With many of us heading off on holiday over the coming months – we’re sure already you have a million things to think about; but when travelling with children, it’s especially important to be prepared for common health issues that may arise. By being well-informed and taking precautions, parents can navigate these challenges and make their travel experience more enjoyable for their children.
Dr Prevatt is an NHS Paediatric Consultant with a special interest in Tropical Diseases and Travel Medicine. She is certified in Paediatric Infectious Diseases, Tropical Medicine, and Travel Medicine. She trained in London and took time out of her childrens’ Infectious Disease training at Great Ormond Street Hospital to train in Travel Medicine at the Hospital for Tropical Diseases (HTD) and complete a fellowship concentrating on the specific needs of travelling pregnant women and children. She has also worked heavily as a paediatrician in Lesotho, Uganda, Kenya, Tanzania, and the Pacific Islands.
Here, she shares her tips on how to have a safe, happy and healthy trip abroad. Read on to find out more…
Travel sickness
Travel sickness is common between 3-12 years of age, especially in girls. Over-the-counter medicines like Joy rides®/ Kwells® have fast anti-sickness effects but they take effect via the brain and cause significant drowsiness. They’re useful when nausea has already begun but if the travel sickness is predictable or you’re making multiple trips it seems unfair to use them repeatedly. In that case, it is better to use an antihistamine such as chlorphenamine (Piriton®). These slightly sedating antihistamines are effective for travel sickness if taken before symptoms begin and they can be given the night before a journey. Test whatever medicine you choose before you fly!
In-flight Ear pain
Children have small eustachian tubes connecting their ears and mouth, so it’s hard for them to equalise the pressure behind their eardrums when the plane goes up or down. We all know sucking and swallowing facilitate equalisation of pressure for us, but for some children it’s not enough, and drinking on ascent or using a device like an otovent balloon or equalizing ear plug is a game changer. For babies; encourage breast or bottle-feeding during ascent and descent, when the pressurisation occurs. It’s a myth that children aren’t allowed to fly with ear infections, but the discomfort is much more and the risk of perforating an eardrum is likely to be higher, though it’s never been proven.
Sunburn
Sun exposure is highest between 10am-4pm when the sun’s directly overhead, and children shouldn’t be in this high sun because sunburn before the age of 15 is strongly associated with melanoma and other skin cancers. Sunscreen should be used on those over 6 months of age and it must always be above SPF30. It should be lavishly and frequently applied. Alternatively, Long-sleeved swimwear and sun-pods can be purchased for times of exposure. Insect repellent reduces the efficacy of sunscreen by about 1/3 and therefore even more regular reapplication will be necessary if both are used. Babies under 6 months should be kept in the shade and clothed such that a minimum amount of sunscreen is needed for the face and feet. Tip: Insect repellent should always be over, not under sunscreen!
Little bites
Biting insects cause skin irritation and vector-borne diseases. Don’t avoid proper repellents. Use of insect repellants, such as DEET (<35%) is safe in children > 2 months. Make sure you allow 20 minutes after applying sunscreen before applying any repellent. Long clothes can further reduce the risk of bites and stings too. Permethrin-treated clothing is safe for children, and children can also sleep under permethrin-treated bed-nets. You can buy baby mosquito nets on the childrenstraveldoc website (www.childrenstraveldoc.com), I bulk buy so everything I sell is always at a lower cost than on the high street.
Big bites
Children are more likely to come into contact with snakes and scorpions- sometimes on purpose! Both bites are more severe in children as they’re smaller so they get more venom per Meter Square. Anti-venom supply is often not available at local hospitals, and it’s so important to get medical insurance! If you don’t have medical insurance, you might have to fund your own evacuation to another country and that bill can run to hundreds of thousands.
A feverish illness overseas
Children under 5 get unwell on average at least every 2 months, so the chances of being feverish abroad are very high! Then you add in the fact that kids raised in the UK are immunologically naïve to many of the viruses they will encounter abroad.. it’s a fever in a hotel waiting to happen. Help decrease exposure by frequent hand washing. Stock up on paracetamol and ibuprofen, and have a low threshold of suspicion for malaria in endemic areas. You can buy an age-appropriate medical kit for a child on the childrenstraveldoc website.
Travellers’ diarrhoea and vomiting
Travellers’ diarrhoea (TD) is the most common problem in all travellers (!) but in children it’s more likely to lead to dehydration because they get dehydrated faster than adults. Always use clean bottled or sterilized water for teeth brushing, drinking and washing fruit. Know the signs of dehydration. Children may get lethargic and try to sleep when they should be rehydrating. Take a supply of oral rehydration sachets with you overseas -or learn how to make it simply from sugar salt and water! Know the difference between normal TD and a case of typhoid fever, which is more dangerous (typhoid causes intermittent constipation and diarrhoea with fever). If your child has a fever with their diarrhoea or blood in their poo seek medical attention. Some children warrant a standby course of antibiotics in case they catch TD, and for some, I will even prescribe preventative treatment- those with weak immune systems or who need stable absorption of any oral medications for example.
Water safety
Drowning is the second leading cause of death in child travellers, after road traffic accidents. There are also a lot of children not counted in the numbers, who ‘almost drowned’ and sustained life-changing neurological damage. At all destinations, children <5years have the highest rates and they most commonly drown in swimming pools (about 75%) rather than open water, which surprises people – it’s probably because parents watch more closely when their child is in the sea than the hotel pool. A huge proportion of the parents whose child drowned were under the influence of alcohol and there is a link with even small amounts of alcohol being consumed. Sadly >90% parents surveyed after a drowning said they were not aware it was happening at the time. So I advise to always watch children in pools- and have a dedicated person who is not drinking but is in the pool with the children within arms reach.
Tip: Also be careful if children are using hot tubs and saunas – there have been lots of drownings where the vent isn’t properly covered and hair gets caught and pulls them under.
Car safety
This is the most common cause of death in children on holiday and they are often in hire cars on unfamiliar roads. Parents get lax about following seatbelt safety in countries where it’s not illegal to travel without a seatbelt. However it is actually illegal not to use a seatbelt or car seat overseas if you use one at home, so you could be tried in the UK for manslaughter if you chose to let your child travel unsafely. Follow the rules of your home country. For us they are:
- Children under 15months: rear-facing car seat
- Children 15 months to 12 years: forward-facing car seats until they are at least 135cm tall
- * note children over 3 can travel without car seats in emergency or unexpected journeys, for example by taxi (but I wouldn’t recommend it)
- Children over 12: use seatbelts
Tip: Adolescents walking near roads and across roads whilst on their phones is now a big part of the RTA burden! Make sure your kids have their phones away when crossing the road.
Malaria
Children suffer very severe malaria that can quickly result in death. Parents need to know the signs of malaria to look for.
As we discussed earlier, children should be dressed in long clothing and use insect repellents such as DEET (on exposed areas, but not beneath the clothes). DEET is very safe for children over 2 months but small children should not apply DEET themselves, or have it applied to their hands, as it is theoretically a neurotoxin and they might put their hands to their mouths afterwards. Infants under two months should be placed in an infant carrier draped with a mosquito net that has elastic edges for a tight fit. As well as these bite avoidance measures, children will also need malaria prophylaxis. There should never ever be a situation where parents are taking antimalarials and the baby isn’t because the GP or travel nurse is worried about giving the baby medication!
Different Antimalarials can be used for children of different ages. They all have a bitter taste and will need to be given with chocolate, jam, or condensed milk! Trial this in advance, don’t let them taste it without. Some antimalarials need to start weeks before travel in order to work at the start of a trip, so that means you need to book a consultation (www.
We still know children will take them <90% of the time… and even if they take every dose, the efficacy it is not 100%.. so be aware that fever could be malaria up to a year after return from abroad! Always report it to a doctor if you’ve visited a malaria-endemic area in the preceding year.
Rabies
Rabies is a fatal virus that kills tens of thousands a year and 40% of them are children. Unfortunately on account of their height they are more likely to be bitten on the head or neck, which causes death faster. All continents aside from Antarctica report rabies. The most cases each year are from Thailand and Indonesia.
The Rabies virus is carried by cats, bats, monkeys, you name it, but by far the commonest culprits are domesticated dogs- they cause 99% of the deaths. Rabies is caught by contact with the animals’ saliva (either a scratch, lick or bite). Many people know to watch out for dogs with what’s called ‘furious rabies’ – where they are hyper-excitable, aggressive and hallucinating, they look scary and kids keep away – but there is another version of rabies called paralytic rabies where the animal is very tired and slow as its muscles gradually become paralysed. Children may try to pet these dogs. That should always be a ‘no’! Unfortunately, it’s not always from purposeful touching- kids can also accidentally antagonise animals by running or cycling and so it’s really best to be vaccinated pre-travel. Then if they get bitten they will just need top-up vaccines… If they have not been vaccinated and they get licked, scratched or bitten you will need to find both the vaccine and a dose of immunoglobulin (antibodies from donor blood, hard to find in many countries) within 24hrs. Since rabies is fatal it would be a truly terrifying 24hours. Numerous families have spent their life savings getting evacuated to a place with immunoglobulin available in-time because they didn’t get vaccinated.
If scratched licked or bitten, immediately wash the wound extensively with soap and water for along time (atleast 15 mins) while seeking prompt medical evaluation. The doctor will decide how many layers of skin have been affected and the risk level. Remember if vaccinated you will still need to get more doses of vaccine within 24 hours.
Vaccine preventable illnesses
Some vaccines are not that useful, but they may be nice to have depending on your stance. For example, I wouldn’t want my child to experience Hepatitis A on holiday but she is under 2 and the risk of being severely unwell for a small child is quite low.
Some vaccines however are so, so, important that it’s essential you don’t travel without them. Which vaccines depend on where you travel, and you would need to research this or consult a travel doctor for advice. I will say that if your child hasn’t had their routine immunisations at the GP they’re much more likely to catch measles or flue overseas or in the airport than anything else – the risks of these diseases that we have herd protection from in the UK are much higher overseas, particularly in low resource settings.
Non-vaccine preventable illnesses
You need to check which diseases spread by biting insects are around at your holiday destination – for example diseases like leishmaniasis, Dengue, Chagas and Zika. For travel to areas with these critters, you just need to pay serious attention to repellent measures.
Other safety
Sadly child abduction during travel is not as rare as you would like to think, it’s a real concern and something you need to ward against. If you lose a child in a busy place, make a lot of fuss and noise about it so that people start looking immediately. You should also make a developmentally appropriate plan with your child in advance for if they get lost- for example a toddler can stay where they are and scream for you or use a whistle or bell, an older child can approach someone in uniform and show your phone number on an armband or other identifier. I use different identifiers in my packs depending on age. Remember they will be in an environment that’s harder to negotiate if they don’t speak the language, and don’t recognise official uniforms for example. Plan in advance, make it into a fun pre-travel game!
Always carry an up to date paper photograph of your child. If your child goes missing report it to the local police immediately, the UK police will not usually get involved but you should still inform them and ask them to liaise with the police wherever you are via Interpol.
The British embassy will be open 24/7 and you should also contact them- they can put you in touch with missing persons charities locally and they’ll help arrange meetings with the local authorities and media. It is important to get media coverage as quickly as possible on local TV and radio. Some countries have an AMBER alert system allowing them to interrupt regular programming or broadcast on digital billboards and traffic signs to seek the assistance of the public. This vastly reduces the chance of a child being taken out of that area. This system exists in several European countries as well as the USA. It goes without saying- find out where the British Embassy is and how to contact them before you fly. I usually find this info for parents but it’s easy to find.
By being well-prepared, and proactive in addressing these concerns, parents can enhance the safety and enjoyment of their family’s travel experiences. So, as you embark on your next adventure, remember to prioritise your children’s health needs!
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