Introduction

The number of children who travel or live outside their home countries has increased dramatically. An estimated 1.9 million children travel overseas each year. Health issues related to pediatric international travel are complex, reflecting varied activities, exposures, and age-specific health risks. While some travel health concerns are similar for children and adults, international pediatric travelers have unique problems because of variable immunity and different age-based behavior; for example, a newly mobile toddler will have different health risks than a sexually active adolescent. Furthermore, many travel-related vaccinations and preventive medications used for adults are not licensed or recommended for pediatric use.

Pediatric travelers have also been impacted by trends in the travel industry. The adventure travel industry is growing rapidly, and a large number of programs are now available for young children, adolescents, and their families. Adventure travelers have diverse geographic and environmental exposures. They participate in unconventional activities, ranging from visiting remote villages in developing countries to mountain climbing and rafting. These trips frequently involve more health hazards than traditional tourism or business travel. Travel opportunities for children with chronic medical conditions have also increased, leading to additional health challenges related to host susceptibility. Although data about the incidence of pediatric illnesses associated with international travel are limited, studies of pediatric travelers have reported serious morbidity and mortality. The most common reported health problems are diarrheal illnesses, malaria, and motor vehicle- and water-related accidents. Children who are visiting family and relatives living in developing countries are at high risk for a variety of travel-related health problems, including malaria, intestinal parasites, and tuberculosis. In addition, travelers visiting friends and relatives are less likely to seek pre-travel preventive care.

Clinicians should obtain a complete assessment of travel-related activities and provide preventive counseling and interventions tailored to specific risks. Adults traveling with young children should be counseled to monitor the children carefully for signs of illness. Irritability may be a response to changes in time zone and environment but may also indicate illness in young children. Excessive or persistent irritability, fevers, or signs of dehydration should be evaluated promptly. Children with chronic diseases or immunocompromising conditions require travel preparations and treatment tailored to their specific underlying condition.

Diarrhea and Dehydration

Diarrhea and associated gastrointestinal illness are among the most common travel-related problems affecting children. Young children and infants are at high risk for diarrhea and other food- and waterborne illnesses because of limited pre-existing immunity and behavioral factors such as frequent hand-to-mouth contact. Infants and children with diarrhea can become dehydrated more quickly than adults.

Prevention

Causes of travelers' diarrhea in children are similar to those in adults. For young infants, breastfeeding is the best way to prevent foodborne and waterborne illness. Travelers should use only purified water for drinking, preparing ice cubes, brushing teeth, and mixing infant formula and foods. Scrupulous attention should be paid to handwashing and cleaning pacifiers, teething rings, and toys that fall to the floor or are handled by others. When proper handwashing facilities are not available, an alcohol-based hand sanitizer can be used as a disinfecting agent. However, alcohol does not remove organic material; visibly soiled hands should be washed with soap and water before application.

Travelers should ensure that dairy products are pasteurized. Fresh fruits and vegetables must be adequately cooked or washed well and peeled without recontamination. Bringing finger foods or snacks (self-prepared or from home) will reduce the temptation to try potentially risky foods between meals. Meats and fish should be well cooked and eaten just after they have been prepared. Travelers should avoid food from street vendors.

Management of Diarrhea in Infants and Young Children

Adults traveling with children should be counseled about the signs and symptoms of dehydration and the proper use of World Health Organization oral rehydration solutions (ORS). Immediate medical attention is required for an infant or young child with diarrhea who has signs of moderate to severe dehydration (Table 8-1), bloody diarrhea, fever >38.5°C (>101.5°F), or persistent vomiting. ORS should be provided to the infant by bottle or spoon while medical attention is being obtained.

Assessment and Treatment of Dehydration

The greatest risk to the infant with diarrhea and vomiting is dehydration. Fever or increased ambient temperature increases fluid losses and speeds dehydration. Parents should be advised that dehydration is best prevented and treated by use of ORS, in addition to the infant's usual food. Rice and other cereal-based ORS, in which complex carbohydrates are substituted for glucose, are also available and may be more acceptable to young children. Adults traveling with children should be counseled that sports drinks, which are designed to replace water and electrolytes lost through sweat, do not contain the same proportions of electrolytes as the solution recommended by WHO for rehydration during diarrheal illness.

ORS packets are available at stores or pharmacies in almost all developing countries. [See information below regarding ORS availability in the United States.] ORS is prepared by adding one packet to boiled or treated water. Travelers should be advised to check packet instructions carefully to ensure that the salts are added to the correct volume of water. ORS solution should be consumed or discarded within 12 hours if held at room temperature or 24 hours if kept refrigerated. A dehydrated child will drink ORS avidly; travelers should be advised to give it to the child as long as the dehydration persists. An infant or child who vomits the ORS will usually keep it down if it is offered by spoon in frequent small sips.

Table 8-1. Assessment of Dehydration Levels in Infants.

Children weighing less than 10 kilograms who have mild to moderate dehydration should be administered 60-120mL ORS for each diarrheal stool or vomiting episode. Children who weigh greater than or equal to10kg should receive 120-240mL ORS for each diarrheal stool or vomiting episode. Severe dehydration is a medical emergency that usually requires administration of fluids by IV or intraosseous routes.

Dietary Modification

Breastfed infants should continue nursing on demand. Formula-fed infants should continue their usual formula during rehydration. They should receive a volume that is sufficient to satisfy energy and nutrient requirements. Lactose-free or lactose-reduced formulas are usually unnecessary. Diluting formula may slow resolution of diarrhea and is not recommended. Older infants and children receiving semi-solid or solid foods should continue to receive their usual diet during the illness. Recommended foods include starches, cereals, yogurt, fruits, and vegetables. Foods that are high in simple sugars, such as soft drinks, undiluted apple juice, gelatins, and presweetened cereals, can exacerbate diarrhea by osmotic effects and should be avoided. In addition, foods high in fat may not be tolerated because of their tendency to delay gastric emptying. The practice of withholding food for greater than or equal to 24 hours is inappropriate. Early feeding can decrease changes in intestinal permeability caused by infection, reduce illness duration and improve nutritional outcome. Highly specific diets (e.g., the BRAT [bananas, rice, applesauce, and toast] diet) have been commonly recommended; however, similar to juice-centered and clear fluid diets, such severely restrictive diets used for prolonged periods of time can result in malnutrition and should be avoided.

ORS packets are available in the United States from Jianas Brothers Packaging Company, 2533 Southwest Boulevard, Kansas City, Missouri 64108, USA (1-816-421-2880). In addition, Cera Products, 8265 I Patuxent Range Road, Jessup, Maryland 20794, USA (1-301-490-4941 or 1-888-Ceralyte; www.ceralyte.com), markets a rice cereal-rather than a glucose-based product, Ceralyte, in several different flavors. ORS packets may also be available at stores that sell outdoor recreation and camping supplies.

Other Measures

Parents should be particularly careful to wash hands well after diaper changes in infants with diarrhea to avoid spreading infection to themselves and other family members.

The use of antimotility agents (e.g., loperamide, lomotil) in children less than 2 years of age is not recommended. Because overdoses of these types of drugs can be fatal, they should be used with extreme caution in children. Side effects of these drugs in adults include opiate-induced ileus, drowsiness, and nausea. Lomotil has been associated with fatal overdoses and other severe complications, including coma and respiratory depression.

Antibiotics

Few data are available regarding empiric administration of antibiotics for travelers' diarrhea in children. Furthermore, the antimicrobial options for empiric treatment in children are limited. Trimethoprim-sulfamethoxazole (TMP/SMX) was previously used for empiric treatment of travelers' diarrhea in children; however, its effectiveness has been reduced by widespread drug resistance and it is no longer routinely recommended. Fluoroquinolones, which are frequently used for empiric treatment in adults, are not approved for children less than 18 years of age because of the potential for cartilage injury, although some travel medicine experts report safely using very short-term (1-3 days) ciprofloxacin for TD treatment for some older children. Tetracyclines can cause teeth staining if used in children less than 8 years of age.

In some studies, azithromycin has been found to be as effective as fluoroquinolones in treating travelers' diarrhea in adults. In practice, some clinicians prescribe azithromycin either as a single dose or at 10mg/kg for 3-5 days for empiric treatment. Flavored oral suspension of azithromycin is available. The suspension does not require refrigeration; however, it should be used within 10 days of mixing. The unreconstituted form of azithromycin has a longer expiration period. In certain circumstances, the unreconstituted form can be provided with clear instructions for preparation and may be useful for children traveling for more than 10 days.

Malaria

Malaria is one of the most serious, life-threatening diseases affecting pediatric international travelers. In the United States, 5,794 cases of malaria in US civilians were reported to CDC from 1992 through 2000. Of these cases, 976 (17%) occurred in children less than 18 years of age. Among children with malaria, 343 (35%) were 1 month to 5 years old, 215 (22%) were 6-9 years old, 226 (23%) were 10-14 years old, and 192 (20%) were 15-17 years old. The largest percentage of cases occurred in persons who were visiting family and friends.

Children with malaria can rapidly develop a high level of parasitemia. They are at increased risk of severe complications of malaria, including shock, seizures, coma, and death. Initial symptoms of malaria in children may mimic may other common causes of pediatric febrile illness and therefore may result in delayed diagnosis and treatment. Clinicians should counsel adults traveling in malarious areas with children to be aware of the signs and symptoms of malaria and to seek prompt medical attention if they develop.

Take your child to their health care provider at least 4-6 weeks before the time of your trip. Any vaccinations your child may need will have time to become fully protective. In addition, all the antimalarial drugs are prescription drugs and your child will need to start taking them before travel. Dosages for infants and children usually have to be specially prepared; allow your pharmacist sufficient time to prepare your prescriptions. Your health care provider will decide which antimalarial drug is the right one for your child. Some drugs may not be effective in some countries in the world. A medical condition may prevent your child from taking a particular antimalarial drug. In addition, children’s dosages are based on their age and weight and need to be carefully calculated. Medications used in infants and young children are the same as those recommended for adults except that doxycycline should not be given to children less than 8 years of age. Aatovaquone/proguanil (Malarone) should not be used for prophylaxis in children weighing less than 5kg (11 lbs) because of lack of data on safety and efficacy. (Updated December 22, 2006) Pyrimethamine-sulfamethoxazole should not be used.

• Give your child their antimalarial drug exactly on schedule. Missing or delaying doses may increase their risk of getting malaria.
• For the best protection against malaria, your child should continue taking their drug as recommended after leaving the malaria-risk area (4 weeks for mefloquine, doxycycline, or chloroquine; 7 days for atovaquone/proguanil or primaquine). Otherwise, they can develop malaria.

Because overdose of antimalarial drugs can be fatal, medication should be stored in childproof containers and kept out of the reach of infants and children. Mefloquine and chloroquine phosphate are manufactured in the United States in tablet form. Aovaquone/proguanil is available in pediatric tablet form. Pediatric doses should be calculated carefully according to body weight. Before departure, pharmacists can be asked to pulverize tablets and prepare gelatin capsules with calculated pediatric doses. Chloroquine, mefloquine, and atovaquone/proguanil have a bitter taste. Mixing the powder in food or drink can facilitate the administration of antimalarial drugs to infants and children. Additionally, any compounding pharmacy can alter the flavoring of malaria medication tablets so that they are more willingly ingested by children. Physicians should calculate the dose and volume to be administered based on body weight because the concentration of chloroquine base varies in different suspensions.

• Buy your drugs before traveling overseas. Drugs purchased overseas may not be made according to United States standards and may not be effective. They may also be dangerous, contain the wrong drug or no active drug, or be contaminated.
  • Halofantrine (also called Halfan) is widely used overseas to treat malaria. CDC recommends that you and your child not use Halfan because of serious heart-related side effects, including deaths.
  • You should avoid using antimalarial drugs that are not recommended unless your child has been diagnosed with life-threatening malaria and no other treatment options are available.
• Most antimalarial drugs are well-tolerated; most travelers do not need to stop taking their drug because of side effects. However, if you are particularly concerned about side effects, discuss the possibility of starting your drug early (3-4 weeks in advance of your trip) with your health care provider. If you cannot tolerate the drug, ask your doctor to change your medication.

Insect and Other Arthropod Precautions

Personal protection against mosquitoes, ticks, and biting flies is an important part of prevention against malaria, yellow fever, and other diseases for which no other prophylaxis is available, such as dengue fever. While outdoors, children should wear as much protective clothing (long sleeves and long pants) as they can tolerate. They should sleep in rooms with air conditioning or screened windows or under bed nets. Mosquito netting should be used over infant carriers. Clothing and mosquito nets can be treated with the repellent permethrin, which is derived from chrysanthemum flowers. However, permethrin should not be applied to the skin. DEET-containing insect repellents should be applied to exposed areas of skin. Repellent should not be applied to skin under clothing. To avoid accidental ingestion, it should not be applied to children's faces or hands. It can be used sparingly around the ears. Children should not be allowed to apply their own repellent. DEET should not be used on children less than 2 months of age.

There had been some controversy regarding the recommended concentration of DEET for pediatric use. In 1998, the Environmental Protection Agency conducted an extensive review of DEET safety. The agency concluded that there is no evidence that DEET is toxic to infants and/or children. Additional evaluations have not demonstrated a link between seizures and topical use.

The concentration of DEET affects the duration of protection. Higher concentrations provide longer protection; however, the duration of protection reaches a plateau at approximately 30%-50%. In a laboratory study, a product with 23.8% DEET provided an average of 5 hours of protection (range 3-6 hours) and a product with 6.65% DEET provided an average of 2 hours of protection (range 1.5-2.8 hours). Duration of protection may be affected by the environmental temperature, sweating, wind conditions, and mosquito density. Thus, DEET formulations as high as 50% are recommended for both adults and children >2 months of age.

Other products have been evaluated for repellent activity. However, they have not been as well studied as DEET and may not be safe for use in children. Products containing 7.5% of IR3535, a repellent that has recently become available in the United States, provided approximately 23 minutes of protection. Most botanical products provide relatively limited or no protection.

Products that contain repellents and sunscreen are generally not recommended because of the need to reapply sunscreen more frequently than repellent. Mosquito coils should be used with extreme caution in the presence of children to avoid burns and inadvertent ingestion.

Infection and Infestation from Soil Contact

Children are more likely than adults to have contact with soil or sand and therefore may be exposed to infectious stages of parasites present in soil, including ascariasis, hookworm, cutaneous larva migrans, trichuriasis, and strongyloidiasis. Children and infants should wear protective footwear and play on a sheet or towel rather than directly on the ground. Clothing should not be dried on the ground. Clothing or diapers dried in the open air should be ironed before use to prevent infestation with fly larvae (myiasis).

Ascaris is a worm that lives in the small intestine. Infection with Ascaris is called ascariasis (ass-kuh-rye-uh-sis). Adult female worms can grow over 12 inches in length, adult males are smaller. Ascariasis is the most common human worm infection. Infection occurs worldwide and is most common in tropical and subtropical areas where sanitation and hygiene are poor. An estimated 1.5 billion persons were infected with Ascaris in 2002. Children are infected more often than adults. In the United States, infection is rare, occurring mainly in rural areas of the Southeast.

Most people have no symptoms that are noticeable, but infection may cause slower growth and slower weight gain. If you are heavily infected, you may have abdominal pain. Sometimes, while the immature worms migrate through the lungs, you may cough and have difficulty breathing. If you have a very heavy worm infection, your intestines may become blocked.

You or your children can become infected after touching your mouth with your hands that have become contaminated with eggs from soil or other contaminated surfaces or by ingesting contaminated food. Diagnosis: Your health care provider will ask you to provide stool samples for testing. Some people notice infection when a worm is passed in their stool or is coughed up. If this happens, bring in the worm specimen to your health care provider for diagnosis. There is no blood test used to diagnose an Ascaris infection.

Treatment: In the United States, Ascaris infections are generally treated for 1-3 days with medication prescribed by your health care provider. The drugs are effective and appear to have few side effects. Your health care provider may request additional stool exams 1 to 2 weeks after therapy. Prevention:

• Avoid contacting soil that may be contaminated with human feces.
• Do not defecate outdoors.
• Dispose of diapers properly.
• Wash hands with soap and water before handling food.
• When traveling to countries where sanitation and hygiene are poor, avoid food that may be contaminated with soil.
• Wash, peel or cook all raw vegetables and fruits before eating.

Hookworm is an intestinal parasite of humans that causes mild diarrhea and abdominal pain. Heavy infection with hookworm can create serious health problems for newborns, children, pregnant women, and persons who are malnourished. Hookworm infections occur mostly in tropical and subtropical climates. In 2002, the estimated number of person infected with hookworm was 1.3 billion.

You can become infected by direct contact with contaminated soil, generally through walking barefoot, or accidentally swallowing contaminated soil. Hookworms have a complex life cycle that begins and ends in the small intestine. Adult female worms produce thousands of eggs, which are excreted in stool. Hookworm eggs are not themselves infective. However, if they reach soil (for example, when infected persons defecate on the ground or when "night soil" is used to fertilize crops) and if the soil conditions are favorable (warm, moist, and shaded), the eggs hatch into larvae. The barely visible larvae penetrate the skin (often through bare feet), are carried to the lungs, go through the respiratory tract to the mouth, are swallowed, and eventually reach the small intestine. This journey takes about a week. In the small intestine, the larvae develop into half-inch-long worms, attach themselves to the intestinal wall, and suck blood.

People who have direct contact with soil that contains human feces in areas where hookworm is common are at high risk of infection. Children --because they play in dirt and often go barefoot-- are at high risk, although the prevalence of hookworm infection in endemic countries continues to rise into young adulthood. Since transmission of hookworm infection requires development of the larvae in soil, hookworm is not spread person to person. Contact among children in institutional or child care settings should not increase the risk of infection.

Symptoms: Itching and a rash at the site of where skin touched soil and is usually the first sign of infection. These symptoms occur when the larvae penetrate the skin. While a light infection may cause no symptoms, heavy infection can cause anemia, abdominal pain, diarrhea, loss of appetite, and weight loss. Heavy, chronic infections can cause stunted growth and mental development. The most serious results of hookworm infection are the development of anemia and protein deficiency caused by blood loss. When children are continuously infected by many worms, the loss of iron and protein can retard growth and mental development, sometimes irreversibly. Hookworm infection can also cause tiredness, and difficulty breathing with exertion. Severe disease can cause congestive heart failure.

Infection is diagnosed by identifying hookworm eggs in a stool sample. Hookworm infections are generally treated for 1-3 days with medication prescribed by your health care provider. The drugs are effective and appear to have few side effects. Your health care provider may decide to repeat a stool exam after treatment. Iron supplements may be prescribed if you have anemia.

Trichuriasis The unembryonated eggs are passed with the stool. In the soil, the eggs develop into a 2-cell stage, an advanced cleavage stage, and then they embryonate; eggs become infective in 15 to 30 days. After ingestion (soil-contaminated hands or food), the eggs hatch in the small intestine, and release larvae that mature and establish themselves as adults in the colon. The adult worms (approximately 4 cm in length) live in the cecum and ascending colon. The adult worms are fixed in that location, with the anterior portions threaded into the mucosa. The females begin to oviposit 60 to 70 days after infection. Female worms in the cecum shed between 3,000 and 20,000 eggs per day. The life span of the adults is about 1 year.

The third most common round worm of humans. Worldwide, with infections more frequent in areas with tropical weather and poor sanitation practices, and among children. It is estimated that 800 million people are infected worldwide. Trichuriasis also occurs in the southern United States.

Diagnosis: Microscopic identification of whipworm eggs in feces is evidence of infection. Because eggs may be difficult to find in light infections, a concentration procedure is recommended. Because the severity of symptoms depend on the worm burden, quantification of the latter (e.g. with the Kato-Katz technique) can prove useful.

Treatment: Mebendazole is the drug of choice, with albendazole as an alternative.

Strongyloidiasis are found in tropical and subtropical areas, but cases also occur in temperate areas (including the South of the United States). More frequently found in rural areas, institutional settings, and lower socioeconomic groups. Symptoms: Frequently asymptomatic. Gastrointestinal symptoms include abdominal pain and diarrhea. Pulmonary symptoms (including Loeffler’s syndrome) can occur during pulmonary migration of the filariform larvae. Dermatologic manifestations include urticarial rashes in the buttocks and waist areas. Disseminated strongyloidiasis occurs in immunosuppressed patients, can present with abdominal pain, distension, shock, pulmonary and neurologic complications and septicemia, and is potentially fatal. Blood eosinophilia is generally present during the acute and chronic stages, but may be absent with dissemination.

Diagnosis rests on the microscopic identification of larvae (rhabditiform and occasionally filariform) in the stool or duodenal fluid. Examination of serial samples may be necessary, and not always sufficient, because stool examination is relatively insensitive. The duodenal fluid can be examined using techniques such as the Enterotest string or duodenal aspiration. Larvae may be detected in sputum from patients with disseminated strongyloidiasis.

Treatment: The drug of choice for the treatment of uncomplicated strongyloidiasis is ivermectin with albendazole* as the alternative. All patients who are at risk of disseminated strongyloidiasis should be treated.

Animal Bites and Rabies

Worldwide, rabies is more common in children than adults. In addition to the potential for increased contact with animals, children are also more likely to be bitten on the head or neck, leading to more severe injuries. They are also less likely to report a bite. Children and their families should be counseled to avoid all stray or unfamiliar animals and to inform parents of any contact or bites. Animal exposure abroad is not limited to rural areas, since stray dogs are common in many urban areas. Children may approach or be unable to avoid animals. Mammal-associated injuries should be washed thoroughly with water and soap (and povidone iodine if available), and the child should be evaluated promptly for the need for rabies postexposure prophylaxis and other measures.

Wild animals accounted for 92% of reported cases of rabies in 2006. Raccoons continued to be the most frequently reported rabid wildlife species (37.7% of all animal cases during 2006), followed by bats (24.4%), skunks (21.5%), foxes (6.2%), and other wild animals (0.6%). While rabies is not commonly found in rabbits, squirrels, and rodents, any mammal can be infected by rabies.

For rabies, the incubation period is more variable than with other infections. The incubation period in humans is usually several weeks to months, but ranges from days to years. The rabies virus attacks the nervous system (brain and spinal cord). The first symptoms of rabies are similar to a flu-like illness--fever, headache, and general discomfort. Within days, the disease can progress to symptoms such as anxiety, confusion, agitation, abnormal behavior, delirium, and hallucinations.

Once symptoms appear, the disease is almost always fatal. Therefore, any person who has been bitten, scratched, or somehow exposed to the saliva of a potentially rabid animal should see a physician as soon as possible for postexposure treatment.

An exposed person who has never received any rabies vaccine will first receive a dose of rabies immune globulin (a blood product that contains antibodies against rabies), which gives immediate, short-term protection. This shot should be given in or near the wound area. They should also be given a series of rabies vaccinations. The first dose should be given as soon as possible after the exposure. Additional doses should be given on days three, seven, and 14 after the first shot. These shots should be given in the deltoid muscle of the arm. Children can also receive the shots in the muscle of the thigh. Properly administered postexposure treatment for rabies has never been known to fail.

Rabies is a big problem in many other countries, especially in Asia, Africa, and Central and South America. Not only is dog rabies common there, but postexposure treatment for humans may be hard to obtain. If you are traveling to a country where rabies is common, you should talk to your health care provider about the possibility of being protected against rabies before your trip. Vaccination may be recommended depending on your planned activities and length of stay. Contact with all animals, including dogs and cats, should be avoided when traveling abroad.

Air Travel

Injuries and deaths can occur in children held on adult laps during turbulence and nonfatal crashes. The American Academy of Pediatrics recommends that children should be placed in a rear-facing Federal Aviation Authority (FAA)-approved child-safety seat until they are at least 1 year old and weigh at least 20 pounds. Children more than 1 year old and 20-40 pounds in body weight should use a forward-facing FAA approved child safety seat, while children weighing greater than 40 pounds can be secured in the aircraft seat belt. Air travel is safe for healthy newborns and infants; however, children with chronic heart or lung problems or with upper or lower respiratory symptoms at the time of travel may be at risk for hypoxia during flight, and a physician should be consulted before travel.

Ear pain can be very troublesome for infants and children during descent. Equalization of pressure in the middle ear can be facilitated by swallowing or chewing; infants should nurse or suck on a bottle. Older children can try chewing gum. Antihistamines and decongestants have not been shown to have benefit. There is no evidence that air travel exacerbates the symptoms or complications associated with otitis media.

Travel to different time zones, "jet lag," and schedule disruptions can disturb sleep patterns in infants and children, as well as adults. Attempts to adjust sleep schedules 2-3 days before departure may be helpful. After arrival, children should be encouraged to be active outside or in brightly lit areas during daylight hours to promote adjustment. Sedative medications may cause oversedation or paradoxical agitation, and melatonin may have effects on sexual development in infants and children. In general, these medications should be avoided in infants and children. Diphenhydramine can be useful for some children but, similar to any medication for sedation, should be administered as a test dose before travel to determine the effect on the individual child.

Motion Sickness

Motion sickness can present as ataxia, dizziness, and nausea in children. Other symptoms include pallor and cold sweats. For symptomatic treatment of children, dimenhydrinate, 1-1.5mg/kg per dose or diphenhydramine, 0.5-1mg/kg per dose, up to 25mg, can be given 1 hour before travel and every 6 hours during the trip. Because some children have paradoxical agitation with these medicines, a test dose should be given at home before departure. Scopalamine causes potentially dangerous adverse effects in children and should not be used; prochloperazine and metoclopramide are minimally effective in children.

If you or they are subject to motion sickness:

Always ride where your eyes will see the same motion that your body and inner ears feel, e.g. in the car, look at the distant scenery; go up on the deck of the ship and watch the horizon; sit by the window of the airplane and look outside. In an airplane choose a seat over the wings where the motion is the least.

• Do not read while traveling.
• Do not sit in a seat facing backward.
• Do not watch or talk to another traveler who is having motion sickness.
• Avoid strong odors and spicy or greasy foods immediately before and during your travel.
• Talk to your doctor about medications.

Accidents Vehicle-Related

Vehicle-related accidents are the leading cause of death in children who travel. While traveling in automobiles and other vehicles, children weighing less than 40 pounds should be restrained in age-appropriate car seats or booster seats. These seats often must be carried from home, since availability of well-maintained and approved seats may be limited abroad. In general, children are safest traveling in the rear seat; they should never travel in the bed of a pick-up truck. Families should be counseled that many developing countries have cars without rear seatbelts.

Drowning and Water-Related Illness and Injuries

Drowning is the second leading cause of death in young travelers; close supervision is essential. Appropriate water safety devices such as life vests may not be available abroad, and families should consider bringing these from home. A variety of diarrheal and parasitic illnesses can be transmitted by swallowing even small amounts of fecally contaminated water, and other infections, such as schistosomiasis, result from skin contact with contaminated water. Thus, while in schistosomiasis-endemic areas, children should not swim in fresh, unchlorinated water and should be carefully supervised while being washed in a bathtub. Protective footwear is important to avoid injury in many marine environments.

Other Injuries

Conditions at hotels and other lodging may not be as safe as those in the United States and should be carefully inspected for exposed wiring, pest poisons, paint chips, or inadequate stairway or balcony railings.

Altitude

Children and infants are more susceptible to acute mountain sickness and the more serious complications of high-altitude cerebral edema and high-altitude pulmonary edema. Young children may present with unexplained fussiness and change in sleep and activity patterns; older children may complain of headache or shortness of breath. Acetazolamide (Diamox) is not approved for use for this indication in children, but it is generally safe for use in children when used for other indications. It is contraindicated in children who are allergic to sulfa medications.

Sun Exposure

Sun exposure and particularly sunburn before age 15 are strongly associated with melanoma and other forms of skin cancer. Exposure to UV light is highest near the equator, at high altitudes, during midday (10 a.m. to 4 p.m.), and where light is reflected off water or snow. Sunscreens (or sun blocks), either physical (titanium or zinc oxides) or chemical, at least SPF 15 and providing protection from both UVA and UVB, should be applied every 2 hours, especially after sweating and water exposure. If both sunscreen and insect repellent are applied separately or as a combined product, the efficacy of the sunscreen is diminished by one third, and covering attire should be worn or time in the sun decreased accordingly. Hats and sunglasses also reduce sun injury to skin and eyes. Babies less than 6 months of age require extra protection from the sun because of their thinner and more sensitive skin; severe sunburn for this age group is considered a medical emergency. Babies should be kept in the shade and wear clothing that covers the entire body; a minimal amount of sunscreen can be applied to small exposed areas, including the infant's face and hands. However, in general, sunscreens are generally recommended for use in children more than 6 months of age.

Other General Considerations

Changes in schedule, activities, and environment can be stressful for children. Including them in planning for the trip and bringing along familiar toys or other objects can decrease these stresses. For children with chronic illnesses, decisions regarding timing and itinerary should be made in consultation with a health-care provider(s).

As for any traveler, insurance coverage for illnesses and accidents while abroad should be verified before departure. Consideration should be given to purchasing special travel insurance for airlifting or air ambulance to an area with adequate medical care. In case family members become separated, each infant or child should carry identifying information and contact numbers in their own clothing or pockets. Because of concerns about illegal transport of children across international borders, if only one parent is traveling with the child he or she may need to carry relevant custody papers or a notarized permission letter from the other parent. See section on "Seeking Health Care Abroad," regarding U.S. embassy contact information in case of illness or medical emergency abroad.

Pediatric Travel Health Kit

In addition to the kit recommended for all travelers, parents should carry safe water and snacks; waterless, alcohol-based hand sanitizer; child-safe hand wipes; ORS packets; diaper rash ointment; and a water- and insect-proof ground sheet for play outside. In addition, many countries may not provide medications and child-care products of the same type and quality as are available at home. As a precaution, travelers with children should consider bringing additional items they might need, such as baby formula and medications specific to the child.