Overseas air transfers - information for parents

Having a premature or sick baby can be extremely worrying for any family, and even more so if you’re in an unfamiliar place away from home. We hope this leaflet will answer some of your questions and give some guidance on what to do next.

What should I do right now?

If your baby has been born in another country, these are the things you will need to do:

First, speak to your insurance company and find out what they will cover – they may have a service that will help you with the arrangements below.
Make sure mum and any partner have accommodation, phone and transport.
Let your hotel or accommodation provider know that there has been a medical emergency.
Speak to your airline or holiday company for support and let them know they will need to delay any flights home.
Find out the name and contact details of the baby’s hospital and treating doctor.
Request a medical report from the hospital.
Get a foreign birth certificate for your baby.
Contact the FCDO, British Embassy, High Commission or Consulate to get assistance and arrange an emergency travel document for your baby.

Getting support from the British Government

The Foreign, Commonwealth & Development Office (FCDO) is responsible for providing support to British citizens worldwide. You can find guides to their support services here: https://www.gov.uk/government/publications/support-for-british-nationals-abroad-a-guide.

The first step should be to contact the local British embassy, high commission, or consulate. You can find a list here: https://www.gov.uk/world/embassies.

The 24-hour FCDO emergency number is +44 207 008 5000. This should only be used in genuine emergencies where you have an urgent need and cannot access other help.

Most mobile phones will automatically dial an international number, but if it doesn’t work you can usually dial the UK by putting in 00 44 then put the phone number in without the first 0. So for the FCDO emergency number it would be 00 44 207 008 5000.

Getting an emergency travel document (ETD)

Also known as an emergency passport, this will be required to bring your baby back to the UK. This is usually issued when someone has lost their passport, and it is unusual that the authorities need to issue one for a baby so you will need to clearly explain your situation. It is a good idea to start this process quite early on as it can take a long time to arrange. You will need to explain:

This is a newborn baby who has never had a passport.
They are having medical treatment that makes taking photographs difficult and there may be medical devices on the face to support baby’s breathing that cannot be removed.
You will need documents that will allow travel within a period of time such as two weeks, not just for a single day, because your baby’s condition could change and flights are complicated to organise.

Once you have spoken to an Embassy, Consulate, High Commission or the FCDO, they should send you a link to an online form to complete. You can also try to access this yourself by emailing etdcentre.fta@fco.gov.uk.

You will asked to provide documents for your baby, including evidence of nationality. This is likely to include:

Passport-style photograph of the baby
Passport and birth certificate of the mother, and also father if present
Marriage certificates of parents if married
Birth certificate and marriage certificate of the maternal grandparents (that means mum’s mum and dad)
Evidence you were pregnant before going away such as hospital or GP letters
Foreign birth certificate for the baby
Proof of travel plans

Photographs

You should take the best photograph of your baby’s face that you can, trying to follow the government guidelines (https://www.gov.uk/photos-for-passports). If your baby is having help with breathing their face might be partially covered. Capital Air Ambulance can provide a doctor’s letter to explain this.

Birth Certificate

You will need to get help from the hospital to register the birth with the foreign government and get a birth certificate. In most countries, this means going to a government registry office and may mean paying a fee. You may need to take a translator as they may not speak English. Most birth certificates are multi-lingual but if it is not clear what it says it may need to be translated.

Proof of travel plans

For normal circumstances, this would mean providing a copy of an airline ticket. For an air ambulance flight there won’t be a ticket but Capital Air Ambulance can provide an invoice with a flight plan as proof.

What does the medical report need to say?

You will need to speak to the doctors or nurses who are looking after your baby to get a medical report. There might be a department in the hospital that deals with overseas visitors, and you might have to pay a fee. The details that are needed are:

The name of the hospital, ward and treating doctor
Baby’s name, date of birth, birth weight and gestational age
What happened to cause mum to go into preterm labour?
What did the medical team do at birth to resuscitate?
How is their breathing being supported?
If they are on a ventilator, what are the settings?
Are they on any medicines to support the heart (inotropes)?
Are they on antibiotics?
What fluids and feeding are they being given?
A printout of their observations, also known as vital signs
A printout of all blood test results
A report of any x-rays or scans, especially scans of the brain or heart

Some of the unfamiliar terms you’ve just read are explained below.

What does it mean for a baby to be premature?

Most pregnancies last 38 to 42 weeks, but some babies are born early. Health professionals refer to the number of weeks the pregnancy lasted as the gestation or gestational age. We also talk about the number of days since baby was born, and this is added on to give the corrected gestation. For example, a baby born at 25 weeks and 3 days would be called 25+3 weeks gestation. When they are three days old they would be 25+6 corrected gestation. You might see this written as 25+6/40.

Babies that are not premature are referred to as term, this means that they reached the full term of the pregnancy then delivered around the normal expected time. The word preterm means the same as premature. Babies that were premature but have got older and reached their original due date are known as term corrected.

The care of premature and sick babies is provided by doctors called neonatologists and specialist neonatal nurses. They may be dieticians, speech therapists and physiotherapists involved in a baby’s care. Some countries have respiratory therapists who look after a baby’s breathing, but in the UK and Europe this is normally done by a doctor. The hospital wards are called a neonatal intensive care unit (NICU) or special care baby unit (SCBU).

Premature babies are classified into different gestational ages which tells us about the risks and likely treatments they will need. These are not hard rules but will give you an idea of what to expect, and some babies act a bit more or a bit less mature than their actual gestational age and babies with more complicated medical conditions will need more support. As babies get better and get older they will progress to the next stage.

Likely support needed dependent on gestational age

All babies born less than 32 weeks gestation:

An incubator to keep baby warm
A tube through the nose and down into the stomach (NG tube) for giving milk
Antibiotics for infection given as a drip (IV)
Monitoring for jaundice, treatment with a special light if needed (phototherapy)
Regular scans to look for bleeding in the brain (IVH)
Regular checks to the eyes to look for eye disease (ROP)
Monitoring of growth by weighing and measuring the head (head circumference)
Regular blood tests

Extremely premature 23-28 weeks:

A tube into the windpipe connected to a life support machine (ventilator)
A tube into the belly button vein and artery (umbilical lines/UAC/UVC)
Medicines to support the heart (inotropes)
Medicines for sedation and pain relief such as morphine Blood transfusions

Very premature 28-32 weeks:

A mask or prongs to the nose to support breathing (CPAP/High Flow Oxygen)
A long line tube in the nose or foot to give feeding into a vein (TPN)

Moderately premature 32-34 weeks:

An incubator or heated cot
Small prongs in the nose to give oxygen
A drip to give fluid into a vein whilst milk feeds are built up

Late preterm 34-37 weeks:

Help keeping warm, possible treatment for infection
Possible treatment for jaundice
Support with feeding – some will need feeding with an NG tube

When can my baby go back to the UK?

For many years, the advice from the insurance and medical assistance industry has been that babies should remain where they are until they are term corrected, as long as they are getting good medical care. However, there is growing evidence from research and the experience of specialist teams that premature babies can be safely moved in an air ambulance. Within the UK and across the world it is part of the normal practice of specialist doctors to move premature babies by road and air.

An expert in neonatal aeromedical transport can assess your baby’s needs and advise on the right time to fly. Usually, this would be after the first two weeks of life and ideally when your baby is showing that they are stable, which means they have good blood test results, good x-ray and scan results, and aren’t needing regular changes in their treatment.

Your baby’s safety will be the most important issue, but your family situation will also be taken into account to decide when your baby can come back to the UK. You may find life very difficult in another country, mum or partner may have to return to work, and there may be other children to consider. It may also help to limit costs by paying for a one-off flight to return to NHS care rather than open-ended medical fees abroad.

If your baby is receiving medical care that is well below the normal standard in the UK, an emergency flight can be organised as a medical evacuation (medevac) either back to the UK or to a closer country where specialist care is available.

How will my baby be taken to the UK?

There are four options for travel, the best option will depend on how premature your baby is, and how much treatment they need. Costs also need to be considered. Usually, at least one parent can fly with their baby. As long as your baby is doing well, you will be able to sit next to them, talk to them and touch them. If they are taking milk feeds we can usually give some feeds during the flight. Parents often like to take photos to share with family and friends and show to their baby when they’re older.

Private Air Ambulance

A neonatal air ambulance has an incubator, ventilator and other medical equipment and a team of senior neonatal doctor or practitioner and neonatal nurse. The pilots will have specialist experience for air ambulance flights and work closely with the medical team to plan the flight. This option is suitable for the smallest and sickest babies but can be expensive, especially for long distances. This might be the best option even for a very well baby to avoid the potential for delays and cancellations with commercial flights.

Commercial Stretcher flight

Some airlines can provide a stretcher which a specialist air ambulance team can equip with a mini-incubator (Baby Pod), ventilator and other medical equipment. The medical team will depend on the needs of your baby. This is a very expensive option for short journeys but becomes most cost-effective for longer distances. This option is suitable for bigger and more stable babies but is not available in every country and requires some time to arrange.

Commercial Medical Escort

Most airlines will allow a baby to travel in a carry-cot (bassinet) provided by the airline if there is a nurse or doctor taking responsibility for their care. This is suitable for babies who do not need an incubator but need some level of support such as NG feeding and a small amount of oxygen. It is a very cost-effective option for longer distances but your baby must be very stable. The team will bring basic resuscitation equipment but would not be able to give advanced care such as ventilation.

A normal commercial flight

If your baby is well and completely discharged from hospital care, this will be the best and most cost-effective option. Airlines may provide a carry-cot (bassinet) or a seatbelt extension to hold your baby and you will look after them during the flight. Each airline has different rules around the age of a baby that they will accept and may require a ‘fit to fly’ letter from a doctor. You might have to wait several weeks past term-corrected to fly.

What are the risks of a medical flight?

The risks of a medical flight can be thought of in terms of the flight itself, things that could affect the baby during the flight, and how the flight might affect the baby afterwards.

Risks of the flight

When anybody travels in an aeroplane, there is always a degree of risk, just like travelling in a car or even walking down the street carries risk. Specifically for air travel, this includes:

Delays and cancellations that mean you have to wait for another time or day to fly
Loss of cabin pressure requiring oxygen masks for passengers
Problems with the plane leading to an emergency landing
Ditching, which means an emergency landing in water

Risks during the flight

The risks during a flight include:

At high altitude the air is less dense, so most babies will need more oxygen
When the air is less dense, air inside the body can expand and cause pain
Noise, vibration and g-forces (acceleration) can cause stress to a baby
Unexpected deterioration requiring emergency medical treatment

We send a specialist neonatal team to every baby to assess their needs and do everything they can to make the flight as comfortable and safe as possible. This includes:

Using an incubator which reduces noise and vibration
Close monitoring and extra oxygen if needed
Using the NG tube to take air out of the stomach that might expand
Wrapping the baby in a ‘nest’ to keep them comfortable
Covering baby’s eyes and ears to decrease noise and light that might cause stress
Giving painkillers or sedatives if needed

Before any flight a risk assessment will be made and the best type of flight recommended. The medical team will carry appropriate equipment for a medical emergency and for a small or less stable baby they can provide full intensive care facilities if needed.

Problems after the flight

Some babies will tolerate the flight very well and be their normal self afterwards. Other babies will find a flight stressful and may be ‘quiet’ for a few hours or days afterwards. They may step backwards in their treatment such as needing more help with breathing or being less able to tolerate milk feeds for a few days.

A small number of babies become very sick after a flight and need full intensive care treatment. In these circumstances it’s very difficult to know whether the flight caused them to become unwell or whether they would have deteriorated whatever happened.

In the UK we are very lucky to have teams of specialist nurses and doctors who provide ambulance transfers for sick and premature babies every day. The staff sent for medical flights work in these specialist teams and are highly experienced in assessing a baby’s needs and making the flight as comfortable and safe as possible.

What can go wrong for a premature baby?

The more premature your baby, the more risk there is of complications during the early days of life. This is not related to a flight but could happen wherever they are. Common complications for any premature baby include:

Jaundice

Most premature babies will have jaundice which makes the skin look yellow. A special light is used to clear the jaundice from the body, if it is allowed to build up it can be harmful.

Infections (sepsis)

Almost all premature babies will require courses of antibiotics. Some babies will be making good progress, then develop a new infection and require more treatment such as being put on a ventilator or milk feeding stopped.

Anaemia

Many premature babies will need several blood transfusions, until their body is able to produce sufficient blood cells on their own.

Intraventricular Haemorrhage (IVH)

The ventricles of the brain are small gaps that we all have within the brain. The lining of the ventricles is very fragile in premature babies and prone to bleeding. Small bleeds will require follow-up with further scans, but bigger bleeds may impact your baby’s long-term health and occasionally require surgery.

Necrotising Enterocolitis (NEC)

This is a condition where the baby’s bowel becomes inflamed and the abdomen becomes swollen. For most babies it required treatment with antibiotics, stopping any milk feeds and resting the bowels for a few days. Some babies become very sick with NEC and will need to be put on a ventilator and may require surgery.

Chronic Lung Disease

Some babies will need oxygen for a long time, even when they are term-corrected and otherwise ready to go home. This is called chronic lung disease. In the UK we can arrange for babies to have oxygen at home for 6-12 months so they can be supported as their lungs grow and develop.

PDA and other heart problems

All babies have an extra blood vessel called the ductus arteriosus that allows some blood to bypass the lungs and flow around the body, which should close after birth. For many premature babies, it doesn’t close and causes them to struggle with their oxygen levels. This is called Patent Ductus Arteriosus or just a duct. Some babies will need medicine to try to close the duct and a few babies will need an operation to close it. There are also other heart problems that may be found on a scan, your doctors will explain what this means.

How can I find out more information?

You can visit our Family Hub or speak to one of our team. Our contact number is 0300 140 9980. We can help with advice, publicity and fundraising, and may be able to provide limited financial support on a case-by-case basis.

When baby’s treatment fails: viability and palliative care

You may find the information in this section distressing. Please read when you have time and space to take it in. You might want to ask a family member or friend to read it with you over the phone.

Under 22 weeks’ gestation, most doctors in the UK would say that a baby is not viable. This means that their chances of survival are so small, and the chances of long-term problems so high that we would not offer any kind of treatment. This would mean treating the baby as a stillbirth even if they appear to be breathing and showing some signs of life. In some countries, they will take a higher figure between 23-25 weeks or even higher depending on the local healthcare system.

For very premature or sick babies, there might be problems in the early days of life that lead doctors to suggest not carrying on with intensive care treatment. Some babies can seem to be doing very well for days or even weeks then deteriorate. The things that might happen include:

Severe bleeds or other abnormalities in the brain
Extremely high settings needed on the ventilator and other medical equipment
The need for multiple medicines (inotropes) to support the heart
The heart stopping and needing to be restarted (CPR)
Very low oxygen levels on blood tests (blood gas) or medical monitor (Sats)
Very high carbon dioxide levels on blood tests (blood gas)
Damage to the bowels or another organ where an operation is not possible

In these circumstances, it may be considered that your baby is very unlikely to survive, and if they do survive the are very likely to have severe long-term problems. This may be described as treatment that is futile. The kinds of problems they might face are:

Blindness and deafness
Severe cerebral palsy, wheelchair or bed-bound and needing continuous nursing care
Severe learning difficulties
Other brain problems such as epilepsy
A very high chance that they will never be able to breathe on their own

Some babies may have a rare diagnosis shown on scans such as very abnormal heart, lungs or kidneys, or blood tests confirming a severe genetic diagnosis. Your doctors should explain what this means and what the future might hold.

Some countries have policies where they will continue with medical treatment as long as a patient is alive. In the UK and Western European countries we would normally discuss the care with parents, and where medical treatment is considered futile we would talk about reorientation or redirection of care (in the past called withdrawal of care).

Reorientation of care is also known as palliative care. It does not mean that care is stopped, but the direction of treatment becomes making baby comfortable and giving parents and family some positive memories rather than baby’s final days and hours being focused on medical treatment that we know will not work. This might mean that your baby does not live as long, but the life they do have is as comfortable and positive as it can be.

If you decide for redirection of care, your baby will have their treatment changed such as:

Most medicines stopped
Most or all IV lines removed
Being taken off the ventilator and breathing tube removed
Painkillers and sedatives given if they appear to be in pain
Baby given to you for cuddles and making memories

Many hospitals have a ‘family room’ that is made to look less like a hospital and more like a home environment where you can have time with your baby with the nurses and doctors on hand to help if needed.

Some parents choose to have palliative care back in the UK, either because they are in a country that will not allow it, or because they would rather be closer to home. In this case arrangements can be made for baby to be flown to a hospice in the UK where you can have time with your baby in a comfortable and compassionate environment.