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Travelling with babies and young children

 - Preparing for travel with babies and young children 

 - Vaccinations available and at what ages

 - Reducing the risk of illness and injury

Just over 55.5 million overseas visits are made by United Kingdom (UK) residents annually; 20% of those visits are made by children younger than 16 years of age.1 Babies and children travel for many reasons, including family holidays, school trips and to visit friends and relatives. Nurses and health visitors may be approached by parents for travel health advice. This article provides a summary of the potential hazards of overseas travel, and the basic principles of tailoring travel health advice to the specific needs of babies and young children. 

Preparation before travel

Ideally all travellers should seek advice regarding the specific hazards at their planned destination before booking a trip. This is particularly important if babies or young children are travelling. However, this does not always happen and there may be occasions where nurses have to discuss the suitability of the planned destination. Issues to consider include whether the child is 

being placed at unnecessary risk due to the travel plans, and whether postponing the travel plans until the child is older would 

be an option.

All travellers should take out comprehensive travel health insurance ensuring that all members of the party are included and any pre-existing medical conditions are declared and covered. Long-term travellers in particular should research the destination and consider access to medical facilities, including specialist paediatric care. A child-specific medical kit should be carried to include items such as paediatric pain relief, oral rehydration salts and a thermometer. 

Although healthy babies can usually travel by aircraft from 

48 hours after birth, it is preferable to wait for seven days.2 Premature babies should be medically evaluated before travelling by air. Babies and children can experience ear pain particularly during take-off and landing. This can be alleviated by sucking 

and swallowing, for example by feeding infants or providing a soother. Parents and guardians should check with individual 

airlines regarding restricted items, which can include infant feeds and formula. 

Vaccinations

It is important for nurses practising travel health to have a good working knowledge of vaccinations, including the minimum age of administration and any dosage differences. The Summary of Product Characteristics (see Resources) and Immunisation against infectious disease should be consulted for specific guidance on vaccine use in babies and children.3

A travel health consultation is an ideal opportunity to ensure that a child's routine vaccinations are up-to-date for their age. Ideally travel plans should be postponed until the primary immunisation schedule has been completed. If necessary, primary immunisations can be commenced at six weeks of age.4 Measles, mumps and rubella (MMR) vaccine is not recommended for infants younger than six months of age. If an infant is assessed as being at an increased risk of exposure through the travel plans, MMR vaccine can be administered from six months of age. However, the immune response may not be as efficient, so this is regarded as an 'extra' dose, and the vaccine should be repeated at the appropriate ages. 

If travelling long-term, parents or guardians will need to register the child at the destination to complete vaccinations according to the local schedule (see Resources). Some vaccines are contraindicated in babies and young children due to potential adverse events or lack of efficacy. See Table 1 for minimum ages of administration of travel vaccines. 

Yellow fever vaccine has been associated with an increased risk of vaccine-associated encephalitis and should never be given to infants younger than six months of age.5 It is routinely given to infants travelling to risk areas from nine months of age, but may be considered from six months if the risk is considered exceptional. Specialist advice should be sought (see Resources).

Babies and young children do not develop a good immune response to polysaccharide vaccines, including injected typhoid and meningococcal vaccines. The conjugate meningococcal vaccine (Menveo) is the recommended vaccine for babies and young children who require protection against serotypes A, C, W135 and Y, and can be administered from two months of age.6 Some travel vaccines have specific children's formulations, for example hepatitis A (Havrix Junior, Vaqta) and tick-borne encephalitis (TicoVac Junior). 

If a baby or child is too young to receive vaccines, the parent or guardian should be provided with advice on behavioural measures to reduce the risk of exposure. For example, breastfed infants are at little risk of food- and water-borne illnesses and the mother may therefore wish to continue breastfeeding for the duration of travel. For non-breastfed infants, advice on the importance of careful attention to hygiene when making up feeds should be provided. See Other Risks section for further information.

Malaria and other insect-borne diseases

Babies and infants are at an increased risk of developing serious complications from malaria, including death.7 Travel to malaria risk areas with babies is not recommended, but if travel is felt to be unavoidable it should at least be postponed until the infant reaches the minimum weight threshold for the recommended malaria chemoprophylaxis for the destination.

Weight is a much more accurate indicator for dosages of malaria chemoprophylaxis than age, although in the UK doxycycline is contraindicated in children younger than 12 years of age due to it causing discolouration of developing teeth.7 See Table 2 and 2a for malaria chemoprophylaxis doses for children.

Nurses providing malaria advice for travelling babies and children should refer to updated guidelines for recommendations for the area to be visited, and then ensure that the drug regimen is appropriate for the infant. See the Resources section for further information.

With the exception of chloroquine (Nivaquine syrup), malaria chemoprophylaxis is only available in tablet or capsule form. Parents or guardians will require instructions on cutting tablets to obtain the correct dosage; pill cutters are available from pharmacies. Tablet portions can then be crushed and mixed with a little expressed breast milk or formula, or for older children, a little jam, chocolate spread, or similar. Doxycycline capsules should never be broken.

No malaria chemoprophylaxis is totally effective and all babies and children should be protected from mosquito bites. DEET (N,N-diethyl-m-toluamide) is strongly recommended, but is not suitable for babies under two months of age.7 Great care should be taken when applying repellents to babies and children to ensure that they do not ingest the product - avoid applying to hands, faces and feet. 

Unless the accommodation is air conditioned or screened, babies and children should sleep under an insecticide-impregnated mosquito net, ensuring that the net is well out of the infant's reach. Cotton clothing is a useful way of protecting babies against mosquito bites.

Other hazards

Many travel-related hazards are of greater risk to babies and children, including gastrointestinal and respiratory infections8 and rapid fluid loss from diarrhoea. Children are at greater risk of rabies due to their closer proximity to animals, and the likelihood of receiving bites to the head and neck region.9 

The greatest life-threatening risk to travellers is accidents and injuries,10 and the leading causes of death among children are road traffic accidents and drowning.9 Infants should be supervised at all times, and especially near roads, around animals, balconies and water. 

Parents and guardians should be provided with hygiene advice for preparing feeds for babies. Bringing tap water to a boil is the most effective method of water purification. Bottled water is not recommended for infants due to mineral levels, but if it is used, the label should be checked carefully to ensure the water contains less than 200mg/litre of sodium and no more than 250mg/litre of sulphate.11 Bottled water is not sterile and should be boiled and allowed to cool before using to prepare feeds.

Children's hands should be washed before eating and drinking and after using the toilet. 

Dehydration can be life threatening in children, and parents/guardians should be able to recognise the signs of dehydration and know how to use rehydration salts and when to seek medical help. Urgent medical attention should be sought for infants with bloody diarrhoea, unexpected drowsiness, or fever. Travellers with diarrhoea should not enter swimming pools. Swim nappies should be worn by babies and infants to avoid faecal accidents. 

Children are at particular risk of the damaging effects of sunlight. Babies under six months of age should never be placed in direct sunlight. Young children should always have a high sun protection factor (SPF) sunscreen applied and wear a hat. 

Summary

The aim of the travel health consultation is to identify hazards and tailor advice to the individual traveller. This is particularly important when babies and young children are travelling and nurses and health visitors should ensure they are confident in making a risk assessment. Familiarity with available immunisations and malaria chemoprophylaxis, including their use in children is vital. Up-to-date resources should be used and specialist advice sought as appropriate. 

Resources

Chiodini P, et al. Guidelines for malaria prevention in travellers from the United Kingdom. London: Health Protection Agency, 2007

Electronic Medicine Compendium (for information on UK licensed medicines)

Field VK, Ford L, Hill DR, eds. Health information for overseas travel. London: National Travel Health Network and Centre; 2010. 

National Travel Health Network and Centre (NaTHNaC)

NaTHNaC Advice line for health professionals

0845 602 6712

Salisbury D, Ramsay M, Noakes K, eds. Immunisation against infectious disease. London: Department of Health, 2006. The 'Green Book', regularly updated online

Travax

World Health Organization (for overseas immunisation schedules)

References

1. Barnes W, Smith R. Travel Trends. London: Office for National Statistics; 2010.

2. Field VK, Ford L, Hill DH, eds. Health information for overseas travel. London: National Travel Health Network and Centre; 2010.

3. Salisbury D, Ramsay M, Noakes K, eds. Immunisation against infectious disease. London: Department of Health; 2006.

4. Halsey N, Galazka A. The efficacy of DPT and oral poliomyelitis immunization schedules initiated from birth to 12 weeks. Bull World Health Organ 1985;63:1151-1169.

5. Monath TP. Yellow fever vaccine. In: Plotkin S, Orenstein W, Offitt P, eds. Vaccines.  Philadelphia: Saunders; 2008.

6. Meningococcal. (Updated 26 March 2012). In: Salisbury D, Ramsay M, Noakes K, eds. Immunisation against infectious disease. London: Department of Health; 2006. 

7. Chiodini P, Hill D, Lalloo D, Lea G, Walker E, Whitty C, Bannister B. Guidelines for malaria prevention in travellers from the United Kingdom. London: Health Protection Agency; 2007.

8. Hagmann S, Neugebauer R, Schwartz E, Perret C, Castelli F, Barnett ED, Stauffer WM. Illness in children after international travel: analysis from the Geosentinel surveillance network. Pediatrics 2010;125:1072-1080.

9. Weinberg N, Weinberg M, Maloney S. Traveling safely with infants and children. In: Centers for Disease Control and Prevention. CDC health information for international travel 2012. Atlanta: US Department of Health and Human Services; 2012.

10. World Health Organization. Injuries and violence. In: World Health Organization. International travel and health 2011. Geneva: World Health Organization; 2011.

11. NHS Choices. Making up infant formula. 1 October 2010.