Tuesday, November 18, 2014

Travelling with babies and toddlers

Travel to far flung destinations is increasing. But what advice should you give to parents who plan to take babies or young children on package holidays?

Taking children on a package holiday can be a positive experience and is often a family's first taste of overseas travel. However, the importance of careful planning and realistic expectations should not be underestimated.1 Babies and young children have always been taken abroad. However, packages to increasingly exotic locations are becoming more common for many UK families.

While package holidays, especially to established tourist resorts, generally offer families a protected environment, they do not give complete immunity from travel-related illnesses or accidents.

The most frequently reported childhood travel problems are diarrhoea, malaria and accidents (specifically related to traffic and water safety).2 Often, parents focus on vaccine-related concerns during their pre-travel consultation. The practice nurse's role involves emphasising safety and non-vaccine preventable hazards, as well as offering appropriate travel vaccines and, if required, anti-malarials.
RISK ASSESSMENT

Practice nurses involved in travel medicine need to develop the skills required for an effective assessment, taking into account the family's travel plans and tailored to the child's individual needs. Usually the package holiday has been booked before the family attends for advice, so working in collaboration with parents is crucial to help ensure children are as fully protected as possible. While no trip can ever be guaranteed as risk free, awareness of issues and careful planning facilitates safer travel.

The risk assessment should consider the child's specific requirements:

* How old are they?

* Where are they going?

* How long are they away for?

* Why are they travelling?

* Have they got any medical or family history of significance?

As it is difficult to reduce exposure to environmental hazards3 all children should be up to date with recommended childhood vaccines. Ideally, travel should be delayed until at least the initial routine childhood vaccines have been given, usually by the age of four months. Parents planning to take babies abroad before completion of these vaccines must be informed that their children are at risk of vaccine preventable diseases.34

Expert advice, from a travel medicine specialist or authority such as NaTHNaC, should be sought about pre-existing medical conditions, special needs or complex travel itineraries.
MALARIA

All health professionals involved in the provision of pre-travel advice must ensure they understand the significance of malaria risks and are familiar with the current UK national guidelines. These recommendations from the Health Protection Agency Guidelines for malaria prevention in travellers from the United Kingdom (see resources section) provide clear information and guidance and are regularly updated online.

Children, particularly babies and very young children, are at risk of severe malaria, which can rapidly be fatal. Parents should be advised not to take children to malarial areas.5 6 Realistically, parents may choose to disregard this advice. In these circumstances, it is essential that the nurse fully informs parents of both the risks and the appropriate preventative measures. These include prescribing appropriate anti-malaria drugs and advising parents to follow the ABCD malaria prevention recommendations:

* Awareness of risk

* Bite prevention

* Chemoprophylaxis

* Diagnosis and prompt treatment.5

DEET- (N, N-diethyl-m-toluamide) based insect repellents are considered safe for babies from the age of two months. Obviously, the manufacturer's guidelines should be carefully followed. Cot nets and protective clothing should also be used.5

These anti-bite measures also help protect against other insect spread diseases, such as dengue and yellow fever (spread by day-biting mosquitoes) and Japanese encephalitis, which - like malaria - is spread by night-biting mosquitoes.
Malaria tablets

Weight rather than age is the best guide for determining correct anti-malarial doses for children.5 Again, practice nurses should refer to the Health Protection Agency guidelines, which includes guidance on appropriate drug regimes, weight/dosage tables, contradictions and country specific drug recommendations. To ensure accuracy, babies and young children need to be weighed in the surgery, by the practice nurse or prescriber.
Symptoms

Anyone who has been to a malaria risk region (and for up to a year after returning home) who becomes ill, especially if they have a fever, flu symptoms or diarrhoea, must seek immediate medical attention. Parents must be informed that malaria in a baby or young child is a medical emergency that can rapidly kill.5,6
FOOD AND WATER HYGIENE

Babies and young children at risk of severe illness if they catch food and water-borne infections, so scrupulous care must be taken with food, water and hand hygiene. This is notoriously difficult with toddlers, and constant vigilance is required. Young children should not be given unpasteurised dairy products or undercooked food.2 3 Parents should also be advised to try to ensure that toddlers avoid salads, unpeeled fruit and any food that has been left uncovered. While hand washing provides the most effective hand hygiene, antiseptic hand wipes and gels can be considered when hand washing is not possible.

For babies, breastfeeding, if possible, is safest. However, dehydration can be an issue if the mother gets diarrhoea and vomiting. Boiled, not bottled mineral, water must be used for reconstituting baby milk, as mineral water can have a high salt content, which is dangerous for babies. Care should be taken with the sterilisation of baby bottles.

Rehydration is essential for diarrhoea and vomiting. Urgent medical advice must always be sought straight away for a baby or child who is dehydrated, has projectile vomiting, bloody stools, diarrhoea with a fever or who cannot keep any fluids down. Heat and humidity can accelerate dehydration.
JOURNEY RISKS

Travelling with young children, particularly long distances, can be stressful. Considering this before travel and formulating strategies to cope with journey pressures, helps parents manage stress more effectively.7 It is helpful to involve older children in this process, but obviously this is not possible with babies and very young children.
Flying

Healthy, full-term babies can fly 48 hours after birth, but it is sensible to wait until they are at least one week old. Premature babies need to be evaluated as fit to fly by a paediatrician.4

Charter flights are often cramped, with less legroom than scheduled flights, and they are more likely to be cancelled or delayed.
Travel sickness

Motion sickness can be a problem for children, especially between the ages of 3 and 12 years. Paediatric over-the-counter remedies are usually effective. Acupressure wristbands may help older children, although currently there is no scientific evidence to support their effectiveness.
Jet lag

Sleeping tablets and medicines to prevent jet lag are not recommended for babies and children. Again, as with adults, young children should be encouraged to try to adapt to local time when they arrive at their holiday destination.
SAFETY

Young children are at increased risk of injury and should always be carefully supervised, especially on balconies, near traffic and in and around water. Drowning is a leading cause of death in children globally.2, 8 Near-drowning is also a serious issue, as it can have lifelong effects and the recovery rate from may be lower among young children than in teenagers and adults.8 Appropriate safety devices, such as inflatable armbands and rubber rings can be used, but are not a substitute for careful supervision by a responsible adult.
SUN

Babies and young children are particularly vulnerable to sun damage, as their skin is much thinner than adult skin. Babies under 6 months should not be exposed to direct sunlight.

All children should be kept out of the sun when it's at its strongest - usually between 11am and 3pm, protected with a high factor UVA/UVB sun cream of at least SPF15+, clothes (there are now clothes available with in-built sun protection), hats, sunglasses for toddlers and sun shelters. Sun cream should be spread thickly on all exposed skin at least 30 minutes before going outside. It needs be reapplied at least two hourly - more frequently, if in contact with water. 'Single' application sun screen preparations are not recommended.
INSURANCE

Specific medical cover, including cover for repatriation costs, is needed for each individual baby and child.
CONCLUSION

Package holidays can be a safe and positive experience for the whole family and health professionals have an important role in preparing and advising families prior to travel.9 However, parents may underestimate the hazards associated with more exotic package holiday destinations and can be unaware of specific health risks. For example, they may not realise young children with malaria are likely to become more severely ill than adults and older children.

Without being alarmist, practice nurses need to provide realistic, consistent advice, encompassing nationally recognised recommendations. The ability to clarify information, often diplomatically, is also required. Undertaking a collaborative risk assessment is an integral part of enabling parents to make informed choices about their family's health.
KEY POINTS

* Parents should be advised not to take babies and young children to malarial regions as, if they catch malaria, their risk of dying is high.

* If parents decide to take young children to malarial areas, they must be advised about appropriate anti-malarial drugs, bite avoidance and the significance of malaria in young children.

* International travel should preferably be delayed until initial routine childhood vaccinations have been completed (usually by the age of four months).

* Babies and young children are more susceptible to serious consequences of diarrhoea. Good food and water hygiene is crucial and whenever possible, breast feeding is best for babies.

* Appropriate paediatric medical care can be limited or non-existent in some regions.

* Comprehensive medical insurance is essential, whatever the child's age.

* Safety issues and behavioural factors need to be highlighted.
CASE STUDY 1

Michelle, 23, and her husband Paul, 24, are taking their two-month-old daughter, Tia, to a coastal tourist resort in Turkey for a two-week package holiday. This is their first family holiday. They plan to go in three weeks' time. All the family are fit and well, with no medical problems. Michelle is breastfeeding Tia.
Action points

* The importance of Tia completing her initial baby vaccines and the possibility of postponing travel should be discussed.

* Recommend the appropriate travel vaccines for the parents, with reassurance about the safety of inactivated vaccines in breastfeeding.

* Explain that Tia is currently too young to have travel vaccines and stress the importance of food and water hygiene (advising Michelle to continue breastfeeding), insurance and prompt medical treatment for Tia if she becomes unwell.

* As Tia is under six months old, emphasise the importance of keeping her out of the sun.
CASE STUDY 2

Dan and Rachel, both 38, are taking their three-year-old son Jake on a two-week package holiday to Tanzania in a month's time. They will be staying in a coastal resort, but are also planning a three-day safari. They are all fit and well.
Action points

* Tanzania is a high-risk country for malaria: prescription anti-malarials are advised for all areas. Highlight the implications of taking such a young child to a malarial area. Suggest the possibility a similar holiday in a country without a malaria risk.

* If Jake's parents remain determined to travel, recommend the appropriate malaria tablets, using current national UK recommendations.

* Stress the importance of insect bite avoidance and seeking emergency medical treatment if Jake becomes unwell, especially with a fever or flu like symptoms, as malaria can rapidly be fatal in young children.

* Make sure that his parents understand that malaria symptoms can be delayed. So if Jake becomes unwell for up to a year after they return home, he will need emergency medical treatment and they must tell his doctor that he has been at risk of malaria.

* Check that Jake is up to date for all his routine childhood vaccinations, including MMR.

* Recommend the appropriate travel vaccines for all the family, advising Tanzania is now considered low risk for yellow fever and vaccination is not usually recommended. Explain that yellow fever vaccination certificate requirements are only for arrival from an endemic country.

* Emphasise the importance of sun protection, food and water hygiene and insurance.
USEFUL RESOURCES

British National Formulary for Children. http://bnfc.org/bnfc/index.htm

Cancer Research UK: Protecting children in the sun. http://www.cancerhelp.org.uk/aboutcancer/cancer-questions/protecting-children-in-the-sun

Health Protection Agency: Guidelines for malaria prevention in travellers from the United Kingdom. http://www.hpa.org.uk/infections/ topics_az/malaria/guidelines.htm

Health Protection Agency: Malaria cases up almost 30 per cent in two years as it's revealed most cases haven't taken antimalaria tablets. http://www.hpa.org.uk/NewsCentre/Nati onalPressReleases/2011 PressReleases/ 110425Malaria/

National Autistic Society: Holidays: preparation and practicalities. http://www.autism.org.uk/living-withautism/out-and-about/holidays-and-days-out/ holidays-preparation-andpracticalities.aspx

National Travel Health Network and Centre: Country Information. http://www.nathnac.org/ds/map_world. aspx

NHS Choices: for advice on diarrhoea and vomiting, motion sickness and travel with children. www.nhs.uk

Royal College of Nursing: RCN competencies: an integrated career and competency framework for nurses in travel health medicine. http://www.rcn.org.uk/__data/assets/ pdf_file/0006/78747/003146.pdf

US Centers for Disease Control and Prevention. A cautionary tale: a family's ordeal with malaria. http://www.cdc.gov/malaria/stories/ malaria_traveling_family.html

Motion sickness is a common problem and can make air travel a misery

Long-distance travel with young children can be stressful
REFERENCES

1. Stauffer W, Christenson J C, Fischer PR. Preparing children for international travel. Travel Med Infect Dis. 2008;6:101-113.

2. Weinberg N, Weinberg M, Maloney S. Chapter 7Travelling Safely with Infants and Children. In Brunette GW, Kozarsky PE, Magill AJ et al, (eds) CDC Health Information for International Travel. 2010. Atlanta. 428 -436. Available at: http://wwwnc.cdc.gov/ travel/ yellowbook/2010/chapter-7/traveling-with-infants-andchildren.aspx

3. World Health Organization. Chapter 6: Vaccine preventable diseases and vaccines. In International Travel and Health 2010, Geneva. 132 Available at: http://www. who.int/ith/chapters/en/index.html

4. Field VF, Ford L. Hill DR, (eds). Special Risks Children. Health Information for Overseas Travel. National Travel Health Network and Centre, London, UK, 2010. 73 -86.

5. Chiodini P, Hill D, Lalloo D et al. Guidelines for malaria prevention in travellers from the United Kingdom. HPA/ ACMP; January 2007, London. Available at: http://www.hpa.org.uk/publications/2006/Malaria/ Chap_6.pdf

6. World Health Organization. Chapter 7: Malaria in International Travel and Health 2011, WHO; May 2011, Geneva.144 - 167. Available at: http://www.who.int/ith/chapters/en/index.html

7. Dawood R,ed. Chapter 11. Travellers at higher risk. In Travellers' Health. Oxford University Press, Oxford, 2002. 484-489.World Health.

8. World Health Organization. Chapter 2: Drowning and injury prevention in Water Sanitation and Health. Guidelines for safe recreational waters. Volume 2. WHO; 2006, Geneva. 12-13. Available at: http://www.who.int/water_sanitation_health/bathing/ bathing2/en/

9. Stauffer WM, Konop RJ, Kamat D. Travelling with Infants and Young Children. Part 1: Anticipatory Guidance: Travel Preparation and Preventive Health Advice. J Travel Med. 2001;8:254 - 259.

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By Mary Gawthrop, RGN, BSc (Hons), Post Graduate Diploma in Travel Medicine, MA, MFTM (RCPSG) Specialist Travel Nurse, National Travel Health Network and Centre, London and Liverpool.

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