*Airplane Travel*
• When traveling with young infants on the plane, if possible you may want to use a car seat. You should check with the airline if this is feasible. There is the possibility that you may have to pay for an extra ticket.
• Many parents inquire about sedation or “help with sleeping” for long trips. While parents often use Benadryl to make their children sleepy for long plane rides, we do not advise this and would suggest that children be allowed to fall asleep on their own.
• Finally, on take-off and landing, try to breast feed/bottle feed children or allow them to chew on gum. This helps to equilibrate the middle ear pressure and prevents unwanted earache.

*Mosquito Repellant*
In 2001 the Environmental Protection Agency made the following recommendations regarding the safe use of insect repellant with DEET for children:

• Do not apply to infants under two months of age. (Skin permeability becomes similar to adult by the second month of life.)
• Read and follow all directions and precautions on the product label.
• Do not apply over cuts, wounds or irritated skin.
• Do not apply to young children’s hands or near eyes or mouth.
• Do not allow young children to apply products themselves.
• Use just enough to cover the exposed skin and/or clothing.
• Do not use under clothing.
• Avoid over-application.
• After returning indoors, wash treated skin with soap and water.
• Wash treated clothing before wearing again.
• Do not use spray solutions in enclosed areas or near food.
• For use on face, apply to adult hands and then rub on face. Do not spray face. Avoid areas around eyes and mouth.

Experts agree that insect repellants containing DEET are the most effective. Years of DEET use have resulted in relatively few reports of adverse reactions. Most reported incidents have not been serious.

The American Academy of Pediatrics states that a 30 percent concentration is safe for both children and adults, but that 10 percent can be used for children if parents are concerned about the potential risks of deet or if the threat of disease-carrying mosquitoes is small.

Even when the insect repellent you select does not contain DEET, citronella and other more “natural” repellents could cause problems in a young child if used liberally on the skin. Look into clothing that is both light for summer weather but also long to cover the skin, and use insect repellent sparingly. Mosquito nets over strollers and car seats can also protect young children.

*Sunscreen*
Choose a sunscreen that protects against both UVA and UVB rays. Babies under 6 months of age should be kept out of the sun as much as possible, and try to use a wide brimmed hat and loose fitting clothing to shield them. For babies between six months to two years, we recommend at least SPF 15 strength sunscreen. For older children, use at least SPF 30.

Sunscreen loses its potency with age, so make sure your child’s sunscreen is not expired or over two years old.

*Tips*
Here are some general tips to keep you healthy during your travels. For more extensive information, please visit the Centers for Disease Control website at www.cdc.gov/travel

• If you’re unsure of whether the drinking water or ice is safe, drink beverages that have been prepared with boiled water or are canned or bottled.
• All raw foods are susceptible to contamination. Be careful when eating salads, uncooked fruits and vegetables, and raw meat.
• Do not eat food from street vendors.
• Bring long-sleeved shirt, long pants, and a hat to wear whenever possible while outside, to prevent illnesses carried by insects.
• Use bed nets treated with permethrin or deltamethrin.
• Make sure you bring enough of your prescription medication to last you during your trip. Also, you may want to bring a copy of your prescription.
• To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, even on beaches.
• Do not handle animals.

*Vaccinations*
Visit your doctor 8-12 weeks before your trip to receive necessary vaccinations.

• These vaccinations (Hepatitis A, Hepatitis B, Tetanus-Diphtheria, and Measles) are recommended but are routinely given and will likely be up to date in all of our patients.
• Risk of Malaria may be high in some of the countries in this region. Antimalarial pills can be prescribed from your doctor or obtained from the clinics listed below. Please call us or set up an appointment to receive medical consultation regarding this matter.
• If you’re traveling to an underdeveloped region and especially if your trip is longer than one month, it may be recommended that you receive the Typhoid vaccine and/or the Japanese Encephalitis Vaccine (see next page)
• Rabies vaccination is generally not recommended but may be necessary depending on if you will have extensive unprotected outdoor exposure in rural areas.

International Vaccinations are available at these clinics:

• *International Medicine Center*
Memorial Hermann Memorial City
920 Frostwood, Suite 670
Houston, TX 77024
713 – 550 – 2000

• *US Health Works*
1414 S. Loop West, Suite 200
Houston, TX 77054
713 – 797 – 6106

• *US Health Works*
17420 N.W. Freeway
Houston, TX 77040
713 – 466 – 0044

For more locations, please check: http://www2.ncid.cdc.gov/travel/yellowfever/state.asp?StateID=44

*Typhoid Vaccine*
Two typhoid vaccines are currently available for use in the United States: an oral live, attenuated vaccine (Vivotif Berna vaccine, manufactured from the Ty21a strain of S. Typhi by the Swiss Serum and Vaccine Institute) and a Vi capsular polysaccharide vaccine (ViCPS) (Typhim Vi, manufactured by Aventis Pasteur) for intramuscular use. Both vaccines have been shown to protect 50%-80% of recipients. The intramuscular heat-phenol-inactivated vaccine (manufactured by Wyeth-Ayerst) has been discontinued. The table below provides information on vaccine dosage and administration. The time required for primary vaccination differs for the two vaccines, as do the lower age limits for use in children.

Primary vaccination with oral Ty21a vaccine consists of a total of four capsules, one taken every other day. The capsules should be kept refrigerated (not frozen), and all four doses must be taken to achieve maximum efficacy. Each capsule should be taken with cool liquid no warmer than 37°C (98.6°F), approximately 1 hour before a meal. This regimen should be completed 1 week before potential exposure. The vaccine manufacturer recommends that Ty21a not be administered to infants or children <6 years of age.

Primary vaccination with ViCPS consists of one 0.5 mL (25 µg) dose administered intramuscularly. One dose of this vaccine should be given at least 2 weeks before expected exposure. The manufacturer does not recommend the vaccine for infants <2 years of age.

*Japanese Encephalitis Vaccine*
The recommended primary immunization series is three doses of 1.0 mL each, administered subcutaneously on days 0, 7, and 30. An abbreviated schedule of days 0, 7, and 14 can be used when the longer schedule is impractical. Both regimens produce similar immunity among recipients. Two doses given a week apart may be used in unusual circumstances and will confer short-term immunity in 80% of vaccinees. The last dose should be administered at least 10 days before beginning travel to ensure an adequate immune response and access to medical care in the event of any delayed adverse reactions (refer to table below). Many Asian countries have adopted a schedule of two primary doses approximately 4 weeks apart, followed by a booster after 1 year, with subsequent boosters at 3-year intervals. The duration of immunity after serial booster doses has not been well established.

Immunization routes and schedules for infants and children 1-3 years of age are identical except that 0.5 mL doses should be administered. No data are available on vaccine efficacy and safety in infants <1 year of age. The full duration of protection is unknown; however, preliminary data indicate that neutralizing antibodies persist for at least 2 years after primary immunization. In infants and children whose primary immunization series included 0.5 mL doses, a 1.0 mL booster dose (0.5 mL for children <3 years of age) may be administered 2 years after the primary series.

^1^ Administered by the subcutaneous route
^2^ For vaccinees who have completed a three-dose primary series, the full duration of protection is unknown; therefore, definitive recommendations cannot be given.