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Navigating International Travel A Pediatrician’s Roadmap

Navigating International Travel A Pediatrician’s Roadmap. Gayatri Bala Jaishankar MD Assistant Professor Associate Program Director ETSU Pediatrics. Disclosure Statement of Financial Interest. I, GAYATRI BALA JAISHANKAR ,

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Navigating International Travel A Pediatrician’s Roadmap

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  1. Navigating International Travel A Pediatrician’s Roadmap Gayatri Bala Jaishankar MD Assistant Professor Associate Program Director ETSU Pediatrics

  2. Disclosure Statement of Financial Interest • I, GAYATRI BALA JAISHANKAR, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

  3. Common Questions • How old does my baby have to be to fly ? • How do I prevent an earache ? • Can you sedate my child ? • Can I travel to high altitudes with my child ? • What can I do to prevent motion sickness ? • What immunizations does my child need ? • What prevention strategies do I need to use ? • What medicines should I carry with me ? • What do I do for Traveler’s Diarrhea ?

  4. How old should my baby be to fly? • Any healthy term infant may travel by commercial pressurized airplane • Risk Vs Benefit ratio analysis when it comes to: • Premature infants • Infants with chronic cardiac or pulmonary conditions UdomittipongK,Stick SM,Verheggen M, et al.Pre-flight testing of preterm infants with neonatal lung disease: a retrospective review. Thorax 2006;61:343-7

  5. How do I prevent an earache? • Differences in pressure are greatest during take off and landing • Use any measures that would help keep the Eustachian tube patent such as • Nursing • Sucking a pacifier • Chewing gum

  6. Can you sedate my child? • Sedation is not recommended • However most commonly used agent is Diphenhydramine or Benadryl at 1mg/kg q 6 h • Does not really put them to sleep • Should definitely first be used at home (3% paradoxical reaction) • If incorrectly dosed , may cause serious complications • Adult sedatives like Diazepam are difficult to dose accurately

  7. ACUTE MOUNTAIN SICKNESS

  8. Can my child travel to high altitudes? • Acute mountain sickness(AMS) • Likely to be as prevalent in children as in adults • Frequently under recognized • Signs of AMS in children could be • Unexplained fussiness • Alterations in appetite • Alterations in activity or sleep patterns

  9. Can my child travel to high altitudes? • Life threatening high-altitude cerebral edema—not reported in kids • Kids can have high-altitude pulmonary edema (HAPE) • Mainstay of prevention-slow ascent • Acetazolamide-not studied for prevention or treatment of AMS in children Pollard AJ, Neirmeyer S, Barry P et al. Children at high altitude :an international consensus statement by an ad hoc committee of the international society for mountain Medicine, March 12 2001.

  10. Can my child travel to high altitudes? • Ginkgo Balboa ?? Promising data?? • 2004 Study- Randomized controlled trial of Gingko Biloba and Acetazolamide for prevention of acute mountain sickness • No benefit when compared to placebo • Acetazolamide Dose-2.5mg/kg/dose bid up to adult dose of 125mg bid • Start one day before ascent and continue two days at high altitude Gertsch JH, Basnyat B,Johnson EW,et al.RCT of Gingko Biloba and acetazolamide for prevention of AMS : (PHAIT). Br Med J 2004;328:797-9

  11. Can I prevent motion sickness in my child? • Non pharmacologic suggestions • Non traditional interventions • Preventive pharmacologic intervention-Antihistamines : Diphenhydramine and Dimenhydrinate – drugs of choice < 12yrs • Scopolamine > 12yrs

  12. What vaccines does my child need? • ROUTINE, REQUIRED OR RECOMMENDED • ROUTINE- Accelerated Schedule? • REQUIRED • Yellow Fever • Quadrivalent Meningococcal • RECOMMENDED • Hepatitis A • Typhoid • Rabies • Japanese Encephalitis

  13. What vaccines does my child need? ROUTINE • The 1st travel plans may require an accelerated schedule • Start as early as 6 wks • Boosters 4 wks. apart

  14. TRAVEL RESOURCES http://wwwnc.cdc.gov/travel/

  15. Current prices of the international travel vaccines that are available at Washington County Health Department • Hep A  33.70 • Hep B  41.70 • Twinrix Hep A/Hep B combo  53.70 • IPT (polio Booster 32.24 • Typhoid 50.70 • yellow fever 73.70 • Menactra ( meningitis Vaccine) 96.70 • These prices vary depending on manufacture’s cost.

  16. What vaccines does my child need? • MMR- given at 12-15mo and 4-6 yrs • 3 to 5 % remain susceptible after the first dose • The 2nd dose is an attempt to seroconvert the non responders • Children > 12 months give two doses at least 28 days apart • Infants can receive a “measles alone vaccine”

  17. What vaccines does my child need? • Hepatitis A at 1yr of age • Two monovalent vaccines • Havre (GSK ) and Vaqta ( Merck ) • Formal CDC recommendation is to give Immunoglobulin < 1yr of age • Expense, interferes with other live vaccines, limited duration and effectiveness, allergic reactions and hypothetical risk of Iatrogenic disease

  18. HEPATITIS A • Prevalent worldwide • In young children is usually asymptomatic • Contaminated water , ice, shellfish harvested from sewage infested water, raw fruits and veggies, or handling by an infected food handler • Stools most infectious 14 to 21 days before disease is apparent • Children can shed hepatitis for up to 10weeks • Long incubation period (2 to 4 wks) so can vaccinate up to travel

  19. What vaccines does my child need? Aedes mosquito • REQUIRED VACCINE - Yellow fever • Never give to children< 6 months of age-risk of developing post vaccination encephalitis • Between 6-9 months, risk of acquiring the disease must be greater than the risk of complications • Safe > 9 months

  20. Yellow fever endemic zones

  21. Yellow fever endemic zones

  22. What vaccines does my child need? • YELLOW FEVER • Only vaccine that requires documentation on an official certificate of vaccination • Must be given 10 DAYS before the date of entry • OFFICIAL STAMP FROM AUTHORISED CLINICS • (Meningococcal vaccine for Hajj travelers to Saudi Arabia)

  23. What vaccines does my child need? • RECOMMENDED VACCINES-TYPHOID • Recommended even for short term travel to Asia, Africa, Latin America, Indian subcontinent • Injectable-Vi capsular > 2 yrs • Oral-Ty21a > 6 years • Fewer side effects longer protection • Capsule every other day for 4 doses, needs a week to complete

  24. What vaccines does my child need? • OTHER RECOMMENDED VACCINES • Travel to Sub Saharan Africa may need Meningococcal vaccine • Rabies vaccine if access to post exposure immunoglobulin or vaccine not likely • Japanese encephalitis vaccine if extended stays in rural Asia JEMB ( Not available currently)

  25. What preventive strategies do I need to use? • MALARIA PREVENTION • Insect avoidance • Chemoprophylaxis

  26. What preventive strategies do I need to use? • INSECT AVOIDANCE-covered clothing, avoid flowery clothes, avoid perfumes, remain in protected environments from dusk till dawn such as air conditioned areas , mosquito netting etc.

  27. What preventive strategies do I need to use? • INSECT AVOIDANCE-Chemical agents • N,N-diethyl-meta-toluamide (DEET) • Rare cases of toxic encephalopathy with dermal application • 25-50 % DEET will protect for up to 4 hrs • Should not be applied on hands, mm, eyes

  28. Malaria Chemoprophylaxis!!!!!

  29. MALARIACHEMOPROPHYLAXIS CHLOROQUIN MEFLOQUIN • Use in destinations with CQ sensitive P.Falciparum • q week • 300 mg base(500mg salt) • Start 1 week before arrival and continue 4 wks after return • Pulverize tablet and place in gelatin capsule • Alternative-Hydroxy Chloroquin sulfate • Use in destinations with CQ resistant P.falciparum • <15kg:5mg/kg base • 15-19kg:1/4 tablet • q week • 228 mg base(250 mg salt) • 2wks prior and 4wks after • Pulverize-gelatin capsule • Alternatives-Atrovaquone/Proguanil, Doxycycline

  30. MALARIACHEMOPROPHYLAXIS ATOVAQUONE/PROGUANIL DOXYCYCLINE • Alternative to Mefloquin in resistant areas • 62.5/25mg peds tablet • 5-8kg ½ tab, >8-10kg ¾ tab,>10-20 kg 1 tab,>20-30kg 2 tabs,>30-40 kg 3 tabs • 250/100mg adult dose 1 tab qd • Start 1-2 days prior and continue for 7 days after • >8yrs : 2mg/kg daily • 100 mg adult dose • qd • Start at least 2 wks. prior and continue for 4 wks. after travel • Alternative to Mefloquin in resistant areas

  31. MALARIACHEMOPROPHYLAXIS PRIMAQUIN • 0.6mg/kg base daily • Adult dose 2 tablets= 30mg daily • Start 1-2 days before arrival and continue for 7days after departure • G6PD testing must be performed prior to taking the tablet; contraindicated in breast feeding unless testing is performed in infant also • Used for “Terminal prophylaxis” to prevent relapses of P.vivax or P.ovale

  32. MALARIA MEDICATIONS- SIDE EFFECTS • Neuropsychiatric disturbances ( Mefloquin ) • Contraindicated in those with seizures , anxiety and depression • Contraindicated in those with cardiac conduction abnormalities • Potential side effects-nausea , upset stomach; less commonly strange dreams, insomnia, dizziness, anxiety, weakness, agitation • Children tolerate the meds better Albright TA, Binnus HG, Katz BZ.Side effects of and compliance with malaria prophylaxis in children. J Travel Med 2002:9(6):289-292

  33. TRAVELERS’ DIARRHEA • DEFINITION?? • In adults - > 3 watery stools per day +- blood/mucus • In children ?? • A recent change in the normal stool pattern with • An increase in frequency (at least 3 stools per day) • A decrease in consistency (unformed state)

  34. TREATING TRAVELERS DIARRHEA IN CHILDREN • WHY TREAT ? • WHEN TREAT ? • WHAT MEDICATIONS ? • WILL IT MAKE MATTERS WORSE ? (HUS CONCERNS)

  35. ETIOLOGY- TRAVELERS’ DIARRHEA Rotavirus is the leading cause of severe dehydrating diarrhea – WHO estimates 1.5 billion episodes in <5yrs of age & 3 million deaths annually • However, community based studies of childhood traveler’s diarrhea indicate its etiology is similar to adult travelers • Limited data in children-study in 1991, 363 children from Switzerland Mackell Traveler's Diarrhea in the Pediatric Population: Etiology and impact .Clin Inf Dis 2005;41:S547-52

  36. ETIOLOGY - TD • Study 1991 Pitzinger et al, 363 children in Switzerland • 31 % of children were < 14yrs old , the rest were 14-20 • During the 1st 2 wks. of travel the overall incidence of diarrhea was 39 % • The rate of diarrhea for children < 3 yrs. was 60% • North Africa 73% • India 61% • Southeast Asia& Latin America < 40% Pitzinger B,Steffen R,Tschopp A.Incidence and clinical features of traveler’s Diarrhea in infants and children.Pediatr Infect DisJ 1991;10:719-23

  37. ETIOLOGY - TD • Associated with 210 million episodes of diarrhea and 380,000 deaths among children yearly • Same bacterial organisms that cause diseases in adults • Enterotoxigenic Escherichia coli, Enteroaggregative E. coli, Salmonella, Campylobacter, Shigella • Enterotoxigenic E.coli is the most commonly isolated organism • Rota virus is found less commonly implicated

  38. TREATMENT – TD • ANTIMOTILITY AGENTS • Traditionally unfavorable reputation with Pediatrics • BISMUTH SALISYLATE • PROBIOTICS • ORAL REHYDRATION THERAPY • ANTIBIOTICS- • Azithromycin • Ciprofloxacin? • Furizolidone • Nalidixic Acid

  39. PREVENTIVE MEASURES • Frequent hand washing, good hygiene practices • “Boil it, peel it, cook it or forget it” • Alcohol containing hand sanitizers “ on the go” • “Safe Milk” ? • Irradiated or Pasteurized products • ( ensure the cold chain has not been broken) • Boiling milk makes it safe • Bring powdered milk and mix it with potable water

  40. SPECIAL TRAVELERS • ADOLESCENTS • Increased “RISK TAKING” behaviors • CHILDREN “ VISITING FRIENDS AND RELATIVES“ VFR’s • They are at overall increased risk of infectious diseases • Prolonged stays in the country • Often in remote places • May believe they are already “immune” to certain diseases • English language skills may influence quality of pretravel visit

  41. A family with three children ages 2,4 and 6 is planning a trip to India to visit grand parents for six weeks. The medications that you may recommend to them would include • Chloroquin • Mefloquin • Doxycycline • Proguanil/Atovaquone • 1or 2 • 2or 4 • 3or 4

  42. Yellow fever vaccine is the only vaccine that requires documentation on an official certificate of vaccination for travel • True • False

  43. Most cases of Traveler’s diarrhea in children are viral and require only supportive care • True • False

  44. Sources Cdc.gov/ Udomittipong K,Stick SM,Verheggen M, et al.Pre-flight testing of preterm infants with neonatal lung disease: a retrospective review. Thorax2006;61:343-7 Pollard AJ, NeirmeyerS, Barry P et al.Children at high altitude:an international Statement by an ad hoc committee of the international society for mountain medicine, March 12, 2001.High Alt Med Bio 2001; 2(3):389-403. Stauffer W, Christenson JC, Fischer PR.Preparing children for international travel. Travel Med & Inf Dis.2008 6,101-113 Christenson JC.Preparing families with children traveling to developing countries Pediatric Annals. Dec 2008;37:12,806-13. Mackell S Traveler's Diarrhea in the Pediatric Population: Etiology and impact.Clin Inf Dis 2006;41:S 547-52. Gertsch JH, Basnyat B, Johnson EW, et al.Randomised controlled trial of gingko Biloba and acetazolamide for prevention of acute mountain sickness: the prevention of high altitude illness trial.PHAIT.Br Med J 2004;328:797-9

  45. Sources • Rongavilit,K Immunisation for Pediatric International Travelers,Pediatric Annals,40:7,July 2011 • Goodyear L,Gibbs J,Medical supplies for Travelers to Developing countries J Travel Med 2004; 11:208-212 • Mackell Traveler’ s Diarrhea in the Pediatric Population: Etiology and Impact, Clin Inf Dis 2005;41:S547-52 • Lee P,Krilov L Germs on a plane-Infectious Issues and the Pediatric International Traveler: What Pediatricians should know ,Pediatric Annals 36:6 June 2007

  46. Thank You!

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