Chapter 7International Travel with Infants & Children

Katherine Shealy, Jessica Allen

The medical preparation of a traveler who is breastfeeding differs only slightly than that of other travelers and depends in part on whether the mother and child will be separated or together during travel. Most travelers should be advised to continue breastfeeding throughout travel. Before departure, mothers may wish to carry with them a written list of local breastfeeding resources at their destination. Clinicians may be able to help breastfeeding mothers find out about available breastfeeding support experts at their destination through sources that may include:

• International Board-Certified Lactation Consul­tants (IBCLCs)—health professionals in approximately 50 countries who specialize in the clinical management of breastfeeding (http://gotwww.net/ilca or www.iblce.org).
• La Leche League Leaders (LLLLs)—trained and accredited volunteer mothers in approximately 60 countries who provide mother-to-mother breastfeeding support and help (www.llli.org).

Mothers who plan to use a breast pump while traveling should have a back-up option available, including written instructions for hand expression; for more detailed instructions about hand expression, see www.workandpump.com/handexpression.htm.

IMMUNIZATIONS AND MEDICATIONS

In almost all situations, clinicians can and should select immunizations and medications that are compatible with breastfeeding. In most circumstances, it is inappropriate to counsel mothers to wean in order to be vaccinated or to withhold vaccination due to breastfeeding status.

Breastfeeding and lactation do not affect maternal or infant dosage guidelines for any immunization or medication; children always require their own immunization or medication, regardless of maternal dose. In the absence of documented risk to the breastfeeding child of a particular maternal medication, known risks of stopping breastfeeding generally outweigh a theoretical risk of exposure via breastfeeding.

Immunizations

Breastfeeding mothers and children should be vaccinated according to routine, recommended schedules; only preventive vaccinia (smallpox) vaccine is contraindicated for use in breastfeeding mothers. Administration of most live and inactivated vaccines does not affect breastfeeding, breast milk, or the process of lactation.

Special Consideration: Yellow Fever Vaccination

Whether this vaccine is excreted in human milk is unknown. However, at least 2 cases of yellow fever vaccine-associated neurologic disease have been documented in infants, presumably associated with breastfeeding transmission of yellow fever vaccine virus. No testing has been done to detect the yellow fever vaccine virus in breast milk, so it can only be said that the vaccine virus was transmitted through breastfeeding, but it has not been definitively determined that transmission occurred via the breast milk. Therefore, breastfeeding is a precaution to yellow fever vaccination, and women should be cautioned to avoid this vaccination while breastfeeding. Since risk exists and there are many gaps in knowledge, breastfeeding mothers should be discouraged from traveling to yellow fever–endemic areas. However, if travel to a yellow fever–endemic area cannot be avoided or postponed, then the mother should be vaccinated.

Medications

The American Academy of Pediatrics (AAP) 2001 Policy Statement: The Transfer of Drugs and Other Chemicals into Human Milk provides an overview of the compatibility or effects on breastfeeding of approximately 250 drugs. The pharmaceutical reference guide, Medications and Mothers’ Milk, is updated every 2 years and provides a comprehensive review of the compatibility or effects on breastfeeding of approximately 1,000 drugs, including generic and trade names, AAP recommendations, risk categories, pharmacologic properties, interactions with other drugs, suitable alternatives, theoretic and relative child dose, pediatric half-life, and many other pediatric concerns.

Special Consideration: Antimalarial Medications

Since chloroquine and mefloquine may be safely prescribed to infants, both are considered safe to prescribe to mothers who are breastfeeding. Most experts consider short-term use of doxycycline compatible with breastfeeding. Primaquine may be used for breastfeeding mothers and children with normal glucose-6-phosphate dehydrogenase (G6PD) levels. Breastfeeding mothers should not use atovaquone-proguanil when the breastfeeding infant weighs <5 kg (about 11 lb).

AIR TRAVEL

X-rays used in airport screenings have no effect on breastfeeding, breast milk, or the process of lactation. Airlines typically consider breast pumps as personal items to be carried onboard, similar to laptop computers, handbags, and diaper bags.

Before departure, mothers who will be traveling by air and expect to have expressed milk with them during travel need to carefully plan how they will transport their milk. Airport security regulations for passengers carrying expressed milk vary internationally and are subject to change. In the United States, the Transportation Security Administration (TSA) recognizes expressed milk in the category of liquid medications that may be carried on, regardless of whether the breastfeeding child is traveling, as long as it is declared before screening. TSA recommends that travelers carrying expressed milk have with them a printed copy of the TSA website page www.tsa.gov/travelers/airtravel/children/formula.shtm to help prevent inadvertent problems at security checkpoints.

Travelers carrying expressed milk in checked luggage should refer to cooler pack storage guidelines in “Proper Handling and Storage of Human Milk” on CDC’s website at www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htm to protect milk during travel. Expressed milk is not considered a biohazard. International Air Transport Authority regulations for shipping category B biological substances (UN 3373) do not apply to expressed milk; it is considered a food for individual use. Travelers shipping frozen milk should follow guidelines for shipping other frozen foods and liquids. Expressed milk does not need to be declared at US Customs upon return to the United States.

TRAVELING WITH A BREASTFEEDING CHILD

Breastfeeding provides unique benefits to mothers and children traveling together. Health clinicians should explain clearly to breastfeeding mothers the value of continuing breastfeeding during travel. Exclusive breast-milk feeding (only breast milk, no other food or drink) protects infants from exposure to contamination and pathogens via foods or liquids. Additionally, feeding only at the breast protects infants from exposure to contamination from containers (bottles, cups, utensils).

Breastfeeding infants require no water supplementation, even in extreme heat environments. Breastfeeding protects children from eustachian tube pain and collapse during air travel, especially during ascent and descent, by allowing them to stabilize and gradually equalize internal and external air pressure, which cannot be replicated by sucking on a bottle or pacifier.

Clinicians should offer information to breastfeeding mothers so that they are better able to continue breastfeeding during travel. Frequent, unrestricted breastfeeding opportunities ensure the mother’s milk supply remains ample and the child’s nutrition and hydration are ideal. Safe use of a fabric infant carrier helps maintain breastfeeding by increasing breastfeeding opportunities and skin-to-skin contact with the child, while also protecting the child from environmental hazards and easing the burden of carrying a heavy child. Mothers who are concerned about breastfeeding away from home may breastfeed modestly with the child in a fabric carrier. In many countries around the world, breastfeeding in public places is more widely practiced than in the United States. US federal legislation protects mothers’ and children’s right to breastfeed on federal property, which includes US Customs and embassies overseas.

Special Consideration: Travelers’ Diarrhea

Exclusive breastfeeding protects infants against travelers’ diarrhea. Breastfeeding is ideal rehydration therapy. Children who are suspected of having travelers’ diarrhea should breastfeed more frequently. Children in this situation should not be offered other fluids or foods that replace breastfeeding. Breastfeeding mothers with travelers’ diarrhea should continue breastfeeding and increase their own fluid intake. The organisms that cause travelers’ diarrhea do not pass through breast milk. Breastfeeding mothers should not use bismuth subsalicylate compounds, because they may transfer salicylate to the child. Compatible alternatives are kaolin-pectin and loperamide. Use of oral rehydration salts is fully compatible with breastfeeding.

TRAVELING WITHOUT A BREASTFEEDING CHILD

A breastfeeding mother traveling without her breastfeeding infant or child may wish to express and store a supply of milk to be fed to the infant or child during her absence. Building a supply to be fed in her absence takes time and patience and is most successful when begun gradually, many weeks in advance of the mother’s departure. Infants who have never consumed milk from a bottle or cup need opportunities to practice this skill with another caregiver before the mother’s departure.

A mother’s milk supply can diminish if she does not express milk while away from her nursing child, but this does not need to be a reason to stop breastfeeding. Clinicians should help mothers determine the best course for breastfeeding based on a variety of factors, including the amount of time she has to prepare for her trip, her flexibility of time while traveling, her options for expressing and storing expressed milk while traveling, the duration of her travel, and her destination. A mother who returns to her nursing infant or child can continue breastfeeding and, if necessary, supplement as needed until her milk supply returns to its prior level. Often, after returning from travel, a nursing infant or child will help bring her milk supply to its prior level. However, nursing infants or children who are separated from their mother for an extended time may have difficulty transitioning back to breastfeeding.

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