Travelling with young children

Prevention

Vaccines

Numerous factors need to be taken into account when developing age-specific recommendations for vaccine administration. These include the age-related capacities of the child to establish an adequate immune response (e.g. polysaccharide vaccines), the presence of maternal antibodies which can interfere with the host immunological reaction (e.g. measles-mumps-rubella vaccine), the age-specific risk for the disease (e.g. rabies vaccine), and the risk for potential side-effects (e.g. yellow fever vaccine).

In the paragraphs below we highlight paediatric recommendations for the most important routine and travel vaccines in children in an alphabetical order. More in-depth information can be found on the specific Wanda pages. 

Routine vaccinations

Always check whether the child is up to date with the routine childhood vaccinations. Catch-up doses should be administrated if necessary, according to the schedule of the Superior Health Council.

Measles

• As outbreaks of measles are frequently seen, an earlier measles vaccination is recommended when travelling to a country with a measles outbreak. If the child is ≥ 6 months and < 12 months an extra dose is recommended, if the child is older than 12 months, advance the second dose.

Meningitis ACWY

• Since the second half of 2023, all children in Belgium are offered vaccination against Meningitis ACWY (Nimenrix®) at the age of 15 months as part of the childhood vaccination programme. 
• A booster is recommended by the Superior Health Council at 15 years of age (even when not travelling) as part of the routine vaccination schedule although not reimbursed.
• For children travelling to the meningitis belt or participating in the Hajj or Umrah, travelling to outbreaks and some students studying abroad, vaccination can be recommended.
• Nimenrix® can be administered intramuscularly from the age of 6 weeks. Menveo® can be administered intramuscularly from the age of 2 years.
• The schedule for primary series and booster doses varies depending on the age of the child.

Poliomyelitis

• Check whether the child is up to date with the routine childhood vaccination schedule against poliomyelitis and assess the need for any catch-up vaccinations, according to the schedule of the Superior Health Council.
• A one-time booster dose of poliomyelitis vaccine, in addition to the completion of the routine childhood vaccination is recommended for all travellers to Asia or Africa ≥ 16 years old.
• In countries with circulating wild polio virus 1 and vaccine derived polio virus 1 or 3, a recent (≤ 12 months) poliomyelitis vaccination is compulsory when leaving the country after a stay of ≥ 4 weeks.

Tetanus-diphtheria-pertussis, hepatitis B and other routine childhood vaccinations

• Check whether the child is up to date with the childhood vaccination schedule for tetanus- diphteria-pertussis, hepatitis B or other routine childhood vaccinations or if catch-up doses should be administrated, according to the schedule of the Superior Health Council.

Travel vaccines

BCG

• The BCG vaccine is indicated in children < 5 years of age who repeatedly visit or spend > 6 months in a high-risk country. The BCG vaccine is not routinely available in Belgium. Parents can consider to get the child vaccinated locally upon arrival.
• This vaccine is administered intradermally on the posterior-lateral side of the upper arm. After 6 to 8 weeks, a local inflammation develops at the injection site, forming a firm nodule. This resolves spontaneously within 2 to 3 months.
• Post-vaccination side effects are observed in 1 to 10% of those vaccinated. These are usually swollen lymph nodes in the armpit or neck area, which disappear on their own within 2 to 3 months. Local abscess formation with skin breakdown may occur if the injection was given subcutaneously or if an excessively high dose was administered. This complication can persist for several months but ultimately heals completely.
• The BCG vaccine is live-attenuated, and is therefore contra-indicated in children with (severe) immune disorders.

Chikungunya

• Vaccination against chikungunya (Ixchiq®, Vimkunya®) can be given from the age of 12 years as a single dose, the indications for vaccination are the same in children as in adults.

Dengue

• Vaccination against dengue (Qdenga®) can be given subcutaneously from the age of 6 years, in a 2-dose schedule with a 3 month interval. The indications are the same in children as in adults.

Hepatitis A

• The indications for hepatitis A vaccination are the same in children as in adults. Hepatitis A infection is usually mild in children under 6 years of age, but paediatric vaccination is recommended to stop viral transmission from young children to susceptible adolescents and adults. 
• Hepatitis A vaccination can be given intramuscularly in children aged ≥ 12 months. The schedule consists of 2 doses, separated by ≥ 6 months. After the first dose, protection is considered to be at least one year. After the second dose, protection is considered to be lifelong.
• In an outbreak situation, the vaccine can be administered from the age of 6 months onwards. In that case, 2 additional vaccine doses should be given with an interval of 6 months after the age of 12 months.
• A paediatric vaccine formulation with a reduced dosing needs to be administered. The upper age limit for the administration of this reduced formulation depends on the vaccine brand. 

Japanese encephalitis

• Ixiaro®, the Japanese encephalitis vaccine available in Belgium, can be given from the age of 2 months. The indications are the same in children as in adults.
• The primary series consists of 2 intramuscular doses administered 28 days apart. No accelerated primary vaccination schedule exists for children < 18 years. A booster vaccination is recommended after 12 to 24 months, after which the duration of protection is at least 10 years.
• Children ≥ 2 months and < 3 years old should receive half of an adult vaccine dose. When preparing the vaccine for administration of half a dose (0,25 ml), you push the plunger stopper up to the edge of the red line on the syringe barrel, to discard excess volume. You then administer the remaining volume. Partial doses cannot be preserved for later use.

Rabies

• Being of younger age is considered an important risk factor for an injury caused by a potentially rabid animal. When travelling to rabies endemic countries, the indication for rabies pre-exposure vaccination can be assessed via the risk score for rabies pre-exposure prophylaxis (PrEP) in travellers.
• After a rabies risk contact, post-exposure prophylaxis (PEP) including proper wound care and additional immunizations is always necessary, even if the child has correctly received rabies PrEP.
• There is no lower age limit for rabies pre-exposure vaccination, although it is generally considered to vaccinate from the age of 12 months onwards (since most children don't walk before and have therefore less risk on bites). 
• The pre-exposure vaccination schedule consists of 2 doses administered with a minimum interval of 7 days. The available vaccines in Belgium, Rabipur® and Verorab®, are interchangeable.
• In children ≥ 2 years, the vaccines can either be given intramuscularly (1,0 ml Rabipur® or 0,5 ml Verorab®) or intradermally (2x 0,1 ml per vaccination moment) if there is sufficient cooperation from the child.
• In children < 2 years old the vaccines are usually given intramuscularly, for Rabipur®, the anterolateral thigh is preferred because of the relatively large injection volume.

 Tick-borne encephalitis

• FSME Immun® junior, the vaccine against tick-borne ecephalitis available in Belgium, can be given intramuscularly from the age of 12 months onwards. The indications are the same in children as in adults.
• The primary series consists of 3 doses with the second dose given 1 to 3 months after the first, and the third 5 to 12 months after the second dose. A first booster vaccination is recommended after 3 years, and a second booster vaccination after 5 to 10 years.
• A reduced paediatric formulation needs to be administered in children < 16 years old, which is either FSME Immun® Junior or half a dose (= 0,25 ml) of FSME Immun®.

 Typhoid fever

• The best protection against typhoid fever is applying safe food and drink measurements. The indications for vaccination are the same in children as in adults.
• The typhoid vaccine available in Belgium (Typhim Vi®) provides a limited protection of 60-70% from 14 days after administration. The primary vaccination consists of one dose, which offers protection for up to 3 years.
• Typhim Vi® can be given intramuscularly from the age of 2 years.

Yellow fever

• Vaccination against yellow fever is recommended in countries where there is a risk of yellow fever virus infection. Some countries demand a proof of vaccination upon entry usually from the age of 9 months or 12 months. 
• The yellow fever vaccine (Stamaril®) can be subcutaneously administered from the age of 9 months.
• Exceptionally, in case of an outbreak, it can be given to 6 - 8 month old children (relative contraindication).
• The vaccine is never given before the age of 6 months because of the risk of ‘yellow fever vaccine-associated neurologic disease’.
• If the vaccine is administered to children ≤ 2 years of age, a revaccination is recommended after their 2nd birthday. If the vaccine is administered to children ≥ 2 years of age, the length of protection is considered to be lifelong.

Travel-associated infectious diseases

Malaria

Malaria is a serious and potentially life-threatening disease, especially in children. They are at higher risk of rapid disease progression and severe complications.

When travelling with children to a malaria endemic area, parents should understand malaria risks, the incubation period, the possibility of delayed onset and the main symptoms. They should seek immediate medical attention if a fever develops one week or more after entering a malaria endemic area, and up to minimally three months after return .

Mosquito bite prevention

Mosquito bite prevention is always a combination of measures like, avoiding certain mosquito infested places at specific times of the day, wearing protective clothing. Using (impregnated) mosquito netting on beds, strollers and infant carriers are recommended from dusk till dawn. Pull the net tightly and tuck the net under the mattress to avoid choking hazards for young children.

There is no international consensus on the minimum age that repellents can be used and at which concentration. UK recommends DEET 50% from the age of 2 months, CDC recommends DEET without minimum age.  The use of repellents for young children should be considered as one of the measures to avoid potential severe diseases transmitted by arthropods and is recommended if other mosquito-repellent measures cannot be implemented adequately. The product should be washed off when it is no longer needed. DEET 20 to 30%, IR3535 20%, and citriodiol 20 to 25% can be used from the age of 6 months onwards. (P)icardine 20 to 25% can be used in children ≥ 2 years of age. The repellents should not be applied on children’s hands and near the mouth and eyes. Regular re-application is important. 

Malaria medication

Children weighing ≥ 5 kg can take preventive malaria medication. All children should take preventive malaria medication in high risk areas. For children < 12 years chemoprophylaxis should be considered in addition to mosquito bite preventive measures when travelling to malaria moderate risk areas (i.e., the orange regions on the malaria maps). 

• Atovaquone-proguanil is most often prescribed for children. A reduced paediatric formulation exists. Tablets can be cut with a pill cutter shortly before intake but this results in a bitter taste. If swallowing is difficult, you can crush the tablet and mix it with a small amount of soft food such as yogurt, honey or jam.
• Doxycycline can be used for children aged ≥ 8 years.
• Mefloquine  can be used for children weighing > 5 kg.

Arboviral infections

Chikungunya, dengue, yellow fever, zika, and Japanese encephalitis viruses can lead to severe disease in children. Children should follow mosquito bite prevention measures strictly, according to the biting pattern of the transmitting mosquitos (i.e. night- or daytime biters). Vaccination against yellow fever, Japanese encephalitis, chikungunya and dengue could be indicated when travelling to endemic areas. 

Traveller’s diarrhoea

Traveller’s diarrhoea is the most common travel-related infectious disease. Traveller’s diarrhoea is typically self-limiting, but children under the age of two years have a higher risk of severe diarrhoea resulting in dehydration.

Prevention

Children should adhere to safe food and water precautions strictly. Special attention should be given to clean and rinse bottles, toys or pacifiers. It is not needed to use bottled water for bathing or showering.
Breastfeeding offers the best protection against traveller’s diarrhoea in infants. Powdered formula should be prepared with bottled water to avoid contamination. The Kind & Gezin website provides guidance on the quality requirements for bottled water used in the preparation of infant formula. 

Treatment

Oral fluid and ORS are the cornerstone in the treatment of mild to moderate dehydration due to traveller’s diarrhoea.  Breastfed infants can continue feeding on demand. Formula-fed infants < 6 months can be given extra bottles. A child older than 6 months can be given water in addition to the normal diet. A child who has been vomiting will usually keep fluid and ORS down if it is offered by spoon in small sips. ORS is widely available in tropical countries, and is prepared by adding 1 package to the indicated volume of boiled or treated water. For children, only commercial packages should be used since the risk of dosing errors in self-made formulations. Lactose-free formulas are usually unnecessary. Diluting formula can slow resolution of diarrhoea and is not recommended.

Prescription of stand-by antibiotics is not advised for healthy travellers, including healthy children due to the lack of benefit and the increased risk of antimicrobial resistance.
Parents are advised to seek local medical care in case of severe diarrhoea (e.g. bloody stools, fever ≥ 38.5°C), moderate to severe dehydration, or persistent vomiting and loss of stools without being able to maintain oral hydration.

General precautions

General precautions to avoid infections are also important for children. Especially pay attention to wearing protective footwear (also when playing on the beach), precautions to avoid schistosomiasis and keep children away from animals, particularly in countries where rabies occurs in pets.

Travel-related non-infectious risks

Sun protection

Sun protection is strongly recommended as children who suffer sunburn have a higher risk of melanoma and other skin cancers later in life. Sunlight is more intense near the equator and at high altitudes. Sand, water and snow amplify the effect of UV radiation. Advise parents that children should be kept in the shade, particularly between 11:00 and 15:00. Infants ≤ 6 months should never be placed in the sun. A high factor sun cream should be applied regularly (SPF 50+). If both sunscreen and a DEET-containing insect repellent are used, apply the sunscreen first, allow it to dry for 10 minutes, and then apply the insect repellent. Because insect repellent can reduce the effectiveness of sunscreen, sunscreen should be reapplied more often. 

Air travel

During air travel, children often experience earache or discomfort while taking off and landing due to changes in middle ear pressure. To alleviate this, it is recommended that they swallow or chew during climbing and descending (bottle, breast or pacifier). For children with a history of recurrent otitis, the use of oxymetazoline nose drops may be considered right before take-off and descent.

Some airlines might have limited safety equipment available. Travelers should check with the airline about specific restrictions and approved child restraint options. 

Infants are allowed to fly from the age of seven days. Air travel is not recommended for premature infants, but urgent transportation in an incubator under medical supervision can be organised from 48 hours after birth. Children with chronic heart or lung problems might be at risk for hypoxia during flight, and caregivers should consult a clinician before travel. 

Travel pace

Travelling can be stressful for children. When travelling with children, it is essential to adopt a relaxed travel pace with an easily adaptable schedule. A jet lag can disturb sleep patterns. 

High altitude

Children are not more susceptible to altitude sickness than adults, but the signs are harder to recognise. Young children can demonstrate non-specific symptoms such as irritability, restlessness, reduced appetite, vomiting, decreased activity, and impaired sleep. Older children might complain of headache or shortness of breath. 

Slow ascent is the preferable approach for avoiding acute mountain sickness. An immediate descent is imperative if children demonstrate unexplained symptoms after an ascent above 2500 metres. It is advised to avoid spending the night at an altitude above 2000 metres for children under two years of age and above 3000 metres for children under ten years of age.

Some common high-altitude destinations require rapid ascent by airplane, placing travellers at risk for altitude sickness. In some cases (e.g., Cusco and La Paz), travellers can descend to places lower than the airport to sleep for 1–2 nights and then begin their ascent.

If a rapid climb is unavoidable, you can consider using acetazolamide (2.5 mg per kg every 12h, max. 125 mg per dose), although experience is limited in children. 

Traffic

Traffic accidents occur with a greater frequency in low- and middle-income countries, where road safety measures may be less strictly enforced. Additionally, travellers may become more relaxed about safety precautions while abroad. It is therefore essential to adhere to the same traffic rules as at home, such as consistently wearing seatbelts in cars, wearing helmets on bikes and motorcycles, and using age-appropriate car seats.

Water-Related Injuries

Drowning is a major cause of death in young travellers. It is crucial to keep a close eye on children while they are swimming and to remain vigilant about potential dangers such as strong currents in rivers and seas. Additionally, providing children with protective footwear can help minimize the risk of injuries and enhance their safety in aquatic environments.