Travel Medicine

Abstract

Injuries to children while traveling is an important topic in travel medicine. Traffic injuries and drowning are the first and second leading causes of death in children who travel, and are a far greater risk than infectious and chronic diseases. Effective prevention strategies are available, particularly for travelers who find themselves in unfamiliar environments and who may be unaware of the potential risks to their family. Despite greater understanding and increased research efforts in this field, data on the magnitude and severity of injuries are still incomplete or unreliable in many countries, but some general advice to parents, children, and adolescents can help keep them safe while traveling.

Introduction

In 2011, approximately 58.7 million US citizens traveled outside the United States. Global travel is on the rise and families can now travel more inexpensively to locations that were previously inaccessible. With expansion of travel itineraries, more travelers than ever are accompanied by family members, including children and adolescents. The number of children who travel or live outside their home countries has also increased dramatically. An estimated 1.9 million children travel overseas each year ¹ and are exposed to many unfamiliar and potentially hazardous environments.

Injuries are still one of the leading causes of death among international travelers and the leading cause of death to healthy US citizens traveling abroad.

Whereas most travelers do not encounter serious health problems in new travel environments, injuries are still one of the leading causes of death among international travelers and the leading cause of death to healthy US citizens traveling abroad. By comparison, infectious diseases account for only about 2% of deaths among US travelers. ³ Contributing to the injury toll while traveling is exposure to unfamiliar and perhaps risky environments; differences in language and communications, less stringent product safety and vehicle standards, and unfamiliar rules and regulations; a carefree holiday or vacation spirit leading to more risk-taking behaviors; and overreliance on travel and tour operators to protect one’s safety and security. ³

Injuries are not inevitable—they can often be prevented or controlled. Modifying environments and changing behavior can play a critical role in reducing the risk of injuries while traveling, especially while traveling with children and adolescents. Travel and country-risk factors and strategies to avoid injuries should be discussed in pretravel consultations with travel medicine clinics, tour guides, and travel agents and among family members.

Travelers should be advised about traffic and water safety; environmental risks such as sun, water, and food; and personal safety. They should be prepared to develop a plan for dealing with medical emergencies, to make sure that they bring sufficient medication(s) for children with chronic medical conditions as well as a note from the child’s primary care provider explaining the child’s condition and treatment plan, and advised on the importance of purchasing adequate medical and emergency evacuation insurance coverage. Adult caregivers should be prepared to provide close supervision of children, be aware of basic first-aid procedures, and know how to access appropriate care, if needed, at their travel location. ⁴

Data on injuries to children who are traveling are hard to obtain, particularly in developing countries. Few countries have injury surveillance systems that produce reliable data on injuries. There are few standardized injury indicators that are used worldwide, particularly when it comes to nonfatal outcomes. In addition, there is widespread underreporting of fatal and nonfatal injuries in many countries.^5,6 These surveillance gaps hinder to the development of effective interventions, especially in countries where the environmental risks for injury are the greatest.

Epidemiology of Pediatric Injuries

Injuries are a major cause of death and worldwide account for 6 of the 15 leading causes of death among persons aged 5 to 44 years and about 40% of all child deaths. ⁵ In 2004, injuries caused approximately 950 000 deaths in children and young people less than 18 years old, with mortality rates of 80.9 deaths per 100 000 among children 0 to 4 years old, 39.9 per 100 000 among children 5 to 14 years old, and 79.5 per 100 000 among young people 15 to 29 years old. ⁵ Unintentional injuries account for almost 90% of these cases and are the leading cause of death for children aged 10 to 19 years. ⁶ Most of these child injuries were the result of traffic crashes, drowning, burns (fire or scalds), falls, or poisoning. Head injuries are the single most common—and potentially most severe—type of injury sustained by children.

Injuries vary by age. Among infants, suffocation, fires, drowning, and falls are the leading causes of injury death in many countries. Among 1- to 4-year-olds (as children start to move about independently), drowning is the leading cause of injury-related death, followed by motor vehicle traffic crashes (including pedestrian injuries) and fires. In children aged 5 to 9 years in Asia, for example, drowning, road traffic injuries, and animal bites are the main causes of death. ⁶ Among minor injuries incurred by children, cuts and bruises are those seen most frequently. Fractures to the arm and leg are the most common nonfatal injuries requiring hospitalization among children younger than 15 years. ⁶

Pediatric Travel Injuries

Many of the injury risks that children face while traveling are likely similar to the risks they face at home; however, global data on the incidence of various pediatric injuries associated with international travel are limited. The levels of protection available overseas and access to quality medical care may be substandard or absent in many travel locations, making injury prevention even more important while traveling overseas.

An analysis of 2007-2009 US State Department data by the CDC found that an estimated 2352 US citizens died from injuries and violence while in foreign countries (excluding deaths occurring in Iraq and Afghanistan). Motor vehicle crashes were the most common cause (32%), followed by homicide (18%) and drowning (14%). ³ By comparison in the United States during 2003 alone, motor vehicle crashes accounted for 27% of injury deaths, homicide 11%, and drowning 2%. In a study that estimated the American tourist population by using data from the World Tourist Organization, a crude US traveler injury mortality rate of 9.1 per 1000 travelers was calculated, compared with 7.6 per 1000 within the United States. ⁷

Injuries have been reported as the primary reason for US travelers to be transported back to the United States by air medical transport, with the main nonfatal causes being motor vehicle traffic crashes (45%); falls (8%); sports injuries, including diving into shallow water (4.5%); boating incidents (2%); aircraft crashes (1.5%); and burns and electrical shocks (1%).^8,9 No data exist to determine risks to specific age groups of children or the circumstances surrounding injuries incurred by children while traveling overseas (US State Department, personal communications).

Road Traffic Injuries

Road traffic injuries are those related to crashes involving drivers and passengers of motor vehicles, trucks, minivans, buses, motorcycles and motorbikes, and bicycles and injuries to pedestrians when hit by a motor vehicle. Traffic injuries are the most serious of risks while traveling. In 2004, road traffic injuries accounted for approximately 262 000 deaths among children and youth younger than 20 years around the world—almost 30% of all injury deaths among children. ⁶ Globally, road traffic injuries are the leading cause of death among 15- to 19-year-olds and the second leading cause among 5- to 14-year-olds, with mortality rates of 12.4 deaths per 100 000 population among children aged 0 to 4 years, 9.8 per 100 000 among children aged 5 to 14 years, and 15.7 per 100 000 among young people aged 15 to 29 years. ⁵ The higher rates of mortality among older children are likely a result of this increased mobility as well as of their increased tendency to engage in risk-taking behaviors. ⁶

Although young children do not drive motor vehicles, they use roads as pedestrians, bicyclists, and occupants of vehicles. ³ The small stature of children makes them less visible and increases their risk in a road environment. When hit, children are also more likely than adults to sustain a head or neck injury and are more vulnerable to the impact of injury than adults. ⁶

The number of children injured or disabled each year as a result of road traffic crashes is not known but has been estimated at around 10 million. This estimate is based on data from health care institutions that suggest that children make up 20% to 25% of those admitted to a hospital for injuries resulting from a motor vehicle crash. ⁶ However, community-based surveys from Asia suggest that the figure could be much higher. ¹⁰ The head and limbs are the most common parts of the body injured in children involved in a motor vehicle crash. The severity of injuries depends on the age of the child, road user type, and whether protective devices (such as seat belts) were used.

Road traffic injury risk factors

Road traffic injuries are common among international travelers of all ages for a variety of reasons. In many developing areas of the world, unsafe roads and vehicles and an inadequate transportation infrastructure contribute to traffic crashes and injuries. Streets and roads in many countries often do not afford the protection of crosswalks, signals and signs, and pedestrian refuge islands. Negotiating pedestrian crossings in a country where cars drive on the opposite side of the road can be challenging and dangerous for children and adults. An additional risk for crashes and injuries in developing countries is the fact that cars, buses, and large trucks share the road with pedestrians, motorbikes, bicycles, rickshaws, and animals. Other factors that can increase the risk for motor vehicle crashes and injuries include the following:

• lack of familiarity with roads;

• use of alcohol, sleep aids, or drugs (including use among hired drivers);

• driving on the opposite side of the road than in one’s home country;

• poorly made or maintained vehicles that lack seat belts, air bags, child restraints, or rollover protection;

• travel fatigue and jet lag;

• poor visibility as a result of lack of adequate lighting, both on the road and on the vehicle;

• overloaded buses, cars, commercial vehicles, trucks, and public transport conveyances; and

• poorly designed, constructed, or maintained roads, especially in mountainous terrains.

Drowning

In 2004, approximately 175 000 children and adolescents younger than 20 years around the world died as a result of drowning, with mortality rates of 18.9 deaths per 100 000 population among children 0 to 4 years old, 9.5 per 100 000 among children 5 to 14 years old, and 5.0 per 100 000 among young people 15 to 29 years old.^5,6 In many Southeast Asian and western Pacific countries, drowning is the leading cause of child injury deaths. Global data show that approximately 28% of all unintentional injury deaths among children are a result of drowning. ⁶ In the United States, more than 25% of fatal drowning victims are children 14 years old and younger, and drowning is the second leading cause of unintentional injury-related death for children aged 1 to 14 years. ¹ In 2005, 3582 fatal unintentional drownings occurred in the United States, an average of 10 deaths per day. An additional 710 people died in boating-related incidents, which included drowning and other causes. ³ Among US citizens visiting countries where the environment supports water recreation as a major tourist attraction, drowning is also the leading cause of injury death, accounting for 13% of deaths of US citizens abroad; drowning is the second leading cause of death in young travelers. ⁴

No accurate estimates are available of the number of serious nonfatal cases of travel-related drowning among children and adolescents. WHO global estimates for nonfatal drowning among children ≤14 years old range from 2 million to 3 million each year. ⁶ In the United States, for every child who dies from drowning, another 4 receive emergency department care for drowning-related injuries. ¹¹ Nonfatal drownings can cause brain damage that may result in long-term disabilities, including memory problems, learning disabilities, and permanent loss of basic functioning (ie, permanent vegetative state). One study also found that two thirds of quadriplegic spinal injury admissions have been linked with a history of diving too steeply into shallow water while on vacation. ¹²

Drowning risk factors

Drowning rates in most rural areas and in low- and middle-income countries, especially those in temperate regions, are generally higher than in urban and high-income countries, especially among high-risk groups such as toddlers. ¹³ The risk factors for drowning among international travelers have not been clearly defined but are suspected to be related to lack of swimming ability, unfamiliarity with local water currents, changing water conditions, and the absence of lifeguards. Very little epidemiology of childhood drowning is available from global studies, so most of the information below derives from US studies. Risk factors for drowning in children and adolescents in the United States include the following:

• Age and developmental stage: children younger than 5 years are at highest risk, followed by adolescents aged 15 to 19 years. A small child can drown in a few centimeters of water at the bottom of a bucket, in the bath, or in an agricultural setting. Children younger than 1 year most often drown in bathtubs, buckets, or toilets. Among children 1 to 4 years old, most drownings of US children occur in residential swimming pools. ¹⁴

• Gender: the rate of drowning in boys in the United States is nearly twice the rate among girls. ¹⁴

• Lack of lifeguards or supervision by parent or caregiver: many swimming environments have no lifeguards, and studies have shown that the presence of lifeguards, especially lifeguards who are trained in close visual supervision, can be a protective factor.^15,16 Inadequate parental or caregiver supervision is an important risk factor for pediatric drowning. In the United States, most young children who drowned in residential pools were last seen inside the home, had been out of sight for less than 5 minutes, and were in the care of one or both parents at the time. ¹⁷

• Lack of barrier environments: in many countries, swimming pools, open bodies of water, wells, and rainwater collection containers are not protected by fencing or barriers to keep children from gaining access without caregivers’ awareness. ¹⁸

• Natural water settings: in the United States, most drownings in children older 15 years of age occur in “natural” water settings, such as lakes, rivers, and the ocean. ¹⁹ Children may not recognize environmental hazards in unfamiliar ocean or river environments. Hypothermia, rather than simply drowning, is the main cause of death at sea.

• Absence of life jackets: In 2006, the US Coast Guard received reports for 4967 boating incidents; 3474 boaters were reported injured, and 710 died. Among those who drowned, 9 out of 10 were not wearing life jackets. ³

• Unsafe vessels: in many countries, people are regularly transported in unsafe or overcrowded boats. The capsizing of boats, launches, and ferries is a particular risk during the rainy season and at periods, such as national holidays, when there are likely to be many people crowding onto boats. ³ Vessel safety standards and their enforcement vary widely around the world.

• Alcohol: adults who are driving watercrafts put themselves and their children at great risk when they are impaired by alcohol. Alcohol use is involved in up to half of adolescent and adult deaths associated with water recreation and about 1 in 5 reported boating fatalities. ²⁰ Alcohol can trigger hypoglycemia and cause a rapid fall in body temperature. Alcohol influences balance, coordination, and judgment, and its effects are heightened by sun exposure and heat.

• Seizure disorders: for children and adolescents with seizure disorders, drowning is the most common cause of unintentional injuries. ⁶

• Pool and spas: serious injuries can occur close to outlets where suction is strong enough to catch small body parts or hair, so that the head is trapped under water. Other risks are related to slipping and tripping, causing a fall that leads to loss of consciousness on impact. ³

Fires and Burns

In 2004, a little more than 310 000 people worldwide died as a result of fire-related burns, of whom 30% were younger than 20 years. ⁵ Fire-related burns are the 11th leading cause of death for children 1 to 9 years of age. Overall, children are at high risk for death from burns, with worldwide mortality rates of 6.6 deaths per 100 000 population among children 0 to 4 years old, 2.5 per 100 000 among children 5 to 14 years old, and 3.9 per 100 000 among young people 15 to 29 years old. ⁵ Among all people globally, infants have the highest death rates from burns. Small children have a lower resistance to burn trauma and are less able to escape in a fire emergency. For children older than 3 years, smoke inhalation is strongly associated with mortality.

Little global data on nonfatal outcomes from burns are available. However, the WHO Global Burden of Disease project for 2004 makes it clear that burns are an important contributor to the overall disease burden in children. ⁵

Whereas burns from fire contribute to the majority of burn-related deaths in children, scalds and contact burns are an important factor in overall morbidity from burns and a significant cause of disability. The skin of infants and young children burns more deeply and quickly and at lower temperatures than the thicker skin of adults. In addition, children’s larger ratio of body surface area to volume means that not only will the size of a burn—for a given volume of hot liquid—be greater than that for an adult, but also, there will be more fluid lost from the burned area, thus complicating the management of the injury. Chemical and electrical burns among children, though, are relatively rare. ⁵

Scald burns are the most frequent type of burn among children younger than 6 years. Typical scald burns occur when a child pulls down a container of hot fluid, such as a cup of tea or coffee, onto his or her face, upper extremities, and trunk. These are typically superficial second-degree burns. Apart from the pain they cause the child and the distress for the parents, these burns will typically heal within weeks, leaving little or no permanent damage. ⁵

Burns to the palms of the hands are common among infants younger than 1 year as a result of touching cups containing hot drinks, heaters, cooking equipment, or hot-water pipes. Because a child has thinner skin on the palms and slower withdrawal reflexes, such contact burns may be deep and thus require prolonged and careful therapy during the healing phase to prevent flexure contractures of the hand. ⁵

Fire and burn risk factors

Fires can be a significant risk in developing countries where building codes are not present or enforced, there may not be smoke alarms in buildings, or there may be no access to emergency services. ³ Most burns to children occur in the kitchen or food preparation areas. Other risk factors for burn injuries in children include the following:

• Unsafe equipment: hotels and residences in many countries are not designed to accommodate the safety of small children and often have unsafe electrical appliances, plugs, wires, and other connections that increase the risk of electrical burns for children. ⁵ Bathroom faucets may have different letters used for hot and cold, and water from the tap may be scalding hot. In some developed countries, plumbing standards require “temperature-limiting devices” to protect from accidental scald burns. Equipment used for heat, light, and cooking for camping may be inherently unsafe. Heating or cooking on open fires that are not enclosed pose significant dangers to children. ¹⁸

• Preexisting health problems: disabled children have a significantly higher incidence of burn injuries than nondisabled children. Children who suffer from uncontrolled epilepsy also appear to be at greater risk for burn injuries. ⁵

• Fireworks: many countries celebrate religious or national festivals by setting off fireworks, which pose a significant risk of burn injuries for children, particularly adolescent boys. ⁵ There is less regulation on the manufacture, sale, and distribution of fireworks in other countries, and their use can be inherently dangerous, whether abroad or in the United States.

• Combustion: flammable substances such as gasoline, kerosene, and paraffin can combust easily and are a serious fire and burn hazard. Old gas stoves may require a match to light the oven, creating an explosion hazard if gas accumulates before lighting.

• Sun exposure: overexposure to the sun, especially in countries close to the equator, can cause severe debilitating sunburn and sunstroke, particularly in light-skinned persons. Adverse skin reactions can also occur with sun exposure while taking antimalarial drugs or antibiotics. UV radiation can penetrate clear water to a depth of 1 m or more, ²¹ so use of a high-SPF-rated sunscreen is essential.

Falls

In 2004, an estimated 424 000 people of all ages died from falls worldwide. In 2004, nearly 47 000 children and youth worldwide younger than 20 years died as a result of a fall, with mortality rates of 2.8 deaths per 100 000 population among children 0 to 4 years old, 1.2 per 100 000 among children 5 to 14 years old, and 1.7 per 100 000 among young people 15 to 29 years old. ⁵ Falls are the twelfth leading cause of death among 5- to 9-year-olds and 15- to 19-year-olds. ⁵

Global statistics on nonfatal injuries from falls are not readily available. In most countries, falls are the most common type of childhood injury seen in emergency departments, accounting for 25% to 52% of assessments. ²² Falls were also identified as the leading cause of injury among 13- to 15-year-olds in the Global School Health Survey, covering 26 countries. ²³

Because children tend to use their arms to protect their heads when falling from a height, limb fractures, particularly of the forearm, are the most common type of fall-related injury in children beyond the age of infancy. ²⁴ Falls are also a leading cause of traumatic brain injury, especially in young children, with a significant risk of long-term consequences. In the United States, about one third of the 1.4 million people suffering traumatic brain injuries are children aged ≤14 years, who have disproportionately high rates of falls compared with other age groups. ⁶

Fall risk factors

The following are risk factors for falls:

• Gender: boys are at greater risk for both fatal and nonfatal falls;

• Height of fall: generally, the greater the height from which a child falls, the more severe the injury. Injuries from falls from heights of more than 2 stories typically involve falls from windows, balconies, and roofs. Falls from stairs, trees, and playground equipment are also common, as are falls into ditches, wells, shafts, and other holes in the ground. ⁶ Children who are traveling may also be at risk of falling when waking up in an unfamiliar setting at night, for example, in hotels where they may not remember where stairs are located or when sleeping in the top bunk of a bunk bed.

• Physical environment: in many developing countries, safety regulations maybe unenforced or nonexistent. As a result, there may be a variety of risks to children such as lack of window guards in high-rise buildings, low balcony railings with enough space for young children to crawl through, or amusement park rides that are rarely inspected. ¹⁸ Falls are more likely to occur with greater exposure to overcrowding and environmental hazards. ⁶

Bites and Stings

Children tend to be fascinated with animals but can use poor judgment around them. They may not report minor bites and stings. Children are particularly vulnerable to dog bites as a result of their small stature and the fact that their face is usually close to that of the dog. Dog bites are a potentially serious injury and a frequent cause of hospitalization, but they are only rarely fatal. Among children, the rate of dog bite–related injuries is highest for those 5 to 9 years old. Children are more likely than adults to be bitten on the head or neck, leading to more severe injuries. ⁶

Animal bites in many developing countries can carry the added risk of rabies. In many areas where rabies exists—including India, China, and many parts of Africa—40% of cases occur in children. Rabies is the tenth most common cause of death from infection worldwide, and there is evidence that 30% to 60% of the victims of dog bites in areas endemic for canine rabies are children younger than 15 years of age. ⁶ Most children who die from rabies were either not treated or else received inadequate postexposure treatment. Many bite victims do not receive rabies immunoglobulin because of a perennial global shortage.

Travelers to tropical, subtropical, and desert areas should be aware of the risks of venomous snakes, scorpions, and spider bites and stings. All venomous bites should be considered a medical emergency requiring immediate medical attention. Aquatic animals such as eels, stingrays, scorpionfish, jellyfish, sea lice, and many forms of coral and sea urchins can inflict serious harm. Swimming in waters populated with these organisms carries a high risk for children.

Bite and sting risk factors

Stray dogs are common in many developing countries. “Bat caves” are popular tourist attractions in many countries. Monkeys congregate around temples and other shrines in Southeast Asia, and some may have rabies.^1,18 Swimming in unfamiliar water environments, camping without insect repellents or protection, outdoor exposures at night, and walking in hostile and unfamiliar environments can increase exposure to bites and stings.

In addition to bites, there are also risks of other injuries associated with animals. Studies from several developing countries point to the increasing number of cases in recent years of children and young people presenting to hospital emergency departments as a result of falling from horses ⁶ and tripping over household pets such as dogs and cats. ²⁵ Travelers with children should be aware of these risks when allowing children to take part in activities such as horseback riding or when interacting with pets and other animals.

Poisoning

An estimated 345 814 people of all ages died worldwide as a result of poisoning in 2004, with an estimated 45 000 poisoning deaths in children and young people under the age of 20 years. ⁵ Among 15- to 19-year-olds, poisoning ranks as the 13th leading cause of death. The global death rates from poisonings are highest in the 0- to 4-year-old group (7.9 deaths per 100 000 population) followed by 15- to 29-year-olds (4.0 per 100 000).^5,6

Data from poison control centers and hospitals ⁶ indicate that the most common agents involved in child poisonings are the following:

• over-the-counter medications, such as aspirin, ibuprofen, cough and cold remedies, iron tablets, antihistamines, and anti-inflammatory drugs;

• prescription medications, such as antidepressants, narcotics, and analgesics;

• recreational drugs, such as cannabis and cocaine;

• household products, such as bleach, disinfectants, detergents, cleaning agents, cosmetics, and vinegar;

• pesticides, including insecticides, rodenticides, and herbicides;

• poisonous plants; and

• animal or insect repellents.

Accurate global data on nonfatal outcomes of poisoning are not available. Data from 2006 from the American Association of Poison Control Centers showed that the most common poisonings among children related to pharmaceutical products. Inquiries relating to children <6 years old made up 50.9% of cases and 2.4% of the total reported fatalities. ²⁶

Poisoning risk factors

The following are some of the risk factors for poisoning:

• Appearance: studies have shown that children prefer, and are therefore more likely to ingest, liquids rather than solids, clear liquids rather than dark-colored ones, and small solids rather than large solids. ⁶ Bright colors in solid medications may also make them more attractive to children.

• Unsafe storage environment: the most obvious risk factor for ingestion of a toxic substance is its presence and access within reach of a child. Even when dangerous products are stored in distinctive containers with visual warning labels (eg, skull and crossbones images), younger children often do not understand the meanings of these signs. ⁶ Some studies suggest that stickers such as a skull and crossbones and “Mr Yuk” are ineffective deterrents, and some can even attract children to the toxic product.^27,28

• Labeling: the “child-resistant” label does not mean it is childproof. Tests have shown that up to 20% of children aged 42 to 51 months can open a child-resistant container. ²⁹ When the top of a tamper-proof container is not replaced properly, its poison-prevention value is lost.

• Exposure: any repellent should be used in strict accordance with the manufacturer’s instructions, and the dosage must not be exceeded, especially for young children and among pregnant women. ²¹

Factors determining the severity of poisoning and its outcome in children include the type of poison, the dose, the route of exposure, the age of the child, child nutrition, and comorbidities.

Travel Advice for Parents and Caregivers

Not all travel is safe for children. Prevention is the best way to stay safe while traveling.^3,8,18,30 Families should be advised to take note of the following:

• Check the health, safety, and security information for travel destinations on the Centers for Disease Control and Prevention’s (CDC) Travelers’ Health (www.cdc.gov/travel and the US Department of State (www.travel.state.gov) Web sites. Parents should consider learning basic first aid and cardiopulmonary resuscitation (CPR) and have a travel medicine or first-aid kit customized to their itinerary. ¹⁸

• Talk to children and adolescents before traveling. Parents should inform them of the risks of various injuries and appropriate prevention strategies. Parents should always encourage children to wear safety devices and act as role models for children by adopting safe behaviors, exercising caution in unfamiliar environments, and using safety devices.^1,18

• Be sure to find out what kind of immunizations are required for you and your family for your specific destination. Consult the CDC’s book Health Information for International Travel (“Yellow Book”) for specific guidance. The Yellow Book, which was originally intended for health care providers, is useful for anyone traveling abroad—people on vacation, business people, recent immigrants returning to visit friends and relatives, people adopting internationally, and missionaries. It is also helpful for the travel industry because they advise travelers (www.cdc.gov/travel)

• Children with chronic health conditions should be advised to wear a MedicAlert identification in case emergency health care is required while abroad. Such identification may help a health care professional access medical information about the traveler in the event of an emergency. ¹⁸

• Avoid unnecessary risk taking while traveling. Many tourists travel to get away from their usual routines. Although this may provide novel experiences, it can also increase injury risks (such as driving a motorcycle for the first time or driving on unsafe roads). Adolescents, in particular, may be inclined to take risks which can lead to injury or death. ⁴

• Prior to departure, identify doctors and hospitals in cities to be visited. For foreign destinations, these can often be obtained from the International Society of Travel Medicine (www.istm.org) and the International Association for Medical Assistance to Travelers (www.iamat.org). Embassies and consulates also have lists of local, English-speaking physicians^3,18,30 and hospitals overseas.

• In the event of emergencies, parents should try to take their children to the largest medical facility in the area or a facility that specializes in treating specific injuries (eg, burns). Such facilities are more likely to have pediatric units and trauma services. Before leaving the facility, parents should ask for the diagnosis, the results of tests performed, and treatments administered, in writing if possible. This information will be very helpful in addressing treatment and rehabilitation back home ¹⁸ as well as for insurance purposes. Medical care facilities in many countries are inadequate to provide rapid, effective, or safe medical treatment, in which case the traveler should seek needed medical care in a neighboring country. US embassies and consulates can advise travelers about available medical facilities and the closest location for specialized care.

• Carry an international-capable cellular phone or mobile communications device, both for emergency contacts within the country you are traveling in as well as for help you may need from abroad.

Prevention Recommendations for Lifestyle Counseling

Traffic Injury Prevention

• Bring a child safety seat or booster seat from home or get one at the travel destination.

• Use safety belts and child safety seats whenever possible, rent newer vehicles with safety belts and airbags, and look for well-maintained newer vehicles to rent.

• Avoid riding a motorcycle or motorbike if you’ve never done so; vacationing in a foreign land is not a good time to learn how to ride safely.

• Rent larger vehicles if possible because they provide more protection in a crash; avoid riding at night or on mountainous roads (or the combination).

• Try to ride only in taxis with functional safety belts and ride in the rear seat.

• Wear helmets when riding motorcycles, motorbikes, bicycles, or horses; if helmets are likely to be unavailable at the destination, bring them from home.

• Consider hiring a driver familiar with the destination and the language and an expert in maneuvering through local traffic.

• Avoid riding on overcrowded, overweight, top-heavy vehicles or riding with any driver who has consumed alcohol or appears intoxicated.

• Visit the Web sites of the Association for International Road Travel (www.asirt.org) and Make Roads Safe (www.makeroadssafe.org) organizations, which have useful safety tips for international travelers, including road safety checklists and country-specific driving risks.

Drowning Prevention

• Close supervision of children around water is essential at all times.

• Children should always wear life jackets around water; life jackets may not be available abroad, so consider bringing them from home.

• Avoid unsafe or overcrowded small boats or vessels.

• Seek advice about currents and tides before swimming in open water.

• Use only reliable, scheduled, and official water sports services for potentially dangerous activities such as scuba diving or jet skiing.^1,3,18

• Remain cautious of sources of carbon emissions in motor boats, and make swimming off the back of the boat off limits because it can be a major source of carbon monoxide poisoning; even emissions from moving motor boats can cause harm.

Fire and Burn Prevention

To minimize the risk of fire-related injuries, whenever possible select accommodations on the 6th floor or below (fire ladders generally cannot reach above the 6th floor). Stay in hotels with smoke alarms and preferably sprinkler systems (carry your own battery-operated smoke alarm if you are not sure). Travelers should identify 2 escape routes from buildings. Escape a fire by crawling low under smoke and by covering the mouth with a wet cloth. ³

• Teach children to “stop, drop, and roll” in the event of their clothes catching fire.

• A child who suffers a serious burn should be stabilized (eg, airway-breathing-circulation and treatment for fluid loss and smoke inhalation) before being transported to a hospital or to a dedicated burn center.

• Ensure that everyone understands that the following:

• first-aid treatment for burn injuries is best accomplished with cool, clean water; and

• traditional treatments, such as putting butter, oil, or other substances on burns, can be harmful because they can cause the skin to slough away, leaving the lower layers of skin exposed and susceptible to infection. ⁶

To avoid scalds, always check the temperature of the water coming from a tap, and supervise young children’s bathing to reduce the chances of exposure to scalding water.

Fall Prevention

• Wear helmets when engaging in recreational activities, for example, zip lines, rock climbing, biking, riding horses, and so on. If helmets are likely to be unavailable at the destination, they should be brought from home.^1,3,18

• Parents must be reminded that hotels and homes they visit may not have child gates on stairs.^3,18

Bite and Sting Prevention

• Avoid all stray or unfamiliar animals, insects, and rodents.

• Never leave infants or young children alone with a dog.

• Do not allow children to play with a dog unless supervised by an adult.

• Teach children to immediately tell adults of any contact with or bites or stings from any animal or insect.

• In the event of a bite, seek medical care immediately. 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.

• Avoid eating food around animals such as dogs or monkeys because they can be aggressive and grab the food and bite the child in the process.^1,3,6,18

• Obtain local advice on the presence of dangerous aquatic animals in the region before swimming.

• Wear shoes when walking on the shore or at the water’s edge.

• Seek medical advice if you suspect a bite or sting from a poisonous animal.

Poisoning Prevention

• Keep all drugs in secure containers and in locations that young children cannot reach.

• Be alert for improperly vented indoor heating devices and motorboat exhaust, which may cause poisoning from carbon monoxide.

• Avoid taking medicine in front of small children because they often copy adults.

• Do not call medicine “candy.”

• When you take medicines yourself, do not put your next dose on the counter or table within the reach of children.

• Never leave children alone with household products or drugs.

• In the event of a poisoning,

• The container or bottle of the poison if available

• The time of the poisoning^1,3,6,18

if you are in an area without access to a poison control help line and you carry a US phone number (eg, cell phone), you can still call the US poison control help line from overseas; contact them before leaving the United States for details.

Health Insurance and Medical Evacuation

Travel insurance is one of the most important safety nets available to travelers in the event of injuries. Travel medicine and health advisers should reinforce this advice. ⁴ Travelers should consider purchasing special travel insurance that includes medical evacuation or air ambulance transport if their destinations include countries where there may be difficulties in accessing adequate medical care.^2,3 Such insurance generally provides worldwide, 24-hour telephone hotlines, which direct callers to English-speaking physicians and hospitals, pay for treatment and hospitalization at the time of the incident, and when medically indicated, arrange and pay for evacuation to a medical facility that can provide necessary treatment. ¹⁸ The United State Department of State provides information about how to select companies that provide such insurance at http://travel.state.gov/travel/cis_pa_tw/cis/cis_1470.html.

Before departure, travelers should verify insurance coverage for each member of the family in case of illness or injury while traveling abroad. Travelers should be advised to read their policies carefully to see who and what is covered and to check for any exclusions. In particular, children who have known preexisting conditions, families who are working long-term overseas, or those whose family members will undertake any form of hazardous recreational or occupational activities may need to obtain a special travel insurance policy or additional coverage. Families should ensure that their travel insurance will cover them and their children in the event of an illness or injury.^4,18

Conclusion

Children have a human right to be safe and protected from injury. ³¹ Travel can expose children to unsafe behaviors and environments that give rise to injuries. ¹³ Injuries are in many ways a greater public health problem while traveling than infectious and chronic diseases because they can be far more deadly and can arise unexpectedly. Effective prevention strategies are available, particularly for travelers who find themselves in new environments and who may be more likely to be unaware of risks or are complacent in exotic surroundings. Vacation travel brings additional risks because families and children may not be aware of cultural norms related to risk taking, may be used to more protected environments in their home country, and tend to have a carefree attitude of adventuresomeness and fun, rather than caution and vigilance. Despite greater understanding and increased research efforts in this field, data on the magnitude and severity of injuries are still incomplete or unreliable in many countries. Travel medicine counseling can be an important strategy to alert patients, parents, and the public to travel risks and to educate them about simple and effective prevention steps that can be taken to protect children from injuries while traveling.