Air Travel
Injuries and deaths can occur in children held on adult laps during turbulence and nonfatal crashes. The American Academy of Pediatrics recommends that children should be placed in a rear-facing Federal Aviation Authority (FAA)-approved child-safety seat until they are at least 1 year old and weigh at least 20 pounds. Children older than 1 year of age and 20-40 pounds in body weight should use a forward-facing FAA-approved child safety seat, while children weighing more than 40 pounds can be secured in the aircraft seat belt (11). Air travel is safe for healthy newborns and infants; however, children with chronic heart or lung problems or with upper or lower respiratory symptoms at the time of travel may be at risk for hypoxia during flight, and a physician should be consulted before travel.
Ear pain can be very troublesome for infants and children during descent. Equalization of pressure in the middle ear can be facilitated by swallowing or chewing; infants should nurse or suck on a bottle. Older children can try chewing gum. Antihistamines and decongestants have not been shown to have benefit. There is no evidence that air travel exacerbates the symptoms or complications associated with otitis media (12,13).
Travel to different time zones, “jet lag,” and schedule disruptions can disturb sleep patterns in infants and children, as well as adults. Attempts to adjust sleep schedules 2-3 days before departure may be helpful. After arrival, children should be encouraged to be active outside during daylight hours to promote adjustment. Sedative medications may cause oversedation or paradoxical agitation, and melatonin may have effects on sexual development in infants and children. In general, these medications should be avoided in infants and children. Diphenhydramine can be useful for some children but, similar to any medication for sedation, should be administered as a test dose before travel to determine the effect on the individual child.
MOTION SICKNESS
Motion sickness can present as ataxia, dizziness, and nausea in children. Other symptoms include pallor and cold sweats. For symptomatic treatment of children, dimenhydrinate, 1-1.5 mg/kg per dose, or diphenhydramine, 0.5-1 mg/kg per dose, up to 25 mg, can be given 1 hour before travel and every 6 hours during the trip. Because some children have paradoxical agitation with these medicines, a test dose should be given at home before departure. Scopalamine causes potentially dangerous adverse effects in children and should not be used; prochlorperazine and metoclopramide should be used with caution in children (see page 524).
Accidents
VEHICLE-RELATED
Vehicle-related accidents are the leading cause of death in children who travel. While traveling in automobiles and other vehicles, children weighing less than 40 pounds should be restrained in age-appropriate car seats or booster seats (as above). These seats often must be carried from home, since availability of well-maintained and approved seats may be limited abroad. In general, children are safest traveling in the rear seat; no one should ever travel in the bed of a pick-up truck. Families should be counseled that many developing countries have cars without rear seatbelts.
DROWNING AND WATER-RELATED ILLNESS AND INJURIES
Drowning is the second leading cause of death in young travelers; close supervision is essential. Appropriate water safety devices such as life vests may not be available abroad, and families should consider bringing these from home. A variety of diarrheal and parasitic illnesses can be transmitted by swallowing even small amounts of fecally contaminated water, and other infections, such as schistosomiasis, result from skin contact with contaminated water. Thus, while in schistosomiasis-endemic areas (see Map 4-11), children should not swim in fresh, unchlorinated water and should be carefully supervised while being washed in a bathtub. Protective footwear is important to avoid injury in many marine environments.
OTHER INJURIES
Conditions at hotels and other lodging may not be as safe as those in the United States and accommodations should be carefully inspected for exposed wiring, pest poisons, paint chips, or inadequate stairway or balcony railings (see Chapter 6).
Altitude
Children are as susceptible to altitude illness as adults, and young children who cannot talk can show very nonspecific symptoms, such as loss of appetite and irritability (14). Young children may present with unexplained fussiness and change in sleep and activity patterns; older children may complain of headache or shortness of breath. Acetazolamide (Diamox) is not approved for pediatric use for altitude illness, but it is generally safe in children when used for other indications. Allergic reactions to acetazolamide are extremely rare, but the drug is related to sulfonamides and should not be used by sulfa-allergic persons, unless a trial dose is taken in a safe environment before travel (see Chapter 6).
Sun Exposure
Sun exposure and particularly sunburn before age 15 are strongly associated with melanoma and other forms of skin cancer. Exposure to UV light is highest near the equator, at high altitudes, during midday (10 a.m. to 4 p.m.), and where light is reflected off water or snow. Sunscreens (or sun blocks), either physical (titanium or zinc oxides) or chemical, at least SPF 15 and providing protection from both UVA and UVB, should be applied as directed, especially after sweating and water exposure. If both sunscreen and insect repellent are applied separately or as a combined product, the efficacy of the sunscreen is diminished by one third, and covering attire should be worn or time in the sun decreased accordingly. Hats and sunglasses also reduce sun injury to skin and eyes. Babies younger than 6 months of age require extra protection from the sun because of their thinner and more sensitive skin; severe sunburn for this age group is considered a medical emergency. Babies should be kept in the shade and wear clothing that covers the entire body; a minimal amount of sunscreen can be applied to small exposed areas, including the infant’s face and hands. However, in general, sunscreens are generally recommended for use in children older than 6 months of age (see Chapter 6).
Other General Considerations
Changes in schedule, activities, and environment can be stressful for children. Including them in planning for the trip and bringing along familiar toys or other objects can decrease these stresses. For children with chronic illnesses, decisions regarding timing and itinerary should be made in consultation with a health-care provider(s).
As for any traveler, insurance coverage for illnesses and accidents while abroad should be verified before departure. Consideration should be given to purchasing special travel insurance for airlifting or air ambulance to an area with adequate medical care. In case family members become separated, each infant or child should carry identifying information and contact numbers in their own clothing or pockets. Because of concerns about illegal transport of children across international borders, if only one parent is traveling with the child he or she may need to carry relevant custody papers or a notarized permission letter from the other parent.
Pediatric Travel Health Kit
In addition to the kit recommended for all travelers (see Chapter 2), parents should carry safe water and snacks; waterless, alcohol-based hand sanitizer; child-safe hand wipes; ORS packets; oral syringes for the administration of medications and ORS; diaper rash ointment; and a water- and insect-proof ground sheet for play outside. In addition, many countries may not provide medications and child-care products of the same type and quality as are available at home. In selected circumstances, rectal preparations of medications, such as acetaminophen; topical antibacterial antibiotics, such as mupirocin; and lice and scabies topical treatments may be useful. As a precaution, travelers with children should consider bringing additional items they might need, such as baby formula and medications specific to the child.
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