Dr Suparna Banavar.
Medical Sciences Department, Pediatric Oncall, Mumbai, India. | Introduction: Statistics from the World Tourism Organization estimate that 4% of international travellers are children. Families travelling with children need to be informed about how to minimize risks prior to and during travel, in order to result in more enjoyable and safer travel for the entire family.
Pre-travel evaluation: The travel physician must consider all the details of the trip, including the destination, time and duration of travel, type of accommodation, activities and potential exposure to insects and animals in the context of the medical and immunisation history of the individual child.
Food and water precautions:
- Hand washing must be carried out frequently, particularly before eating, with soap and water, although alcohol-based hand-washes may be used if no water is available.
- It is particularly important to remind children to use safe water sources for all drinking, tooth-brushing and food preparation. For infants, breastfeeding is the safest form of nutrition.
- Boil it, cook it, peel it or forget it? has been a long-standing axiom for travellers. Families travelling with children should travel with supplies of snacks so to avoid buying food from street vendors.
- Avoid unpasteurised dairy products so as to eliminate the risk of brucellosis and other bacterial infections. Raw or undercooked meat and fish should also not be consumed owing to the risk of parasitic infections.
Insect avoidance: Insect-borne diseases, most notably, malaria, dengue and other arbovirus infections, result in significant morbidity and some mortality among paediatric travellers. To ensure adequate protection:
- Children should be dressed in light-coloured clothing that covers their arms and legs and perfumes that may attract insects should be avoided.
- Stay in air-conditioned or well-screened accommodation and use insecticide-treated bed nets.
- The best chemical protection against mosquito bites is the use of a combination of permethrin-treated clothing and DEET on exposed skin. DEET may be used in children 2 months of age and older, but it should not be applied to the mouth or eyes or to any body parts of young children, such as the hands, that are likely to go in their mouths.
Medical kit: Advice regarding a travel medical kit could be very helpful for families travelling with children. It is advisable to carry a personal information card with details about chronic medical conditions, regular medications, allergies, blood type, vaccination record and emergency contact information. Families should also be advised about carrying first aid supplies and essential medications
Other infectious issues: Fresh water exposure should be avoided in areas that are endemic for schistosomiasis or where Leptospira organisms may contaminate the water. Due to the risk of rabies, children should be cautioned to stay away from dogs, monkeys and other domestic animals. Exposure to the infected stools of animals or humans can result in several types of parasitic infection.
Malaria: Malaria is one of the top five killers of children under the age of 5. There is currently no vaccine available for the prevention of malaria infection. In addition to the personal protective measures to prevent mosquito bites mentioned earlier, the appropriate use of chemoprophylaxis is critical. It is important to remember that even breastfeeding infants require prophylaxis since anti-malarials do not reach adequate levels in breast milk.
Malaria chemoprophylaxis for children.
| Drug | Indication | Paediatric dose | Maximum dose | Supplied as | Side Effects | | Chloroquine phosphate | Chloro
quine-sen
sitive malaria. | Can be
used in
infants and chil
dren of any age. 5 mg/kg base/week. Start 1 week prior to travel and continue 4 weeks after return | 300 mg
base/week | 300 mg
base tablets | Well tolerated. Mild
side effe
cts like G.I
upset, headache,
dizziness, blurring
of vision etc. | | Mefloquine | Chloro
quine-resi
stant mala
ria | Start 1-2
weeks prior
to travel
and continue
4 weeks after return. <15 kg: 5 mg/kg/week | 250 mg
/week | 250 mg
tablets | Contrain
dicated in
children
with a H/O
seizures,
psychiatric
illness or
cardiac
condu
ction dist
urbances | | | | 15-19 kg:
1/4 tablet/
week | | | | | | | 20-30 kg:
1/2 tablet/
week | | | | | | | 31-45 kg:
1/3 tablet
/week | | | | | | | 45 kg:
1 tablet/
week | | | | Atova
quone
/proguanil
(Malarone) | Chloro
quine-resi
stant mala
ria | Start 1-2
days prior
to travel
and continue
for 7 days
after expo
sure ceases. 11-20 kg: 1 pediatric tablet/day | 1 adult
tablet/day | Paediatric tabl
ets: 62.5 mg
atovaquone
/25 mg proguanil | Give with
food and
milk to dec
rease G.I.
side effects.
Do not
give with
tetracyclines,
metoclopra
mide
and rifampicin. | | | | 21-30 kg:
2 pediatric tabl
ets/day | | Adult tabl
ets: 250 mg
atovaquone
/100 mg
proguanil | | | | | 31-40 kg:
3 pediatric
tablets/day | | | | | | | 40 kg:
1 adult tab
let/day | | | | Doxy
cycline | Chloro
quine-resi
stant
malaria | Start 1-2
days prior
to travel
and continue
for 4
weeks
following
exposure. Start >12
years (UK)
and >8 years
(Canada, USA)
: 2 mg/kg
/day | 100 mg
/day | 100 mg
tablets | Take with
food and
fluids to
avoid G.I.
sensitivity.
Other side
effects
are
photo-
sensitivity and vaginal
candidiasis | Prima
quine | Terminal prophylaxis | 0.6 mg
base/kg
/day×14
days | 30 mg
base/day | 15 mg base tablets | Check for G-6PD deficiency prior to use |
Immunisation
Travel vaccines are divided into the categories of routine, required and recommended. Travel vaccine recommendations must be individualized for each child based on the details of the child's itinerary, style and purpose of travel, travel-related activities, season of travel, time before departure and underlying health status.
Routine vaccines are those provided as part of national health-care programmes to provide protection against common diseases. Ensuring that a child is up to date with his or her routine vaccine schedule is particularly important if the travel itinerary includes countries with low immunisation rates, Routine vaccines may be given in an accelerated schedule as determined by the vaccination history of the child, the itinerary and the timing of the travel.
Required vaccines are those needed by travellers to cross international borders, according to the health regulations at their destination... Yellow fever vaccine is a live vaccine that may be required or recommended for travel to central South America and sub-Saharan Africa. Vaccination against meningococcus and polio are currently required for travellers to the Hajj in Saudi Arabia as also to the meningitis belt in Equatorial Africa during the period from December to June.
Recommended vaccines include those which should be considered according to risk of infection during travel. These include vaccines against hepatitis A and B (if it has not been included in the routine vaccination schedule), typhoid, Japanese and tick-borne encephalitis, rabies and influenza, and B.C.G.Hepatitis A vaccine is recommended for children travelling to developing countries as well as certain high-risk areas in the USA and Canada. Typhoid vaccine is recommended for paediatric travellers to most developing countries. The Japanese B encephalitis vaccine is recommended for all travellers older than 1 year who are travelling in rural endemic areas for longer than 1 month, at which time the risk of disease increases to 1 in 5000. Influenza vaccine should be considered for children at risk of developing complications, such as those with chronic diseases. Influenza occurs from April to September in the southern hemisphere and year-round in the tropics. Vaccination with BCG could be considered for a young HIV-negative traveller (under 5 years of age) who will be spending a substantial period of time in a country that is highly endemic for TB when contact with individuals with active TB is likely. In addition, children who have travelled to a high-TB burden country should have a tuberculin skin test prior to and 3 months after their travel.
Traveller's diarrhoea
Travellers diarrhoea defined as a two-fold increase in the frequency of unformed stools lasting at least 2-3 days, is one of the most common illnesses among travellers, occurring in 9-40% of paediatric travellers. The prevention of traveller's diarrhoea in children can only be achieved by counselling regarding food and water.
Fluoroquinolones are generally considered safe in children for the short course required for travellers diarrhoea, although this is an off-label use for patients under 18 years of age. A 3-day course of ciprofloxacin at a dose of 20-30 mg/kg/day divided twice daily, with a maximum dose of 500 mg twice a day, is recommended. | | | | Compliance with Ethical Standards | | Funding None | | | | Conflict of Interest None | | |
| Cite this article as: | | Banavar S. TRAVEL GUIDELINES FOR CHILDREN. Pediatr Oncall J. 2006;3. |
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