Travel Health: Selecting, Dosing, Storing & Administering Medications for Children

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1 Travel Health: Selecting, Dosing, Storing & Administering Medications for Children B. Seifert, Pharm.D., FCSHP Pediatric Clinical Pharmacist WRHA Regional Pharmacy Program April 2009

3 Increasing number of children traveling, either for short holidays or extended stays Children come in different sizes and stages of development

4 General Considerations 1. Age of child 2. Duration of travel 3. Destination, including planned activities 4. Mode of travel 5. General medical condition of traveller

5 Some common problems Sun hazards and sunscreen Travel safety: car seats, seat belts Mosquito precautions, repellents and nets Animal bites Envenomation Sexually transmitted infections for adolescents Travelers diarrhea and food hygiene Oral Rehydration and dehydration Altitude illness

6 Outline 1. Pre-travel Medications 2. In-transit Medications 3. Destination Medications 4. Administration of Medications 5. Extended Travel Medication Considerations

8 Pre-Travel Medication Considerations

9 Pre-Travel Medication Considerations Vaccines Malaria Prevention Chronic Medications

10 Vaccines for Travel Domestic vs. International Routine Destination Specific

11 Recommended Immunization Schedule for Infants, Children & Adolescents Age Vaccine Notes 2 months DTaP-IPV + HIB + PCV-7 4 months DTaP-IPV + HIB + PCV-7 6 months DTaP-IPV + HIB + PCV-7 + Influenza (fall) 12 months MMR + Varicella + Men-C 18 months DTaP-IPV + HIB + PCV years DTaP-IPV + MMR + Var varicella if susceptible only 9 years (Gr. 4) Hep B + Men-C + Var school based 12 years (Gr. 6) HPV females only years (Gr. 9) Tdap school based

12 Vaccines: Routine insure routine vaccines are up to date according to Manitoba vaccination schedule do NOT rely on herd immunity in all countries boost pertussis at least once in adult schedule i.e. Adacel consider boost of polio received second dose of MMR? may need accelerated schedule especially for prolonged travel or for infants

13 Vaccines: Additional Meningococcal disease in Manitoba, provide Meningococcal C conjugate vaccine at age Grade 4 or 1 year (new 2009) for many countries, Meningococcus serotype A may be a concern substitute or add quadrivalent conjugate vaccine (i.e. Menactra to age 55 years) note: if child never received Men-C vaccine, then recommend Menactra followed in 4-8 weeks by a Men-C conjugate vaccine

14 Vaccines: Additional hepatitis A and B Manitoba children receive hepatitis B in grade 4 although hepatitis A rarely produces significant illness in children but high transmissible if hepatitis B series complete hepatitis A vaccine if never received hepatitis B vaccine combined A & B vaccine children 2 dose schedule with Twinrix or 3 dose schedule with Twinrix Junior difference in response to initial dose only administer at least 2, preferably 4 weeks, pre-travel

15 Vaccines: Destination Specific Vaccine Hepatitis A Hepatitis A/B Hepatitis B Typhoid Capsular Rabies Men-C conjugate Men Quadrivalent Conj. Japenese encephalitis Youngest Age 1 year 1 year Birth 2 years Birth 2 months 2 years 1 year

16 Chronic Medications BE PREPARED sufficient supply labelled by pharmacy (name must match passport) copy of prescription(s) list of medications (with generic and brand name) permission letter for controlled drugs and needles note: what is controlled differs between countries for longer term travel, consider oral solid dosage forms or non-reconstituted suspensions divide supply of medications in 2 pieces of luggage

17 In Transit Medication Considerations

18 Considerations mode of travel duration of travel time of travel

19 Sedation not recommended generally safe alternatives diphenhydramine (Benadryl ) 1 mg/kg/dose q6h (max. 50 mg) chloral hydrate mg/kg/dose up to TID test dose at home for effectiveness & safety

20 Motion Sickness dietary precautions (similar to adults) ginger root little published information in children diphenhydramine (e.g. Benadryl ) or dimenhydrinate (e.g. Gravol ) may be considered NOT BOTH (salt of same drug)

21 Travel Kit - medications acetaminophen chewable ibuprofen chewable hydrocortisone 0.5% ointment antihistamine (e.g. diphenhydramine) antacid oral rehydration solution anti-diarrheal medication sunscreen insect repellent infants diaper rash cream anti-malarial medications (as appropriate for destination and age) antibiotic ointment antifungal ointment antibiotic (e.g. amoxicillin, azithromycin) medications used by child in past 6 months (e.g. for ear infections)

22 Destination Medications

23 Traveller s Diarrhea prevalent in children < 3 years of age (up to 40%?) concurrent fever more common in > 2 y/o, similar infectious etiologies as adults prevention more difficult good hand washing (including caregivers) most effective

24 Traveller s Diarrhea Antimicrobial prophylaxis discouraged bismuth subsalicylate (e.g. Pepto-Bismal) caution in children < 3 years of age (risk of salicylate intoxication) loperamide may be used in > 2 years of age

25 Traveller s Diarrhea - Treatment adequate hydration with an oral sugar-electrolyte solution mainstay of therapy small volumes frequently preferred co-trimoxazole (e.g. Septra) of limited value in many parts of the world azithromycin good choice for ages > 1 year 10 mg/kg PO once daily x 3 days ciprofloxacin acceptable for > 2 years of age 10 mg/kg/dose PO BID x 3 days antibiotics may be used with Pepto-Bismal seek medical attention if person has severe diarrhea with fever or bloody stools for over 24 hours

26 Malaria Prevention higher incidence in children? (up to 20%) highest incidence in immigrants and children returning from VFRs preventative measures most important chemically treated mosquito nets DEET (up to 35%) or alternative short term travel (< 3 weeks) may not require chemoprophylaxis preventative measures still important

27 Malaria Prevention chemoprophylaxis do NOT prevent infection only kill the parasite once it leaves the liver (exception atovaquone-proguanil) same general indications as for adult travellers also consider age of child in choice of agent

28 Anti-malarials pediatric preparations not often available caution with different tablet strengths (e.g. Malarone adult vs. ped tablets) tablet forms may be difficult to cut or crush bitter taste e.g. chloroquine not available in all pharmacies overdose may be fatal (e.g. chloroquine) pharmacist may be your new best friend

29 Antimalarials - Availability Chloroquine Hydroxychloroquine (Plaquenil) Available Ped. Dosage Notes 150 mg, 300 mg tab (base) 5 mg/kg/dose once weekly or divide dose twice weekly 155 mg (base) 5 mg/kg/dose once weekly Mefloquine 250 mg (base) refer to next table bitter taste bitter taste Atovquone/Proguan il (Malarone) Ped: 62.5/25 mg Adult: 250/100 mg refer to next table place in sweet food or syrup Doxycycline 100 mg tab or capsule 2 mg/kg PO once daily (max 100mg) Primaquine 15 mg tab (base) 0.6 mg/kg once daily caution: G6PD def.

30 Anti-malarials Age Weight (kg) Chloroquine Mefloquine Doxycycline Malarone Term 12 wks. < 6 ¼tab NR NR NR 3 11 mo ½tab ¼tab NR NR 1 3 yrs ¾tab ¼tab NR 1 ped tab 4 7 yrs tab ½tab NR 2 ped tab 8 12 yrs ½ tab ¾tab ½-1 tab 3 ped tab > 13 yrs. > 45 2 tab 1 tab 1 tab or caps 1 adult tab

31 Antimalarial drugs Mefloquine (5mg/kg) Doxycycline (2mg/kg) not < 8 years (effect on teeth etc) Malarone (atovaquone + proguanil) (1/4 pill per 10kg to max at 40kg) not recommended in guidelines in some countries for children < 40 kg Chloroquine (5mg/kg)+ proguanil (4mg/kg) Primaquine appears safe not in G6PD deficiency (screening test available)

32 Duration of Therapy Start Time Pre-travel Continue Post-exposure Chloroquine 1 week 4 weeks Mefloquine 3 weeks 4 weeks Doxycycline 1 to 2 days 4 weeks Atovaquone/ proguanil 1 to 2 days 1 weeks

33 Administering Medicines to Children

34 Administration Challenges non-compliance with travel prophylaxis or treatment medications common many medications not in pediatric friendly dosage form or concentration consider test dose of any first time medications at home well prior to travel many medications bitter (e.g. chloroquine)

35 Tips take unreconstituted suspensions most are stable at room temperature may reconstitute with potable or boiled (and cooled) water - have pharmacist mark add water to this level reconstituted suspension appropriate for in transit portion of trip caution on maximum volume for in cabin supply MUST be labeled appropriately

36 TIPS (2) for prophylactic or chronic medications consider oral solid dosage forms no extraordinary storage conditions compact, light in weight stability longer than for liquid medications appropriate for infant to adolescent when available, choose chewable dosage form dissolve or crush easily for younger age groups» often may be added/sprinkled on food (check with pharmacist)

37 TIPS (3) if child unable to take oral solid dosage form crush (not for extended release) dissolve and dose in a syringe place in food may need flavour or vehicle

38 Tips (4)

39 TIPS (5) to facilitate swallowing of oral solid dosage forms (while avoiding bitter taste) insert in mini-marshmallow insert in grape or banana crush and sprinkle inside cream filled cookie very young children: pharmacist may need to create powder in a capsule open capsule and sprinkle on food or mix with small amount of breast milk or formula

40 Extended Travel Medication Considerations

41 Extended Travel chronic medications list should include generic and brand name depending on destination and storage facilities, consider supply for entire trip for infants, have table of dose adjustments for weight

42 Extended Travel Vaccines keep vaccinations up to date immunization record should include list of components as well as brand name of vaccines received different names and products in many countries consider scheduling booster doses during visits to Canada

43 SUMMARY 1. Pre-travel Medications 2. In-transit Medications 3. Destination Medications 4. Administration of Medications 5. Extended Travel Medication Considerations

44 Additional Resources Four part series on Travelling with Infants and Children by

46 QUESTIONS?

HEALTH CONSIDERATIONS FOR INTERNATIONAL TRAVEL. James Madison University Health Center

HEALTH CONSIDERATIONS FOR INTERNATIONAL TRAVEL James Madison University Health Center PURPOSE Highlight potential health risks for international travelers Review recommended vaccinations Provide information