NAVIGATING INTERNATIONAL TRAVELA PEDIATRICIANS ROUTEMAP

Navigating International Travel A Pediatricians Roadmap

Gayatri Bala Jaishankar MDAssistant ProfessorAssociate Program DirectorETSU Pediatrics

Good morning every one-I am a general pediatrician at ETSU peds and I would like to take you on a journey so you will be able to successfully navigate your way when you need to provide advice for your pediatric patients traveling internationally.So if I may have everyone fasten their seat belts and ensure your seats are in the upright position in preparation for take off and pay attention to the front of the cabin.here we go1

Disclosure Statement of Financial InterestI, GAYATRI BALA JAISHANKAR, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Traveling with children can be one of the most aggravating and frustrating of experiences , or on the other hand a wonderful part of parenthood.

What may be a potentially difficult journey can be transformed into a lifetime of fond memories with just a little forethought and planning.

Although traveling with children has existed since time immemorial, the field of pediatric travel medicine is just emerging and I think it behooves us as caregivers of children to become familiar with the basic ins and outs of travel medicine2Common QuestionsHow old does my baby have to be to fly ?How do I prevent an earache ?Can you sedate my child ?Can I travel to high altitudes with my child ?What can I do to prevent motion sickness ?What immunizations does my child need ?What prevention strategies do I need to use ?What medicines should I carry with me ?What do I do for Travelers Diarrhea ?3How old should my baby be to fly?Any healthy term infant may travel by commercial pressurized airplaneRisk Vs Benefit ratio analysis when it comes to:Premature infants Infants with chronic cardiac or pulmonary conditions

Udomittipong K,Stick SM,Verheggen M, et al.Pre-flight testing of preterm infants with neonatal lung disease: a retrospective review. Thorax 2006;61:343-7A nice study in 2006 in thorax addressed exactly this query-the conclusions-basically for a term baby with no significant cardiac or pulmonary conditions there really are no restrictions. However throw a preemie into the plane with possibly a history of RDS at birth and or a cardiac lesion and you have a totally different situation 4How do I prevent an earache?Differences in pressure are greatest during take off and landingUse any measures that would help keep the Eustachian tube patent such asNursingSucking a pacifierChewing gum

5Can you sedate my child?Sedation is not recommendedHowever most commonly used agent is Diphenhydramine or Benadryl at 1mg/kg q 6 hDoes not really put them to sleepShould definitely first be used at home (3% paradoxical reaction)If incorrectly dosed , may cause serious complicationsAdult sedatives like Diazepam are difficult to dose accurately

6 ACUTE MOUNTAIN SICKNESS

7Can my child travel to high altitudes?Acute mountain sickness(AMS)Likely to be as prevalent in children as in adultsFrequently under recognizedSigns of AMS in children could beUnexplained fussinessAlterations in appetiteAlterations in activity or sleep patterns

8Can my child travel to high altitudes?Life threatening high-altitude cerebral edemanot reported in kidsKids can have high-altitude pulmonary edema (HAPE)Mainstay of prevention-slow ascentAcetazolamide-not studied for prevention or treatment of AMS in children

Pollard AJ, Neirmeyer S, Barry P et al. Children at high altitude :an international consensus statement by an ad hoc committee of the international society for mountain Medicine, March 12 2001.

9Can my child travel to high altitudes?Ginkgo Balboa ?? Promising data?? 2004 Study- Randomized controlled trial of Gingko Biloba and Acetazolamide for prevention of acute mountain sicknessNo benefit when compared to placeboAcetazolamide Dose-2.5mg/kg/dose bid up to adult dose of 125mg bidStart one day before ascent and continue two days at high altitude

Gertsch JH, Basnyat B,Johnson EW,et al.RCT of Gingko Biloba and acetazolamidefor prevention of AMS : (PHAIT). Br Med J 2004;328:797-910Can I prevent motion sickness in my child?Non pharmacologic suggestionsNon traditional interventionsPreventive pharmacologic intervention-Antihistamines : Diphenhydramine and Dimenhydrinate drugs of choice < 12yrsScopolamine > 12yrs

11What vaccines does my child need?ROUTINE, REQUIRED OR RECOMMENDED ROUTINE- Accelerated Schedule?REQUIREDYellow Fever Quadrivalent MeningococcalRECOMMENDED Hepatitis A Typhoid Rabies Japanese Encephalitis

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What vaccines does my child need?The 1st travel plans may require an accelerated schedule

Start as early as 6 wks

Boosters 4 wks. apart

ROUTINE14TRAVEL RESOURCEShttp://wwwnc.cdc.gov/travel/

15Current prices of the international travel vaccines that are available at Washington County Health DepartmentHep A 33.70Hep B 41.70Twinrix Hep A/Hep B combo 53.70IPT (polio Booster 32.24Typhoid 50.70yellow fever 73.70Menactra ( meningitis Vaccine) 96.70These prices vary depending on manufactures cost.

16What vaccines does my child need?MMR- given at 12-15mo and 4-6 yrs3 to 5 % remain susceptible after the first doseThe 2nd dose is an attempt to seroconvert the non respondersChildren > 12 months give two doses at least 28 days apartInfants can receive a measles alone vaccine

17What vaccines does my child need?Hepatitis A at 1yr of ageTwo monovalent vaccines Havre (GSK ) and Vaqta ( Merck )Formal CDC recommendation is to give Immunoglobulin < 1yr of ageExpense, interferes with other live vaccines, limited duration and effectiveness, allergic reactions and hypothetical risk of Iatrogenic disease

18HEPATITIS APrevalent worldwideIn young children is usually asymptomaticContaminated water , ice, shellfish harvested from sewage infested water, raw fruits and veggies, or handling by an infected food handlerStools most infectious 14 to 21 days before disease is apparentChildren can shed hepatitis for up to 10weeksLong incubation period (2 to 4 wks) so can vaccinate up to travel

19What vaccines does my child need?

Aedes mosquito REQUIRED VACCINE - Yellow feverNever give to children< 6 months of age-risk of developing post vaccination encephalitis Between 6-9 months, risk of acquiring the disease must be greater than the risk of complicationsSafe > 9 months

20Yellow fever endemic zones

21Yellow fever endemic zones

22What vaccines does my child need?YELLOW FEVEROnly vaccine that requires documentation on an official certificate of vaccinationMust be given 10 DAYS before the date of entryOFFICIAL STAMP FROM AUTHORISED CLINICS(Meningococcal vaccine for Hajj travelers to Saudi Arabia)

23What vaccines does my child need?RECOMMENDED VACCINES-TYPHOID Recommended even for short term travel to Asia, Africa, Latin America, Indian subcontinentInjectable-Vi capsular > 2 yrsOral-Ty21a > 6 yearsFewer side effects longer protection Capsule every other day for 4 doses, needs a week to complete

24What vaccines does my child need?OTHER RECOMMENDED VACCINES Travel to Sub Saharan Africa may need Meningococcal vaccineRabies vaccine if access to post exposure immunoglobulin or vaccine not likelyJapanese encephalitis vaccine if extended stays in rural Asia JEMB ( Not available currently)

25What preventive strategies do I need to use?MALARIA PREVENTIONInsect avoidanceChemoprophylaxis

26What preventive strategies do I need to use?INSECT AVOIDANCE-covered clothing, avoid flowery clothes, avoid perfumes, remain in protected environments from dusk till dawn such as air conditioned areas , mosquito netting etc.

27What preventive strategies do I need to use?INSECT AVOIDANCE-Chemical agentsN,N-diethyl-meta-toluamide (DEET)Rare cases of toxic encephalopathy with dermal application25-50 % DEET will protect for up to 4 hrsShould not be applied on hands, mm, eyes

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Malaria Chemoprophylaxis!!!!!29MALARIA CHEMOPROPHYLAXIS CHLOROQUIN MEFLOQUINUse in destinations with CQ sensitive P.Falciparum q week300 mg base(500mg salt)Start 1 week before arrival and continue 4 wks after returnPulverize tablet and place in gelatin capsuleAlternative-Hydroxy Chloroquin sulfate

Use in destinations with CQ resistant P.falciparum8-10kg tab,>10-20 kg 1 tab,>20-30kg 2 tabs,>30-40 kg 3 tabs250/100mg adult dose 1 tab qdStart 1-2 days prior and continue for 7 days after

>8yrs : 2mg/kg daily100 mg adult dose qdStart at least 2 wks. prior and continue for 4 wks. after travelAlternative to Mefloquin in resistant areas

31MALARIA CHEMOPROPHYLAXISPRIMAQUIN0.6mg/kg base dailyAdult dose 2 tablets= 30mg dailyStart 1-2 days before arrival and continue for 7days after departureG6PD testing must be performed prior to taking the tablet; contraindicated in breast feeding unless testing is performed in infant alsoUsed for Terminal prophylaxis to prevent relapses of P.vivax or P.ovale

32MALARIA MEDICATIONS- SIDE EFFECTSNeuropsychiatric disturbances ( Mefloquin )Contraindicated in those with seizures , anxiety and depressionContraindicated in those with cardiac conduction abnormalitiesPotential side effects-nausea , upset stomach; less commonly strange dreams, insomnia, dizziness, anxiety, weakness, agitationChildren tolerate the meds better

Albright TA, Binnus HG, Katz BZ.Side effects of and compliance with malaria prophylaxis in children. J Travel Med 2002:9(6):289-29233 TRAVELERS DIARRHEADEFINITION??

In adults - > 3 watery stools per day +- blood/mucus

In children ??A recent change in the normal stool pattern withAn increase in frequency (at least 3 stools per day)A decrease in consistency (unformed state)

34TREATING TRAVELERS DIARRHEA IN CHILDRENWHY TREAT ?WHEN TREAT ?WHAT MEDICATIONS ?WILL IT MAKE MATTERS WORSE ? (HUS CONCERNS)35ETIOLOGY- TRAVELERS DIARRHEA Rotavirus is the leading cause of severe dehydrating diarrhea WHO estimates 1.5 billion episodes in