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August 21, 2008

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International Travel with Children

According to the Center’s for Disease Control and Prevention (CDC), the number of children who travel outside their home country has increased dramatically. An estimated 1.9 million children travel overseas each year (1).

While some travel health concerns are similar for children and adults, international pediatric travelers have unique problems because of variable immunity and different age-based behavior.

The CDC publishes the "Yellow Book" every two years as a reference for those who advise international travelers of health risks (http://wwwn.cdc.gov/travel/contentYellowBook.aspx).

The Yellow Book is written primarily for health care providers, but I believe parents may find it useful as well.

According to the Yellow Book, children who are vacationing or visiting family and relatives living in developing countries are at high risk for a variety of travel-related health problems, including diarrheal illnesses and malaria.

The following information is a summary of specific topics covered in the Yellow Book that I believe will be the most useful to a parent regarding international travel with their child(ren).

For information on airplane travel with children as well as restaurant and hotel safety on your family get-aways, go to Travel Safety.

Diarrhea and Dehydration

Traveler’s diarrhea and associated gastrointestinal illness are among the most common travel-related problems affecting children. Young children and infants are at high risk for diarrhea and other food- and waterborne illnesses because of a more vulnerable immune system and behavioral factors such as frequent hand-to-mouth contact.

Infants and children with diarrhea can become dehydrated more quickly than adults.

Prevention of Diarrheal Illnesses

1.  For young infants, breastfeeding is the best way to reduce the risk of foodborne and waterborne illness.

2.  Travelers should use only purified water for drinking, preparing ice cubes, brushing teeth, and mixing infant formula and foods.

3.  Hand washing and cleaning pacifiers, teething rings, and toys that fall to the floor are very important.

4. Be sure to wash hands after changing an infant’s diaper.

5. When proper hand washing facilities are not available, an alcohol-based hand sanitizer can be used as a disinfecting agent. However, alcohol does not remove organic material; visibly soiled hands should be washed with soap and water.

6. Travelers should ensure that dairy products are pasteurized.

7. Fresh fruits and vegetables must be adequately cooked or washed well and peeled without recontamination.

8. Meat, fish and eggs should always be well cooked and eaten just after they have been prepared.

9. Travelers should avoid food from street vendors.

Recognition of Dehydration in Children

The greatest risk to the infant with diarrhea and vomiting is dehydration. Immediate medical attention is required for an infant or young child with diarrhea who has signs of moderate to severe dehydration, bloody diarrhea, high fever, or persistent vomiting. Keep in mind that fever increases fluid losses and speeds dehydration.

Signs and Symptoms of Dehydration

Urinates less frequently
No tears when crying
Dry, sticky mouth or tongue
Thirst
Headache
Sunken eyes
Sunken soft spot on the front of the head in babies (called the fontanel)
Lethargy (less active than normal)
Irritability (more crying, fussiness)
Darken urine (should be clear or very pale yellow

For more details on dehydration, go to http://www.kidemergencies.com/DEHYDRATION.cfm.

Treatment of Traverler’s Diarrhea in Children

Dehydration is best prevented and treated by use of World Health Organization oral rehydration solutions (ORS), in addition to the infant’s or young child’s usual food.

Rice and other cereal-based ORS, in which complex carbohydrates are substituted for glucose, are also available and may be more acceptable to young children.

Sports drinks, which are designed to replace water and electrolytes lost through sweat, do not contain the same proportions of electrolytes as the solution recommended by WHO for rehydration during diarrheal illness.

ORS packets are available at stores or pharmacies in almost all developing countries. ORS is prepared by adding one packet to boiled or treated water.

Travelers should be advised to check packet instructions carefully to ensure that the salts are added to the correct volume of water.

Give ORS to the child as long as the dehydration persists AND offered by spoon or oral syringe in frequent small sips. Children weighing less than 10 kilograms (22 pounds) who have mild to moderate dehydration should be administered 60-120 mL ORS for each diarrheal stool or vomiting episode. Children who weigh 10 kilograms or more should receive 120-240 mL ORS for each diarrheal stool or vomiting episode. Severe dehydration is a medical emergency that usually requires administration of fluids in other ways.

ORS packets are available in the United States from Jianas Brothers Packaging Company, 2533 Southwest Boulevard, Kansas City, Missouri 64108, USA (1-816-421-2880). In addition, Cera Products, 9017 Mendenhall Court, Columbia, Maryland 21045, USA (1-410-309-1000 or 1-888-Ceralyte; http://www.ceraproductsinc.com), markets a rice cereal rather than a glucose-based product, Ceralyte, in different flavors. ORS packets may also be available at stores that sell outdoor recreation and camping supplies.

The use of antimotility agents (e.g., loperamide, lomotil) in children younger than 2 years of age is not recommended due to potentially serious side effects. The routine use for antibiotics for traveler’s diarrhea is not recommended.

Dietary Modification

Breastfed infants should continue nursing on demand.

Formula-fed infants should continue their usual formula during rehydration.

Diluting formula may slow resolution of diarrhea and is not recommended.

Older infants and children receiving semisolid or solid foods should continue to receive their usual diet during the illness.

Recommended foods include starches, cereals, yogurt, fruits, and vegetables.

Foods that are high in simple sugars, such as soft drinks, undiluted apple juice, gelatins, and presweetened cereals, can make diarrhea worse and should be avoided.

In addition, foods high in fat may not be tolerated because of their tendency to delay gastric emptying.

The practice of withholding food for 24 hours or more is inappropriate. Early feeding can reduce illness duration and improve nutritional outcome.

Highly specific diets (e.g., the BRAT [bananas, rice, applesauce, and toast] diet) have been commonly recommended; however, similar to juice-centered and clear fluid diets, such severely restrictive diets used for prolonged periods of time can result in malnutrition and should be avoided.

Malaria

Malaria is one of the most serious, life-threatening diseases affecting pediatric international travelers. In the United States, 4,110 cases of malaria in US civilians were reported to CDC from 2000 through 2004. Of these cases, 572 (14%) occurred in children <18 years of age.

Among children with malaria, 182 (32%) were 1 month to 5 years old and 126 (22%) were 6-9 years old (1).

Malaria is caused by parasites of the Plasmodium species, which are carried by mosquitoes infected from biting someone who already has the disease.

Signs and Symptoms of Malaria

A child with early symptoms of malaria may be irritable and drowsy, with poor appetite and trouble sleeping.
These symptoms are usually followed by chills, then a fever with rapid breathing.
The fever may either gradually increase over 1 to 2 days or may rise very suddenly to 105 degrees Fahrenheit or above.
Then, as fever ends and body temperature quickly returns to normal, the child has an intense episode of sweating.
Other symptoms of malaria include headache, nausea, aches and pains all over the body and an abnormally large spleen.
Children with malaria are at increased risk for severe complications, including shock, seizures, coma, and death.
Initial symptoms of malaria in children may mimic many other common causes of pediatric febrile illness; therefore, may result in delayed diagnosis and treatment.

Medications for Prevention of Malaria
Medications used for infants and young children are the same as those recommended for adults except that doxycycline should not be given to children younger than 8 years of age.
Atovaquone/proguanil (Malarone) should not be used in children weighing less than 5 kg (11 lbs) because of lack of data on safety and efficacy.
Because overdose of antimalarial drugs can be fatal in small amounts, medication should be stored in childproof containers and kept out of the reach of infants and children.
Antimalarial drugs are available only in tablet form and may taste quite bitter. Pharmacists can pulverize tablets and prepare gelatin capsules for each measured dose. If the child is unable to swallow the capsules or tablets, parents should prepare the child’s dose of medication by breaking open the gelatin capsule and mixing the drug with a small amount of something sweet, such as applesauce, chocolate syrup, or jelly, to ensure the entire dose is delivered to the child. Giving the dose on a full stomach may minimize stomach upset and vomiting
General Recommendations for Prevention (chemoprophylaxis)
Recommendations for the most appropriate medication to give your child will depend on the specific area of travel because some areas have malaria that are resistant to certain drugs (e.g., chloroquine).

Chemoprophylaxis should begin anywhere between 2 days and 2 weeks before travel to areas with malaria (depending on the medication), continue during travel in areas with malaria and after leaving these areas (4 weeks after travel for chloroquine, mefloquine, and doxycycline, and 7 days after travel for atovaquone/proguanil and primaquine).

Chemoprophylaxis during Pregnancy

Malaria infection in pregnant women can be more severe than in nonpregnant women.

Malaria can increase the risk for adverse pregnancy outcomes, including prematurity, abortion, and stillbirth.

For these reasons and because no chemoprophylactic regimen is completely effective, women who are pregnant or likely to become pregnant should be advised to avoid travel to areas with malaria transmission if possible.

If travel to a malarious area cannot be deferred, use of an effective chemoprophylaxis regimen is essential.
Antimalarial Drugs during Breastfeeding

Data are available for some antimalarial agents on the amount of drug excreted in breast milk of lactating women.

Very small amounts of chloroquine and mefloquine are excreted in the breast milk of lactating women. The amount of drug transferred is not thought to be harmful to a nursing infant.

For advice: Discuss with your pediatrician about your travel plans and need for prophylaxis in advance.

You can call the CDC Malaria Hotline (770-488-7788) as an additional resource.

Other ways to Prevent Malaria and other Diseases
Personal protection against mosquitoes, ticks, and biting flies is an important part of prevention against malaria, yellow fever, and other diseases for which no other prophylaxis is available, such as dengue fever.
1. While outdoors, children should wear as much protective clothing (long sleeves and long pants) as they can tolerate.
2. They should sleep in rooms with air conditioning or screened windows or under bed nets.
3. Mosquito netting should be used over infant carriers.
4. Clothing and mosquito nets can be treated with permethrin, a repellent and insecticide derived from chrysanthemum flowers that repels and kills ticks, mosquitoes and other arthropods. Permethrin should not be applied to the skin.
5. CDC recommends the use of repellents with the active ingredient of DEET (N,N-dimethyl-m-toluamide) or picaridin.
6. For details on Insect Repellent Safety, go to http://www.kidemergencies.com/InsectRepellentSafety.cfm
Other Safety Issues for Children Travelling Internationally

Infection from Soil Contact

Children are more likely than adults to have contact with soil or sand and therefore may be exposed to infectious stages of parasites present in soil, including ascariasis, hookworm, cutaneous larva migrans, trichuriasis, and strongyloidiasis.

Children and infants should wear protective footwear and play on a sheet or towel rather than directly on the ground.

Clothing should not be dried on the ground. Clothing or diapers dried in the open air should be ironed before use to prevent infestation with fly larvae (myiasis).

Animal Bites and Rabies

Worldwide, rabies is more common in children than adults. In addition to the potential for increased contact with animals, children are also more likely to be bitten on the head or neck, leading to more severe injuries.

They are also less likely to report a bite. Children and their families should be counseled to avoid all stray or unfamiliar animals and to inform adults of any contact or bites.

Animal exposure abroad is not limited to rural areas, since stray dogs are common in many urban areas.

These injuries should be washed thoroughly with water and soap, and the child should be evaluated promptly for the need for rabies postexposure prophylaxis and other measures.

For more information, go to Rabies.

Accidents
Vehicle-related

Vehicle-related accidents are the leading cause of death in children who travel. While traveling in automobiles and other vehicles, children weighing less than 40 pounds should be restrained in age-appropriate car seats or booster seats in the back. These seats often must be carried from home, since availability of well-maintained and approved seats may be limited abroad.

Water-related Illness and Drowning
Drowning is the second leading cause of death in young travelers.

Appropriate water safety devices such as life vests may not be available abroad, and families should consider bringing these from home.

A variety of diarrheal and parasitic illnesses can be transmitted by swallowing even small amounts of fecally contaminated water, and other infections, such as schistosomiasis, result from skin contact with contaminated water. Thus, while in schistosomiasis-endemic areas, children should not swim in fresh, unchlorinated water.

Other Injuries

Conditions at hotels and other lodging may not be as safe as those in the United States and accommodations should be carefully inspected for exposed wiring, pest poisons, paint chips, or inadequate stairway or balcony railings.

Insurance and Contact Information
As for any traveler, insurance coverage for illnesses and accidents while abroad should be verified before departure.
Consideration should be given to purchasing special travel insurance for airlifting or air ambulance to an area with adequate medical care.

In case family members become separated, each infant or child should carry identifying information and contact numbers in their own clothing or pockets.

Supplies Just in Case
Preparation is very important before taking your child on an international trip. Here are some supplies to strongly consider taking along on your trip:

1.        First aid kit
2.        Your child’s regular medications
3.        Water and snacks
4.        Alcohol-based hand sanitizer
5.        Child-safe hand wipes
6.        ORS packets with oral syringes
7.        Baby formula
8.        Diaper rash ointment
9.        Benadryl or another antihistamine for allergic reactions
10.     Water- and insect-proof ground sheet for play outside
11.     Insect repellent
12.     Acetaminophen (Tylenol) rectal suppositories
13.     Acetaminophen (Tylenol) or ibuprofen (Motrin) for oral use
14.     Topical antibacterial antibiotics (Neosporine)
15.     Lice and scabies topical treatments

Also, consider creating a medical history form for your child that includes the following information:

·  child’s and parent’s name, address, and home phone number
·  blood type
·  immunizations
·  doctor’s name, address, and office and emergency phone numbers
·  health insurance information
·  a list of any ongoing health problems
·  a list of current medications
·  a list of allergies to medications, food

Vaccine Recommendations for Infants and Children

For all children, decisions regarding vaccinations should be made in cooperation with a health-care provider who will review the traveler’s medical history and itinerary. Each traveler should be up to date with their routine childhood vaccinations because many of the diseases prevented by these vaccines are rare or non-existent in the United States but are still common in other parts of the world.

The routine vaccinations include:
1. Hepatitis B Vaccine
2. Diphtheria and Tetanus Toxoid and Pertussis Vaccine
3. Haemophilus influenzae Type b Conjugate Vaccine
4. Polio Vaccine
5. Rotavirus Vaccine - Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide. In developing countries rotavirus gastroenteritis is responsible for approximately 500,000 deaths per year among children younger than 5 years.
6. Measles, Mumps, and Rubella Vaccine
7. Varicella Vaccine
8. Meningococcal Vaccine
9.  Pneumococcal Vaccine
10. Influenza Vaccine
11. Hepatitis A Vaccine or Immune Globulin for Hepatitis A
For a printable version of the latest vaccine schedules, go to http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable

Other Vaccines
1. Yellow Fever Vaccine - Yellow fever, a disease transmitted by mosquitoes, is endemic in certain areas of Africa and South America. Proof of yellow fever vaccination is required for entry into some countries.

2. Typhoid Vaccine - Typhoid fever is a life-threatening febrile illness caused by the bacterium Salmonella enterica Typhi. Vaccination is recommended for travelers to areas where there is a recognized risk of exposure.

3. Japanese Encephalitis Vaccine - Japanese encephalitis (JE) is transmitted by primarily night-biting mosquitoes in rural areas of Asia and the Pacific Rim.

4. Rabies Vaccine - the decision to vaccinate will depend on the itinerary and expected activities during internatonal travel.

Immunizations for Breastfeeding Mothers During Travel

Most nursing mothers may be immunized routinely, based on recommendations for the specific travel itinerary.
Neither inactivated nor live vaccines administered to a lactating woman affect the safety of breast-feeding for mothers or infants.
Breast-feeding does not adversely affect immunization and is not a contraindication for any vaccine. However, there is a theoretical risk to the infant with the use of yellow fever vaccine in breastfeeding mothers.
When travel of nursing mothers to high-risk yellow fever-endemic areas cannot be avoided or postponed, such persons can be vaccinated.

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