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Chapter 7International Travel With Infants & Children

Traveling Safely with Infants & Children

Nicholas Weinberg, Michelle Weinberg, Susan A. Maloney

OVERVIEW

The number of children who travel or live outside their home countries has increased dramatically. In 2010, an estimated 2.2 million US resident children aged ≤18 years traveled internationally. Although data about the incidence of pediatric illnesses associated with international travel are limited, the risks that children face while traveling are likely similar to those their parents face. Children are less likely to receive pre-travel advice. In a review of children with post-travel illnesses seen at clinics in the GeoSentinel Surveillance Network, only 51% of all children and 32% of the children visiting friends and relatives (VFRs) had received pre-travel medical advice, compared with 59% of adults. The most commonly reported health problems among children are:

  • Diarrheal illnesses
  • Dermatologic conditions, including animal bites
  • Systemic febrile illnesses, especially malaria
  • Respiratory disorders

Motor vehicle and water-related injuries are also major health problems for child travelers. In assessing a child who is planning international travel, clinicians should:

  • Review routine childhood and travel-related vaccinations. The pre-travel visit is an opportunity to ensure that children are up-to-date on routine vaccinations.
  • Assess all anticipated travel-related activities.
  • Provide preventive counseling and interventions tailored to specific risks, including special travel preparations and treatment that may be required for infants and children with underlying conditions, chronic diseases, or immunocompromising conditions. Older adolescents traveling in a student group or program may require counseling about disease prevention and the risks of sexually transmitted infections, empiric treatment and management of common travel-related illnesses, sexual assault, and drug and alcohol use during international travel (see Chapter 8, Study Abroad & Other International Student Travel).
  • Give special consideration to the risks of children who are VFR travelers in developing countries. Conditions may include increased risk of malaria, intestinal parasites, and tuberculosis.
  • Consider counseling adults and older children to take a course in basic first aid before travel.

DIARRHEA

Diarrhea and associated gastrointestinal illness are among the most common travel-related problems affecting children. Infants and children with diarrhea can become dehydrated more quickly than adults. The etiology of travelers’ diarrhea (TD) in children is similar to that in adults (see Chapter 2, Travelers’ Diarrhea).

Prevention

For infants, breastfeeding is the best way to reduce the risk of foodborne and waterborne illness. Infant formulas available abroad may not be the same as in the United States; parents feeding their child formula should consider whether they need to bring formula from home.

Water served to young children, including water used to prepare infant formula, should be disinfected (see Chapter 2, Water Disinfection for Travelers). In some parts of the world, bottled water may also be contaminated and should be disinfected before consumption.

Similarly, food precautions should be followed diligently. Foods served to children should be thoroughly cooked and eaten while still hot; fruits eaten raw should be peeled by the caregiver immediately before consumption. Additionally, caution should be used with fresh dairy products, which may not be pasteurized and may be diluted with untreated water. For short trips, parents may want to bring a supply of safe snacks from home for times when the children are hungry and the available food may not be appealing or safe. See Chapter 2, Food & Water Precautions for more information.

Scrupulous attention should be paid to handwashing and cleaning bottles, pacifiers, teething rings, and toys that fall to the floor or are handled by others; water used to clean these items should be potable. Parents should be particularly careful to wash hands well after diaper changes, especially for infants with diarrhea, to avoid spreading infection to themselves and other family members. When proper handwashing facilities are not available, an alcohol-based hand sanitizer (containing ≥60% alcohol) can be used as a disinfecting agent. However, because alcohol-based hand sanitizers are not effective against certain types of germs, hands should be washed with soap and water as soon as possible. Additionally, alcohol does not remove organic material; visibly soiled hands should be washed with soap and water.

Chemoprophylaxis with antibiotics is not generally used in children.

Treatment

Antiemetics and Antimotility Drugs

Because of potential side effects, antiemetics are generally not recommended for self- or family-administered treatment of children with vomiting and TD. Because of the association between salicylates and Reye syndrome, bismuth subsalicylate (BSS), the active ingredient in both Pepto-Bismol and Kaopectate, is not generally recommended to treat diarrhea in children aged <12 years. However, some clinicians use it off-label with caution in certain circumstances. Caution should be taken in administering BSS to children with viral infections, such as varicella or influenza, because of the risk for Reye syndrome. BSS is not recommended for children aged <3 years. A recent Cochrane Collaboration Review of the use of antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents showed some benefits with ondansetron, metoclopramide, or dimenhydrinate. However, the routine use of these medications for emesis associated with TD has not yet been determined and is not generally recommended.

Antimotility drugs, such as loperamide and diphenoxylate, are rarely given to small children. Loperamide is not recommended for children aged <6 years. Diphenoxylate and atropine combination tablets are not recommended for children aged <2 years. These drugs should be used with caution in children because of potential side effects (See Chapter 2, Travelers’ Diarrhea).

Antibiotics

Few data are available regarding empiric treatment of TD in children. The antimicrobial options for empiric treatment of TD in children are limited. In practice, when an antibiotic is indicated for moderate to severe diarrhea, some clinicians prescribe azithromycin as a single daily dose (10 mg/kg) for 3 days. Physicians can prescribe unreconstituted azithromycin powder before travel, with instructions from the pharmacist for mixing it into an oral suspension if it becomes necessary to use it. Although resistance breakpoints have not yet been determined, elevated minimum inhibitory concentrations for azithromycin have been reported for some gastrointestinal pathogens. Therefore, patients should be counseled to seek medical attention if they do not improve after empiric treatment. Clinicians should review possible contraindications, such as QT prolongation and cardiac arrhythmias with azithromycin, before prescribing medications for empiric treatment of TD.

Although fluoroquinolones are frequently used for the empiric treatment of TD in adults, they are not approved by the Food and Drug Administration for this purpose among children aged <18 years because of cartilage damage seen in animal studies. The American Academy of Pediatrics suggests that fluoroquinolones be considered for the treatment of children with severe infections caused by multidrug-resistant strains of Shigella species, Salmonella species, Vibrio cholerae, or Campylobacter jejuni. Clinicians should be aware that fluoroquinolone resistance in gastrointestinal organisms has been reported from some countries, particularly in Southeast Asia. Routine use of fluoroquinolones for chemoprophylaxis or empiric treatment for TD among children is not recommended.

Management

The biggest threat to the infant with diarrhea and vomiting is dehydration. Fever or increased ambient temperature increases fluid loss and speeds dehydration. Adults traveling with children should be counseled about the signs and symptoms of dehydration and the proper use of oral rehydration salts (ORS). Medical attention may be required for an infant or young child with diarrhea who has:

  • Signs of moderate to severe dehydration
  • Bloody diarrhea
  • Temperature >101.5°F (38.6°C)
  • Persistent vomiting (unable to maintain oral hydration)

The mainstay of management of TD is adequate hydration.

ORS Use and Availability

Parents should be advised that dehydration is best prevented and treated by use of ORS, in addition to the infant’s usual food. ORS should be provided to the infant by bottle, cup, oral syringe (often available in pharmacies), or spoon while medical attention is obtained. Low-osmolarity ORS is the most effective in preventing dehydration, although other formulations are available and may be used if they are more acceptable to young children. Homemade sugar-salt solutions are not recommended. Adults traveling with children should be counseled that sports drinks, which are designed to replace water and electrolytes lost through sweat, do not contain the same proportions of electrolytes as the solution recommended by the World Health Organization for rehydration during diarrheal illness. However, if ORS is not readily available, children should be offered whatever safe, palatable liquid they will take until ORS is obtained.

ORS packets are available at stores or pharmacies in almost all developing countries. ORS is prepared by adding 1 packet to boiled or treated water. Travelers should be advised to check packet instructions carefully to ensure that the salts are added to the correct volume of water. ORS solution should be consumed or discarded within 12 hours if held at room temperature or 24 hours if kept refrigerated.

A dehydrated child will usually drink ORS avidly; travelers should be advised to give it to the child as long as the dehydration persists. As dehydration lessens, the child may refuse the salty-tasting ORS solution, and another safe liquid can be offered. An infant or child who has been vomiting will usually keep ORS down if it is offered by spoon or oral syringe in small sips; these small amounts must be offered frequently, however, so the child can receive an adequate volume of ORS. Older children will often drink well by sipping through a straw. Severely dehydrated children, however, often will be unable to drink adequately. Severe dehydration is a medical emergency that usually requires administration of fluids by intravenous or intraosseous routes.

In general, children weighing <22 lb (10 kg) who have mild to moderate dehydration should be administered 2–4 oz (60–120 mL) ORS for each diarrheal stool or vomiting episode. Children who weigh ≥22 lb (10 kg) should receive 4–8 oz (120–240 mL) of ORS for each diarrheal stool or vomiting episode. The American Academy of Pediatrics provides detailed guidance on rehydration for vomiting and diarrhea; see “Care Advice” at www.healthychildren.org/English/tips-tools/Symptom-Checker/Pages/Vomiting-With-Diarrhea.aspx.

ORS packets are available in the United States from Jianas Brothers Packaging Company (816-421-2880; http://rehydrate.org/resources/jianas.htm). ORS packets may also be available at stores that sell outdoor recreation and camping supplies. In addition, Cera Products (843-842-2600 or 888-237-2598; www.ceraproductsinc.com) markets a rice-based, rather than glucose-based, product.

Dietary Modification

Breastfed infants should continue nursing on demand. Formula-fed infants should continue their usual formula during rehydration. They should receive a volume that is sufficient to satisfy energy and nutrient requirements. Lactose-free or lactose-reduced formulas are usually unnecessary. Diluting formula may slow resolution of diarrhea and is not recommended. Older infants and children receiving semisolid or solid foods should continue to receive their usual diet during the illness. Recommended foods include starches, cereals, pasteurized yogurt, fruits, and vegetables, following safe food selection guidelines. Foods that are high in simple sugars, such as soft drinks, undiluted apple juice, gelatins, and presweetened cereals, can exacerbate diarrhea by osmotic effects and should be avoided. In addition, foods high in fat may not be tolerated because of their tendency to delay gastric emptying.

The practice of withholding food for ≥24 hours is not recommended. Early feeding can decrease changes in intestinal permeability caused by infection, reduce illness duration, and improve nutritional outcome. Highly specific diets (such as the BRAT [bananas, rice, applesauce, and toast] diet) have been commonly recommended; however, similar to juice-based and clear fluid diets, such severely restrictive diets have no scientific basis and should be avoided.

MALARIA

Malaria is among the most serious and life-threatening diseases that can be acquired by pediatric international travelers. Pediatric VFR travelers are at particularly high risk for acquiring malaria if they do not receive chemoprophylaxis.

Children with malaria can rapidly develop high levels of parasitemia. They are at increased risk for severe complications of malaria, including shock, seizures, coma, and death. Initial symptoms of malaria in children may mimic many other common causes of pediatric febrile illness and therefore may result in delayed diagnosis and treatment. Clinicians should counsel adults traveling with children in malaria-endemic areas to use preventive measures, be aware of the signs and symptoms of malaria, and seek prompt medical attention if they develop.

Antimalarial Drugs

Pediatric doses for malaria chemoprophylaxis are provided in Table 3-10. Pediatric doses of medications used for treatment are included in Table 3-08. All dosing should be calculated on the basis of body weight. Medications used for infants and young children are the same as those recommended for adults, except under the following circumstances:

  • Doxycycline should not be given to children aged <8 years because of the risk of teeth staining.
  • Atovaquone-proguanil should not be used for prophylaxis in children weighing <5 kg (11 lb) because of lack of data on safety and efficacy.

Chloroquine, mefloquine, and atovaquone-proguanil have a bitter taste. Before departure, pharmacists can be asked to pulverize tablets and prepare gelatin capsules with calculated pediatric doses. Mixing the powder in a small amount of food or drink can facilitate the administration of antimalarial drugs to infants and children. Additionally, any compounding pharmacy can alter the flavoring of malaria medication tablets so that children are more willing to take them. Assistance with finding a compounding pharmacy is available on the International Academy of Compounding Pharmacists’ website (www.iacprx.org). Because overdose of antimalarial drugs, particularly chloroquine, can be fatal, medication should be stored in childproof containers and kept out of the reach of infants and children.

Personal Protection Measures

Children should sleep in rooms with air conditioning or screened windows or sleep under bed nets, when available. Mosquito netting should be used over infant carriers. Children can reduce skin exposed to mosquitoes by wearing long pants and long sleeves while outdoors in areas where malaria is transmitted. Clothing and mosquito nets can be treated with insect repellents such as permethrin, a repellent and insecticide that repels and kills ticks, mosquitoes, and other arthropods. Permethrin remains effective through multiple washings. Clothing and bed nets should be retreated according to the product label. Permethrin should not be applied to the skin. Although permethrin provides longer duration protection, recommended repellents that can be applied to skin (DEET [N,N-diethyl-m-toluamide], picaridin, oil of lemon eucalyptus [OLE] or PMD, and IR3535) can also be used on clothing and mosquito nets. See Chapter 2, Protection against Mosquitoes, Ticks, & Other Insects & Arthropods for more details about these protective measures.

Repellent Use

CDC recommends the use of repellents containing 1 of the following active ingredients, which are registered with the US Environmental Protection Agency, according to the product labels: DEET, picaridin, OLE or PMD, and IR3535. Most repellents can be used on children aged >2 months, with the following considerations:

  • Products containing OLE specify that they should not be used on children aged <3 years.
  • Repellent products must state any age restriction. If none is stated, the Environmental Protection Agency has not required a restriction on the use of the product.
  • Many repellents contain DEET as the active ingredient. The concentration of DEET varies considerably among products. The duration of protection varies with the DEET concentration: higher concentrations protect longer. Products with DEET concentration above 50% do not offer a marked increase in protection time. The American Academy of Pediatrics recommends:
    • ≤30% DEET should be used on children aged >2 months.
    • Repellents with DEET should not be used on infants aged <2 months.

Repellents can be applied to exposed skin and clothing; however, they should not be applied under clothing. Repellents should never be used over cuts, wounds, or irritated skin. Young children should not be allowed to handle the product. When using repellent on a child, an adult should apply it to his or her own hands and then rub them on the child, with the following considerations:

  • Avoid the child’s eyes and mouth, and apply sparingly around the ears.
  • Do not apply repellent to children’s hands, since children tend to put their hands in their mouths.
  • Heavy application and saturation are generally unnecessary for effectiveness. If biting insects do not respond to a thin film of repellent, then apply a bit more.
  • After returning indoors, wash treated skin with soap and water or bathe. This is particularly important when repellents are used repeatedly in a day or on consecutive days.

Products that contain both repellents and sunscreen are generally not recommended, because instructions for use are different and the need to reapply sunscreen is usually more frequent than with repellent alone. In general, apply sunscreen first, then apply repellent. Mosquito coils should be used with caution in the presence of children to avoid burns and inadvertent ingestion.

For more information about repellent use, see Chapter 2, Protection against Mosquitoes, Ticks, & Other Insects & Arthropods.

DENGUE

Pediatric VFR travelers who may have frequent and prolonged travel may have risk similar to children living in dengue-endemic areas. Among 8 children who were diagnosed with acute dengue infection after visiting friends and relatives in the Caribbean, 3 developed either dengue hemorrhagic fever or dengue shock syndrome. Children traveling to areas with dengue should use the same mosquito protection measures described for malaria. However, families should be counseled that, unlike the mosquitoes that transmit malaria, the Aedes mosquitoes that transmit dengue bite during the daytime. Clinicians should consider dengue in children with fever if they have recently been in an endemic area. For more information about dengue, see Chapter 3, Dengue.

INFECTION AND INFESTATION FROM SOIL CONTACT

Children are more likely than adults to have contact with soil or sand, and therefore, they may be exposed to diseases caused by infectious stages of parasites present in soil, including ascariasis, hookworm infestation, cutaneous or visceral larva migrans, trichuriasis, and strongyloidiasis. Children and infants should wear protective footwear and play on a sheet or towel rather than directly on the ground. Clothing should not be dried on the ground. In countries with a tropical climate, clothing or diapers dried in the open air should be ironed before use to prevent infestation with fly larvae.

ANIMAL BITES AND RABIES

Worldwide, rabies is more common in children than adults. In addition to the potential for increased contact with animals, children are also more likely to be bitten on the head or neck, leading to more severe injuries. Children and their families should be counseled to avoid all stray or unfamiliar animals and to inform adults of any contact or bites. Bats throughout the world are considered to have the potential to transmit rabies virus. Mammal-associated injuries should be washed thoroughly with water and soap (and povidone iodine if available), and the child should be evaluated promptly to assess the need for rabies postexposure prophylaxis. Because rabies vaccine and rabies immune globulin may not be unavailable in certain destinations, families should seriously consider purchasing medical evacuation insurance.

AIR TRAVEL

Although air travel is safe for healthy newborns, infants, and children, a few issues should be considered in preparation for travel. Children with chronic heart or lung problems may be at risk for hypoxia during flight, and a physician should be consulted before travel. Making sure that children can be safely restrained during a flight is a safety consideration. Severe turbulence or crash can create enough momentum that a parent cannot hold onto a child:

  • Children should be placed in a rear-facing Federal Aviation Authority–approved child-safety seat until they are aged ≥1 year and weigh ≥20 lb.
  • Children aged ≥1 year and 20–40 lb should use a forward-facing Federal Aviation Authority–approved child-safety seat.
  • Children who weigh >40 lb can be secured in the aircraft seat belt.

Ear pain can be troublesome for infants and children during descent. Pressure in the middle ear can be equalized by swallowing or chewing:

  • Infants should nurse or suck on a bottle.
  • Older children can try chewing gum.
  • Antihistamines and decongestants have not been shown to be of benefit.

There is no evidence that air travel exacerbates the symptoms or complications associated with otitis media. Travel to different time zones, jet lag, and schedule disruptions can disturb sleep patterns in infants and children, as well as adults.

INJURIES

Vehicle-Related

Vehicle-related injuries are the leading cause of death in children who travel. While traveling in automobiles and other vehicles, children weighing ≤40 lb should be restrained in age-appropriate car seats or booster seats, as described above. These seats often must be carried from home, since availability of well-maintained and approved seats may be limited abroad. In general, children are safest traveling in the rear seat; no one should ever travel in the bed of a pickup truck. Families should be counseled that in many developing countries, cars may lack front or rear seatbelts. They should attempt to arrange transportation in vehicles or rent vehicles with seatbelts and other safety features.

Drowning and Water-Related Illness and Injuries

Drowning is the second leading cause of death in young travelers. Children may not be familiar with hazards in the ocean or in rivers. Swimming pools may not have protective fencing to keep toddlers from falling into the pool. Close supervision of children around water is essential. Water safety devices such as life vests may not be available abroad, and families should consider bringing these from home. Protective footwear is important to avoid injury in many marine environments. Schistosomiasis is a risk to children and adults in endemic areas. While in schistosomiasis-endemic areas (see Map 3-12), children should not swim in fresh, unchlorinated water such as lakes or ponds.

Accommodations

Conditions at hotels and other lodging may not be as safe as those in the United States, and accommodations should be carefully inspected for exposed wiring, pest poisons, paint chips, or inadequate stairway or balcony railings.

ALTITUDE

Children are as susceptible to altitude illness as adults. Young children who cannot talk can show nonspecific symptoms, such as loss of appetite and irritability. They may have unexplained fussiness and change in sleep and activity patterns. Older children may complain of headache or shortness of breath. If children demonstrate unexplained symptoms after an ascent, it may be necessary to descend to see if they improve. Acetazolamide is not approved for pediatric use for altitude illness, but it is generally safe in children when used for other indications.

SUN EXPOSURE

Sun exposure, and particularly sunburn before age 15 years, is strongly associated with melanoma and other forms of skin cancer (see Chapter 2, Sunburn). Exposure to UV light is highest near the equator, at high altitudes, during midday (10 am–4 pm), and where light is reflected off water or snow. Sunscreens are generally recommended for use in children aged >6 months. Sunscreens (or sun blocks), either physical (such as titanium or zinc oxides) or chemical (SPF ≥15 and providing protection from both UVA and UVB), should be applied as directed and reapplied, as needed, after sweating and water exposure. Babies aged <6 months require extra protection from the sun because of their thinner and more sensitive skin; severe sunburn for this age group is considered a medical emergency. Babies should be kept in the shade and wear clothing that covers the entire body. A minimal amount of sunscreen can be applied to small exposed areas, including the infant’s face and hands.

Sun-blocking shirts are available that are made for swimming and preclude having to rub sunscreen over the entire trunk. Hats and sunglasses also reduce sun injury to skin and eyes. If both sunscreen and a DEET-containing insect repellent are applied, the sun protection factor (SPF) of the sunscreen may be diminished by one-third, and covering clothing should be worn or time in the sun decreased accordingly.

OTHER GENERAL CONSIDERATIONS

Travel Stress

Changes in schedule, activities, and environment can be stressful for children. Including children in planning for the trip and bringing along familiar toys or other objects can decrease these stresses. For children with chronic illnesses, decisions regarding timing and itinerary should be made in consultation with the child’s health care providers.

Insurance

As for any traveler, insurance coverage for illnesses and injuries while abroad should be verified before departure. Consideration should be given to purchasing special medical evacuation insurance for airlifting or air ambulance to an area with adequate medical care (see Chapter 2, Travel Insurance, Travel Health Insurance, & Medical Evacuation Insurance).

Identification

In case family members become separated, each infant or child should carry identifying information and contact numbers in his or her own clothing or pockets. Because of concerns about illegal transport of children across international borders, if only 1 parent is traveling with the child, he or she may need to carry relevant custody papers or a notarized permission letter from the other parent.

BIBLIOGRAPHY

1. American Academy of Pediatrics. Insect repellents. Elk Grove Village, IL: American Academy of Pediatrics; 2012 [cited 2012 Sep 26]. Available from: http://www.healthychildren.org/English/safety-prevention/at-play/Pages/Insect-Repellents.aspx.

2. American Academy of Pediatrics. Sun safety. Elk Grove Village, IL: American Academy of Pediatrics; 2012 [cited 2012 Sep 26]. Available from: http://www.healthychildren.org/English/safety-prevention/at-play/Pages/Sun-Safety.aspx.

3. American Academy of Pediatrics. Vomiting with diarrhea. Elk Grove Village, IL: American Academy of Pediatrics; 2012 [cited 2012 Sep 26]. Available from: http://www.healthychildren.org/English/tips-tools/Symptom-Checker/Pages/Vomiting-With-Diarrhea.aspx.

4. Bradley JS, Jackson MA, Committee on Infectious Diseases. The use of systemic and topical fluoroquinolones. Pediatrics. 2011 Oct;128(4):e1034–45.

5. DuPont HL, Ericsson CD, Farthing MJ, Gorbach S, Pickering LK, Rombo L, et al. Expert review of the evidence base for prevention of travelers’ diarrhea. J Travel Med. 2009 May–Jun;16(3):149–60.

6. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011(9):1–71.

7. Hagmann S, Neugebauer R, Schwartz E, Perret C, Castelli F, Barnett ED, et al. Illness in children after international travel: analysis from the GeoSentinel Surveillance Network. Pediatrics. 2010 May;125(5):e1072–80.

8. Han P, Balaban V, Marano C. Travel characteristics and risk-taking attitudes in youths traveling to nonindustrialized countries. J Travel Med. 2010 Sep–Oct;17(5):316–21.

9. Herbinger KH, Drerup L, Alberer M, Nothdurft HD, Sonnenburg F, Loscher T. Spectrum of imported infectious diseases among children and adolescents returning from the tropics and subtropics. J Travel Med. 2012 May–Jun;19(3):150–7.

10. Hunziker T, Berger C, Staubli G, Tschopp A, Weber R, Nadal D, et al. Profile of travel-associated illness in children, Zurich, Switzerland. J Travel Med. 2012 May–Jun;19(3):158–62.

11. King CK, Glass R, Bresee JS, Duggan C. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003 Nov 21;52(RR-16):1–16.

12. Krishnan N, Purswani M, Hagmann S. Severe dengue virus infection in pediatric travelers visiting friends and relatives after travel to the Caribbean. Am J Trop Med Hyg. 2012 Mar;86(3):474–6.

13. Murphy ME, Montemarano AD, Debboun M, Gupta R. The effect of sunscreen on the efficacy of insect repellent: a clinical trial. J Am Acad Dermatol. 2000 Aug;43(2 Pt 1):219–22.

14. US Department of Commerce, Office of Travel and Tourism Industries. Profile of US resident travelers visiting overseas destinations: 2010 outbound. 2011 [cited 2012 Sep 26]. Available from: http://tinet.ita.doc.gov/outreachpages/download_data_table/2010_Outbound_Profile.pdf.

15. van Rijn SF, Driessen G, Overbosch D, van Genderen PJ. Travel-related morbidity in children: a prospective observational study. J Travel Med. 2012 May–Jun;19(3):144–9.

 
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