Author(s): Michelle Weinberg, Nicholas Weinberg, Susan Maloney

Children increasingly are traveling and living outside their home countries. Although data about the incidence of pediatric illnesses associated with international travel are limited, the risks that children face when traveling are likely similar to those faced by their adult travel companions.

Compared with adults, however, children are less likely to receive pretravel advice. In a review of children with posttravel illnesses seen at clinics in the GeoSentinel Global Surveillance Network, 51% of all children and 32% of children visiting friends and relatives (VFRs) had received pretravel medical advice, compared with 59% of adults. The most commonly reported health problems among child travelers are dermatologic conditions, including animal and arthropod bites, cutaneous larva migrans, and sunburn; diarrheal illnesses; respiratory disorders; and systemic febrile illnesses, especially malaria.

Motor vehicle and water-related injuries, including drowning, are other major health and safety concerns for child travelers. See Box 7-03 for recommendations on assessing and preparing children for planned international travel.

Travel-Associated Infections & Diseases

Arboviral Infections

Pediatric VFR travelers with frequent or prolonged travel to areas where arboviruses (e.g., chikungunya, dengue, Japanese encephalitis, yellow fever, and Zika viruses) are endemic or epidemic could be at increased risk for infection. Children traveling to areas with arboviruses should use the same mosquito protection measures described elsewhere in this chapter (also see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods). Unlike mosquitoes that transmit malaria, the Aedes mosquitoes that transmit chikungunya, dengue, yellow fever, and Zika are aggressive daytime biters; they also bite at night, especially in areas with artificial light. Consider dengue or other arboviral infections in children with fever if they recently returned from travel in endemic areas. Vaccination against dengue, tick-borne encephalitis, and yellow fever could be indicated for some children (see Sec. 7, Ch. 4, Vaccine Recommendations for Infants & Children, for details).

Diarrhea & Vomiting

Diarrhea and associated gastrointestinal illnesses 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 Sec. 2, Ch. 6, Travelers’ Diarrhea).

Prevention

Adults traveling with children should ensure the children follow safe food and water precautions and frequently wash their hands to prevent foodborne and waterborne illness. For infants, breastfeeding is the best way to reduce the risk for foodborne and waterborne illness (see Sec. 7, Ch. 2, Travel & Breastfeeding). Infant formulas available abroad might not have the same nutritional composition or be held to the same manufacturing safety standards as in the traveler’s home country; parents feeding their child formula should consider whether they need to bring formula from home. If the infant is fed with formula, travelers should consider using liquid formula, which is sterile. Use of powdered infant formula has been associated with Cronobacter infection; infants <3 months old, infants born prematurely, and infants with weakened immune systems are at greatest risk. Parents should take extra precautions for preparing powdered infant formula.

Travelers should disinfect water served to young children, including water used to prepare infant formula (see Sec. 2, Ch. 8, Food & Water Precautions, and Sec. 2, Ch. 9, Water Disinfection, for details on safety practices). In some parts of the world, bottled water could be contaminated and should be disinfected to kill bacteria, viruses, and protozoa before consumption.

Similarly, travelers with children should diligently follow food precautions and ensure foods served to children are cooked thoroughly and eaten while still hot; caregivers should peel fruits typically eaten raw immediately before consumption. Additionally, adults should use caution with fresh dairy products, which might not be pasteurized or might be diluted with untreated water. For short trips, parents might want to bring a supply of safe snacks from home for times when children are hungry and available food might not be appealing or safe (see Sec. 2, Ch. 8, Food & Water Precautions, for more information).

Adult travelers with children should pay scrupulous attention that potable water is used for handwashing and cleaning bottles, pacifiers, teething rings, and toys that fall to the floor or are handled by others. After diaper changes, especially for infants with diarrhea, parents should be particularly careful to wash hands well to avoid spreading infection to themselves and other family members. When proper handwashing facilities are not available, hand sanitizer containing ≥60% alcohol can be used as a disinfecting agent. Because alcohol-based hand sanitizers are not effective against certain pathogens, however, adults and children should wash hands with soap and water as soon as possible. In addition, alcohol does not remove organic material, and people should wash visibly soiled hands with soap and water.

Chemoprophylaxis with antibiotics is not generally used in children; typhoid vaccine might be indicated, however (see Sec. 5, Part 1, Ch. 24, Typhoid & Paratyphoid Fever).

Treatment

Antibiotics

Azithromycin

Few data are available regarding empiric treatment of TD in children. 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. Clinicians can prescribe unreconstituted azithromycin powder before travel, with instructions from the pharmacist for mixing it into an oral suspension prior to administration. Although resistance breakpoints have not yet been determined, elevated minimum inhibitory concentrations for azithromycin have been reported for some gastrointestinal pathogens. Therefore, counsel parents to seek medical attention for their children if they do not improve after empiric treatment. Before prescribing azithromycin for empiric TD treatment, review possible contraindications and the risks for adverse reactions (e.g., QT prolongation and cardiac arrhythmias).

Fluoroquinolones

Although fluoroquinolones frequently are used for empiric TD treatment in adults, these medications are not approved by the US Food and Drug Administration (FDA) for this purpose in children aged <18 years because of cartilage damage seen in animal studies. The American Academy of Pediatrics (AAP) suggests that fluoroquinolones be considered for treatment of children with severe infections caused by multidrug-resistant strains of Campylobacter jejuni, Salmonella species, Shigella species, or Vibrio cholerae.

Fluoroquinolone resistance in gastrointestinal organisms has been reported from some countries, particularly in Asia. In addition, use of fluoroquinolones has been associated with tendinopathies, development of Clostridioides difficile infection, and central nervous system side effects including confusion and hallucinations. Routine use of fluoroquinolones for prophylaxis or empiric treatment for TD among children is not recommended.

Rifaximin

Rifaximin is approved for use in children aged ≥12 years but has limited use for empiric treatment since it is only approved to treat noninvasive strains of Escherichia coli. Children with bloody diarrhea should receive medical attention, because antibiotic treatment of enterohemorrhagic E. coli, a cause of bloody diarrhea, has been associated with increased risk for hemolytic uremic syndrome (see Sec. 5, Part 1, Ch. 7, Diarrheagenic Escherichia coli).

Antiemetics & Antimotility Drugs

Antiemetics generally are 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 <12 years old. In certain circumstances, however, some clinicians use it off-label, with caution. Care should be taken if administering BSS to children with viral infections (e.g., influenza, varicella), because of the risk for Reye syndrome. BSS is not recommended for children aged <3 years.

Use of antiemetics for children with acute gastroenteritis is controversial; some clinical practice guidelines include the use of antiemetics, others do not. A Cochrane Collaboration Review of the use of antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents showed some benefits with dimenhydrinate, metoclopramide, or ondansetron. Guidelines from the Infectious Diseases Society of America suggest that an antinausea and antiemetic medication (e.g., ondansetron) can facilitate tolerance of oral rehydration in children >4 years of age, and in adolescents with acute gastroenteritis.

A recent systematic review and network meta-analysis comparing several antiemetics in acute gastroenteritis in children showed that ondansetron was the best intervention to reduce vomiting and prevent hospitalization and the need for intravenous rehydration. Routine use of these medications as part of self-treatment for emesis associated with TD in children has not yet been studied, however, and is not generally recommended.

Antimotility drugs (e.g., the opioid receptor agonists loperamide and diphenoxylate), generally should not be given to children <18 years of age with acute diarrhea. Loperamide is particularly contraindicated for children aged <2 years because of the risks for respiratory depression and serious cardiac events. Diphenoxylate and atropine combination tablets should not be used for children aged <2 years, and should be used judiciously in older children because of potential side effects (see Sec. 2, Ch. 6, Travelers’ Diarrhea).

Fluid & Nutrition Management

The biggest threat to an infant with diarrhea and vomiting is dehydration. Fever or increased ambient temperature increases fluid loss and accelerates dehydration. Advise adults traveling with children about the signs and symptoms of dehydration and the proper use of oral rehydration solution (ORS). Advise adults traveling with children to seek medical attention for an infant or young child with diarrhea who has signs of moderate to severe dehydration, bloody diarrhea, body temperature >101.3°F (38.5°C), or persistent vomiting (unable to maintain oral hydration). Adequate hydration is the mainstay of TD management.

Oral Rehydration Solution: Use & Availability

Counsel parents that dehydration is best prevented and treated by ORS in addition to the infant’s usual food. While seeking medical attention, caregivers should provide ORS to infants by bottle, cup, oral syringe (often available in pharmacies), or spoon. Low-osmolarity ORS is the most effective agent in preventing dehydration, although other formulations are available and can be used if they are more palatable to young children. Homemade sugar-salt solutions are not recommended.

Sports drinks are designed to replace water and electrolytes lost through sweat, and do not contain the same proportions of electrolytes as the solution recommended by the World Health Organization for rehydration during diarrheal illness. Drinks with a high sugar content (e.g., juice, soft drinks) can worsen diarrhea. If ORS is not readily available, however, offer children whatever safe liquid they will take until ORS is obtained. Breastfed infants should continue to breastfeed (for more details, see Sec. 7, Ch. 2, Travel & Breastfeeding).

ORS can be made from prepackaged glucose and electrolytes packets available at stores or pharmacies in almost all countries. Some pharmacies and stores that specialize in outdoor recreation and camping supplies also sell ORS packets.

ORS is prepared by adding 1 packet to boiled or treated water (see Sec. 2, Ch. 9, Water Disinfection). Advise travelers to check packet instructions carefully to ensure that the contents are added to the correct volume of water. Once prepared, ORS should be consumed or discarded within 12 hours if held at room temperature, or within 24 hours if kept refrigerated. A dehydrated child will usually drink ORS avidly and should continue to receive ORS if dehydration persists.

As dehydration lessens, the child might refuse the salty-tasting ORS, and adults can offer other safe liquids. 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; adults should offer these small sips 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 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) of 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. AAP provides detailed guidance on rehydration for vomiting and diarrhea.

Diet Modification

Breastfed infants should continue nursing on demand. Formula-fed infants should continue their usual formula during rehydration and should receive a volume sufficient to satisfy energy and nutrient requirements. Lactose-free or lactose-reduced formulas usually are unnecessary. Diluting formula can 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 cereals, fruits and vegetables, starches, and pasteurized yogurt. Travelers should avoid giving children food high in simple sugars (e.g., undiluted apple juice, presweetened cereals, gelatins, soft drinks) because these can exacerbate diarrhea by osmotic effects. In addition, foods high in fat tend to delay gastric emptying, and thus might not be well tolerated by ill children.

Travelers should not withhold food for ≥24 hours. Early feeding can decrease changes in intestinal permeability caused by infection, reduce illness duration, and improve nutritional outcome. Although highly specific diets (e.g., the BRAT [bananas, rice, applesauce, toast] diet) or juice-based and clear fluid diets commonly are recommended, such severely restrictive diets have no scientific basis and should be avoided.

Malaria

Malaria is among the most serious and life-threatening infections acquired by pediatric international travelers. Pediatric VFR travelers are at particularly high risk for malaria infection if they do not receive prophylaxis. Among people reported with malaria in the United States in 2017, 17% were children <18 years old; 89% had traveled to Africa. Seventy percent of the children who were US residents also were VFR travelers, and 61% did not take malaria chemoprophylaxis.

Children with malaria can rapidly develop high levels of parasitemia and are at increased risk for severe complications of malaria, including seizures, coma, and death. Initial symptoms can mimic many other common causes of pediatric febrile illness, which could delay diagnosis and treatment. Among 33 children with imported malaria diagnosed at 11 medical centers in New York City, 11 (32%) had severe malaria and 14 (43%) were initially misdiagnosed. Counsel adults traveling with children to malaria-endemic areas to use preventive measures, be aware of the signs and symptoms of malaria, and seek prompt medical attention if symptoms develop.

Antimalarial Drugs

Pediatric doses for malaria prophylaxis are provided in Table 5-27. Calculate dosing based on body weight. Medications used for infants and young children are the same as those recommended for adults, except atovaquone-proguanil, which should not be used for prophylaxis in children weighing <5 kg because of lack of data on safety and efficacy. Doxycycline should not be recommended for malaria prophylaxis for children aged <8 years. Although doxycycline has not been associated with dental staining when given as a routine treatment for some infections, other tetracyclines might cause teeth staining.

Atovaquone-proguanil, chloroquine, and mefloquine have a bitter taste. Mixing pulverized tablets in a small amount of food or drink can facilitate the administration of antimalarial drugs to infants and children. Clinicians also can ask compounding pharmacists to pulverize tablets and prepare gelatin capsules with calculated pediatric doses. A compounding pharmacy can alter the flavoring of malaria medication tablets so that children are more willing to take them. The Find a Compounder section on the Alliance for Pharmacy Compounding website (281-933-8400) can help with finding a compounding pharmacy. Because overdose of antimalarial drugs, particularly chloroquine, can be fatal, store medication in childproof containers and keep out of the reach of infants and children.

Personal Protective Measures & Repellent Use

Children should sleep in rooms with air conditioning or screened windows, or sleep under mosquito nets when air conditioning or screens are not 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. Clothing and mosquito nets can be treated with an insect repellent/insecticide (e.g., permethrin) that repels and kills ticks, mosquitoes, and other arthropods. Permethrin remains effective through multiple washings. Clothing and mosquito nets should be retreated according to the product label. Permethrin should not be applied to the skin.

Although permethrin provides a longer duration of protection, recommended repellents that can be applied to skin also can be used on clothing and mosquito nets (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods, for more details about these protective measures). The Centers for Disease Control and Prevention (CDC) recommends using US Environmental Protection Agency (EPA)–registered repellents containing one of the following active ingredients: DEET (N,N-diethyl-m-toluamide); picaridin; oil of lemon eucalyptus (OLE); PMD (para-menthane-3,8-diol); IR3535; or 2-undecanone (methyl nonyl ketone). Repellent products must state any age restriction; if no age restriction is provided, EPA has not required a restriction on the use of the product. Most EPA-registered repellents can be used on children aged >2 months, except products containing OLE or PMD that specify they should not be used on children aged <3 years. Insect repellents containing DEET, picaridin, IR3535, or 2-undecanone can be used on children without age restriction.

Many repellents contain DEET as the active ingredient. DEET concentration varies considerably between products. The duration of protection varies with DEET concentration; higher concentrations protect longer; products with DEET concentration >50% do not, however, offer a marked increase in protection time.

The EPA has approved DEET for use on children without an age restriction. If used appropriately, DEET does not represent a health problem. The AAP states that the use of products with the lowest effective DEET concentrations (i.e., 20%–30%) seems most prudent for infants and young children, on whom it should be applied sparingly. For more tips on protecting babies and children from mosquito bites, see Box 7-04.

Combination products containing repellents and sunscreen are generally not recommended because instructions for use are different, and sunscreen might need to be reapplied more often and in larger amounts than repellent. In general, apply sunscreen first, and then apply repellent. Mosquito coils should be used with caution in the presence of children to avoid burns and inadvertent ingestion. For detailed information about repellent use and other protective measures, see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods.

Rabies

Depending on travel destination and activities, animal exposures and bites might be a health risk for pediatric travelers. Worldwide, rabies is more common in children than adults. In addition to the potential for increased contact with animals, children also are more likely to be bitten on the head or neck, leading to more severe injuries. Counsel children and their families to avoid all stray or unfamiliar animals and to inform adults of any animal contact or bites. Bats throughout the world have the potential to transmit rabies virus.

Travelers should clean all bite and scratch wounds as soon as possible after the event occurs by using soap and water, or povidine iodine if available, for ≥20 minutes to prevent infections, (e.g., rabies). Wounds contaminated with necrotic tissue, dirt, or other foreign materials should be cleaned and debrided promptly by health care professionals, where possible. A course of antibiotics might be appropriate after animal bites or scratches, because these can lead to local or systemic infections. For mammal bites and scratches, children should be evaluated promptly to assess their need for rabies postexposure prophylaxis (see Sec. 4, Ch. 7, Zoonotic Exposures: Bites, Stings, Scratches & Other Hazards; and Sec. 5, Part 2, Ch. 18, Rabies).

Because rabies vaccine and rabies immune globulin might not be available in certain destinations, encourage families traveling to areas with high risk for rabies exposure to seriously consider preexposure rabies vaccination and to purchase medical evacuation insurance, depending on their destination and planned travel activities (see Sec. 7, Ch. 4, Vaccine Recommendations for Infants & Children, and Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance).

Soil & Water Contact: Infections & Infestations

Children are more likely than adults to have contact with soil or sand, and therefore could be exposed to diseases caused by infectious stages of parasites in soil, including ascariasis, hookworm, cutaneous or visceral larva migrans, strongyloidiasis, and trichuriasis. 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.

Schistosomiasis is a risk to children and adults in endemic areas. While in schistosomiasis- endemic areas (see Sec. 5, Part 3, Ch. 20, Schistosomiasis), children should not bathe, swim, or wade in fresh, unchlorinated water (e.g., lakes, ponds).

Noninfectious Hazards & Risks

Air Travel

Although air travel is safe for most newborns, infants, and children, people traveling with children should consider a few issues before departure. Children with chronic heart or lung problems might be at risk for hypoxia during flight, and caregivers should consult a clinician before travel.

Ear Pain

Ear pain can be troublesome for infants and children during descent. Pressure in the middle ear can be equalized by swallowing or chewing; thus, infants should nurse or suck on a bottle, and older children can try chewing gum. Antihistamines and decongestants have not been shown to be of benefit. No evidence suggests that air travel exacerbates the symptoms or complications associated with otitis media.

Jet Lag

Travel to different time zones, jet lag, and schedule disruptions can disturb sleep patterns in infants and children, just as in adults (Sec. 8, Ch. 4, Jet Lag).

Safety Restraints

Travelers also should ensure that children can be restrained safely during a flight. Severe turbulence or a crash can create enough momentum that an adult cannot hold onto a child. The safest place for a child on an airplane is in a government-approved child safety restraint system (CRS) or device. The Federal Aviation Administration (FAA) strongly urges travelers to secure children in a CRS for the duration of the flight. Car seats cannot be used in all seats or on all planes, and some airlines might have limited safety equipment available. Travelers should check with the airline about specific restrictions and approved child restraint options. FAA provides additional information.

Altitude Illness & Acute Mountain Sickness

Children are as susceptible to the deleterious effects of high elevation travel as adults (see Sec. 4, Ch. 5, High Elevation Travel & Altitude Illness). Slow ascent is the preferable approach for avoiding acute mountain sickness (AMS). Young children unable to talk can show nonspecific symptoms (e.g., loss of appetite or irritability, unexplained fussiness, changes in sleep and activity patterns). Older children might complain of headache or shortness of breath. If children demonstrate unexplained symptoms after an ascent, descent could be necessary.

Acetazolamide is not approved for pediatric use in children aged <12 years for altitude illness but is generally safe for use in children for other indications. Some providers prescribe acetazolamide to prevent AMS in pediatric travelers <12 years of age when a slow ascent is not feasible. The dose is 2.5 mg/kg every 12 hours, up to a maximum of 125 mg per dose, twice a day. No liquid formulation is available, but tablets can be crushed or packaged by a compounding pharmacy for a correct dose.

Drinking Water Contaminants

Drinking water disinfection does not remove environmental contaminants (e.g., lead or other metals). Travelers might want to carry specific filters designed to remove environmental contaminants, particularly for travel where the risk for exposure is greater due to larger amounts of water consumed (e.g., long-term travel or when living abroad). Filters should meet National Science Foundation (NSF) and American National Standards Institute (ANSI) standards 53 or 58.

Injuries

Accommodations: Hotels & Other Lodgings

Conditions at hotels and other lodgings abroad might not be as safe as those in the United States; adults traveling with children should carefully inspect accommodations for paint chips, pest poisons, inadequate balcony or stairway railings, or exposed wiring.

Adult caregivers should plan to provide a safe sleeping environment for infants during international travel. Caregivers should follow general recommendations from the AAP task force on preventing sudden infant death syndrome (SIDS) and other sleep-related causes of infant death. Cribs in some locations might not meet US safety standards. Additional information about crib safety is available from the US Consumer Product Safety Commission.

Motor Vehicles

Vehicle-related injuries are the leading cause of death in children who travel. Whenever traveling in an automobile or other vehicle, children should be properly restrained in a car seat, booster seat, or with a seat belt, as appropriate for their age, height, and weight. See information about child passenger safety. Car seats often must be brought from home because well-maintained and approved seats might not be available (or limited in availability) in other countries.

In general, children ≤12 years of age are safest when properly buckled in the rear seat of the car while traveling; no one should ever travel in the bed of a pickup truck. Advise families that cars might lack front or rear seatbelts in many low- and middle-income countries. Traveling families should attempt to arrange transportation or rent vehicles with seatbelts and other safety features.

All family members should wear helmets when riding bicycles, motorcycles, or scooters. Pedestrians should take caution when crossing streets, particularly in countries where cars drive on the left, because children might not be used to looking in that direction before crossing.

Water-Related Injuries & Drowning

Drowning is the second leading cause of death in young travelers. Children might not be familiar with hazards in the ocean or in rivers. Swimming pools might not have protective fencing to keep toddlers and young children from accessing pool areas unattended. Adults should closely supervise children around water. An adult with swimming skills should be within an arm’s length when infants and toddlers are in or around pools and other bodies of water; even for older children and better swimmers, the supervising adult should focus on the child and not be engaged with any distracting activities.

Water safety devices (e.g., personal flotation devices [lifejackets]) might not be available abroad, and families should consider bringing these from home. In addition, adults should ensure children wear protective footwear to avoid injury in many marine environments.

Sun Exposure

Sun exposure, and particularly sunburn before age 15 years, is strongly associated with melanoma and other forms of skin cancer (see Sec. 4, Ch. 1, Sun Exposure). Exposure to ultraviolet (UV) light is greatest near the equator, at high elevations, during midday (10 a.m.–4 p.m.), and where light is reflected off water or snow.

Physical, also known as inorganic, UV filters (sunscreens) generally are recommended for children aged >6 months. Less irritating to children’s sensitive skin than chemical sunscreens, physical UV filters (e.g., titanium oxide, zinc oxide) 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 in young infants is considered a medical emergency.

Advise parents that babies should be kept in the shade and dressed in 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. For older children, sun-blocking shirts made for swimming preclude having to apply 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 used, apply the sunscreen first and the insect repellent second (i.e., over the sunscreen). Because insect repellent can diminish the level of UV protection provided by the sunscreen by as much as one-third, children should also wear sun-protective clothing, reapply sunscreen, or decrease their time in the sun, accordingly.

Other Considerations

Identification

In case family members become separated, each infant or child should carry identifying information and contact numbers in their clothing or pockets. Because of concerns about illegal transport of children across international borders, parents traveling alone with children should carry relevant custody papers or a notarized permission letter from the other parent.

Insurance

As with adult travelers, verify insurance coverage for illnesses and injuries while abroad before departure. Travelers should consider purchasing special medical evacuation insurance for an airlift or air ambulance transport to facilities capable of providing adequate medical care (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance).

Travel Stress

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