Travelling with Children: Travel Health: NEVDGP

TRAVELLING WITH CHILDREN

INTRODUCTION

Travelling with children poses some challenges but can also he very rewarding. Children usually adapt better to time and climate changes than adults. People of all ages and cultures often warm in a special way to children. Sharing new surroundings and cultures can be enriching for children and their families alike.

The resistance of children to illness, however, is generally lower than that of adults. A child can be overcome by dehydration within a few hours. But although children may become ill with alarming speed, their recovery is often also impressively rapid. Travel-related illness in children is more likely to be due to common problems such as skin infections, injuries , respiratory infections and diarrhoea, than to exotic tropical diseases. Malaria is an important exception, and it tends to be more frequent and severe than among adults.

IMMUNISATlONS

All children whether they travel or not should receive basic immunisations Measles, Diphtheria and Poliomyelitis are still common in many countries and travel in densely populated areas may favour transmission.
see copy of vaccination table - p 50. Australian Immunisation Handbook, 8th Edition - 9/2003 Accelerated Schedule:

DTP & Hib can be given from 6 weeks of age, and then 4 weeks apart
Sabin can be commenced at birth, and then 4 weeks apart
Hep B can be commenced at birth, and then at 0, 1, 2, 12 months - This is the new health schedule as of 1st May 2000.
MMR can be given at 6 months but with booster at 12 or 18 months and at 5 years.

Hepatitis A is the commonest vaccine preventable disease of travellers. However hepatitis A in children under 5 is a very mild illness and vaccination is not essential. However it is often given to prevent asymptomatic children spreading the disease to others on return from overseas. (virus excreted for as long as 3 months) The safe, effective, long-lasting hepatitis A vaccine (Havrix or VAQTA) is recommended for children over the age of 2 years but Twinrix junior can be given from 12 months. (seems inconsistent)

Hepatitis B. Children who will be in close contact with local people should be immunised. Infected children rarely develop acute disease, BUT 25-90% become chronic carriers. Approximately 25% of carriers will die from liver cirrhosis or primary liver cancer. Child to child transmission is very common.( www.cdc.gov/travel/diseases/hbv.htm )

Typhoid vaccine (injectable or oral) is recommended for children over the age of 2 years travelling to developing countries. ( p 50. Australian Immunisation Handbook, 8th Edition - 9/2003 )
Clinical disease is uncommon in children under the age of 2 years but vaccination can be given down to the age of 12 months if stay in an endemic area is longer. The new injectable typhi vax has fewer side effects than the old typhoid vaccination and is preferred. The oral vaccine is also effective. In children too young to swallow the capsules whole, several options exist: on an empty stomach, first giving at least half a glass of water in which a Ural sachet has been dissolved, followed by the contents of an opened capsule in jam or honey; suspending the contents of an opened capsule in a glass of cool, low-fat milk in which a quarter of a teaspoon of baking soda (0.8 g sodium bicarbonate) has been dissolved. More recently some centres have been using the capsules rectally in children and early reports suggest this to be a simple effective method.

Yellow fever. In general, children should not he immunised below the age of 9-12 months. with an absolute lower limit of six months.

Tuberculosis. TB is more commonly severe in young children and BCG vaccine should be considered for any child going for 6 weeks or longer to an endemic area. BCG does not prevent infection with tuberculosis and is listed as providing only 50% protection against clinical disease. However it appears to have a higher protective rate against disseminated TB and Tuberculous meningitis which are the more serious infections. Also Tuberculosis is becoming muti-drug resistant world wide and BCG is the best preventative we have at the moment.

Meningococcal, Rabies, Japanese encephalitis vaccination may be indicated for children over 1 year of age staying for 6 - 12 months or more in developing countries. Rabies is a particular concern particularly on Indian subcontinent, SE Asia and Central America. Children are more likely to befriend animals and will often fail to report a bite.

Chicken Pox vaccines: 0.5cc IMI upper arm 9 months - 12 years (88% efficacy for complete prevention & 100% against severe illness ie. > 30 lesions)
Adolescents and adults - further 0.5cc 6 weeks later. (75.9% protection)
Side effects: infrequent & mild (NB. Has been used regularly for 20 years in Japan)

Individuals with functional or anatomical asplenia *
Children <5 years of age with splenic dysfunction, most frequently due to sickle cell disease, should be vaccinated with pneumococcal conjugate vaccine (see Part 3.18, ‘Pneumococcal infections’). To further reduce the risk of pneumococcal disease, they should also be treated with daily prophylactic doses of penicillin V, commencing before the age of 4 months (penicillin V 125 mg twice daily, rising to 250 mg twice daily when they reach 4 years of age, until 5 years of age).
* extract from Australian Immunisation Handbook, 8th Edition 9/2003 p56. **see also AFP

Preterm babies **- Despite their immunological immaturity, preterm babies should be vaccinated according to the recommended schedule at the usual chronological age, provided that they are well and that there are no contraindications to vaccination. All preterm babies born at less than 28 weeks’ gestation or with chronic lung disease should be offered the 7-valent pneumococcal conjugate vaccine ** extract from Australian Immunisation Handbook, 8th Edition 9/2003 p52.

Breastfeeding and vaccination: The rubella vaccine virus may be secreted in human breast milk and transmitted to breastfed infants but where infection has occurred in an infant it has been mild. Otherwise there is no evidence of risk to the breast feeding baby if the mother is vaccinated with any of the live or inactivated vaccines described in this Handbook. Breastfeeding does not adversely affect immunisation and is not a contraindication for the administration of any vaccine to the baby. see also CDC

DIARRHOEA

Diarrhoea is unfortunately common, for children and adults alike. However bacterial dysentery is more common in children. Also children, especially babies. are much more susceptible to dehydration. Prevention involves eating and drinking safely and attention to personal hygiene, especially handwashing after bowel movements and before eating.
Scrupulous attention should be paid to handwashing and cleaning pacifiers, teething rings, and toys that fall to the floor or are handled by others. Parents should carry safe water and snacks; waterless, child-safe hand wipes (alcohol based)
Breast-fed infants are at substantially less risk of food or water-borne infections. Most diarrhoeal illnesses are acute and self-limited. The main complication of dehydration can be avoided in the great majority of cases by adequate fluid intake.

Mild diarrhoea: - give extra fluids such as water, oral rehydration solution (ORS eg Gastrolyte) or dilutions of drinks as follows:

cordials (not low calorie) - I part to 6 parts water.

lemonade (not low calorie) - 1 part to 4 parts water.

fruit juice (not concentrated) - 1 part to 4 parts water.

home made ORS solution - Using a 5 ml teaspoon, 8 level spoons of table sugar and half a level teaspoon of salt can he added to a litre of water.

Severe diarrhoea:give one cup of ORS for every watery stool. Adults travelling with children should carry a supply of Gastrolyte sachets. If the child is hungry give a normal diet.
The most reliable signs of dehydration are weight loss and a fall in urine output A dehydrated child will drink ORS avidly and should be given as much as he/she will drink. A child who vomits will retain some ORS if given frequent small sips. Feeding, particularly breast feeding, should be continued. Solids should be stopped for no longer than 24 hours and preferably not at all. Starvation delays recovery.
Antidiarrhoeal drugs (lomotil and loperamide), and anti-nausea drugs such as prochlorperazine (Stemetil) and metoclopramide (Maxolon) should not be used in young children because they can cause serious problems. Medical help should be sought if;

there is blood in the stool
a high fever is present
diarrhoea persists for more than 3 days in a child or 1 day in a baby.
any other cause for concern is present.

Antibiotics: These are sometimes recommended for diarrhoea with high fever and abdominal pain. Cotrimoxazole & Ciprofloxacin have been used. (data now suggests that ciprofloxacin is now safe for use in children.) Azithromycin is sometimes recommended for children ** WHO

Malaria

Because young children are at increased risk of severe malaria, you should reconsider your travel plans.
In a young child, medical advice (including a blood smear examination) should be sought within 24-36 hours of the onset of fever while in or after being in a malarious area.
The risk of malaria (and the multitude of other insect-borne diseases) can be substantially reduced by minimising mosquito exposure, particularly at night (see malaria pamphlet). DEET, is the most effective repellent, but can be dangerous in children. Used appropriately, it is quite safe. Preparations containing more than 30% DEET should be avoided, and repellent should be applied sparingly & best not to face (ears OK).
Breast-fed babies are not protected by their mother's preventive medication, and require their own. Overdose of antimalarial drugs, even chloroquine, can be fatal ( see Children's dosage). Store medication in childproof containers out of reach of children.

Other Hazards

There is concern about oxygen desaturation in neonates on long haul air flights. Also young children with bronchiolitis or any other chest infection are best to delay air travel.
Be prepared to sedate your child during the flight, but this may not be required until the 2nd leg of the flight. The most commonly used agent for this is promethazine (Phenergan). This has the additional benefit of assisting with motion sickness and is available without prescription. Try a test dose before your travel. In some children it causes hyperactivity rather than sedation. A larger dose may overcome this.
Earache occurs in approx 15% of children during airplane descent. Encouraging children to chew or swallow at this time may be helpful to equalize the pressure in the middle ear. Local anaesthetic drops inserted into the problem ear are often effective.(Auralgan)
Altitude sickness is more common in children especially under the age of 2 years. Royal Children's Hospital, Melbourne does not recommend children under 2 years sleeping above 2,000 metres and 2 - 3 year olds should not sleep above 3,000 metres. [NB. Sedatives will increase the danger of hypoxia (low oxygen).]

Medical Examination after travel: It is advisable (if not essential) to visit your local doctor promptly if you:

suffer from a chronic disease, such as cardiovascular disease, diabetes mellitus, chronic respiratory disease;
experience illness in the weeks following their return home, particularly if fever, persistent diarrhoea, vomiting, jaundice, urinary disorders, skin disease or genital infection occurs;
consider that you may have been exposed to a serious infectious disease while travelling;
have spent more than 3 months in a developing country.

Source: WHO - http://whqlibdoc.who.int/publications/2005/9241580364_chap1.pdf (page 8)