Peter%20A.%20Leggat,%20MD,%20PhD,%20DrPH,%20FAFPHM,%20FACTM,%20FFTM

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Travel health for special groupsChildren

• Peter A. Leggat, MD, PhD, DrPH, FAFPHM, FACTM,
  FFTM
• Associate Professor
• School of Public Health and Tropical Medicine
• James Cook University

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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.

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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

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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

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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

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An est. 1.9 m children travel overseas annually
Children come in different sizes and stages
of development
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Some common problems

• 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

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Sun and sunscreen

• Children lt6 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

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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 seatsmay have to take own child
  seats
• Appropriate vehicle safety should be maintained
  by all adults and children

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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

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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

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Antimalarial drugs

• Mefloquine (5mg/kg)
• Doxycycline (2mg/kg)
• not lt 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 lt 40 kg
• Chloroquine (5mg/kg) proguanil (4mg/kg)
• Primaquine appears safe
• not in G6PD deficiency (screening test available)

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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

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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
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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

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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

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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)

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TD and food hygiene

• Anti-TD agents probably dont 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 lt 8 years
• Antimotility drugs such as loperamide have not
  traditionally been used in young children but is
  probably safe in teenagers (Fischer, 2001)

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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

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Last word on traveling with children.

• Success of travel with children depends on
  planning the trip from the childs 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

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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.

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Specific WWW sites Internet 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.travellingwit
  hchildren.co.uk)

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General WWW resources

• www.who.int/ith
• www.cdc.gov/travel
• www.istm.org

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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)