Travelers’ Diarrhea in Children: From Adventure to Adversity

Introduction:

Diarrhea is a common condition that many people experience when traveling to developing countries. It affects adults and children, but young children are more vulnerable and may experience more severe symptoms. It is estimated that around half of the travelers from developed countries who visit developing countries will have at least one episode of acute diarrhea during a two-week trip. This diarrhea usually starts suddenly while traveling or shortly after returning home; however, it usually goes away on its own without needing treatment.

What Are the Causes of Travelers Diarrhea?

The causes of travelers' diarrhea can vary depending on location and travel circumstances. The most common reasons are as the following:

• Food Contamination: Most cases of travelers' diarrhea are caused by consuming food contaminated with enterotoxigenic bacteria. This is the primary cause of travelers' diarrhea.

• Risky Eating Habits: Engaging in risky eating habits, such as consuming poorly cooked meat, contaminated raw vegetables, and unpasteurized dairy products, increases the likelihood of acquiring travelers' diarrhea.

• Poor Hygiene: Poor hygiene practices and unhygienic food handling practices contribute to the spreading of bacteria and increase the risk of travelers' diarrhea.

• Gastric Hypochlorhydria: Reduced stomach acid levels (gastric hypochlorhydria) can make individuals more susceptible to contracting travelers' diarrhea.

• Immunodeficiency Diseases: People with immunodeficiency diseases are more likely to acquire travelers' diarrhea due to their weakened immune systems.

• Lack of Gut Immunity in Children: Children have a relative lack of gut immunity compared to adults, making them more susceptible to severe consequences from travelers' diarrhea.

• Water Contamination: Although less common than foodborne transmission, waterborne transmission can also cause travelers' diarrhea, primarily through enterotoxigenic Escherichia coli (ETEC). Contaminated water sources can pose a risk.

• Inadequate Food Storage and Handling: In developing countries, insufficient storage and transport of food, unreliable refrigeration, lack of pasteurization, and unhygienic food handling practices can lead to food contamination and travelers' diarrhea.

• Contaminated Street Food: Eating food purchased from street vendors while providing cultural experiences carries an increased risk of travelers' diarrhea due to inadequate sanitary facilities and poor refrigeration at these food stalls.

• Injected Contaminated Water in Fruits and Vegetables: Even meticulous peeling and washing of fruits may not guarantee safety as fruits and vegetables are sometimes injected with contaminated water to increase their weight and value.

• Antibiotic Use: Clostridium difficile, a bacterial pathogen that causes travelers' diarrhea, should be considered, especially in individuals using antibiotics, including older children taking Doxycycline for malaria prophylaxis.

• Bacterial, Parasitic, and Viral Pathogens: Bacterial pathogens, primarily enterotoxigenic strains of E. coli (ETEC), Campylobacter jejuni, Salmonella species, and Shigella species, are the most commonly isolated organisms causing travelers' diarrhea. Parasitic pathogens such as Giardia lamblia, Cryptosporidium parvum, Cyclospora cayetanensis, and Entamoeba histolytica can also cause the condition. Viral agents like the Norwalk and rotavirus can also cause diarrhea for travelers.

• Antimicrobial Resistance: Enteric bacterial isolates from developing countries increasingly resist antimicrobial agents, including Tetracyclines, Sulfonamides, Ampicillin, and Fluoroquinolones.

How to Prevent Travelers Diarrhea in Children?

Travelers' diarrhea can be prevented by following the below-mentioned measures:

• Education and Handwashing: Educate children about safe food and beverage ingestion practices. Emphasize the importance of frequent handwashing, even when soap and water are unavailable. Waterless hand sanitizing agents can be used as convenient alternatives.

• Food Selection: While it may not always be practical to follow strict dietary recommendations, avoiding potentially contaminated food and water can reduce the risk of travelers' diarrhea. Choose foods that are well-cooked, recently cooked, and served piping hot. Avoid salad bars, raw vegetables, fruits that are difficult to clean, custards, mousses, mayonnaise, hollandaise sauce, and raw seafood. Peel fruits and vegetables or ensure they are freshly cooked. Avoid raw or undercooked fish and meat.

• Safe Beverages: Offer children safe beverages in developing countries, such as carbonated soft drinks without ice, carbonated bottled water, and fruit juices. Ensure the cap seal of commercially bottled water is intact. Ice cubes should be avoided. Rainwater that has been properly collected and stored is usually safe to drink.

• Dairy Products: Only consume pasteurized and properly refrigerated dairy products. For infants, consider using the premixed formula for shorter trips and prepare powdered formula with boiled water for longer trips. Maintain meticulous cleanliness of bottles used for formula feeding. Breastfeeding is a preferred option as it is more hygienic and may provide protection against gut pathogens.

• Water Purification: Purify water through boiling, filtration, or chemical disinfection. Boiling water is the most effective method to produce safe drinking water. Portable heater coils or carrying a water bottle with a portable kettle can ensure a reliable supply of purified water. Tap water that is too hot to touch can be safe to drink once cooled. Filters can remove bacteria and parasites but not viral pathogens, so chemical decontamination with a halogen is recommended.

• Chemoprophylaxis: Consider chemoprophylaxis using bismuth subsalicylate or antimicrobial agents for high-risk short-term child travelers. However, bismuth subsalicylate should be avoided in certain conditions, and parents should take caution with children due to the risk of Reye's syndrome.

• Vaccines: While there are currently no vaccines available for travelers' diarrhea, immunoprevention for the most common cause, enterotoxigenic Escherichia coli (ETEC), could significantly reduce the incidence. A killed, whole-cell ETEC vaccine is being developed. The typhoid vaccine is recommended for significant exposure to contaminated food and water. Cholera vaccination is generally not recommended for most travelers.

How Is Travelers Diarrhea in Children Managed?

Below are the measures that can be taken to manage travelers' diarrhea in children:

• Fluid replacement through oral rehydration solutions is crucial for managing travelers' diarrhea in children.

• Children under two years of age are at higher risk of dehydration and should receive immediate medical attention if signs of moderate to severe dehydration occur.

• Older children can maintain hydration with canned juices, carbonated soft drinks, purified water, or clear salty soups.

• Caffeine-containing beverages, dairy products, prune juice, orange juice, and apple juice should be avoided.

• Antimotility agents like Loperamide can be used in children over two years old to reduce the duration and severity of diarrhea, but caution is needed in younger children.

• Bismuth subsalicylate can help reduce the severity and duration of diarrhea but has delayed onset and frequent dosing.

• Antibiotic therapy with Azithromycin or Fluoroquinolones may be necessary for moderate to severe cases.

• Fluoroquinolones are effective in adults, while Azithromycin and Cefixime are more suitable for children under 16.

Conclusion:

Traveler's diarrhea is a gastrointestinal condition characterized by abdominal cramps and loose stools, typically caused by consuming contaminated food and water. However, it is generally not a severe condition but is usually unpleasant for children. The common causes behind traveler's diarrhea include bacteria such as enteroaggregative E. coli, enterotoxigenic Escherichia coli, Salmonella, Campylobacter, and Shigella.