Airlines that are members of the International Air Transport Association (IATA) voluntarily adhere to accessibility codes similar to those of American carriers. Aircraft with fewer than 30 seats are exempt, and smaller airlines may not be IATA members. The US Department of Transportation maintains a toll-free hotline offering real-time assistance for disabled travelers, including help with travel on foreign airlines (800-778-4838).

Seeing what life is like for the disabled in poor countries may be especially disturbing to a child with a disability. In these countries, people with a disability often do not have access to a wheelchair, may be abandoned by family members who cannot afford to care for them, and are often found begging in the street. Families should keep this in mind when deciding on travel destinations.

Children with a chronic disease should travel with enough medication for the entire trip, and the family should be prepared to handle common complications. If the child is likely to require hospital care, parents should restrict travel to a short distance from a reliable medical center. They can purchase special travel insurance that allows the family to return home early without penalty if a medical problem arises.

Preparing for the journey

Before leaving home, a family needs to review its health insurance to determine the extent of coverage when out of the country. Evacuation insurance, which covers emergency evacuation and access to health-care providers 24 hours a day, can be purchased before travel. Examples include SOS, MEDEX, and CMI Insurance. Local travel clinics, as well as the Web sites listed on offer the names and contact information of reliable sources of medical care at many destinations.

Parents should write down the telephone numbers of every physician for every member of the family. Even most remote and impoverished countries have cell phone access. If the family plans to travel to a very isolated area, they may be able to rent or purchase a local cell phone with which to contact help in case of an emergency.

Children require safe entertainment and distraction during travel, beginning with the journey to the destination. Children should have sufficient quiet entertainment for the length of the journey. For overnight air travel with a child who is older than 2 years, parents may choose to use diphenhydramine to help the child sleep. They should give the child a test dose of the medication before the trip, however, because some children have a paradoxical response and become more active and restless.

Sedation is usually unnecessary, however. Most children who get plenty of activity before boarding the plane and take along one or two familiar items—a blanket, a pillow—can make themselves comfortable in an airplane seat and fall asleep. Parents who use sleeping medication themselves should be cautioned to make sure that one adult who is not under the influence of sedating medication is always available to tend to the children.

Many opinions exist about how to minimize infants' discomfort during air travel. Changes in altitude increase pressure and the vacuum effect in the middle ear, which can cause pain on descent. Awakening a sleeping infant does not alter the adjustment of the tympanic membrane and only leads to increased crying. The act of swallowing, such as drinking from a bottle, may hasten equalization of ear pressure for infants who are uncomfortable, and chewing gum may help older children.

Dry air on airplanes increases insensible fluid loss, so all airplane travelers should consume liquids regularly during flight. Superficial dryness of the mucous membranes should not be misinterpreted as dehydration, however. Infants should not be fed more than usual because higher altitude causes gases to expand, and infants may experience abdominal distension during air travel.

General advice about safety

Much travel-related advice for children is the same anticipatory guidance you offer at routine visits. Injury, not infectious disease, is the leading cause of death among travelers.^3,4 Standard safety measures, such as seat belts in vehicles, may not be routinely available in developing countries. In case of a collision, the rear seat of a car is safer than the front seat. Encourage parents to bring a car seat if their child needs one, unless they are sure one of adequate quality will be available at their destination.

The Guide for Parents on lists some recommended items to include in a medical kit for travel with children to developing countries.

The physical environment in developing countries is often much less safe than Americans anticipate. Any area the child is likely to explore must be inspected for potential dangers, including exposed electrical wires and outlets, broken glass, dangerous small animals such as scorpions, inadequate guardrails, and incomplete or decaying construction.

Children who are accidentally separated from their parents during international travel are especially vulnerable. A home telephone number and address—important information for lost children at home—might not be helpful when traveling abroad. Personal information, including the child's name, address where the family is staying, and contact phone numbers, should be put in the child's pocket, not displayed in plain sight.

Preventing infection: Food safety

Most common causes of gastrointestinal infection in travelers are transmitted by the fecal-oral route. Although encounters with these pathogens are often inevitable, careful attention to hand washing and avoiding unsafe foods can prevent exposure and decrease the intensity of the exposure, which may avert clinical illness.

Hand hygiene is critical to preventing gastrointestinal infection. Washing hands with soap and water, even if the water is contaminated, provides adequate protection before eating.⁵ Young children may fill the period between washing hands and eating with crawling on the ground, playing with dirty toys, or other activities that can soil the hands. Once visible dirt has been removed with soap and water, a water-free sanitizer, either in gel form or on prepared wipes, can be used immediately before eating. Water-free hand sanitizer can also be used when water for hand washing is not available. These alcohol-based products should be used only in small amounts and no more often than necessary, because of the potential risk of toxic ingestion or absorption, although no such incidents have been reported to date.

Choosing safe foods while traveling in developing countries demands constant vigilance. Travelers should never consume tap water, juice mixed with tap water, or ice cubes made from tap water. Tap water should not even be used for brushing teeth. Safe water can be bought in sealed bottles. Because local vendors sometimes "recycle" old water bottles and fill them with tap water, travelers should check that the seal is not broken or should buy carbonated water only to be sure that tap water has not been substituted.

Online Resources for Foreign Travel

What products can be used for EC?

Water that has come to a rapid boil for at least one minute (longer than three minutes at high altitude) is considered safe. Treating water with iodine kills bacteria and viruses but may not kill all parasites. Water filters remove most bacteria—and filters with an absolute pore size from 0.1 to 1 micrometer and labeled as reverse osmosis remove most parasites such Giardia and Cryptosporidium—but cannot filter out viruses. Iodine must be added to filtered water to kill viruses. Pregnant women should not consume iodinated water.

The often-quoted phrase to remember for food safety is: boil it, cook it, peel it, or forget it. Some foods can be spotted and avoided easily: uncooked fruits or vegetables from which the outer skin has not been removed, undercooked meat and seafood, and drinks or frozen popsicles made with water. Any food that is washed in water should be cooked before eating. Milk should be avoided unless it is known to be pasteurized.

Unsafe foods may come in innocent guises: Sandwiches and other dishes may be topped with lettuce or tomatoes, fruits that have been peeled at outdoor stands (such as mangoes and pineapples) are often dipped in water to keep them appearing moist, and sauces placed on hot food are often made with raw vegetables.

A hungry child in the midst of a market full of potentially contaminated foods can be more than any parent can handle. Parents should always carry snacks with them for situations when local food options are potentially unsafe. Food in local markets can often appear very appealing, so parents should be prepared with satisfying snacks.

Food and drink are not the only ways young children can encounter environmental contamination. They also have pacifiers and toys that they put in their mouths, along with other objects they may want to explore. Sanitary toys should be available for the child who is at an age of exploring with her mouth to substitute for other items that might catch her interest. When possible, pacifiers, and other toys should be sterilized often in boiling water.

Protection against insects

Insects in developing countries can be more than a nuisance. They can carry life threatening diseases, such as malaria, dengue, filariasis, Japanese encephalitis and Chagas disease. Barriers—including clothing, protective nets, and personal insecticides—are essential for preventing exposure to insects that can lead to infection. When possible, parents should dress children in light-colored clothing that covers their arms and legs and treat clothing with 0.5% permethrin to increase protection. Permethrin remains effective for several weeks, even after clothes are washed.

In tropical climates, wearing long sleeves and long pants all the time may not be feasible. Parents should find out at what time of day potentially infectious exposures occur in the region they are visiting, and focus protective measures on those times. Anopheles mosquitoes that carry malaria often bite at dusk, for example, whereas Aedes aegypti, the mosquito that carries the dengue virus, feeds during the day.

N, N-diethy-3-methylbenzamide (DEET) is the most effective personal insecticide available. It is active against many biting insects, including mosquitoes, flies, chiggers, fleas, and ticks. DEET is available in many concentrations; 20% or 30% provides adequate protection under most circumstances and is safe to use on children. Higher concentrations provide longer duration of protection, but concentrations greater than 50% offer only a marginal increase in protection time. New formulations of microencapsulated DEET—such as Sawyer's Controlled Release with 20% DEET and 3M Ultrathon Lotion with 23% DEET—last longer on the skin and have less systemic absorption. Most ethanol-based DEET products require reapplication within six hours, whereas microencapsulated products last for at least 12 hours.

DEET should be applied to all exposed areas of the skin. Because it is an eye irritant, can cause a mild dermatitis, and should not be orally ingested, DEET should not be applied to the hands and face of young children. It can also decrease the efficacy of sunscreen.

Although DEET has an outstanding safety profile and has been used by millions of people worldwide for almost 50 years, anecdotal reports of encephalopathy have been associated with its use. These cases generally involved misuse of the chemical. Animal studies have shown that DEET is not a selective neurotoxin.⁶

Instruct parents to use 20% or 30% DEET and reapply it every six hours for the standard formulation or every 12 hours for the controlled-release formulation. It should be washed off with soap when the child is in an area away from mosquitoes, such as under a bed net. (Mosquitos are often present in screened or air-conditioned rooms, however.) Remind parents who are reluctant to use DEET that the risks of mosquito bites and other insect bites are real and significant: Insects transmit diseases, and secondary skin infections can develop at the site of a bite.

Bed nets provide an effective barrier to insect bites, especially because they protect children during sleep, when biting insects go unnoticed and the child does not move much. For less mobile children, nets can be purchased that fit over carseats and strollers, and freestanding nets can be placed over the child's play area. Netting should be treated with permethrin to maximize its effectiveness. Because the insecticide becomes less active with time, netting must be retreated every year.

REFERENCES

1. Ryan ET, Kain KC: Primary care: Health advice and immunizations for travelers. N Engl J Med 2000;342:1716

2. Bacaner N, Stauffer B, Boulware DR, et al: Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA 2004;291:2856

3. Baker TD, Hargarten SW, Guptill KS: The uncounted dead—American civilians dying overseas. Public Health Reports 1992;107(2):155

4. Centers for Disease Control and Prevention: Health Informaton for the International Traveler 2003-2004. Atlanta, US Department of Health and Human Services, Public Health Service, 2003

5. Curtis V, Cairncross S: Effect of washing hands with soap on diarrhoea risk in the community: A systematic review. Lancet Infect Dis 2003;3:275

6. Fradin MS: Mosquitoes and mosquito repellents: A clinician's guide. Ann Intern Med 1998;128:931

International Association for Medical Assistance to Travelers www.iamat.org

International Society of Travel Medicine www.istm.org

Most up-to-date information about epidemics and outbreaks www.promedmail.org; www.who.int/wer; www.cdc.gov/mmwr

The second part of this article, on immunizations and malaria prophylaxis, will appear in the March 2006 issue.

GUIDE for PARENTS

A sample medical kit for traveling with a child to a developing country

Child's health records, including
Immunization record
Chronic medical conditions
Names and dosages of medications the child takes
Blood type
All allergies

Prescription medications (adequate supply for full length of stay)
Medication for unexpected exacerbation of a chronic condition (such as a course of steroids for asthma, even if it is well controlled)
Epinephrine pens
Ciprofloxacin or azithromycin for traveler's diarrhea (bismuth subsalicylates [Pepto-Bismol, Kaopectate] or loperamide [Imodium] for older children and adults)
Medication to prevent malaria
For remote travel: cephalexin or other antibiotic for cellulitis, medication for treating malaria (not for young children)

Extra pair of prescription glasses

Basic first aid supplies
Bandages, moleskin for blisters, water-resistant tape, gauze to cover wounds, wound closure strips (Steristrips)

Over-the-counter medications
Acetaminophen or ibuprofen, antihistamine, antibiotic ointment, topical antifungal preparation, cortisone cream, cold medication, decongestant

Skin barrier protection for children in diapers (petroleum jelly, zinc oxide)

Insect repellent containing DEET

Sun screen

Thermometer

Oral rehydration packets

Water purification system and/or iodine tablets

Flashlight

This guide may be photocopied and distributed without permission to give to your patients and their parents. Reproduction for any other purpose requires express permission of the publisher, Advanstar Medical Economics Healthcare Communications. (c) 2006