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Pediatrics is a large and integral part of travel medicine and is growing.1,2

Three recent developments in travel medicine regarding children merit discussion: (1) the increase in the number of articles whose main focus is children, as illustrated in this issue of the Journal of Travel Medicine (JTM);3–5 (2) the launching of a Pediatric Interest Group within the International Society of Travel Medicine (ISTM);6 and (3) the results of an informal survey of ISTM members showing that most of the responders are “less than comfortable” in caring for young children.7

Articles such as the ones in this issue of JTM will help practitioners feel more comfortable in dealing with children, both pre- and post-travel. Virtually all travel medicine practitioners, regardless of their primary speciality and areas of interest—and whether they welcome it or not—are frequently confronted with pediatric-related issues.7 They see children in their offices as part of families going overseas. Parents are taking their children on work assignments in remote areas of the world, on pleasure trips to high altitude destinations, on safaris, or back to the country where the parents, and sometimes the children, were born. Teenagers visit developing countries on work projects and university students spend school semesters studying overseas.

Travel medicine is a unique speciality, one that goes against general trends in medicine. The separation of medicine into well-defined specialities is well established. And these specialities are splintering further into ever more sub-entities. As an example, within pediatrics, there are pediatric neuro-ophthalmologists. While such specialized care is essential in certain circumstances, it narrows the focus of the care away from the person as a whole and is time consuming, expensive, and generally impersonal.

Travel Medicine Practitioners Possess Unique Knowledge

  1. Top of page
  2. Travel Medicine Practitioners Possess Unique Knowledge
  3. Travel-Related Illnesses Are Surprisingly Rare in Children
  4. Conclusion
  5. Declaration of Interests
  6. References

Such divisions need not and should not be the rule in travel medicine. The ISTM membership is comprised of individuals from numerous medical specialities as well as nurses, pharmacists, and others. Its focus is and should continue to be on travelers and their interaction with the environments they are planning to visit—or have recently exited with travel-related health issues. This makes the “travel” part of travel medicine as important as the “medicine” part, and occasionally more so. For example, in most countries, virtually any medical practitioner and many pharmacists and nurses can obtain a yellow fever vaccine permit, look up the lower age limits and contraindications for giving it, and check maps/tables for the countries where the disease currently exists. But only practitioners with travel medicine backgrounds are likely to know the nuances of the “travel” part of travel medicine such as knowing whether vaccination is necessary as a condition of entry into a country or only for visits to remote areas. And whether travelers need yellow fever vaccine for visiting a country where the disease does not exist because the traveler recently stopped ever so briefly at an airport in a country where the disease does exist.

Travel medicine practitioners should not unnecessarily shy away from seeing children, both pre- and post-travel. Yet in the ISTM survey, many responders said that they do not generally see children, or they have their own rules for seeing them.7 These rules include upper age cutoffs, which vary from 6 months to 21 years, with most ages in between mentioned. Other responders see children on the basis of the complexity of the issues presented; the more complex an issue, the higher the age of the cutoff. Many responders see pre-travel children but do not see children who return home ill.

Very likely, experienced travel medicine practitioners can better advise parents on keeping children safe and healthy overseas than can practitioners whose speciality is children but who have no background in travel medicine. For children who return home ill, experts in travel medicine are more likely to provide meaningful differential diagnosis, based on the family's micro itinerary, mode of travel, and numerous other factors. The pediatric-oriented articles in this issue generally agree that by category (eg, diarrhea, respiratory infections, and skin issues), travel-related illnesses seen in children are surprisingly similar to those seen in adults. This is generally true for specific destinations, length of stay, and the type of travelers involved (eg, tourists vs visiting friends and relatives). Only the proportions of children with specific illnesses differ within the categories, the same as for adults. In children who return home ill, referrals to pediatric infectious disease or dermatology specialists, for example, may be essential in treating the ill child, but input from experienced travel medicine practitioners can be invaluable.

Arguably, in most cases, counseling young children for overseas travel is no more difficult than counseling adults, and in some cases actually simpler. Children are far less likely to have ongoing diseases or be on medications, factors which confound counseling adults, especially older adults. And most children are up to date on vaccinations and have accurate and easily decipherable vaccination records. Many vaccines adults need for travel have in recent years become routine childhood vaccines. Depending on the country, this includes vaccines against hepatitis A and B and meningitis. Recommendations on preventing arthropod-borne diseases, food and water precautions, sun exposure, and automobile-related accidents are basically similar for the entire family.

But children are not miniature adults. Obvious and important travel health-related difference do exist; for example, vaccines have lower age cutoffs, certain malaria prevention medications are inappropriate, and lower concentrations of DEET are recommended. However, a fundamental understanding of general travel-related issues overrides these hurdles. And good information is included in the articles in this issue of the JTM, in virtually all tables on vaccines and malaria prevention, and on the Pediatric Interest Group page on the ISTM website. (The ISTM Certificate in Travel Health® calls for familiarization with pediatric aspects by including many questions on the subject.)

What is presently lacking is a uniform definition of “children,” a dilemma which extends into the travel medicine literature. In recent articles in the JTM and elsewhere, authors of major articles use 14, 16, 18, and 20 years of age as the upper age limit of their subjects. And while the authors do segregate their subjects into groups by age (apparently agreeing that infants have little in common with older teenagers), there is no uniformity in the segregations, making comparisons difficult. Moreover, some authors compare travel-related illness among adults versus those in children, using the author's definition of “children.” (The American Academy of Pediatrics defines pediatrics as “beginning with the fetus and continuing until the age of 21 years—and longer if it is an ongoing problem that is basically a childhood condition.”)8

Travel-Related Illnesses Are Surprisingly Rare in Children

  1. Top of page
  2. Travel Medicine Practitioners Possess Unique Knowledge
  3. Travel-Related Illnesses Are Surprisingly Rare in Children
  4. Conclusion
  5. Declaration of Interests
  6. References

The many recent studies in this issue and elsewhere on children returning home ill should not give a false impression that taking children overseas is particularly hazardous. Until recently, little data existed on the specific morbidity and mortality though anecdotal experience and informal surveys suggested that serious illness and deaths were rare.9 The present studies reinforce those impressions. These studies limit themselves to describing the types of illnesses seen in returning children and the vast majority of the illnesses were relatively minor. This was true even for children who go on adventurous trips and for very young children. But the studies included only children seen in specific large medical centers with which the authors are affiliated. Excluded are children who returned home ill but were seen at other medical centers, by private physicians, or not at all. But likely, children with serious travel-related illnesses would have gravitated to the larger medical centers. No deaths were reported. But deaths occurring overseas could have escaped inclusion in the studies.

Conclusion

  1. Top of page
  2. Travel Medicine Practitioners Possess Unique Knowledge
  3. Travel-Related Illnesses Are Surprisingly Rare in Children
  4. Conclusion
  5. Declaration of Interests
  6. References

Experienced travel medicine practitioners, even those who possess little formal training in caring for children, generally possess the expertise to counsel parents on keeping their children healthy when they travel. And generally such practitioners should be the first consulted when children return home ill. The articles on pediatric travel medicine in this issue of JTM add substance to the growing literature on the subject, are evidence based, and all the articles reach the same general conclusion, that the risk of major travel-related illnesses in children is quite small.

References

  1. Top of page
  2. Travel Medicine Practitioners Possess Unique Knowledge
  3. Travel-Related Illnesses Are Surprisingly Rare in Children
  4. Conclusion
  5. Declaration of Interests
  6. References