Traveling Safely with Infants and Children | Yellow Book

Introduction

Children increasingly are traveling and living outside of their home countries. Although data about the incidence of pediatric illnesses associated with international travel are limited, the risks that children face when traveling are, with a few caveats discussed below, largely similar to those faced by their adult travel companions. The most commonly reported health problems among child travelers are dermatologic conditions, including animal and arthropod bites, cutaneous larva migrans, and sunburn; diarrheal illnesses; respiratory disorders; and systemic febrile illnesses, especially malaria. Motor vehicle and water-related injuries, including drowning, are other major health and safety concerns for child travelers (see Injury and Death During Travel chapter). See Box 6.3.1 for recommendations on assessing and preparing children for planned international travel.

Box 6.3.1

Travel-associated infections and diseases

Arboviral infections

Pediatric travelers with travel to areas where arboviruses (e.g., chikungunya, dengue, Japanese encephalitis, yellow fever, and Zika viruses) are endemic or epidemic are at risk for infection. Children traveling to areas with arboviruses should use the same mosquito-protection measures described later in this chapter (see also Mosquitoes, Ticks, and Other Arthropods chapter). Vaccination against Japanese encephalitis, tick-borne encephalitis, and yellow fever could be indicated for some children (see Travel Vaccine Recommendations for Infants and Children chapter), particularly those with prolonged or frequent travel.

Diarrhea and vomiting

Diarrhea and associated gastrointestinal illnesses are among the most common travel-related problems affecting children. Infants and children with diarrhea can become dehydrated more quickly than adults. The etiology of travelers’ diarrhea (TD) in children is similar to that in adults (see Travelers’ Diarrhea chapter). The evidence base for indications, outcomes, and risks of stand-by treatment of children with antibiotic, antimotility agents, and/or antiemetics is limited and largely extrapolated from adult studies. Additional pediatric-specific studies would improve the basis of evidence for pre-travel counseling on this topic.

Prevention

Adults should ensure that traveling children follow safe food and water precautions (see Food and Water Precautions for Travelers chapter) and frequently wash their hands to prevent food-borne and waterborne illness. Breastfeeding is the best way to reduce infants’ risk for food-borne and waterborne illness (see Travel and Breastfeeding chapter). Infant formulas available abroad might not have the same nutritional composition or be held to the same manufacturing safety standards as in the traveler’s home country. Parents feeding their child formula should consider whether they need to bring formula from home and can consider using liquid formula, which is sterile. Travelers should disinfect water served to young children, including water used to prepare infant formula (see Water Disinfection for Travelers chapter). In some parts of the world, bottled water could be contaminated and should be disinfected to kill bacteria, viruses, and protozoa before consumption.

Parents might want to bring a supply of safe and familiar snacks from home for times when children are hungry and available food might not be appealing or safe (see Food and Water Precautions for Travelers chapter).

Potable water should be used for cleaning bottles, pacifiers, teething rings, and toys that fall to the floor or are handled by others. Parents should be particularly careful to wash hands well following diaper changes, especially for infants with diarrhea, to avoid spreading infection to themselves and other family members.

Typhoid vaccine might be indicated (see Typhoid and Paratyphoid Fever chapter).

Treatment

Fluid and nutrition management

The biggest threat to an infant or young child with diarrhea or vomiting is dehydration. Travelers need to be aware of the signs and symptoms of dehydration and the proper use of oral rehydration solution (ORS). ORS can be made from prepackaged glucose and electrolytes packets available at stores or pharmacies in almost all countries and can also be purchased in the United States before the trip. ORS is prepared by adding 1 packet to boiled, treated, or bottled water (see Water Disinfection for Travelers chapter); instructions on the packet should be checked carefully to ensure the contents are added to the correct volume of water. Dehydration is best prevented and treated by ORS in addition to the infant’s usual food. Breastfed infants should continue to breastfeed (see Travel and Breastfeeding chapter). Medical attention should be sought for an infant or child with diarrhea who has signs of moderate to severe dehydration (such as irritability or lethargy, markedly decreased urine output, dry mucous membranes, reduced skin turgor or tenting, delayed capillary refill, cool extremities, and a sunken fontanelle (if present), bloody diarrhea, body temperature 38.5°C (>101.3°F), or persistent vomiting (unable to maintain oral hydration). Severe dehydration is a medical emergency that usually requires administration of fluids by intravenous or intraosseous routes.

The AAP provides detailed guidance on rehydration for vomiting and diarrhea. Older infants and children receiving semisolid or solid foods should continue to receive their usual diet during the illness. Generally, no dietary restrictions are indicated if otherwise tolerating oral intake, although food high in simple sugars (e.g., undiluted apple juice, presweetened cereals, gelatins, soft drinks) should be limited because these can exacerbate diarrhea by osmotic effects. Foods high in fat tend to delay gastric emptying, and thus might not be well tolerated by some ill children. Early feeding can decrease changes in intestinal permeability caused by infection, reduce illness duration, and improve nutritional outcome. Purposefully limited diets (e.g., the BRAT (bananas, rice, applesauce, toast) diet) or juice-based and clear fluid diets have no evidence basis, delay resumption of normal dietary intake, and should be avoided.

Antibiotics

Azithromycin

Few data are available regarding empiric treatment of TD in children. In practice, when an antibiotic is indicated and used for moderate to severe diarrhea (see Travelers’ Diarrhea chapter), most healthcare professionals prescribe azithromycin as a single daily dose (10 mg/kg) for 3 days. Healthcare professionals can prescribe unreconstituted azithromycin powder before travel, with instructions from the pharmacist for mixing it into an oral suspension with sterile or disinfected water prior to administration. Counsel parents to seek medical attention for their children if they do not improve after empiric treatment or are getting sicker during treatment. Before prescribing azithromycin for empiric TD treatment, review possible contraindications and the risks for adverse reactions (e.g., QT prolongation and cardiac arrhythmias).

Fluoroquinolones

Although fluoroquinolones frequently are used for empiric TD treatment in adults, these medications are not approved by the U.S. Food and Drug Administration (FDA) for this purpose in children aged Campylobacter jejuni, Salmonella species, Shigella species, or Vibrio cholerae, hence their use in the setting of TD when other alternatives are not available could be considered. Considering rising quinolone resistance, the potential for adverse effects, and the availability of azithromycin as a safe and effective alternative, fluoroquinolones as empiric treatment are generally not recommended.

Rifaximin

Rifaximin is approved for use in children aged ≥12 years, although approval is limited to treatment of noninvasive strains of Escherichia coli.

Antiemetics and antimotility drugs

Although single-dose or short-course ondansetron is increasingly used in emergency department or clinic management of gastroenteritis, antiemetics generally are not recommended for self- or family-administered treatment of children with vomiting associated with TD.

A Cochrane Collaboration Review of the use of antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents showed some benefits with dimenhydrinate, metoclopramide, or ondansetron. Guidelines from the Infectious Diseases Society of America suggest that an antinausea and antiemetic medication (e.g., ondansetron) can facilitate tolerance of oral rehydration in children >4 years of age and in adolescents with acute gastroenteritis. Routine use of these medications as part of self-treatment for emesis associated with TD in children has not yet been studied.

Controversy remains about use of antimotility drugs (e.g., the opioid receptor agonists loperamide and diphenoxylate) in children. Data are lacking about their use in the context of TD, and there is potential for adverse events, especially in younger children. Loperamide is contraindicated for children aged Travelers’ Diarrhea chapter). Bismuth subsalicylate, the active ingredient in some formulations of Pepto-Bismol and Kaopectate, is not recommended in children

Malaria

Malaria is among the most serious and life-threatening infections acquired by pediatric international travelers (see Malaria chapter). Pediatric travelers are at particularly high risk for malaria infection if they do not receive prophylaxis. Among people reported with malaria in the United States in 2018, 88% had traveled to Africa, 16% were children

Children with malaria can rapidly develop high levels of parasitemia and are at risk for severe complications of malaria, including seizures, coma, or death. Initial symptoms can mimic many other common causes of pediatric febrile illness, which could delay diagnosis and treatment. Delays in diagnosis resulting in severe malaria are common, particularly when the diagnosis is not considered from the outset. Healthcare professionals should have a high index of suspicion for malaria in all travelers returning from malaria-risk areas with fever and/or flu-like symptoms and should be aware of alterations of the typical presentation of illness that can occur in the setting of incomplete or inadequate courses of prophylaxis or treatment.

Adults traveling with children to malaria-endemic areas should use preventive measures, be aware of the signs and symptoms of malaria, and know how to seek prompt medical attention from a facility capable of making the diagnosis in a timely manner (e.g., an emergency department or other clinic with on-site rapid diagnostic tests).

Antimalarial drugs

Pediatric doses for malaria prophylaxis are weight-based and are provided in Table 4.10.3 (see Malaria chapter). Chloroquine, mefloquine, and primaquine may be given to children of all ages, atovaquone-proguanil to children ≥5 kg, doxycycline to children over age 8, and tafenoquine to those >18 years of age. G6PD testing is required before using primaquine or tafenoquine because these medications should not be used for malaria prophylaxis in those with G6PD deficiency.

Training children as young as the age of 4 years to swallow pills using small candies or similarly sized food items can be a valuable strategy when time allows. Atovaquone-proguanil, chloroquine, and mefloquine have a bitter taste; mixing pulverized tablets in a small amount of food or drink can help children to take them. Healthcare professionals also can ask compounding pharmacists to pulverize tablets and prepare gelatin capsules with calculated pediatric doses or to alter the flavoring of malaria medication tablets so that children are more willing to take them. The Find a Compounder section on the Alliance for Pharmacy Compounding website (281-933-8400) can help with finding a compounding pharmacy. Overdose of antimalarial drugs, particularly chloroquine, can be fatal. Medications should be stored in childproof containers and kept out of the reach of infants and children. If vomiting occurs within 1–2 hours of administration, repeat dose. If repeated doses are vomited, discussion with a medical provider is warranted.

Personal protective measures and repellent use

Children should sleep in rooms with air conditioning or screened windows. When air conditioning or screens are not available, children should sleep under mosquito nets. Mosquito netting should be used over infant carriers. Children can reduce skin exposed to mosquitoes by wearing long pants and long sleeves appropriate to the climate while outdoors. Clothing and mosquito nets can be treated according to product instructions with an insect repellent/insecticide (e.g., permethrin) that repels and kills ticks, mosquitoes, and other arthropods. Permethrin remains effective through multiple washings. Permethrin should not be applied to the skin. Some repellents that can be applied to skin can also be used on clothing and mosquito nets, though permethrin provides a longer duration of protection (see Mosquitoes, Ticks, and Other Arthropods chapter).

The U.S. Environmental Protection Agency (EPA) regulates registered repellents containing one of several active ingredients. DEET (N,N-diethyl-m-toluamide); picaridin; IR3535 (3-(N-butyl-N-acetyl)-aminopropionic acid, ethyl ester); or 2-undecanone (methyl nonyl ketone) is recommended without age restriction in amounts and frequency as per the label, although for children under the age of 2, application to the hands should be avoided. Products containing oil of lemon eucalyptus (OLE) and PMD (para-menthae-3,8-diol) should not be used on children

Many repellents contain active ingredient concentrations that vary considerably between products. The EPA now encourages manufacturers to provide approved labeling on products voluntarily that specifies the repellency time for mosquitos and ticks, which varies between both active ingredients and various formulations. The repellency time of products with DEET begins to plateau above a concentration of 30% and those >50% do not offer a marked increase in protection time but carry higher rates of skin irritation and other adverse effects. The AAP states that the use of products with the lowest effective DEET concentrations (i.e., 20%–30%) seems most prudent for infants and young children, on whom it should be applied sparingly. For more tips on protecting babies and children from mosquito bites, see Box 6.3.2.

When using insect repellent with sunscreen, apply sunscreen first (see Sun Exposure in Travelers chapter). Combination products containing repellents and sunscreen are generally not recommended because instructions for use are different, and sunscreen might need to be reapplied more often and in larger amounts than repellent. Mosquito coils should be used with caution in the presence of children to avoid burns and inadvertent ingestion (for detailed information about repellent use and other protective measures, see Mosquitoes, Ticks, and Other Arthropods chapter).

Box 6.3.2

Rabies

Animal exposures and bites are a health risk for pediatric travelers because they may not understand the need or have the ability to avoid animals. They are more likely to be bitten on the head or neck, leading to more severe injuries. Worldwide, rabies is more common in children than adults. Children and their families should be counseled to avoid all stray or unfamiliar animals and to inform adults of any animal contact or bites. Bats throughout the world have the potential to transmit rabies virus, as do dogs, cats, and monkeys in many countries.

Travelers should clean all bite and scratch wounds as soon as possible after the event occurs by using soap and water, or povidone-iodine if available, for ≥20 minutes to prevent infections, (e.g., rabies). Wounds contaminated with necrotic tissue, dirt, or other foreign materials should be cleaned and debrided promptly by healthcare professionals, where possible. A course of antibiotics might be appropriate after animal bites or scratches because of the risk of local or systemic infections. For mammal bites and scratches, children should be evaluated promptly to assess their need for rabies post-exposure prophylaxis and tetanus vaccination (see Zoonotic Exposures: Bites, Scratches, and Other Hazards and Rabies chapters).

Because rabies vaccine and rabies immune globulin might not be available in certain destinations, encourage families traveling to areas with high risk for rabies exposure to consider pre-exposure rabies vaccination, which since 2022 is a 2-dose series, and to purchase medical evacuation insurance, depending on their destination and planned travel activities (see Travel Vaccine Recommendations for Infants and Children and Travel Insurance, Travel Health Insurance, and Medical Evacuation Insurance chapters). For travelers likely to return to high-risk settings numerous times, particularly VFR travelers, the cumulative risk of rabies exposure should be factored into the decision to offer and receive pre-exposure rabies vaccination.

Soil and water contact: infections and infestations

Children are more likely than adults to have contact with soil or sand, and therefore could be exposed to diseases caused by infectious stages of parasites in soil, including ascariasis, hookworm, cutaneous or visceral larva migrans, strongyloidiasis, and trichuriasis (see Post-Travel Parasitic Disease Including Evaluation of Eosinophilia chapter). 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. In countries with a tropical climate, clothing or diapers dried in the open air should be ironed before use to prevent infestation with fly larvae.

Schistosomiasis is a risk to children and adults in endemic areas. While in schistosomiasis-endemic areas (see Schistosomiasis chapter), children should not bathe, swim, or wade in fresh, unchlorinated water (e.g., lakes, ponds). This risk extends to white water rafting excursions common at some destinations.

Noninfectious hazards and risks

Air travel

Air travel is safe for most newborns, infants, and children (see Air Travel chapter). Children with chronic heart problems, lung problems, or sickle cell disease might be at risk for hypoxia during flight, and caregivers should consult a healthcare professional before travel.

Ear pain

Ear pain can be troublesome for infants and children during descent. Pressure in the middle ear can be equalized by swallowing or chewing; thus, infants should nurse or suck on a bottle, and older children can try chewing gum. Antihistamines and decongestants have not been shown to be of benefit. Antihistamines are contraindicated under the age of 1 year, and the FDA and AAP caution against their use under the age of 6 years except for allergic conditions. The AAP recommends against the use of decongestants for any reason under the age of 4 years. No evidence suggests that air travel exacerbates the symptoms or complications associated with otitis media.

Jet lag

Travel to different time zones, jet lag, and schedule disruptions can disturb sleep patterns in infants and children, just as in adults (see Jet Lag Disorder chapter).

Safety restraints

Children should be restrained safely during a flight. Severe turbulence or a crash can create enough momentum that an adult cannot hold onto a child. The safest place for a child on an airplane is in a government-approved child safety restraint system (CRS) or device. The Federal Aviation Administration (FAA) strongly urges travelers to secure children in a CRS for the duration of the flight. Car seats cannot be used in all seats or on all planes, and some airlines might have limited safety equipment available. Travelers should check with the airline about specific restrictions and approved child restraint options. The FAA provides additional information, Flying with Children.

Altitude illness and acute mountain sickness

Children are as susceptible to the deleterious effects of high elevation travel as adults (see High Altitude Travel and Altitude Illness chapter). Slow ascent is the preferable approach for avoiding acute mountain sickness (AMS). Young children unable to talk can show non-specific symptoms (e.g., loss of appetite or irritability, unexplained fussiness, changes in sleep and activity patterns). Older children might complain of headache or shortness of breath. If children demonstrate unexplained symptoms after an ascent, descent could be necessary.

Acetazolamide is not approved for use in children aged

Drinking water contaminants

Drinking water disinfection (see Water Disinfection for Travelers chapter) does not remove environmental contaminants (e.g., lead or other metals). Travelers might want to carry specific filters designed to remove environmental contaminants, particularly for travel where the risk for exposure is greater due to larger amounts of water consumed (e.g., long-term travel or when living abroad). Filters should meet National Science Foundation and American National Standards Institute standards 53 or 58.

Injuries

Accommodations: hotels and other lodgings

Conditions at hotels and other lodgings abroad might not be as safe as those in the United States; adults traveling with children should carefully inspect accommodations for paint chips, pest poisons, inadequate balcony or stairway railings, or exposed wiring.

Adult caregivers should plan to provide a safe sleeping environment for infants during international travel. Caregivers should follow general recommendations from the AAP task force on preventing sudden infant death syndrome and other sleep-related causes of infant death. Cribs in some locations might not meet U.S. safety standards. Additional information about crib safety is available from the U.S. Consumer Product Safety Commission.

Motor vehicles

Vehicle-related injuries are among the leading causes of death in travelers (see Injury and Death During Travel chapter). Whenever traveling in an automobile or other vehicle, children should be properly restrained in a car seat, booster seat, or with a seat belt, as appropriate for their age, height, and weight. See information about child passenger safety. Car seats often must be brought from home because well-maintained and approved seats might not be available (or limited in availability) in other countries.

In general, children ≤12 years of age are safest when properly buckled in the rear seat of the car while traveling; no one should ever travel in the bed of a pickup truck. Cars might lack front or rear seatbelts in many low- and middle-income countries. Traveling families should attempt to arrange transportation or rent vehicles with seatbelts and other safety features.

All family members should wear helmets that meet U.S. safety standards when riding bicycles, motorcycles, or scooters. Pedestrians should take caution when crossing streets, particularly in countries where cars drive on the left, because children might not be used to looking in that direction before crossing.

Water-related injuries and drowning

Drowning is a leading cause of death among travelers (see Injury and Death During Travel chapter). Children might not be familiar with hazards in the ocean or in rivers. Swimming pools might not have protective fencing to keep unattended toddlers and young children from accessing pool areas. Adults should closely supervise children around water. An adult with swimming skills should be within an arm’s length when infants and toddlers are in or around pools and other bodies of water. Even for older children and better swimmers, the supervising adult should focus on the child and not be engaged with any distracting activities. The AAP recommends swim lessons, as early as age 1 year, as part of a layered approach to reduce the risk of drowning.

Children and weak swimmers should always wear a lifejacket when boating. Water safety devices (e.g., personal flotation devices (lifejackets)) might not be available abroad, and families should consider bringing these from home. Children should wear protective footwear to avoid injury in many marine environments.

Sun exposure

Sun exposure, particularly sunburn before age 15 years, is strongly associated with melanoma and other forms of skin cancer (see Sun Exposure in Travelers chapter). Exposure to ultraviolet (UV) light is greatest near the equator, at high elevations, during midday (10 a.m. to 4 p.m.), and where light is reflected off water or snow.

Physical (also known as inorganic) UV filters (sunscreens) generally are recommended for children aged >6 months. Less irritating to children’s sensitive skin than chemical sunscreens, physical UV filters (e.g., titanium oxide, zinc oxide) should be applied as directed and reapplied as needed after sweating and water exposure. Babies aged

If both sunscreen and insect repellent are used, apply the sunscreen first and the insect repellent second (i.e., over the sunscreen). Because insect repellent can diminish the level of UV protection provided by the sunscreen by as much as one-third, children should also wear sun-protective clothing, reapply sunscreen, or decrease their time in the sun, accordingly.