Gayatri Bala Jaishankar MD Assistant Professor Associate Program Director ETSU Pediatrics.

Gayatri Bala Jaishankar MD Assistant Professor Associate Program Director ETSU Pediatrics

Disclosure Statement of Financial Interest I, GAYATRI BALA JAISHANKAR, I, GAYATRI BALA JAISHANKAR, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Common Questions How old does my baby have to be to fly ? How do I prevent an earache ? Can you sedate my child ? Can I travel to high altitudes with my child ? What can I do to prevent motion sickness ? What immunizations does my child need ? What prevention strategies do I need to use ? What medicines should I carry with me ? What do I do for Travelers Diarrhea ?

How old should my baby be to fly? Any healthy term infant may travel by commercial pressurized airplane Risk Vs Benefit ratio analysis when it comes to: Premature infants Infants with chronic cardiac or pulmonary conditions Udomittipong K,Stick SM,Verheggen M, et al.Pre-flight testing of preterm infants with neonatal lung disease: a retrospective review. Thorax 2006;61:343-7

How do I prevent an earache? Differences in pressure are greatest during take off and landing Use any measures that would help keep the Eustachian tube patent such as Nursing Sucking a pacifier Chewing gum

Can you sedate my child? Sedation is not recommended However most commonly used agent is Diphenhydramine or Benadryl at 1mg/kg q 6 h Does not really put them to sleep Should definitely first be used at home (3% paradoxical reaction) If incorrectly dosed, may cause serious complications Adult sedatives like Diazepam are difficult to dose accurately

ACUTE MOUNTAIN SICKNESS

Can my child travel to high altitudes? Acute mountain sickness(AMS) Likely to be as prevalent in children as in adults Frequently under recognized Signs of AMS in children could be Unexplained fussiness Alterations in appetite Alterations in activity or sleep patterns

Can my child travel to high altitudes? Life threatening high-altitude cerebral edemanot reported in kids Kids can have high-altitude pulmonary edema (HAPE) Mainstay of prevention-slow ascent Acetazolamide-not studied for prevention or treatment of AMS in children Pollard AJ, Neirmeyer S, Barry P et al. Children at high altitude :an international consensus statement by an ad hoc committee of the international society for mountain Medicine, March 12 2001.

Can my child travel to high altitudes? Ginkgo Balboa ?? Promising data?? 2004 Study- Randomized controlled trial of Gingko Biloba and Acetazolamide for prevention of acute mountain sickness No benefit when compared to placebo Acetazolamide Dose- 2.5mg/kg/dose bid up to adult dose of 125mg bid Start one day before ascent and continue two days at high altitude Gertsch JH, Basnyat B,Johnson EW,et al.RCT of Gingko Biloba and acetazolamide for prevention of AMS : (PHAIT). Br Med J 2004;328:797-9

Can I prevent motion sickness in my child? Non pharmacologic suggestions Non traditional interventions Preventive pharmacologic intervention-Antihistamines : Diphenhydramine and Dimenhydrinate drugs of choice < 12yrs Scopolamine > 12yrs

What vaccines does my child need? ROUTINE, REQUIRED OR RECOMMENDED ROUTINE- Accelerated Schedule? REQUIRED Yellow Fever Quadrivalent Meningococcal RECOMMENDED Hepatitis A Typhoid Rabies Japanese Encephalitis

What vaccines does my child need? The 1 st travel plans may require an accelerated schedule Start as early as 6 wks Boosters 4 wks. apart ROUTINE

TRAVEL RESOURCES http://wwwnc.cdc.gov/travel/

Current prices of the international travel vaccines that are available at Washington County Health Department Hep A 33.70 Hep B 41.70 Twinrix Hep A/Hep B combo 53.70 IPT (polio Booster 32.24 Typhoid 50.70 yellow fever 73.70 Menactra ( meningitis Vaccine) 96.70 These prices vary depending on manufactures cost.

What vaccines does my child need? MMR- given at 12-15mo and 4- 6 yrs 3 to 5 % remain susceptible after the first dose The 2 nd dose is an attempt to seroconvert the non responders Children > 12 months give two doses at least 28 days apart Infants can receive a measles alone vaccine

What vaccines does my child need? Hepatitis A at 1yr of age Two monovalent vaccines Havre (GSK ) and Vaqta ( Merck ) Formal CDC recommendation is to give Immunoglobulin < 1yr of age Expense, interferes with other live vaccines, limited duration and effectiveness, allergic reactions and hypothetical risk of Iatrogenic disease

HEPATITIS A Prevalent worldwide In young children is usually asymptomatic Contaminated water, ice, shellfish harvested from sewage infested water, raw fruits and veggies, or handling by an infected food handler Stools most infectious 14 to 21 days before disease is apparent Children can shed hepatitis for up to 10weeks Long incubation period (2 to 4 wks) so can vaccinate up to travel

What vaccines does my child need? Aedes mosquito REQUIRED VACCINE - Yellow fever Never give to children< 6 months of age-risk of developing post vaccination encephalitis Between 6-9 months, risk of acquiring the disease must be greater than the risk of complications Safe > 9 months

Yellow fever endemic zones

What vaccines does my child need? YELLOW FEVER Only vaccine that requires documentation on an official certificate of vaccination Must be given 10 DAYS before the date of entry OFFICIAL STAMP FROM AUTHORISED CLINICS (Meningococcal vaccine for Hajj travelers to Saudi Arabia)

What vaccines does my child need? RECOMMENDED VACCINES- TYPHOID Recommended even for short term travel to Asia, Africa, Latin America, Indian subcontinent Injectable-Vi capsular > 2 yrs Oral-Ty21a > 6 years Fewer side effects longer protection Capsule every other day for 4 doses, needs a week to complete

What vaccines does my child need? OTHER RECOMMENDED VACCINES Travel to Sub Saharan Africa may need Meningococcal vaccine Rabies vaccine if access to post exposure immunoglobulin or vaccine not likely Japanese encephalitis vaccine if extended stays in rural Asia JEMB ( Not available currently)

What preventive strategies do I need to use? MALARIA PREVENTION Insect avoidance Chemoprophylaxis

What preventive strategies do I need to use? INSECT AVOIDANCE-covered clothing, avoid flowery clothes, avoid perfumes, remain in protected environments from dusk till dawn such as air conditioned areas, mosquito netting etc.

What preventive strategies do I need to use? INSECT AVOIDANCE-Chemical agents N,N-diethyl-meta-toluamide (DEET) Rare cases of toxic encephalopathy with dermal application 25-50 % DEET will protect for up to 4 hrs Should not be applied on hands, mm, eyes

Malaria Chemoprophylaxis!!!!!

MALARIA CHEMOPROPHYLAXIS CHLOROQUIN MEFLOQUIN Use in destinations with CQ sensitive P.Falciparum q week 300 mg base(500mg salt) Start 1 week before arrival and continue 4 wks after return Pulverize tablet and place in gelatin capsule Alternative-Hydroxy Chloroquin sulfate Use in destinations with CQ resistant P.falciparum

MALARIA CHEMOPROPHYLAXIS ATOVAQUONE/PROGUANIL DOXYCYCLINE Alternative to Mefloquin in resistant areas 62.5/25mg peds tablet 5-8kg tab, >8-10kg tab,>10-20 kg 1 tab,>20- 30kg 2 tabs,>30-40 kg 3 tabs 250/100mg adult dose 1 tab qd Start 1-2 days prior and continue for 7 days after >8yrs : 2mg/kg daily 100 mg adult dose qd Start at least 2 wks. prior and continue for 4 wks. after travel Alternative to Mefloquin in resistant areas

MALARIA CHEMOPROPHYLAXIS PRIMAQUIN 0.6mg/kg base daily Adult dose 2 tablets= 30mg daily Start 1-2 days before arrival and continue for 7days after departure G6PD testing must be performed prior to taking the tablet; contraindicated in breast feeding unless testing is performed in infant also Used for Terminal prophylaxis to prevent relapses of P.vivax or P.ovale

MALARIA MEDICATIONS- SIDE EFFECTS Neuropsychiatric disturbances ( Mefloquin ) Contraindicated in those with seizures, anxiety and depression Contraindicated in those with cardiac conduction abnormalities Potential side effects-nausea, upset stomach; less commonly strange dreams, insomnia, dizziness, anxiety, weakness, agitation Children tolerate the meds better Albright TA, Binnus HG, Katz BZ.Side effects of and compliance with malaria prophylaxis in children. J Travel Med 2002:9(6):289-292

TRAVELERS DIARRHEA DEFINITION?? In adults - > 3 watery stools per day +- blood/mucus In children ?? A recent change in the normal stool pattern with An increase in frequency (at least 3 stools per day) A decrease in consistency (unformed state)

TREATING TRAVELERS DIARRHEA IN CHILDREN WHY TREAT ? WHEN TREAT ? WHAT MEDICATIONS ? WILL IT MAKE MATTERS WORSE ? (HUS CONCERNS )

ETIOLOGY- TRAVELERS DIARRHEA Rotavirus is the leading cause of severe dehydrating diarrhea WHO estimates 1.5 billion episodes in

Gayatri Bala Jaishankar MD Assistant Professor Associate Program Director ETSU Pediatrics.

Documents

child travel

gum slide

high altitudes

acute mountain sickness

child need

prevention of ams

prevention strategies

placebo acetazolamide