What do we know about travel for children with special health care needs? A review of the literature

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Abstract

Background

Children travel with their families, including children with chronic illness. We know that adults with chronic illness who travel are more likely than their healthy peers to become sick while traveling. A review of the literature was undertaken to identify what is known about traveling with children with special health care needs and to identify gaps in our knowledge.

Methods

An Online search of the PubMed, CINAHL and Google databases of English language literature was conducted June 2016, October 2017, June 2018 and April 2019 using the terms children and travel, air travel, travel health, disabled child, children with special healthcare needs, parents of disabled children, vacations, recreation, international, wheelchairs, planning techniques, asthma, diabetes, altitude, cystic fibrosis, inflammatory bowel disease, sickle cell disease, depression, food allergies, Attention Deficit Hyperactivity Disorder (ADHD), and seizures. The search was limited to years 2000-2019. A secondary search of relevant articles was conducted using the reference sections of articles identified in the primary search.

Results

185 papers were examined for travel health related outcomes for children and adults with chronic diseases. Articles were excluded if they addressed the educational needs of students with disabilities traveling abroad, did not directly address travel health (e.g travel skills, travel itineraries), contained outdated policy statements, or were case reports of a single patient. The remaining 84 papers were organized and reviewed by organ systems. The articles were primarily descriptive and did not lend themselves to a systematic review.

Conclusion

Children traveling with chronic and complex health conditions are a heterogeneous group of vulnerable travelers. Closing the knowledge gap about how to best help these travelers requires a multipronged approach. Research is urgently needed to identify best practices for five of the most common chronic childhood diseases: asthma, depression, ADHD, food allergies and autism. For less common illnesses, ones typically cared for in specialty clinics, expert consensus opinion and multi-center studies are needed. Families and disease advocacy societies should be included in the research as they may have already identified the most pressing travel-related health concerns and solutions for these problems.

Section snippets

Background

Most children are healthy, yet the proportion of children with chronic disease has been steadily increasing over the past few decades [1]. Children with chronic illness comprise 12-15% of the US pediatric population, which is similar to The World Health Organization (WHO) prevalence of children with disability [2,3]. Children and youth with special health care needs (CSHCN) have a chronic physical, developmental, behavioral or emotional condition that needs health care services [4]. Although

Methods

An Online search of the PubMed, CINAHL and Google databases of English language literature was conducted June 2016, October 2017, June 2018 and April 2019 using the terms children and travel and air travel, travel health, disabled child, children with special healthcare needs, parents of disabled children, vacations, recreation, international, wheelchairs, planning techniques, asthma, diabetes, altitude, cystic fibrosis, inflammatory bowel disease, sickle cell disease, depression, food

Results

185 papers were examined for travel health related outcomes for children and adults with chronic diseases. Articles were excluded if they addressed the educational needs of students with disabilities traveling abroad, did not directly address travel health (e.g. travel skills, travel itineraries), contained outdated policy statements, or were case reports of a single patient. The remaining 84 papers were organized by organ systems. The articles were primarily descriptive and thus did not lend

Motor vehicle safety

Seat belts and car safety seats (CSS) are recommended for proper restraint of children when traveling. Alternative harnesses are available for children whose height and weight qualify them for CSS but their medical equipment, such as a halo head brace, hip spica cast, tracheostomy or omphalocoele interfere with the straps [23]. Children who need support for their head and neck may require a medical CSS for safe transportation. Specialized medical CSS and travel vests are available for larger

Asthma

Asthma is the most common chronic disease of childhood. In the US 8.4% of children suffer from asthma [37,38]. Managing asthma while traveling includes minimizing triggers, treating typical flare-ups and working with families to identify when and where to seek treatment. Common triggers associated with travel include low humidity air in airplanes, passive smoke, pollution, mold, pollen, animal dander and respiratory infections. Asthma attacks are one of the top pediatric in-flight emergencies;

Congenital heart disease

Congenital heart disease affects 1% of babies worldwide [51]. A pre-travel consultation with a cardiologist is recommended to determine the need for in-flight oxygen. Families are adept at adjusting schedules to accommodate their child's activity tolerance, which they can extend to travel. Children with complex congenital heart disease are often in various stages of repair; consultation with a pediatric cardiologist is advised to review flying, exercise restrictions, and the need for ongoing

Immunosuppression

Significant advances in the care for children with underlying inflammatory and autoimmune diseases have created a large group of children who feel well, but are partially immune suppressed either as a result of their underlying illness or treatment. Travel medicine providers will need to assess unique risk of acquiring infections at the destination as well as the effectiveness of immunizations and/or prophylactic medications for their immune suppressed travelers [54]. The Infectious Disease

Sickle cell anemia

Sickle cell disease (SCD) is a heterogeneous inherited disorder of hemoglobin. Many children with SCD have families who have migrated from Africa, Arabia or India. Pediatric patients with sickle cell disease (SCD) who travel are susceptible to infection with encapsulated bacteria (e.g. meningococcus, pneumococcus), malaria and salmonella [[68], [69], [70]]. Two sickle cell centers analyzed their center's data on ill-returned travelers with differing results. Ten to 59% of pediatric travelers

Diabetes

Type 1 diabetes affects 0.24% of Americans under age 20 [72]. A large retrospective study showed that young adults18-32 years of age with Type 1 diabetes with good glycemic control prior to departure do not suffer increased travel-related illness over their healthy peers. Additionally, they maintain good glycemic control when traveling [73]. Similar findings were supported in a large prospective study of adults [74]. An older study noted that hypoglycemia occurred in 10% of type 1 diabetic

Hearing and visual impairments

Communication barriers and unfamiliar environments associated with international travel are compounded for children with hearing and/or vision impairment. Travel skills for children with vision impairments should be taught early in childhood, often well in advance of planned travel. Families of children with low or no vision can describe the environment to the child, pointing out traffic, landmarks and give the child responsibility for planning routes. Ideally orientation and mobility skills

Intellectual and behavioral health problems

Careful preparation for a child with a developmental or behavior disorder is essential to successful travel. Many of the experiences involved in travel such as tolerating loud noises, long waits in line, unfamiliar foods and altered sleep habits can cause a deterioration of a child's behavior. Data are not available about travel-related health outcomes for children with Autism or ADHD despite their high prevalence (2.5% and 9.4% respectively) [85,86].

Parents and therapists have found ways to

General travel preparation

Traveling internationally with children with special health care needs requires pre-travel planning. A summary of an approach to preparing a CSHCN for travel is provided in the Fig. 1. Several authors recommend a practice or ‘trial run’ of travel to a near-by city for a weekend. This ‘mini travel’ gives the patient and family a chance to identify and solve many obstacles such as completing activities of daily living, providing routine medical care and finding safe transportation prior to

Conclusion

Travel health professionals, general practitioners and pediatric specialists all share in the responsibility of caring for children with chronic and complex healthcare needs who travel internationally. General principles of travel health such as providing safe transportation, preventing infections, updating immunizations and managing common travel illnesses are important. In addition, care plans must include day-to-day needs as well as management of flare-ups of illness while away from home.

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