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High-Yield Facts

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  • The most common cause of fever in the child returned from international travel is the nonspecific viral illness.

  • It is imperative to consider treatable causes of fever (e.g., malaria) or fever etiologies at risk for decompensation and the need for supportive care (e.g., dengue).

  • Diagnostic evaluation and differential diagnosis should be driven by the history of pre-travel immunizations and receipt of prophylactic medication, region of travel, activities undertaken while abroad, return date, physical examination findings (including severity and duration), and knowledge of the most common pathogens seen in a given area.

  • A population at considerable risk for travel infections is termed visiting friends and relatives (VRFs), as these families often opt not to seek medical attention prior to travel.

  • Thick and thin smears for malaria are indicated for any febrile child returning from a malaria-endemic region. Negative smears to not exclude malaria, and if strong clinical suspicion exists, smears should be repeated every 6 to 12 hours.

  • Malaria treatment often is empiric, and chloroquine resistance should be assumed. Therapy for children with high-grade parasitemia may involve blood transfusion (or exchange transfusion) and treatment with a combination of parenteral agents. These may include clindamycin in addition to quinidine or quinine.

  • Typhoid fever is very common in travelers (especially from the Indian subcontinent and Asia). Diarrhea is not always seen. Bacteremia may be common. Increasing antibiotic resistance in Salmonella typhi isolates makes microbiologic confirmation important.

  • Dengue is extending its geographical distribution and is now seen in southern portions of the United States. It is a biphasic illness, with an initial nonspecific febrile illness with or without a viral exanthema. After a few days, hemorrhagic manifestations and symptoms corresponding to capillary leak are manifest, lasting 2 to 3 days. Treatment is supportive.

  • Evaluation of the child with diarrheal disease after return from international travel warrants stool culture. Although antimicrobial therapy (often, macrolide-based) can reduce symptom duration, disease severity, and secondary spread within the household, the mainstay of therapy is fluid resuscitation.

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The emergency department (ED) is a common venue of care for children who are ill after a recent international travel. At least three categories of pediatric travelers can be identified: children returning home after travel; international adoptees; and recently arrived immigrants. Barriers to access to care, severity of illness, timing of symptom onset (weekends, holidays), and community referral patterns may result in children in all the above mentioned groups presenting to the ED.

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Individuals VFRs often neglect to seek travel advice prior to trips under the preconception that children have residual immunity when returning to the family's country of origin. Waning immunity, failure to develop effective long-term immune responses to certain infections (e.g., malaria), and lack of preventive strategies result in many of these children becoming ill. In the Houston area, for example, the single greatest risk factor for childhood malaria is being a VFR traveling to Nigeria; few of these children had received adequate malarial prophylaxis....

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