Pediatric Annals

Special Issue Article 

Pediatric Travelers and Immigrant Children

John C. Christenson, MD; Hiba Chehab, MD

Abstract

Children comprise a special group of international travelers. Immigrant and refugee children, along with children traveling to visit friends and relatives abroad or on leisure trips, require special attention by clinicians to prevent and treat travel-related conditions. [Pediatr Ann. 2019;48(9):e360–e369.]

Abstract

Children comprise a special group of international travelers. Immigrant and refugee children, along with children traveling to visit friends and relatives abroad or on leisure trips, require special attention by clinicians to prevent and treat travel-related conditions. [Pediatr Ann. 2019;48(9):e360–e369.]

The migration of populations between countries is not a new event. In 2017, 258 million people worldwide lived outside their country of birth; 30 million were children.1 In times of war, famine, economic hardships, and political turmoil, the displacement of people of all ages occurs, and it mostly affects the poor, the persecuted, and the disadvantaged. About one-half of the world's refugees (10 million) (ie, people who are forcibly displaced from their countries) are children.2 Many refugees cross into countries illegally and are detained in refugee centers, whereas others may be expatriated to countries with different customs, climates, and health problems. Immigrants comprise about 13.7% of the United States population.3 Language barriers may challenge their assimilation to a new geographic area. Other barriers include lack of knowledge of screening and preventive medical practices and how to navigate the health system. Clinicians must become familiar with potential health problems of refugees and immigrants so they can provide the most appropriate care. In addition, many immigrants travel back to their countries of origin to visit family and friends. It is estimated that about 2.8 million children living in the US travel internationally each year.4 Clinicians must learn how to protect pediatric travelers by performing risk assessments according to country and regions to be traveled, administer needed vaccines, and prescribe prophylactic medications when indicated. This article will help the clinician become familiarized with knowledge needed for providing care to immigrant children and preparing them for international travel.

Health Problems of Immigrant Children

Most immigrant and refugee children are healthy, but some suffer from serious medical conditions. Because many countries have limited resources, infants and children may not have had neonatal screening tests for hypothyroidism and other metabolic disorders, making it necessary for clinicians to screen for these on arrival. Malnutrition, iron deficiency anemia, micronutrient and vitamin deficiencies, and lead poisoning can be additional medical problems. Vitamin D deficiency was found in about 37% of Burmese refugees in Australia.5 At two US-based GeoSentinel clinics, dental caries, anemia, and hypertension were observed in 32%, 11%, and 5% of migrants, respectively.6

Immigrants and refugees may pose a challenge to clinicians because many of the medical conditions, especially infectious diseases in their country of origin, may be unfamiliar to them. Countries with limited resources have a higher burden of tuberculosis, gastrointestinal pathogens, and skin conditions. In a retrospective observational study from a tropical medicine unit in Spain, 45% of adult immigrants were found to have a medical condition at the time of evaluation.7 The most frequent diagnoses were Chagas disease (in immigrants coming from Latin America), latent tuberculosis, anemia, intestinal parasitosis, hepatitis B, and HIV.7 Similar results were observed in data collected at two US-based GeoSentinel clinics.6,8 In a study involving clinics in multiple countries, of the 20% of migrants hospitalized, active tuberculosis and febrile illnesses represented 24% and 21% of cases, respectively.8 Malaria was responsible for 83% of hospitalized febrile illnesses.8Helicobacter pylori infection was found in about 80% of Burmese refugees in Australia, tuberculosis infection in 70%, and chronic hepatitis B in about 14%.1 Stool parasites were found in about 24% of refugees.5 Studies have demonstrated that 5% to 20% of international adoptees have evidence of tuberculosis infection, and 30% are infected with H. pylori.9 Giardiasis is another common gastrointestinal infection observed in immigrants, refugees, and children who were adopted from developing nations.10 Among refugees from Sudan and Somalia, schistosomiasis was present in 44% and 73%, respectively, and strongyloidiasis was detected in 46% and 23% of refugees, respectively.11 Portal hypertension or transverse myelitis may be complications of chronic infections with Schistosoma mansoni, whereas gross hematuria may be the initial presentation of infection with Schistosoma haematobium.12

Children who resided in tropical countries, especially in sub-Saharan Africa, may have evidence of past infection with malaria parasites. Those infected with Plasmodium vivax and Plasmodium ovale may suffer relapses in later months and years. Clinicians must be familiar with the epidemiology of malaria when children present with febrile illnesses. Parasitemia with certain species of Plasmodium may be low grade (such as in the case of Plasmodium malariae), making the laboratory diagnosis at times difficult.

Medical Evaluation of the Immigrant Child

Clinical presentations vary according to the nutritional status of the child, as it influences his or her immune function. On arrival, the medical history of all pediatric immigrants and refugees should be reviewed with parents. Frequently, a professional language interpreter will be needed to complete such an interview. It is key to remember that multiple dialects may exist in a given country, so an interpreter for a specific dialect may be required. Medical records frequently need translation, especially immunization records. Online resources (such as https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/b/foreign-products-tables.pdf) contain foreign language terms for most vaccines and preventable diseases from around the world. Adoptive parents of children younger than age 10 years must agree to start vaccination within 30 days of arrival to the United States.13

Refugees and immigrants, especially those age 15 years and older, are screened for infectious diseases in their country of origin before travel. Testing for HIV, syphilis, and a chest radiograph to assess for active tuberculosis is frequently performed before migration.14 Children age 2 to 14 years arriving from regions with endemic tuberculosis require a tuberculin skin test or interferon-gamma release assay. A health assessment should be performed on all arrivals so medical conditions can be addressed early. Immigrant children will need a complete physical examination and screening tests for tuberculosis, a tuberculin skin test, or interferon-gamma release assay depending on the age. Children also need to be screened for hepatitis B surface antigen and antibody, hepatitis C antibody, lead level, and thyroid-stimulating hormone, and should also have a complete blood count and differential. Screening for HIV is indicated in children coming from endemic regions such as Africa. Screening for eosinophilia to detect parasitic pathogens may be useful in some children, but specific serologic testing is likely to be needed because many children who are infected will lack visible eosinophilia. In one study, only 35% of children infected with schistosomiasis and/or strongyloidiasis had eosinophilia.15 Testing stool for H. pylori antigen deserves consideration as well. Mental health assessment is another important part of health screening. Immigrant children must be assessed for posttraumatic stress disorder, depression, and adjustment behavior disorders, especially in cases of forced migration.16 Pediatricians should make sure children have access to education and provide guidance on resources for those with learning difficulties or special needs.

Pediatric Travelers

Immigrant families tend to travel internationally to visit their families during school breaks and holidays. These families may be at a higher risk of acquiring an infectious disease such as typhoid fever, diarrhea, and malaria. Travelers visiting friends and relatives (VFR) frequently travel to areas within a country with limited access to medical care, and they tend to stay in the country for extended periods of time. Many VFR travelers do not seek pretravel advice, vaccinations, and/or prophylactic medications to prevent malaria.17,18 Clinicians must be familiar with specific travel recommendations for travelers. Necessary vaccines, prophylaxis against malaria, and medicines for the self-treatment of traveler's diarrhea (TD) are reviewed in the following text. Similar recommendations pertain to the pediatric traveler going on a leisure or study-abroad trip to high-risk countries. Although at-risk children may not visit a travel clinic, they may be seen by their primary care health provider. Pediatricians, through setting expectations for parents and answering their questions, play an important role in providing a safer and more comfortable travel experience.

Traveler's Diarrhea

TD is associated with significant morbidity. Young children are the most vulnerable and frequently require medical attention.19,20 TD is one of the most frequently encountered illnesses among travelers. The incidence varies by destination, with the highest rates being in North and Tropical Africa, Western and South Asia, and Central America.21 VFR travelers are at risk because they are more likely to ingest contaminated local foods and beverages. Bacteria encountered most frequently in patients with TD are diarrheagenic strains of Escherichia coli, with the most common being enterotoxigenic E. coli (ETEC) and enteroaggregative E. coli (EAEC), followed by Campylobacter species, Shigella species, and Salmonella species.22 Viral pathogens include norovirus and rotavirus. Parasites like Giardia intestinalis are responsible for protracted diarrhea. Cryptosporidium species usually causes a self-limited diarrheal illness.

Adequate hydration should be provided to every child with TD. Commercial oral rehydration solutions with adequate amounts of glucose and electrolytes are to be administered frequently in small amounts, with a teaspoon if necessary. Appropriately made homemade solutions can also be used. Intravenous solutions are necessary in cases of severe dehydration when oral rehydration is not tolerated or not sufficient to correct the deficits. Use of undiluted fruit drinks, sodas, and sport drinks should be discouraged. They contain large amounts of glucose which is likely to worsen the diarrhea and contain too few electrolytes for appropriate rehydration and replacement of losses. Antibiotics are not routinely used in children with mild TD but are reserved for moderate to severe cases. Antibiotics play a role in reducing the severity and duration of TD, which in turn decreases the need for intravenous fluids and hospitalization. Azithromycin is the first-line antibiotic to use in children with TD. The dose is 10 mg/kg per dose. Fluoroquinolones are frequently prescribed for adults with TD except for those who travel to and from South and Southeast Asia, where resistance is common. A single dose of antibiotic is generally sufficient. If symptoms persist, a daily dose of antibiotic can be given for up to 3 days. Loperamide is not recommended for young children.

Insect Bite Prevention

The use of insect repellents is an effective measure to reduce insect bites and prevent insect-borne illnesses. Mosquitoes, ticks, and flies are responsible for spreading illnesses such as malaria, Zika, Chikungunya, dengue, yellow fever, and rickettsial diseases. N, N-diethyl-m-toluamide (DEET) and picaridin are the most effective repellents against mosquito bites. Products with concentration of 10% or less are effective for about 1 to 2 hours, whereas a concentration of about 30% may last for about 5 hours. Concentrations between 25% and 30% are frequently recommended for visits to tropical regions. Concentrations of DEET higher than 50% do not confer greater protection. DEET is also effective against ticks and some flies. Use of concentrations of 20% or higher on exposed skin is recommended to protect against tick bites. DEET is safe in children older than 2 months of age when properly applied.23

Picaridin at a concentration of at least 20% protects well against mosquitoes, but less so against ticks, fleas, chiggers, and flies, and is equivalent to DEET. It is odorless and causes less skin irritation than DEET. At 20% it protects for about 8 hours. The use of combination products containing an insect repellent and sunscreen is not recommended. Permethrin, a contact insecticide, can be applied on clothing, bed nets, and sleeping bags.

Malaria Chemoprophylaxis

Medications should be prescribed to children for malaria chemoprophylaxis when traveling to areas with malaria. Chemoprophylaxis is intended to prevent disease by killing the parasite after it leaves the liver; however, infections may still occur. Compliance with prophylaxis is vital. Factors such as weight, age, ability to swallow tablets, medication frequency, and availability influence the choice of medications. The choice of antimalarial chemoprophylaxis agent is first determined by the presence of resistance to chloroquine. In addition, frequency of dosing and potential for side effects are major determinants. Agents are not available in liquid form. Tablets need to be cut and crushed for young children. At times they need compounding by a pharmacy. Medications are known to cause gastrointestinal discomfort when taken on an empty stomach. Although most children tolerate these medications well, additional side effects, such as abnormal dreams, anxiety, insomnia, and depressed mood have been reported.24 These side effects may be disturbing to some parents and children receiving mefloquine. People with a history of depression, anxiety, seizures, and cardiac conduction problems should avoid use of mefloquine. Other agents such as atovaquone-proguanil may be preferred, even when they require daily administration. Table 1 summarizes medications used for malaria prophylaxis.

Frequently Used Antimalarial Prophylaxis Regimens

Table 1:

Frequently Used Antimalarial Prophylaxis Regimens

Immunizations

Vaccine-preventable illnesses are still prevalent in some countries; thus, it is important to ensure that children traveling to these areas are up to date on their routine immunizations. Children may benefit from an accelerated vaccine schedule depending on the risk at their destination. The most recent recommendations on routine immunizations and catch-up schedules are accessible on the American Academy of Pediatrics ( https://redbook.solutions.aap.org/SS/Immunization_Schedules.aspx) and the Centers for Disease Control and Prevention ( https://www.cdc.gov/vaccines/schedules/index.html) websites. Routine immunizations such as measles-mumps-rubella, hepatitis A, and meningococcus require special attention. Additional destination-specific immunizations may be needed.25 These include typhoid fever, rabies, yellow fever, and Japanese encephalitis virus vaccines. Table 2 summarizes most of the immunizations needed for travel.

Important Immunizations for TravelersImportant Immunizations for TravelersImportant Immunizations for Travelers

Table 2:

Important Immunizations for Travelers

Measles is still epidemic in many countries, including Europe. In the current immunization schedule, the MMR (measles, mumps, and rubella) vaccine is routinely administered at age 12 to 15 months and again at age 4 to 6 years. Traveling children who received their first MMR vaccine at age 12 to 15 months should receive a second MMR vaccine at least 28 days apart from the first vaccine to ensure vaccine effectiveness, as 7% of children might not respond after one dose.26 The second vaccine will complete their MMR series and they will not need additional doses at age 4 to 6 years. Infants age 6 to 11 months should receive the MMR vaccine if traveling outside the US. This early dose does not replace the subsequent routinely scheduled doses of MMR vaccine.

Hepatitis A is a viral illness that is highly prevalent in lower-resource countries. Hepatitis A vaccine is routinely given in the US at age 1 year with a second dose 6 months later. Children are known to easily transmit the virus to older people, in whom the disease could be more serious. Traveling infants age 6 months or older should be vaccinated with hepatitis A vaccine. Immune globulin injections would interfere with MMR vaccination. Some experts do not believe immune globulin injections are warranted in young infants because hepatitis A is a relatively mild and usually asymptomatic infection in younger children. However, immune globulin injections can be used as protection.27

Meningococcal quadrivalent conjugate vaccine (MenACWY) is routinely administered in the US at age 11 or 12 years with a booster dose 5 years later. Children traveling to areas of high risk such as sub-Saharan Africa during the dry season (December to June) should receive the vaccine at an earlier age. The meningococcal vaccine is required for entry to Saudi Arabia for religious visits like the Hajj or Umrah.28 MenACWY-D and MenACWY-CRM are conjugate meningococcal vaccines that can be administered to children as young as age 9 months and age 2 months, respectively. The MenB vaccine is not recommended for travel to sub-Saharan Africa Africa, as meningococcal B disease is not prevalent in this region.

Typhoid vaccine is recommended for children traveling to areas with increased risk of exposure to Salmonella enterica serotype typhi. Available vaccines are not 100% protective and travelers must be advised to follow proper hygiene and food and water precautions even when vaccinated.29

Rabies virus, which causes a rapidly progressive fatal encephalomyelitis, is prevalent in many areas worldwide. It is important to educate travelers on the importance of pre-exposure vaccination, avoidance of animal bites, and post-exposure management of wounds and prophylaxis. Children have higher risk for rabies exposure because they tend to be more attracted to animals, and the bites might involve higher risk areas like the face and head. Availability of rabies immune globulin and vaccines is limited or nonexistent in many countries, making pre-exposure vaccination more desirable when considering travel to high-risk regions.30

Yellow fever vaccine is a live attenuated vaccine recommended for all children age 9 months or older traveling to endemic regions.31 A proof of vaccination is required for entry to some countries. It is sometimes advised to postpone travel if possible if a child is younger than age 9 months. Yellow fever vaccine is contraindicated in children younger than age 6 months because it has higher risk of neurologic complications such as vaccine-associated encephalitis. The vaccine should be considered, with precautions, in children age 6 to 8 months who are traveling to areas with yellow fever.

Japanese encephalitis (JE) vaccine is recommended for all children older than age 2 months who are traveling to areas endemic for JE virus during the transmission season and staying for at least 1 month.32 It is also recommended for people staying less than 1 month if they have plans for high-risk activities or itineraries or travel occurring during rainy seasons. The vaccine is safe and immunogenic in young children.33–35

Illnesses After Travel

Diarrheal and skin infections are among the most common travel-related ailments affecting pediatric travelers. Children with febrile infections such as malaria and typhoid fever frequently become severely ill and require hospitalization.35–38 Most of these children did not receive proper antimalarial prophylaxis, appropriate vaccines, or did not follow proper health and safety precautions. Clinicians must be attentive to the development of fever, skin lesions, and exanthems in returned travelers. Incubation periods in relation to duration of travel and time of return from travel have to be considered when evaluating the pediatric traveler who is sick.16

Conclusions

Preparing families with children for travel will result in safer, healthier, and more comfortable trips for the whole family. General travel recommendations are summarized in Table 3 and Table 4 provide a list of some of the available resources for preparing travelers.

General Recommendations for Pediatric Travelers

Table 3:

General Recommendations for Pediatric Travelers

Resources for Commonly Asked Pediatric Travel Questions

Table 4:

Resources for Commonly Asked Pediatric Travel Questions

References

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Frequently Used Antimalarial Prophylaxis Regimens

Medication Pediatric Dose Adult Dose Comments
Chloroquine 8.3 mg/kg salt (5 mg/kg base) weekly, up to maximum adult dose of 500 mg salt 500 mg salt (300 mg base) tablet, once weekly Start at least 1 week before arrival in malaria region. Continue for 4 weeks after leaving malaria region. Take with food
Atovaquone/proguanil 62.5/25 mg pediatric tablet:   5–8 kg: 1/2 of tablet once daily   >8–10 kg: 3/4 of tablet once daily   >10–20 kg: 1 tablet once daily   >20–30 kg: 2 tablets once daily   >30–40 kg: 3 tablets once daily   >40 kg: 1 adult tablet once daily 250/100 mg adult tablet, once daily Start 1–2 days before arrival in malaria region. Continue for 7 days after leaving malaria region. Take with food
Mefloquine Dose given weekly   ≤9 kg: 5 mg/kg salt (4.6 mg/kg base)   10–19 kg: 1/4 of tablet   20–30 kg: 1/2 of tablet   31–45 kg: 3/4 of tablet   >45 kg: 1 tablet 250 mg salt (228 mg base) tablet, once weekly Start at least 2 weeks before arrival in malaria region. Continue for 4 weeks after leaving malaria region. Take with food
Doxycycline ≥8 years : 2.2 mg/kg daily Maximum dosage: 100 mg/day 100 mg tablet, once daily Start 1–2 days before arrival in malaria region. Continue for 4 weeks after leaving malaria region. Take with food and plenty of fluids. Use sunscreen while taking this medication
Primaquine Terminal prophylaxis (antirelapse therapy):   0.8 mg/kg of salt form (0.5 mg/kg of base) once daily for 14 days after departure from malarious area Short-term prophylaxis for regions with predominately Plasmodium vivax   Begin 1–2 days before travel to malarious areas. Continue for 7 days after leaving area Terminal prophylaxis (antirelapse therapy)   26.3 mg salt (15 mg base) tablets   Two tablets once daily for 14 days after departure from malarious area Short-term prophylaxis for regions with predominatelyPlasmodium vivax   Begin 1–2 days before travel to malarious areas. Continue for 7 days after leaving area Terminal prophylaxis used to reduce risk of relapses by Plasmodium vivax and Plasmodium ovale. Must confirm G6PD sufficiency prior to administration
Tafenoquine Not recommended 150 mg tablets ≥16 years: two tablets, single dose Terminal prophylaxis used to reduce risk of relapses by Plasmodium vivax and Plasmodium ovale. Must confirm G6PD sufficiency prior to administration

Important Immunizations for Travelers

Vaccine Formulation Route and Dose Schedule Indications Comment
Hepatitis A Havrix Pediatric (GlaxoSmithKline, Brentford, UK) Hepatitis A VAQTA Pediatric (Merck, Kenilworth, NJ) Injectable, 720 EU Injectable, 25 U IM, 0.5 mL Primary series: 2 doses, 6–18 months apart Booster: currently not recommended Routine vaccination: children ≥1 year through 18 years Travel-specific: infants ≥6 months should be vaccinated if visiting a country at high risk for hepatitis A. Two additional doses will still be required after first birthday Inactivated vaccine Lifelong protection likely
Hepatitis A Havrix Adult (GlaxoSmithKline) Hepatitis A VAQTA Adult (Merck) Injectable, 1440 EU Injectable, 50 U IM, 1 mL Primary series: 2 doses, 6–18 months apart Booster: currently not recommended Adults ≥19 years Inactivated vaccine Lifelong protection likely
Hepatitis A and B Twinrix (GlaxoSmithKline) Injectable IM, 1 mL Primary series: 3 doses at 0, 1, and 6 months Accelerated schedule: 0, 7, and 21 days; fourth dose 12 months later Booster not needed Adults ≥18 years Inactivated vaccine Lifelong protection likely Accelerated schedule is as effective asroutine schedule, but requires a 4th dose
Immune globulin, human Injectable IM Preexposure prophylaxis: Up to 1 month of travel: 0.1 mL/kg Up to 2 months of travel: 0.2 mL/kg 2 months of travel or longer: 0.2 mL/kg (repeat every 2 months) Maximum dose: No more than 5 mL at one site No maximum dosage for hepatitis A prophylaxis Hepatitis A vaccine is preferred as preexposure protection against hepatitis A virus Immune globulin may be indicated for infants <6 months
Japanese encephalitis virus Ixiaro (Intercell USA, Gaithersburg, MD) Injectable IM Age 2 months to <3 years: 0.25 mL Age ≥3 years: 0.5 mL Primary series: 2 doses at days 0 and 28 Accelerated schedule: 2 doses at days 0 and 7 Booster: 1 dose 1 year later if exposure to JEV expected Travel to high-risk areas Prolonged stays anticipated or shorter stays during rainy seasons Booster dosing in children is well-tolerated and is immunogenic26
MMR (measles, mumps, rubella) Injectable SC Primary series: Age 12 through 15 months Second dose is recommended at least 28 days after first dose Routine vaccination and for infant travelers ≥6 months Routine vaccination in US: 12–15 months of age with second dose at age 4–6 years Infant travelers ≥6 months should receive a single dose of MMR. Two additional doses will still be required after first birthday Older children <4 years should receive second dose of MMR before travel if 28 days after first dose
Meningococcal conjugate quadrivalent, ACWY-D: Menactra (Sanofi Pasteur, Lyon, France) Injectable IM, 0.5 mL Children age 9–23 months: 2 doses, 3 months apart People age 2–55 years: 1 dose Routine vaccination in US at ≥11–12 years with recommended booster 5 years later Required for entry to Saudi Arabia during the Hajj Recommended for travelers visiting sub-Saharan Africa during dry months This vaccine should not be used in infants <9 months as it may interfere with antibody production by pneumococcal conjugate vaccine
Meningococcal conjugate quadrivalent, ACWY-CRM: Menveo (GlaxoSmithKline) Injectable IM, 0.5 mL Children initiating vaccination at age 2 months: doses at 2, 4, 6, and 12 months Children starting vaccination at age 7–23 months: 2 doses, with second dose after age 2 years Routine vaccination in US at ≥11–12 years with recommended booster 5 years later Required for entry to Saudi Arabia during the Hajj Recommended for travelers visiting sub-Saharan Africa during dry months
Rabies Inactivated human diploid cell vaccine Imovax (Sanofi Pasteur/Novartis, Basel, Switzerland) Purified chicken embryo cell vaccine RabAvert (Sanofi Pasteur/Talecris, Barcelona, Spain) Injectable IM, 1 mL Preexposure series: 3 doses at days 0, 7, and 21 or 28 Booster: based on risk category and serological testing Postexposure: rabies immune globulin; day 0 (20 IU/kg) with vaccines at days 0, 3, 7, and 14 A 5th dose is recommended if host is immunocompromised Consider for young travelers planning prolonged stays, especially away from large urban centers with adequate medical care systems and airport Young toddlers are at an increased risk of rabies and are candidates for vaccination
Typhoid fever Polysaccharide Vi antigen inactivated Injectable IM; 0.5 mL Primary series: 1 dose Booster: every 2 years People ≥2 years -
Typhoid fever Ty21a live attenuated vaccine Oral 1 capsule per dose Primary series: 1 capsule every other day for 4 doses Boosters: every 5 years People ≥6 years If series sequence not completed, all 4 doses need to be epeated Contraindicated in immunocompromised hosts Cannot be taken with hot beverages Person must not be taking antibiotics Capsules must be swallowed whole; they cannot be opened, chewed, or crushed
Yellow fever Live attenuated vaccine Injectable SC, 0.5 mL Primary series: 1 dose   Dose must be given at least 10 days before arrival to risk area Booster: No longer required by WHO   US travelers: recommended every 10 years for travelers to high-risk areas ≥9 months Contraindicated in immunocompromised hosts Avoid in pregnancy and in breast-feeding mothers, unless high-risk travel cannot be avoided Contraindicated for infants <4 months Avoid in persons with thymus disorders Infants 6–8 months: consider vaccination with caution if travel cannot be avoided; consult travel medicine specialist Caution in persons ≥60 years (high riskfor vaccine-related infection) Requires official certificate of vaccination US-produced yellow fever vaccine is not available in US at this time Specific vaccination centers have beendesignated by CDC for the administration of a French vaccine Consult CDC yellow fever website for acenter near you

General Recommendations for Pediatric Travelers

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Safety and injury prevention: use car seats and seat belts. Sit in the back seats. Never leave children unattended. Childproof all rooms. Inspect sliding doors and balconies. Inspect under beds and chairs

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Pack a first aid kit. Keep all prescription medications in their original containers. Bring printed copies of pharmacy-provided information with generic names. Place all medications in carry-on hand luggage

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Bring photocopies or digital photos of passports, birth certificates, naturalization and/or permanent residency papers—this makes reentry into the United States easier if original documents are lost or stolen

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Be careful crossing streets: watch out for bikes, motorcycles, people, and vehicles in the left lane. Look both ways before crossing

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Ear discomfort: provide child with something to drink or eat during ascent and descent of airplane

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Avoid cutaneous larva migrans, other parasitic infections such as hookworms: do not walk barefoot on ground or dry sand. Use a towel when laying on sand or grass/turf

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Avoid swimming in freshwater in the tropics: this prevents schistosomiasis, intestinal parasitic infections, traveler's diarrhea, and hepatitis. Chlorinated pools are fine to swim in

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During long flights, get out of seat and walk: this helps prevent thrombosis

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Resources for Commonly Asked Pediatric Travel Questions

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CDC Travel Health (Yellow Book): <ext-link ext-link-type="uri" xlink:href="https://wwwnc.cdc.gov/travel/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://wwwnc.cdc.gov/travel/</ext-link>

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CDC Vaccines (vaccine information statements): <ext-link ext-link-type="uri" xlink:href="https://www.cdc.gov/vaccines/index/html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.cdc.gov/vaccines/index/html</ext-link>

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American Academy of Pediatrics. Red Book: 2018 Report of the Committee on Infectious Diseases

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US State Department. Travel advisories: <ext-link ext-link-type="uri" xlink:href="https//travel.state.gov/content/travel/html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https//travel.state.gov/content/travel/html</ext-link>

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Authors

John C. Christenson, MD, is a Professor of Clinical Pediatrics. Hiba Chehab, MD, is a Fellowship Trainee. Both authors are affiliated with the Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Riley Hospital for Children.

Disclosure: The authors have no relevant financial relationships to disclose.

Address correspondence to John C. Christenson, MD, Ryan White Center for Pediatric Infectious Diseases and Global Health, Riley Hospital for Children, 705 Riley Hospital Drive, RI-3032, Indianapolis, IN 46202; email: jcchrist@iu.edu.

10.3928/19382359-20190812-01

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