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Today’s topic: Travelling with Children Speaker: Dr. Heather MacDonnell child & youth Pediatric Telehealth Rounds Friday, September 13, 2013

Pediatric Telehealth child & youth Rounds

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Traveling with Childrenchild & youth
Pediatric Telehealth
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Travelling with Children
Co-Head International Adoption Clinic
Assistant Professor of Pediatrics, University of Ottawa
Telehealth Rounds September 13, 2013
To list common travel immunizations
and medications for children
To provide resources for travel
advice and immunizations
– Destination
– Activities and Exposures*
of variable immunity and different age-
based behaviour
Research destination-specific infectious diseases
Potential Travel Vaccinations
Hepatitis A – 2 IM doses, 6-12 mos apart, begin at 1 year old (may
give HepA Immunoglobulin before that)
Hepatitis B (if prior to provincial schedule)
Twinrix (Hep A+B) – Age > 1 yr, 3 doses (0, 1, 6 months)
Typhoid (highest risk Indian subcontinent) – IM capsular polysaccharide, 1 dose, age >2 yrs, lasts
for 2 yrs
– oral live attenuated, age > 6 yrs, 3-4 doses depending on preparation, lasts for 5 yrs
See NACI guidelines, AAP Red Book for dosing details
Potential Travel Vaccinations
Meningococcus (African belt)
Yellow Fever (South America, SS Africa)
– IM live attenuated, 1 dose, age > 9 mos, F/X
Japanese Encephalitis (South Asia)
– IM inactivated, 3 doses, given over 3-4 wks (0,1, 3-4 wks), age > 1yr
The Hajj: Oct 13-18, 2013, Saudi Arabia
PHAC and City of Ottawa Public Health Travel
Health Notices http://www.phac-aspc.gc.ca
people attend spiritual pilgrimage to Mecca”
increased risk: meningococcus, TB, influenza,
GI, “be aware of” Middle East Respiratory
Syndrome Coronavirus (MERS-CoV)
Yellow Fever (certain source countries)
CDC Yellow Book
Transmission : CDC Yellow Book
Malaria Prophylaxis
Chloroquine and Mefloquine (Larium) – Begin one week before travel and continue
through 4 wks after return to non-endemic country
– Safe for > 5 kg (11 lbs) or no lower wt limit
– Easier to crush, better tolerated
Doxycycline – daily, 2 days pre, 4 weeks post, age > 8 yrs
Atovaquone/Proguanil (Malarone) – 1-2 days pre, 1 wk post, expensive (although cost
likely similar to Mefloquine for 2-3 wk trips)
– Safe for > 5 kg, harder to crush tablets
See CDC website for per kilo dosing details
Prevention of Vector-Borne
– CPS recommendations for children
socks tucked into boots
Avoid prime biting times
CPS DEET recommendations
be used
10% DEET or less
encouraged same
10% DEET or less
encouraged same
Reapply after:
encouraged same
Generally not recommended < 6 months old
Multiple reapplications, esp with swimming
Do not use combination SPF/DEET
Wear sun hats, use stroller UV shades
Beware of dehydration
Do not stay out in direct sunlight for long periods during the hottest time of day (10am-2pm)
Food and Water Safety
“Boil it, peel it, cook it or avoid it”
– Raw or not hot foods (eg. fruits + veggies unless self-peeled + washed in bottle H20)
– Unpasteurized dairy products
Infant Feeding
If < 6 months: breastfeeding is best
All anti-malarial medications are excreted in breast milk, but in concentrations insufficient for infant prophylaxis
If already weaned: formula prepared from commercial powder + boiled water is safest
Case 1: India
Healthy 30 yr old parents + 2 daughters ages 11 mos, 2.5 yrs
“VFR’s” = “Visiting Friends and Relatives” in several states, staying in homes
Length of travel = 6 weeks
What diseases are they at risk of contracting?
How should they medically prepare?
Other vaccine preventable:
Non-vaccine preventable diseases
Water filter, iodine tablets
Level 2: Exercise high degree of caution
“There is no nationwide advisory in effect for India. However, you should exercise a high degree of caution due to a continuing threat of terrorist attacks throughout the country at all times.”
<Terrorist attacks have occurred throughout India in 2008, often taking the form of bomb blasts, remotely detonated, in crowded markets of major centres at peak shopping time in the early evening. Such attacks occurred in Jaipur in May 2008, in Bangalore and Ahmedabad in late July and in New Delhi in mid- September and again in late September. The most recent terrorist attacks in Mumbai in late November 2008, were different in nature, as the targets included a railway station, a restaurant and luxury hotels where foreign business people and tourists congregate, and the weapons used were machine guns and grenades. Canadian citizens were among the over 170 persons killed in the Mumbai attack>
Level 3: Avoid non-essential travel
“Foreign Affairs and International Trade Canada advises against non- essential travel to Manipur and the border areas of Arunachal Pradesh (border with Burma) due to the threat of insurgency.”
Level 4: Avoid all travel - OFFICIAL WARNING:
Foreign Affairs and International Trade Canada advises against all travel to the following regions:
a) Jammu and Kashmir
b) Border areas in Manipur (border with Burma) and Nagaland (border with Burma),
which are significantly affected by insurgency;
c) Areas in immediate vicinity of border with Pakistan: Gujarat, Rajasthan and
Punjab due to possibility of landmines and unexploded ammunition, as well as
unmarked border areas (within immediate vicinity of the Line of Control: military
control line between India and Pakistan).
Case 2: Dominican Republic
Grandmother travelling to Punta Cana, DR on March break x 2 weeks
Taking 2 healthy grandchildren: 9 and 12 yrs old
Staying at an all inclusive resort
What diseases are they at risk of contracting?
How should they medically prepare?
Punta Cana
– Typhoid
– Rabies
– Histoplasmosis
Air Canada medical incidents: 1.7-3.4 per 100,000
passengers (CMAJ 1991)
risk during flight
– Their child’s medical condition
– Any need for medication or supplies (needles, EpiPen)
– Medical action plan in case of emergencies (contact
numbers of medical personnel)
CPS Position Statement: Paed Child Health Vol 12 No 1 Jan 2007
Infectious Diseases
• Exposure time
– WHO feels same risk as bus or train
Intestinal and vector-borne Illness:
– Malaria (despite insecticide spraying)
Equals 15% O2 at sea level hypoxia
High risk patients:
– Known hypercapnia, hypoxemia
– Already requiring O2 on ground (eg. BPD)
– Need MD review pre-flight
CPS 2007
Other Recommendations
Holding an infant on a lap is improper restraint, may potentially contribute to injury, look into car seat protocol of airline
Children with AOM should wait 2 weeks before air travel; topical nasal decongestants may be used (oral not recommended)
Some children with cardiopulmonary disease or sickle cell disease may require O2 during flight
Jet lag affects children – try to keep to same nap, sleep routine
Pay attention to food allergies CPS 2007
Air Travel Tips
– “Travelling safely with infants and children, IA”
– “Yellow Book” 2012 = Health info for int’l travel
World Health Organization (WHO)
Public Health Agency of Canada (PHAC)
– Traveller’s Health www.phac-aspc.gc.ca/tmp-pmv/
AAP Red Book, 29th Ed. 2012 pp103-109
American Society of Tropical Medicine and Hygiene www.astmh.org
Travel Medicine: Helping Patients Prepare for Trips Abroad www.aafp.org/afp/980800ap/dick.html
Infectious Disease Clinics of North America Volume 19, Issue 1, Pages 1-280 (March 2005) Travel and Tropical Medicine
Canadian Paediatric Society www.cps.ca
www.caringforkids.ca (www.cps.ca)
Questions or Comments?
Webcasters: Type your question
Pediatric Telehealth Rounds
Join us next time: Pediatric Headaches: Migraines or Tumour? with Dr. Jane Roberts Friday, September 27th from 12-1 p.m.
Thank you!