23000

22000
Extreme Altitude 21000

20000 Denali, AK (20,310 feet)

6000m 19000

18000

17000

5000m 16000
Very High Altitude 15000
Mt. Whitney, CA (14,494feet)
14000

4000m 13000

12000

11000
Cusco, Peru (11,182 feet)
10000 Breckenridge, CO (10,000 feet)
3000m 9000

8000
High Altitude 7000 Mexico City (7,382 feet)
Mt. Washington, NH (6,289 feet)
2000m 6000
Denver, CO (5,280 feet)
5000

4000

1000m 3000

Sea Level 2000

1000
Lebanon, NH (581 feet)
Thursday, March 2, 17

FIGURE 1. High-altitude travel destinations. Common travel destinations and their corresponding altitudes are shown
(reproduced with permission from [1]).

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 High-altitude illness in pediatrics Garlick et al.

FIGURE 2. Lake Louise Score. Lake Louise scoring sheet is commonly used to quantify symptoms and diagnose acute mountain
sickness. The first five questions are known as the AMS self-report questionnaire and are to be reported by the individual. The
second portion of the score (questions six through eight) is known as the clinical assessment score and is based on the clinical
exam by the examiner. The last question is the functional score and is an optional part of the assessment. Reproduced from
[6]. All efforts have been made to obtain permission for this content.

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Office pediatrics
The reported incidence of AMS in children is
variable, but most studies report incidence rates
similar to those in adults (approximately 25% of
individuals who travel above 2500 m) [4 ,7,8].
However, this traditionally accepted observation
has recently been questioned by recent studies.
For example, a frequently referenced study in Chile
found significantly lower hemoglobin saturation in
children than in adolescents and adults at altitude.
Additionally, the study found that 100% of the
children, 50% of adolescents, and 27% of adults
developed AMS [9]. The sample size of this study
was relatively small and the results have not been
reproduced. However, the most recently published
study documenting the incidence of AMS in chil-
dren (31%) to be similar to the incidence in adults
(28–36%) after accounting for discrepancies in the
trekkers was conducted in Taiwan and found AMS
incidence to be 59% in children aged 11–12 years –
a figure significantly higher than that found in a
similar study of adults in the same region (28–36%)
&
[10 ,11]. However, this finding has been disputed,
primarily due to significant heterogeneity among
the included trekkers’ rates of ascent. When this
discrepancy is accounted for, the incidence of
AMS in children is very close to the incidence in
&
adults (31%) [12,13 ].
So whereas newer studies are questioning the
commonly accepted observation that the rate of HAI
is similar across age groups, further studies are
needed to assess whether age is truly a predictive
Table 1. Recommended dosages for medications used in the prevention and treatment of altitude illness
Medication Indication
Acetazolamide AMS; HACE prevention
AMS treatmenta
Dexamethasone AMS; HACE prevention
AMS; HACE treatment
Nifedipineb HAPE prevention
HAPE treatment
Tadalafilb HAPE prevention
Sildenafilb HAPE prevention
Salmeterolb HAPE prevention
AMS, acute mountain sickness; HACE, high-altitude cerebral edema; HAPE, high-altitude pulmonary edema; i.m., intramuscular; i.v., intravenous; SR, sustained
release.
Reproduced with permission from [12].
a
Acetazolamide can also be used at this dose as an adjunct to dexamethasone in HACE treatment, but dexamethasone remains the primary treatment for that
disorder.
b
Medication is not recommended for this indication in the pediatric population because data in children are limited.
c
Should not be used as monotherapy and should only be used in conjunction with oral medications.
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factor. In the meantime, less controversial positive
predictive factors for the development of AMS
include altitude, time at altitude, physical activity,
&& &&
and rate of ascent [5 ].
Gradual ascent is largely accepted as one of the
best ways to prevent acute mountain sickness. Of
particular importance is the altitude at which one
sleeps. General guidelines recommend that individ-
uals above an altitude of 3000 m should not increase
sleeping elevation by more than 500 m per day and
should include a rest day (i.e. no ascent to higher
sleeping elevation) every 3–4 days [6]. For example,
families may want to consider spending the night in
Denver (elevation 1625 m) prior to heading up to
Aspen (elevation 2400 m) when flying to Colorado
for a ski holiday.
Although gradual ascent is ideal, it is not always
a practical option. Adult cases of unavoidable rapid
ascent are often managed with prophylactic aceta-
zolamide, which aids in acclimatization by promot-
ing renal excretion of bicarbonate, thus resulting in
metabolic acidosis and offsetting altitude induced
respiratory acidosis. The end effects of acetazola-
mide are numerous, but most experts attribute ace-
tazolamide’s efficacy to respiratory stimulation and
&&
increased alveolar and arterial oxygenation [5 ].
Acetazolamide can be used off label in children at
a dose of 2.5 mg/kg/dose b.i.d. (not to exceed 125 mg
b.i.d.) (Table 1) [12]. However, given that most high-
altitude travel is recreational and the drug has side
effects (e.g. parathesias, increased urination, and
Route Dosage
Oral 125 mg twice per day
Pediatrics: 2.5 mg/kg every 12 h
Oral 250 mg twice per day
Pediatrics: 2.5 mg/kg every 12 h
Oral 2 mg every 6 h or 4 mg every12 h
Pediatrics: should not be used for prophylaxis
Oral, i.v., i.m. AMS: 4 mg every 6 h
HACE: 8 mg once then 4 mg every 6 h
Pediatrics: 0.15 mg/kg/dose every 6 h
Oral 30 mg SR version, every 12 h or 20 mg of SR version every 8 h
Oral 30 mg SR version, every 12 h or 20 mg of SR version every 8 h
Oral 10 mg twice per day
Oral 50 mg every 8 h
Inhaled 125 mg twice per dayc
Volume 29  Number 4  August 2017

metallic taste), pharmacological prophylaxis is not
generally recommended [12].
If a child develops AMS, further ascent should be
halted. Children with AMS can remain at their
current altitude and manage their symptoms with
nonopioid analgesics and antiemetics. Acetazola-
mide can also help treat AMS, although it typically
is more effective for prophylaxis. The recommended
treatment dose of acetazolamide is the same as the
prophylactic dose. If symptoms of AMS are very
severe, dexamethasone can be administered and
descent should be initiated. The recommended
treatment dose of dexamethasone is 0.15 mg/kg/
dose every 6 h (Table 1) [12]. Once symptoms of
AMS resolve, ascent can be resumed and addition of
acetazolamide for further ascent may be prudent.
However, if symptoms do not resolve, further ascent
or ascent to previously attained altitude should not
be undertaken [12].
HIGH-ALTITUDE CEREBRAL EDEMA
High-altitude cerebral edema (HACE) is clinically
distinguished from AMS by the presence of neuro-
logical findings such as ataxia, confusion, or altered
mental status during ascent to high altitude. HACE
can follow AMS or occur in conjunction with high-
altitude pulmonary edema. The cause of HACE has
not been clearly elucidated. Whereas conventional
theory is that hypobaric hypoxia results in increased
cerebral blood flow leading to increased intracranial
pressure (ICP), recent studies suggest that cerebral
venous congestion may be an underappreciated
&
mechanism of the increased ICP [14 ].
Incidence of HACE is very low and almost non-
existent below very high altitude (4000 m). It is
reported to be about 0.5% in adults, with no studies
or case reports documented in children [8]. HACE is
a very serious form of altitude illness that warrants
immediate descent. In areas with access to medical
care supplemental oxygen and dexamethasone
should be administered. The recommended treat-
ment dose of dexamethasone is 0.15 mg/kg/dose
every 6 h (Table 1) [12].
HIGH-ALTITUDE PULMONARY EDEMA
High-altitude pulmonary edema (HAPE) is a noncar-
diogenic pulmonary edema caused by high-altitude
induced hypoxia. HAPE presents with dyspnea,
reduced exercise tolerance, cough, hemoptysis,
tachycardia, tachypnea, cyanosis, and rales on
physical examination. It is the most fatal of all HAIs.
Fortunately, HAPE is rare. The incidence of HAPE is
reported at 0.5–15%, although most literature
suggests it is much closer to 0.5% than 15% [15].
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High-altitude illness in pediatrics Garlick et al.
Although the incidence of HAPE in lowland
children traveling to high altitude is similar to that
in adults, it appears that re-entrant HAPE (highland
children developing the condition after returning
home to a high altitude) is more common in chil-
dren. A child’s risk of developing HAPE is largely
dependent on genetic factors, altitude attained (very
low risk below 3000 m), rate of ascent, and time
spent at altitude. There is also evidence suggesting
children with a history of recent upper respiratory
tract infection are at increased risk of developing
HAPE [15].
The best way to prevent HAPE is gradual ascent
at the same rate detailed above to prevent AMS. In
adults, with history of HAPE, who cannot avoid
rapid ascent, prophylaxis with nifedipine (60 mg
sustained release preparation in divided doses) or
acetazolamide is often recommended (Table 1) [12].
However, use of these medications for HAI in chil-
dren is off-label, and these drug regimens have never
been studied in children, so they should be pre-
scribed with caution. Furthermore, it is difficult to
imagine a situation in which rapid ascent could not
be avoided in the pediatric population; thus gradual
ascent should always be the mainstay of
HAPE prevention.
The single best treatment for HAPE is descent.
However, children should be discouraged from
exerting themselves on descent, and are ideally
carried, as exertion can further increase pulmonary
artery pressure and exacerbate pulmonary edema
[12]. Historically in adults, HAPE has been managed
heterogeneously with a mixture of diuretics, nifedi-
pine, dexamethasone, and supplemental oxygen.
However, recent studies and case reports suggest
that rest and supplemental oxygen alone are suffi-
cient and pharmacological therapy does not hasten
&&
recovery [16 ].
CHILDREN AT HIGHER RISK OF HIGH-
ALTITUDE ILLNESS
In general, any child with a medical condition
associated with underlying predisposition to pul-
monary hypertension is thought to be at risk for
HAI, particularly HAPE. Such conditions include
Down’s syndrome, congenital heart disease,
obstructive sleep apnea (OSA), bronchopulmonary
dysplasia, cystic fibrosis, severe scoliosis, and sickle
cell anemia [15].
Of these conditions, children with Down’s syn-
drome are at a uniquely high risk because they often
have concurrent congenital heart malformations
and OSA. With this in mind, a recent study compar-
ing children with Down’s syndrome and OSA to
children with only OSA found that at elevations
www.co-pediatrics.com 507
Office pediatrics
of above 1500 m, children with Down’s syndrome
and OSA have a disproportionately higher risk for
hospitalization than children with only OSA. Thus,
it seems reasonable to encourage greater awareness
and earlier screening for OSA and its complications
in patients with Down’s syndrome living at high
altitude [17].
Otherwise, healthy children with recent upper
respiratory tract infections, otitis media, or bronchio-
litis also have an increased risk of developing HAPE.
This is likely due to a combination of factors. Chil-
dren have greater pulmonary vascular reactivity than
adults, and inflammation increases capillary per-
meability. Together, this causes proportionally more
pulmonary edema in children [18]. Whereas these
children are at an increased risk of HAPE, the overall
incidence is still quite low. They do not need to be
precluded from high-altitude travel, but families
should be educated on risk, signs, and symptoms
of HAPE that should alert them to seek medical care.
Studies and anecdotal evidence indicate that
residence above 2500 m is an independent risk fac-
tor for severe respiratory syncytial virus (RSV) lower
respiratory tract infection requiring hospitalization
[19]. Thus, families living at this altitude should be
counseled on ways to reduce risk of severe infection,
signs and symptoms that require prompt medical
attention, and interventions during illness.
Additionally, it is reasonable for practitioners to
consider the risk of living at altitude, when making
decisions regarding RSV prophylaxis for patients
[19].
INFANTS AT ALTITUDE
Infants residing at altitudes of above 8000 ft. are at
an increased risk of sudden infant death syndrome
(SIDS). That said, the impact of the ‘Back to Sleep
Campaign’ has been similar across altitudes; thus it
is strongly recommended that all infants sleep in
prone position at altitude [20]. Also of note, studies
looking at altitude and SIDS have focused on
mother’s residential address; thus it is not possible
to infer whether lowland infants traveling to high
altitude are at an increased risk of SIDS [20].
CONCLUSION
As the number of children traveling to destinations
at significant altitude continues to increase, pedia-
tricians are in a position to provide families with
strategies to prevent the development of, and also
manage, HAI. Because rapid ascent is rarely war-
ranted in the pediatric populations, the mainstay
of HAI prevention is gradual ascent, with the knowl-
edge that further ascent may need to be halted
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depending on the severity of symptoms. Symptoms
of HAPE and HACE should be taken very seriously
and managed with immediate descent, supple-
mental oxygen, and, in some cases, pharmacologi-
cal intervention. Children with predisposing
conditions, particularly disorders associated with
increased pulmonary artery pressure, should be
thoroughly counseled about the risks, and signs
and symptoms of HAI, particularly HAPE. Whereas
the incidence of HAI does not appear to be higher in
the pediatric population, the phenomenon of re-
entrant pulmonary edema does have a significantly
higher incidence in children and should be con-
sidered in any child with dyspnea, cough, and rales
on physical examination upon returning to altitude.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Barton C. Grand Rounds: Pediatric Wilderness Medicine. Dartmouth Hitch-
cock Medical Center; 2016.
2. National Park Service. Park Statistics: Rocky Mountain National Park [Inter-
& net]. Washington DC: National Park Service; [cited 2017 Feb 26]. Available
from: https://www.nps.gov/romo/learn/management/statistics.htm. [Accessed
21 January 2017]
A study highlighting the recent increase in travelers of all ages to parks located at
high altitude.
3. Kim SB, Kim JS, Kim SJ, et al. Altitude stress during participation of Medical
Congress. Neurointervention 2016; 11:73–77.
&
A review that emphasizes the stress of altitude at common travel destinations.
4. Kriemler S, Radtke T, Burgi F, et al. Short-term cardiorespiratory adaptation to
high altitude in children compared with adults. Scand J Med Sci Sports 2016;
&&
26:147–155.
A recent study examining the effects of altitude on physiology in both adults and
children. The findings emphasize that the incidence and severity was similar across
ages and that cardiorespiratory adaptation to altitude seems to have a heritable
component.
5. Roach RC, Lawley JS, Hackett PH. High-altitude physiology. In: Auerbach
&& PS, editor. Auerbach’s Wilderness Medicine, 7th ed. Philadelphia: Elsevier;
2016. pp. 2–7.
The most recent edition of arguably the most well respected text in wilderness
medicine. The chapter is written by world experts in the field of altitude medicine.
6. Roach RC. Hypoxia and Molecular Medicine. 1st ed. Burlington, VT: Queen
City Press; 1993; Figure 1; pp. 273–274.
7. Yaron M, Waldman N, Niermeyer S, et al. The diagnosis of acute mountain
sickness in preverbal children. Arch Pediatr Adolesc Med 1998; 152:683–687.
8. Neuman K. Children at altitude. Travel Med Infect Dis 2007; 5:138–141.
9. Moranga FA, Osorio JD, Vargas ME. Acute mountain sickness in tourists with
children at Lake Chungara (4400) in northern Chile. Wilderness Environ Med
2002; 13:31–35.
10. Chan CW, Lin YC, Chiu YH, et al. Incidence and risk factors associated with
& acute mountain sickness in children trekking on Jade Mountain, Taiwan. J
Travel Med 2016; 23:1–5.
A study that questions the accepted incidence of AMS in children, stating that it is
higher than commonly accepted.
Volume 29  Number 4  August 2017

11. Wang SH, Chen YC, Kao WF, et al. Epidemiology of acute mountain sickness
on Jade Mountain, Taiwan: an annual prospective observational study. High
Alt Med Biol 2010; 11:43–49.
12. Luks AM, McIntosh SE, Grissom CK, et al. Review article: wilderness medical
society consensus guidelines for the prevention and treatment of acute
altitude illness. Wilderness Environ Med 2010; 21:146–155; Table 2:
recommended dosages for medications used in the prevention and treatment
of altitude illness.
13. Sikri G, Srinivasa AB, et al. Letter to the editor: acute mountain sickness in
& children at Jade Mountain. J Travel Med 2016; 23:4.
A letter to the editor that highlights differing reports of incidence of AMS in children
and adults.
14. Sagoo RS, Hutchinson CE, Wright A, et al. Magnetic resonance investigation
& into the mechanisms involved in the development of high-altitude cerebral
edema. J Cereb Blood Flow Metab 2017; 37:319–331.
A study that emphasizes that cerebral venous outflow obstruction could possibly
be a larger contributor to HACE than ever previously considered.
1040-8703 Copyright ß 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
High-altitude illness in pediatrics Garlick et al.
15. Duster M, Derlet M. High-altitude illness in children. Pediatr Ann 2009;
38:218–223.
16. Yanamandra U, Nair V, Singh S, et al. Managing high-altitude pulmonary
&& edema with oxygen alone: results of a randomized controlled trial. High Alt
Med Biol 2016; 17:294–299.
A study that demonstrates that oxygen alone is equally efficacious to pharmaceu-
tical management of HAPE, thus having large implications for future practice.
17. Jensen KM, Sevick CJ, Seewald LA, et al. Greater risk of hospitalization in
children with Down’s syndrome and OSA at higher elevation. Chest 2015;
147:1344–1351.
18. Durmowicz AG, Noordeweir E, Nicholas R, Reeves JT. Inflammatory pro-
cesses may predispose children to high-altitude pulmonary edema. J Pediatr
1997; 130:838–840.
19. Choudhurt JA, Ogden LG, Ruttenber AJ, et al. Effect of altitude on hospita-
lizations for respiratory syncytial virus infection. Pediatrics 2006; 117:349–356.
20. Katz D, Shore S, Bandle B, et al. Sudden infant death syndrome and
residential altitude. Pediatrics 2015; 135:1442–1449.
www.co-pediatrics.com 509