Transcript 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.

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
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.
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
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
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
An est. 1.9 m children
travel overseas
annually
Children come in
different sizes and
stages of
development
Some common problems
• Sun hazards and
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sunscreen
Travel safety: car
seats, seat belts
Mosquito
precautions,
repellents and nets
Animal bites
Envenomation
• Sexually
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transmitted
infections for
adolescents
Travelers diarrhea
and food hygiene
Oral Rehydration
and dehydration
Altitude illness
Sun and sunscreen
• Children <6 months should be shaded /
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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
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
Mosquito precautions
• Comfortable loose fitting clothes
• Keep children in mosquito free zones as
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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 applicationsFischer et al, 1998, usually after
excessive/higher strength application
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
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)
Animal bites and rabies
• Children are curious of animals and have
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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
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
Body fluid exposures
• Sexual exposure, body piercing, tattooing,
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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
TD and food hygiene
• Risk of TD generally appears to be same in
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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
Oral rehydration and dehydration
• Oral rehydration has remained the
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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)
TD and food hygiene
• Anti-TD agents probably don’t differ too
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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)
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
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pulmonary or cerebral edema) about the
same in children as adults (Fischer, 2001)
Acetazolamide not studied as extensively in
children, but considered effective
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
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.
Specific WWW sites
Internet Guide to Travel Health by
Connor, 2004 (Harworth Press)
• Travelling with children
– Health on the road
(http://www.familytravelguides.com/articl
es/health/index.html)
– Travelling with children
(http://www.travellingwithchildren.co.uk)
General WWW resources
• www.who.int/ith
• www.cdc.gov/travel
• www.istm.org
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)