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Travelling with children: reducing the stress and risk

Carolyn Driver
RGN RM RHV FPCert
MSc(TravelMed)
Independent Travel Health Specialist Nurse
Cheshire
E:thecompany@driverc.freeserve.co.uk

Asthe travel industry has grown and more exotic destinations have becomeavailable to most travellers regardless of their budget, many familieswith young children are travelling to long-haul, tropical destinations.But amid the excitement of planning the family holiday, potentialhealth risks can be forgotten or not entirely appreciated.
There aremany reasons why children travel other than for the family holiday,such as those whose parents work abroad or those embarking oneducational visits. Children may also travel with parents orgrandparents to their country of ethnic origin, and this "visitingfriends and relations group" (VFRs) often underestimate health risks,regarding their travel as going home rather than as foreign.(1) In thissituation their travel may take them to more remote rural parts oftheir destination than most tourists would venture. They will almostcertainly mix more closely with the indigenous population, and theytend to stay for longer periods.(2)
Healthcare professionals shoulduse every opportunity to make patients aware of the importance oftravel health advice and should publicise information resources thatindividuals can use when planning their trip. "Fit for Travel" is apublic access website run by the Scottish Centre for Infection andEnvironmental Health (SCIEH), which contains a wealth of information aswell as telephone information services run by tropical medicineinstitutions and organisations such as the Medical Advisory Servicesfor Travellers Abroad (MASTA) (see Box 1).

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The consultation
Withinthe consultation there are a number of specific areas that need to beaddressed, and the need for each topic will be identified by a detailedrisk assessment. This requires the adviser to ascertain the:

  • Departure date and duration of trip.
  • Destination/s.
  • Mode of transport and length of journey.
  • Type of accommodation.
  • Likely activities while at destination.

Inaddition to this new information, the adviser must also consider theage, vaccination status and general health of the traveller. Theadviser should also remind the family about the importance of travelhealth insurance for all members of the family and about informing theinsurance company if anyone is travelling with pre-existing medicalconditions.

Practical points for consideration include:

  • The journey - planning for all eventualities.
  • Thedestination - general facilities, such as shops, ­medical care andwaste disposal (nappies), plus ­possible disease risks,vaccines/malaria ­chemoprophylaxis/bite avoidance/food and waterprecautions.
  • The effect of climate.
  • Safety - personal and general.

The journey
Parentswho have never travelled long haul before may underestimate the stressof travelling with young children. They need to plan for eventualitiessuch as delays and the disruption to the child's normal routine. It canbe very tiring having a bored, wriggling toddler on your lap for 8hours or more, and the lack of space on commercial aircraft means thatthe child will not be able to run around as it would normally prefer todo. Carrying plenty of portable entertainment and drinks and snacks canhelp. Young children may experience ear discomfort on takeoff andparticularly during descent, and those with a history of otitis mediaare especially vulnerable. Sucking on a bottle, the breast or a dummycan help with infants, while older children can be taught to usedecompressing manoeuvres such as holding the nose and blowing.(3)Chewing gum may also help, and there are devices called "Earplanes"which are commercially available and are inserted into the aural canal(see www.earplanes.com).

The destination

Malaria risks
Malariarepresents a significant risk to a child's health, and parents need togive this careful consideration when choosing a destination - ifpossible, such destinations are best avoided. Travel to malarious areaswill require parents to administer tablets to their child and toregularly apply insect repellents (which contain 20-30% DEET) toexposed skin. Application of an insecticide such as permethrin to thechild's clothing will give additional protection. Permethrin- treatedbednets should also be used to protect the child while asleep. As theytend to have a bitter taste, tablets can be crushed and mixed with asmall quantity of foods such as peanut butter or chocolate spread. Itis important to ensure that the entire dose is taken, which can provedifficult with very young infants. Currently there are no effectiveantimalarial medications available in elixir form for high-risk areas -Table 1 lists the currently available medications. Dosages for childrenare calculated by weight rather than age - see the latest edition ofthe British National Formulary. Parents should also be advised aboutthe importance of prompt medical attention and mention of their travelhistory should the child develop a fever for up to a year after travel.

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Evenif malaria is not present at the destination, bite avoidance measuresmay be necessary because of the presence of other insect-borneinfections such as dengue fever. The adviser should check for suchrisks using up-to-date resources; the databases run by SCIEH or MASTAfor healthcare professionals are ideal.

Vaccinations
Thechild should have completed its primary immunisation schedule to theappropriate point for its age, and any overdue doses should be givenbefore travel. Children travelling as VFRs to Africa, the Indiansubcontinent or any other developing country should be protectedagainst measles. If a child is between 6 and 12 months old, MMR can begiven, but they should still receive the normal schedule upon theirreturn to ensure lasting immunity.(4) It is also important to encourageparents not to take a child to these destinations until they have hadthree doses of the oral polio vaccine, as they may not haveseroconverted to all three serotypes of the virus until this time.
Generally,travel-specific vaccinations are not given to children under 2 years ofage who are travelling abroad for short vacations, with the exceptionof yellow fever, which can be given from the age of 9 months and shouldbe given to all travellers to endemic areas. Over the age of 2 years,children travelling abroad for holidays should be assessed for travelvaccines in the same way as their parents. Children under 2 years ofage going to live abroad or those going for prolonged visits such asVFRs may be advised to have hepatitis B and rabies vaccines, both ofwhich have no lower age limit, while Japanese encephalitis vaccine canbe given from 1 year of age. Rabies vaccine is strongly recommended forchildren going to spend time in developing countries, ­especially ifthey will be in rural locations, as they are less likely to heed adviceto stay away from animals and may not disclose minor wounds promptly totheir parents. Hepatitis B is also recommended for this group as thereis evidence of horizontal transmission among children, and also asyoungsters tend to need access to medical care more frequently thanadults, which could put them at risk through unsterile needles orsurgical equipment.

Other considerations
Children'sskin is even more vulnerable to sun damage than adults, and it isimportant to stress the importance of skincare to parents (ie, using ahigh-factor sunscreen, covering up and limiting full sun exposure).(3)Keeping the child adequately hydrated is also important by ensuringthat they drink extra fluids during the trip.
Children are morevulnerable to the effects of diarrhoea than adults, so teaching foodand water precautions and reminding parents to encourage good personalhygiene among the family while away are important. Boiled water isbetter than bottled for young babies because of the possible mineralcontent of the bottled variety. Milk should also be boiled even if itis pasteurised. If a baby is bottle-fed it is useful to carry at leasta 24-hour supply of the ready-to-feed bottles to allow time to organisethe preparation of the powdered feeds. Parents should be advised tocarry rehydration salts with them and to encourage the use of these ifthe child develops diarrhoea, as they may help to prevent severeillness. However, parents should also be encouraged to seek earlymedical attention if the child has a severe bout of diarrhoea that doesnot settle within 24 hours, and always if the child has a fever or ispassing blood and/or mucus.
Trauma is a more common cause ofill-health in travellers than infection, and parents need to beespecially observant for hazards.(5) Safety standards are not universalaround the world, and balconies, staircases, swimming pools as well asroads can all present risks. Hire cars may not automatically beequipped with seatbelts and child restraints, and parents should avoidthe temptation to sit with a child on their lap, especially in thefront seat, rather than insisting on a vehicle that is correctlyequipped. Children can easily become lost in crowded places, and thedistress of this is compounded when the language is different.

Conclusion
Travellingwith children can and should be enjoyable, but parents need to givecareful thought to their destinations so as not to take unnecessaryrisks. Thorough planning can help to avoid situations that have thepotential to spoil the trip. Healthcare professionals need to be awareof the importance of encouraging parents to seek advice when planningto take their children abroad, especially for those groups who do notreadily present for such advice.

References

  1. Ladhani S, El Bashir H, Patel VS, Shingadia D. Childhood malaria in East London. Pediatr Infect Dis J 2003;22:814-9.
  2. Departmentof Health. National statistics: travel trends. A report on the 2001­international passenger survey. The Stationery Office; London; 2002.
  3. StaufferWM, Konop RJ, Kamat D. Travelling with infants and young ­children.Part 1: anticipatory ­guidance: travel preparation and preventivehealth advice. J Travel Med 2001; 8(5):254-9.
  4. Stauffer WM, Kamat D. Travelling with infants and young children. Part 2: immunizations.J Travel Med 2002;9(2):82-90.
  5. Wilson-HowarthJ, Ellis M. Your child's health abroad. A manual for ­travellingparents. Chalfont St Peter: Bradt Publications; 1998.

Resources
TRAVAX
Anexcellent database, free to healthcare ­professionals in Scotland, andthrough the NHS intranet in Wales, but there is a £100 annualsubscription in England and Northern Ireland. PCTs in England cansubscribe their entire trust for £500
NaTHNaC
National Travel Health Network and Centre
T:020 7380 9234

Further­ ­reading
Wilson-HowarthJ, Ellis M. Your child's health abroad. A manual for travellingparents. Chalfont St Peter: Bradt Publications; 1998