Travel health for special groups: Children

1. Travel health for special groups:Children Peter A. Leggat,MD, PhD, DrPH, FAFPHM, FACTM, FFTM Associate Professor School of Public Health and Tropical Medicine James Cook University

2. About the author • Dr Peter Leggat has co-ordinated the Australian postgraduate course in travel medicine since 1993. He has also been on the faculty of the South African travel medicine course, conducted since 2000, and the Worldwise New Zealand Travel Health update programs since 1998. Dr Leggat has assisted in the development of travel medicine programs in several countries and also the Certificate of Knowledge examination for the International Society of Travel Medicine.

3. Objectives of the session • To review the general approach to travel health advice • To familiarize ourselves with some of the potential concerns relevant to traveling with children

4. General Approach (after Ericsson, 2003) • Risk assessment, determining the risks of the destination, mode of travel and the special conditions of the traveler • Vaccinate when possible and indicated; • Provide the traveler with appropriate empirical self-treatment • Consider chemoprophylaxis

5. General Approach (after Ericsson, 2003) • Consider any concerns regarding underlying conditions and possible drug interactions • Consult experts in travel medicine or specialty areas as necessary • Educate the traveler • Remind the traveler that these precautions are not 100% protective

6. An est. 1.9 m children travel overseas annuallyChildren come in different sizes and stages of development

7. Sun hazards and sunscreen Travel safety: car seats, seat belts Mosquito precautions, repellents and nets Animal bites Envenomation Sexually transmitted infections for adolescents Travelers diarrhea and food hygiene Oral Rehydration and dehydration Altitude illness Some common problems

8. Sun and sunscreen • Children <6 months should be shaded / clothed • Older children can use an approved sunscreen (cancer council) SPF ~ 30 • Blistering sunburn is being associated with malignant skin problems later in life • Related issues • Children should be supervised while swimming • Children should not be left in cars unattended

9. Travel safety • Aircraft restraints are generally unsatisfactory, however air travel is usually safer than car travel • Age appropriate restraints should be used • Requires advanced planning to ensure suitable vehicle/child seats…may have to take own child seats • Appropriate vehicle safety should be maintained by all adults and children

10. Mosquito precautions • Comfortable loose fitting clothes • Keep children in mosquito free zones as much as possible during the evening and night hours • Impregnated bed nets have been shown to be effective • Clothing can also be impregnated • DEET (up to 35%) containing insecticides • has been controversial, however only 13 adverse events in millions of applications-Fischer et al, 1998, usually after excessive/higher strength application

11. Malaria • Malaria can be a serious disease in young children • Chemoprophylaxis: • Refer to your local availability and guidelines and requirements for destination • Problems lie mainly in compliance • Pediatric preparations, where available, may help

12. Antimalarial drugs • Mefloquine (5mg/kg) • Doxycycline (2mg/kg) • not < 8 years (effect on teeth etc) • Malarone (atovaquone + proguanil) (1/4 pill per 10kg to max at 40kg) • not recommended in guidelines in some countries for children < 40 kg • Chloroquine (5mg/kg)+ proguanil (4mg/kg) • Primaquine appears safe • not in G6PD deficiency (screening test available)

13. Animal bites and rabies • Children are curious of animals and have traditionally been considered at risk of rabies, particularly expatriate children staying for longer periods in endemic countries • Rabies vaccine can be given after the first year of age (Fischer, 2001) • Children should be discouraged from petting stray animals even if they appear well and they may not tell you if they have been bitten • Animal bites need the usual precautions including post-exposure treatment and prophylaxis

14. Envnomation-bites and stings • Children can be more easily effected by envenomation by snake bite, spider bites etc • First aid management can be important, such as pressure immobilization techniques e

15. Body fluid exposures • Sexual exposure, body piercing, tattooing, non-sterile medical procedures can lead to unwanted infections • Need clear advice to adolescents as well as older travelers; it is difficult to predict who may need safe sex advice • HIV, HCV are risks; HBV vaccine is now being included in many immunization programs

16. TD and food hygiene • Risk of TD generally appears to be same in children as adults, except for the youngest children (Fischer, 2001; Ericsson, 2003) • Infants also appeared to have more severe diarrhea illness and to have diarrhea longer than other travelers (Fischer, 2001) • Hand-mouth contamination is probably important; cleanliness of any object put into their mouths is important

17. Oral rehydration and dehydration • Oral rehydration has remained the mainstay of traveler's diarrhea and dehydration in children • Definitive treatment may still be needed • Prevention of dehydration is important – keeping up fluids • Children can become severely dehydrated very quickly • (Children should not be left in cars unattended)

18. TD and food hygiene • Anti-TD agents probably don’t differ too much to adults, but limited evidence for rifamixin • Traditionally there has been concerns about the use of ciprofloxacin (10mg/kg bd) • musculoskeletal toxicity has been a concern; doxycycline not used < 8 years • Antimotility drugs such as loperamide have not traditionally been used in young children but is probably safe in teenagers (Fischer, 2001)

19. Altitude illness • In some infants, chronic exposure to high altitudes has been shown to have some negative effects, including death (Fischer, 2001) • But in general altitude tolerated well • Acute mountain sickness (High altitude pulmonary or cerebral edema) about the same in children as adults (Fischer, 2001) • Acetazolamide not studied as extensively in children, but considered effective

20. Last word on traveling with children…. • Success of travel with children depends on planning the trip from the child’s perspective • Can be easily bored, so need lots of activities • Break up long trips into smaller segments can be helpful • Seating on aircraft important for infants and families • ?sedation in children (diphenhydramine 1mg/kg); adults responsible for children should avoid being themselves sedated

21. WANT MORE INFORMATION?ISTM JOURNAL RESOURCES • Travelling with children • Leggat PA, Speare R, Kedjarune U. Traveling with children. J Travel Med 1998; 5: 142-146. • Three part mini-series, “Traveling with infants and children” by Stauffer et al: JTM 2001; 8: 254-259. JTM 2002; 9: 82-90. JTM 2002; 9: 141-150.

22. Specific WWW sitesInternet Guide to Travel Health by Connor, 2004 (Harworth Press) • Travelling with children • Health on the road (http://www.familytravelguides.com/articles/health/index.html) • Travelling with children (http://www.travellingwithchildren.co.uk)

23. General WWW resources • www.who.int/ith • www.cdc.gov/travel • www.istm.org

24. Textbooks • Many textbooks have useful chapters dealing with issues related to children, e.g. • Manual of Travel Medicine and Health 2nd Ed (Part 1) (Decker) • Principles and Practice of Travel Medicine (Ch 23) (Wiley) • Primer of Travel Medicine 3rd Ed (Ch 9) (ACTM)