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

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. 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 review the general approach to travel health advice To familiarize ourselves with some of the potential concerns relevant to traveling with children 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 Risk assessment, determining the risks of the destination, mode of travel and the special conditions of the traveler Vaccinate when possible and indicated; Vaccinate when possible and indicated; Provide the traveler with appropriate empirical self-treatment Provide the traveler with appropriate empirical self-treatment Consider chemoprophylaxis Consider chemoprophylaxis

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

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

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

8. Sun and sunscreen Children <6 months should be shaded / clothed Children <6 months should be shaded / clothed Older children can use an approved sunscreen (cancer council) SPF ~ 30 Older children can use an approved sunscreen (cancer council) SPF ~ 30 Blistering sunburn is being associated with malignant skin problems later in life Blistering sunburn is being associated with malignant skin problems later in life Related issues 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 Aircraft restraints are generally unsatisfactory, however air travel is usually safer than car travel Age appropriate restraints should be used Age appropriate restraints should be used Requires advanced planning to ensure suitable vehicle/child seats…may have to take own child seats 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 Appropriate vehicle safety should be maintained by all adults and children

10. Mosquito precautions Comfortable loose fitting clothes Comfortable loose fitting clothes Keep children in mosquito free zones as much as possible during the evening and night hours 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 Impregnated bed nets have been shown to be effective Clothing can also be impregnated Clothing can also be impregnated DEET (up to 35%) containing insecticides 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 Malaria can be a serious disease in young children Chemoprophylaxis: Chemoprophylaxis: –Refer to your local availability and guidelines and requirements for destination Problems lie mainly in compliance Problems lie mainly in compliance –Pediatric preparations, where available, may help

12. Antimalarial drugs Mefloquine (5mg/kg) Mefloquine (5mg/kg) Doxycycline (2mg/kg) Doxycycline (2mg/kg) –not < 8 years (effect on teeth etc) Malarone (atovaquone + proguanil) (1/4 pill per 10kg to max at 40kg) 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) Chloroquine (5mg/kg)+ proguanil (4mg/kg) Primaquine appears safe 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 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) 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 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 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 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 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 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 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 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) 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) 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 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 Oral rehydration has remained the mainstay of traveler's diarrhea and dehydration in children Definitive treatment may still be needed Definitive treatment may still be needed Prevention of dehydration is important – keeping up fluids Prevention of dehydration is important – keeping up fluids Children can become severely dehydrated very quickly Children can become severely dehydrated very quickly (Children should not be left in cars unattended) (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 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) 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) 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) 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 But in general altitude tolerated well Acute mountain sickness (High altitude pulmonary or cerebral edema) about the same in children as adults (Fischer, 2001) 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 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 Success of travel with children depends on planning the trip from the child’s perspective Can be easily bored, so need lots of activities Can be easily bored, so need lots of activities Break up long trips into smaller segments can be helpful Break up long trips into smaller segments can be helpful Seating on aircraft important for infants and families Seating on aircraft important for infants and families ?sedation in children (diphenhydramine 1mg/kg); adults responsible for children should avoid being themselves sedated ?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 sites Internet Guide to Travel Health by Connor, 2004 (Harworth Press) Travelling with children Travelling with children –Health on the road (http://www.familytravelguides.com/articl es/health/index.html) http://www.familytravelguides.com/articl es/health/index.htmlhttp://www.familytravelguides.com/articl es/health/index.html –Travelling with children (http://www.travellingwithchildren.co.uk) http://www.travellingwithchildren.co.uk

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

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