Traveling Safely with Infants and Children

Malaria

Malaria is one of the most serious, life-threatening diseases affecting pediatric international travelers. In the United States, 4,110 cases of malaria in US civilians were reported to CDC from 2000 through 2004. Of these cases, 572 (14%) occurred in children <18>

Children with malaria can rapidly develop a high level of parasitemia. They are at increased risk for severe complications of malaria, including shock, seizures, coma, and death. Initial symptoms of malaria in children may mimic many other common causes of pediatric febrile illness and therefore may result in delayed diagnosis and treatment. Clinicians should counsel adults traveling in malarious areas with children to be aware of the signs and symptoms of malaria and to seek prompt medical attention if they develop.

Detailed information about malaria risk and chemoprophylaxis, as well as precautions for avoiding mosquito bites, is presented in Chapter 4. Medications used for infants and young children are the same as those recommended for adults except that doxycycline should not be given to children younger than 8 years of age. Atovaquone/proguanil (Malarone) should not be used for prophylaxis in children weighing less than 5 kg (11 lbs) because of lack of data on safety and efficacy. Pediatric doses for malaria chemoprophylaxis are provided in Tables 4-10 and 4-11. Pediatric doses of medications used for self-treatment are included in Table 4-12.

Because overdose of antimalarial drugs can be fatal, medication should be stored in childproof containers and kept out of the reach of infants and children. Mefloquine and chloroquine phosphate are manufactured in the United States in tablet form. Atovaquone/proguanil is available in pediatric tablet form. Pediatric doses should be calculated carefully according to body weight. Before departure, pharmacists can be asked to pulverize tablets and prepare gelatin capsules with calculated pediatric doses. Chloroquine, mefloquine, and atovaquone/proguanil have a bitter taste. Mixing the powder in a small amount of food or drink can facilitate the administration of antimalarial drugs to infants and children. Additionally, any compounding pharmacy can alter the flavoring of malaria medication tablets so that they are more willingly ingested by children. A list of compounding pharmacies is available at http://www.iacprx.org/referral_service/index.html. Physicians should calculate the dose and volume to be administered based on body weight because the concentration of chloroquine base varies in different suspensions.

Insect and Other Arthropod Protection

Personal protection against mosquitoes, ticks, and biting flies is an important part of prevention against malaria, yellow fever, and other diseases for which no other prophylaxis is available, such as dengue fever (5,6). While outdoors, children should wear as much protective clothing (long sleeves and long pants) as they can tolerate. They should sleep in rooms with air conditioning or screened windows or under bed nets. Mosquito netting should be used over infant carriers. Clothing and mosquito nets can be treated with permethrin, a repellent and insecticide derived from chrysanthemum flowers that repels and kills ticks, mosquitoes and other arthropods. Permethrin remains effective through multiple washings. Clothing and bednets should be retreated according to product label. Permethrin should not be applied to the skin.

CDC recommends the use of repellents, with active ingredients registered with the United States Environmental Protection Agency (EPA), according to the product labels. In scientific studies, two registered products, DEET (N,N-dimethyl-m-toluamide) and picaridin, have been demonstrated to have a higher degree of efficacy than products containing other repellents. In recent studies, repellent products containing oil of lemon eucalyptus were tested against mosquitoes in the United States and were found to provide protection similar to low concentrations of DEET. Other products have been evaluated for repellent activity. However, they have not been as well studied as DEET and may not be safe for use in children. Most botanical products provide relatively limited or no protection.

There had been some concern about potential toxicity of DEET and controversy regarding the recommended concentration of DEET for pediatric use. In 1998, the EPA conducted an extensive review of DEET safety. The agency concluded that there is no evidence that DEET is toxic to infants and/or children. Additional evaluations have not demonstrated a link between seizures and topical use (7). The EPA has concluded that concentrations up to 30% can be used on children. DEET should not be used on infants younger than 2 months of age because of concern about increased skin permeability. The American Academy of Pediatrics supports this recommendation (8).

The concentration of DEET affects the duration of protection. Higher concentrations provide longer protection; however, the duration of protection reaches a plateau at approximately 30%-50%. In a laboratory study, a product with 23.8% DEET provided an average of 5 hours of protection (range 3-6 hours), and a product with 6.65% DEET provided an average of 2 hours of protection (range 1.5-2.8 hours). Duration of protection may be affected by the environmental temperature, sweating, and wind conditions (9).

The EPA recommends the following precautions when using insect repellents:

• Apply repellents only to exposed skin and/or clothing.
• Never use repellents over cuts, wounds or irritated skin.
• Do not allow young children to handle the product.
• When using repellent on a child, an adult should apply it to his or her own hands and then rub them on the child. Avoid the child’s eyes and mouth and apply sparingly around the ears.
• Do not apply repellent to children’s hands. (Children tend to put their hands in their mouths.)
• Use just enough repellent to cover exposed skin and/or clothing. Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, then apply a bit more.
• After returning indoors, wash treated skin with soap and water or bathe. This is particularly important when repellents are used repeatedly in a day or on consecutive days.

Products that contain repellents and sunscreen are generally not recommended because of the need to reapply sunscreen more frequently than repellent. Mosquito coils should be used with extreme caution in the presence of children to avoid burns and inadvertent ingestion (10).

Infection and Infestation from Soil Contact

Children are more likely than adults to have contact with soil or sand and therefore may be exposed to infectious stages of parasites present in soil, including ascariasis, hookworm, cutaneous larva migrans, trichuriasis, and strongyloidiasis. 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. Clothing or diapers dried in the open air should be ironed before use to prevent infestation with fly larvae (myiasis).

Animal Bites and Rabies

Worldwide, rabies is more common in children than adults. In addition to the potential for increased contact with animals, children are also more likely to be bitten on the head or neck, leading to more severe injuries. They are also less likely to report a bite. Children and their families should be counseled to avoid all stray or unfamiliar animals and to inform adults of any contact or bites. Animal exposure abroad is not limited to rural areas, since stray dogs are common in many urban areas. Children may approach or be unable to avoid animals. Mammal-associated injuries should be washed thoroughly with water and soap (and povidone iodine if available), and the child should be evaluated promptly for the need for rabies postexposure prophylaxis and other measures (see Chapter 4).