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Advising pregnant and young travellers

Following on from her article in the last issue of Nursing in Practice on advising travellers with specific medical conditions, Liz Rosies provides advice for pregnant mothers and parents travelling with young children

Liz Rosies
RGN MSc(TravelHealth) PGCE
Travel Health Adviser
Lecturer
Author of
www.travelhealth.co.uk

The needs of pregnant and child travellers are both wide and varied, demanding individual care and attention. A high level of competency is necessary to respond to the requirements of pregnant mothers and young travellers.

Pregnant travellers
Pregnant travellers are, more often than not, healthy individuals. They are, however, more vulnerable when travelling due to the significant risk of infection for both the mother and the unborn child.(1) Research has also shown that pregnant women have a limited knowledge of travel-related health issues and are often unaware of the risks associated with DVT and infectious diseases such as malaria.(2) In advising this group of women, who are increasingly taking long-haul travel during pregnancy, advice given will cover many variables, looking at the health of both the pregnant mother and the unborn child. While obvious considerations will need to be made regarding malarial prophylaxis and immunisations, nurses must also offer practical common sense health education advice, an area often overlooked in a busy surgery. 
It is generally considered that the safest time for travel during pregnancy is in the second trimester (weeks 13-26). This is the time when the mother will usually feel at her best with less chance of spontaneous abortion or premature labour.(3) Travel is not routinely recommended after the 30th week when most complications can occur, and the risk of pre-eclampsia is most common. Travel should also be restricted for up to seven days following the birth. Most airlines will not allow travel after 36 weeks gestation (32 for multiple births), with many airlines requiring a doctor's medical certificate from 28 weeks.(4) Women travelling to long-haul destinations in late pregnancy should be aware that travel home could be restricted should they have any complications while away. 
Educating pregnant travellers to be better at forward planning is difficult but essential if they are to ensure that they have made a careful evaluation of the available medical care in their chosen destination. This is particularly important if they are in the last trimester or have a history of complications in pregnancy. Those travelling for extended periods of time should ensure that they are able to obtain any necessary medical tests and care normally required in the prenatal period. They should ensure that they know their blood group and have all necessary blood tests, carrying their notes with them at all times.(5) It is important that they are also aware of any signs that might indicate the need for medical treatment, such as unusual bleeding, cramps or leg swelling.

Immunisation
It would be wonderful if all pregnant travellers had all of their immunisations prior to getting pregnant.  Unfortunately this does not happen in real life and one study even suggests that pregnant women are very often "last-minute" travellers.(6) Live vaccines are considered to be best avoided in pregnancy; however, in some situations of travel to high-risk areas further discussion will be required.  Much of the thought against vaccinations is theoretical and pregnant mothers will require clear information in order to enable them to make informed choices, especially when travelling to high-risk areas. Some experts would argue that if there is any reasonable time to give a vaccination in pregnancy, it would be in the second and third trimester.(7)
For nurses advising pregnant travellers going to malarious destinations it is essential to be aware of the Guidelines for malaria prevention in travellers from the United Kingdom. Understanding which antimalarial can be given safely in pregnancy is essential along with bite prevention advice. Some antimalarials are believed to have a toxic effect on the fetus and should be avoided. Other prophylactics may cause adverse side-effects in pregnancy, but must be weighed up against the risk to mother and fetus should malaria be contracted.(8)

Insurance
Travel insurance is essential for pregnant travellers. A study looking at health in pregnancy in 2003 showed that just one-third of pregnant women are likely to take out travel insurance before going overseas.(3) While it is essential that all pregnant travellers should be cleared for travel by their doctor or midwife before planning a trip overseas, they should also be in possession of adequate insurance cover. Insurance should include cover for medical evacuation and the pregnancy should be fully declared. It is also important to remind travellers that medical insurance will only be as good as the medical facilities in the host country.
Travel in pregnancy is not always the most comfortable of experiences. Many pregnant travellers experience tiredness, constipation and haemorrhoids as well as cramps in the legs, not to mention heartburn and the need to urinate more frequently.9 Specific dietary advice on avoiding spicy foods, drinking plenty of clear fluids, avoiding gas producing food and drink before flying, as well as teaching specific leg exercises to increase venous blood flow will all help make the journey more comfortable. Research has shown that even though DVT has had immense publicity over the years, many pregnant travellers are still unaware of their potential risk.(2)
Travelling while pregnant can be an exciting experience, however, it is essential that good planning and preparation are not replaced with last-minute rushing, stress and unnecessary health risks placed on the mother and her unborn child.

Child traveller
Among those with individual needs we can not overlook the young child traveller who is more frequently travelling with parents to areas once considered too dangerous for the most experienced, let alone the young and vulnerable whose health while overseas is vitally important. Their needs differ from any other group of travellers due to a number of factors, not least the wide age group - from the very young to the independent teenager. 
Research has shown that the most common health problems facing the child traveller are diarrhoeal illness, malaria and accidents, especially those involving water. Those children who are visiting friends and family overseas face individual health issues and are also known to be at high risk  of tuberculosis and intestinal parasites, with this group being the most unlikely to visit the travel clinic for advice.(10)

Vaccination and malaria
Before travel to any destination overseas a child should be up-to-date with all childhood routine vaccinations.(11) Due to the underdeveloped immune system of a child under one year, many vaccinations are considered unsuitable.(12) Antimalarials should also be used from birth and are routinely calculated on the body weight of the child.(13)
In an ideal world children under six months should avoid malarious destinations; however, when travel is necessary it is very important that a doctor's advice is obtained regarding the most suitable antimalarial for a child. Antimalarials should be used from birth and prophylactic dosage is routinely calculated on the body weight and age of the child for suitability.(13) While there are some preparations that are specifically formulated for children in syrup form, many preparations will need to be crushed on a spoon using honey or jam to hide the taste. It is important that parents realise the need for prophylaxis and bite prevention tools, such as impregnated nets, in preventing serious illness in a young child.

Diarrhoea
Diarrhoeal illness is a major concern. The first priority for a child with diarrhoea should be rehydration - babies should continue to be breastfed and a child should be given plenty to drink.(14) The use of commercial rehydration mixtures for children can be bought over the counter in most countries, but parents should ensure they understand the child doses; for this reason bringing a recognised product from home is a good option. Nurses should advise parents to locate suitable medical services before travel. This will enable them to seek medical advice should the child become pyrexial, begin vomiting or pass blood in their stools.
Preventing diarrhoea in children is very much the same as for adults.(15) Those travelling with young babies should be encouraged to continue breastfeeding, which is one of the best ways to prevent infection. For the older child encouraging good handwashing and use of hand sanitisers are essential in a high-risk country.(16)

Skin care
With many of the higher-risk destinations being those with the hottest climates, parents will need to be aware of potential skin problems. Nappy rashes, prickly heat and sunburn are exacerbated in a hot, humid climate. Parents should take their own barrier creams from home. The use of protective clothing and high-factor sun cream of factor 15-20 is essential. Sun cream above 25 encourages children to stay in the sun for longer periods increasing the risk of skin cancer before any signs of burning are observed. Keeping children out of the sun between 11am and 3pm as well as encouraging fluids in the hot weather will also promote safety in the sun.(17)

Accidents
Accidents are also a major issue when advising parents. Children should not swim in unchlorinated pools and fresh water or lakes in tropical countries to minimise the risk of infection.(18) With drowning mortality rates highest in the under-fives it is essential that children are supervised at all times near water.(19) Cars also produce a risk factor for children, especially in countries where rear seat belts are not required by law, or are not even routinely in place. It is important that parents consider the safety of the child whenever they travel in a car in a foreign destination.
Risks of infection from cuts and grazes can be high in a tropical destination if the wound is not cleaned and dressed. It is worth advising parents to take a small first-aid kit with them to address minor injuries. 
Other issues that might need consideration when advising parents with children include:(20-22)

  • How to deal with motion sickness, which is common among the three to 12-year-olds.
  • Safety issues when flying as well as dealing with cabin pressure, turbulence and ear complaints as well as the potential of flight delays and jetlag.
  • The need to take medications such as analgesia for minor illness from home.
  • Baby foods are sometimes unavailable or very expensive in developing countries and parents should consider taking products from home. 
  • Travelling with teenagers can also present its own issues including the need for sexual health advice.
  • Travelling anywhere with children is not for the faint hearted, but if parents are aware of the potential problems and are able to think ahead, the experience can be fulfilling for all concerned.

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References

  1. McGovern LM, Boyce TG, Fischer PR. Congenital infections associated with international travel during pregnancy. J Travel Med 2007;14:117-28.
  2. Kingman CE, Economides DL. Travel in pregnancy: pregnant women's experiences and knowledge of health issues. J Travel Med 2003;10:330-3.
  3. Lankester T. Pregnant. The traveller's good health guide. London: Sheldon Press; 2006.
  4. International Air Transport Association. Health tips for air travellers. Available from: http://www.iata.org/Whip/_Files/WgId_0073/HEALTH%20TIPS.pdf
  5. Fit For Travel. Advice for pregnant travellers. Available from: http://www.fitfortravel.scot.nhs.uk/advice/travellers/pregnant.htm
  6. Van De Winkel K, Van den Daele A, Van Gompel A, et al. Factors influencing standard pretravel health advice — a study in Belgium. J Travel Med 2007;14:288-96.
  7. Kassianos G. Travellers at risk. In: Immunisation, childhood and travel health. 4th ed. Oxford: Blackwell Science; 2001.
  8. Chiodini P, Hill D, Lalloo D, et al. Guidelines for malaria prevention in travellers from the United Kingdom. London: HPA; 2007.
  9. 9. Marrero JM, Goggin PM, de Caestecker JS, et al. Determinants of pregnancy heartburn. Br J Obstet Gynaecol 1992;99:731-4.
  10. Bacaner N, Stauffer B, Boulware DR, et al. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA 2004;291:2856-64.
  11. NHS. Immunisation schedule. 2008. Available from: http://www.immunisation.nhs.uk/Immunisation_Schedule
  12. Lankester T. Children. The traveller's good health guide. London: Sheldon Press; 2006.
  13. National TravelHealth Network and Centre. Malaria chemoprophylaxis fact sheet. 2008. Available from: http://www.nathnac.org/pro/factsheets/malariaproph.htm
  14. Stauffer WM, Konop RJ, Kamat D. Traveling with infants and young children. Part III: travelers' diarrhea. J Travel Med 2002;9:141-50.
  15. National TravelHealth Network and Centre. Travellers diarrhoea fact sheet. 2008. Available from: http://www.nathnac.org/pro/factsheets/trav_dir.htm
  16. Wilson-Howarth J, Ellis M. Your child's health abroad: a manual for travelling parents. Bucks: Bradt Travel Guides; 2004.
  17. Wired For Health. Sun Safety. 2008. Available from: http://www.wiredforhealth.gov.uk/cat.php?catid=903&docid=7321
  18. Dawood R. Recreational water and beaches. In: Travellers health: how to stay healthy abroad. Oxford: Oxford Press; 2002.
  19. Cortés LM, Hargarten SW, Hennes HM. Recommendations for water safety and drowning prevention for travelers. J Travel Med 2006;13:21-34.
  20. NHS Direct. Travel sickness. Available from: http://www.nhsdirect.nhs.uk/articles/article.aspx?articleId=671
  21. Stauffer W, Konop R, Kamat D. Traveling with infants and young children. Part I: Anticipatory guidance: travel preparation and preventive health advice. J Travel Med 2001;8:254-9.
  22. Mulhall B. Sexual risks related to travel, including HIV. In: Travel medicine and migrant health. London: Churchill Livingstone; 2000.