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.
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. Adults and older children should consider taking a course in basic first aid prior to travel.
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 (1). 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 (TD) in children are similar to those in adults (see Chapter 4). For young infants, breastfeeding is the best way to reduce the risk of 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.
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. Meat, fish and eggs should always 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 higher than 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 (Table 4-20). 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.
Children weighing less than 10 kilograms who have mild to moderate dehydration should be administered 60-120 mL ORS for each diarrheal stool or vomiting episode. Children who weigh 10 kg or more should receive 120-240 mL 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.
Other Measures
Parents should be particularly careful to wash hands well after diaper changes for infants with diarrhea to avoid spreading infection to themselves and other family members.
Oral syringes that are available in most pharmacies for oral medications can be useful for the administration of ORS and can be included as part of the travelers’ health kit for young children.
The use of antimotility agents (e.g., loperamide, lomotil) in children younger 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. Antinausea medications, such as promethazine and prochlorperazine, are not routinely recommended. They are contradicated for use in children less than 2 years of age. Fatal respiratory depression in children has been reported with use of promethazine. Children with an acute illness, including gastroenteritis and dehydration, are more susceptible to neuromuscular reactions, especially dystonias, associated with prochlorperazine, than adults. The extrapyramidal side effects associated with these medications can be confused with symptoms of other undiagnosed primary diseases associated with vomiting, such as Reye syndrome. These medications should not be routinely prescribed as empiric treatment for children with possible TD. Adults traveling with children should be fully counseled about the indications, dosage, frequency and possible side effects if these medications are prescribed.
Antibiotics
Few data are available regarding empiric administration of antibiotics for TD in children. Furthermore, the antimicrobial options for empiric treatment in children are limited. Trimethoprim-sulfamethoxazole (TMP/SMX) was previously used for empiric treatment of TD in children; however, its effectiveness has been reduced by widespread drug resistance and it is no longer routinely recommended. Fluoroquinolones are frequently used for the empiric treatment of TD in adults. The use of fluoroquinolones is not generally recommended for use in children and adolescents less than 18 years of age because of cartilage damage seen in animals tested. The only indication for fluoroquinolone use in children that has been approved by the Federal Drug Administration is for complicated urinary tract infections. The American Academy of Pediatrics suggests some special circumstances for fluoroquinlone use, including the treatment of gastrointestinal infection caused by multidrug-resistant Shigella species, Salmonella species, Vibrio cholerae, or Campylobacter jejuni. Although not FDA-approved, some travel medicine advisors have reported using 1-3 days of ciprofloxacin for treatment of TD in some older children. However, the routine use for empiric treatment for TD is not recommended. Tetracyclines can cause teeth staining if used in children less than 8 years of age (3).
In some studies, azithromycin has been found to be as effective as fluoroquinolones in treating TD in adults (4). In practice, some clinicians prescribe azithromycin either as a single dose or at 10 mg/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 longer than 10 days.
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