Chapter 9 – Children in Disasters

Abstract

Children are amongst the most vulnerable members of society. In disasters that vulnerability is magnified, especially for the very young and those children who are unaccompanied or have pre-existing medical needs.

Chapter 9 Children in Disasters

Simon Hendel

Introduction

The intention of this chapter is to serve as a useful and pragmatic guide to the occasional pediatric practitioner or for the health worker who is in or preparing for a disaster.

There are a number of key differences between the management of children and adults in disasters. These differences will form the basis of the discussion in this chapter. There are also many differences in the availability of expertise and resources to prepare for and manage disasters when they occur. This changes how different jurisdictions may be able to realistically respond, but not the key principles of how to respond.

Children are not little adults and so the key differences in their physiology and development will be examined, as will the different equipment, drugs, and fluids used to treat children in disasters. Responding to disasters involving children is emotionally challenging and psychologically draining. This may have significant effects on health workers and emergency personnel.

There is an enormous difference in development and independence between a newborn through to a 16-year-old young person. This difference is reflected in the broad range of issues that can affect children in disasters. For example, the risk of environmental extremes is significantly greater in a newborn than a teenager. Conversely, the risk of emotional trauma or post-traumatic stress disorder is greater in the teenager exposed to a disaster.

Preparing for, responding to, and recovering from any disaster requires complex systems and multi-agency collaboration. Doing so with children in mind needs all the same responses in addition to an approach that addresses children’s unique needs and special vulnerabilities.

The general principles for disaster preparedness and specific responses in a disaster have been discussed in previous chapters and so they will not be repeated in detail here, except where they are necessary for making the point about caring for children.

Preparing for a Disaster

A disaster involving children may overwhelm a non-pediatric hospital, or the emergency medical services response more rapidly than an equivalent event not involving children.

In a disaster, it is highly likely that organisations and individuals who do not usually manage pediatric patients will need to have the capacity to respond outside their normal scope of practice.

The World Association of Disaster Emergency Medicine defines a disaster as:

“A situation or event that overwhelms local capacity, necessitating a request to national or international level for external assistance, or an unforeseen and often sudden event that causes great damage, destruction and human suffering.”

Disasters are then further described in terms of natural or man-made. When managing involved children the specific type of disaster will present slightly different issues and challenges for planning and response. More distinctly defined are mass casualty incidents. These events are distinct from larger scale disasters in that they may not effect the community-at-large, despite nonetheless overwhelming local capacity for effective response. It is also important to distinguish these from multiple casualty incidents. By definition, these do not overwhelm local resources or capacity to respond.

This definition is useful in terms of understanding the types of events that are likely to be “disasters.” It is important to note that disasters are not contingent only on a significant number of affected individuals but on the overwhelming of local capacity. This is an important consideration for organizations as they prepare for dealing with children involved in a disaster.

Responding to disasters is stressful. For responders it is physically and emotionally draining work. When children are involved the added degree of emotional and psychological stress may make the risk of exhaustion and burnout amongst responding health staff greater. This risk should be discussed in the preparation phase and, as best possible, plans made to mitigate this risk.

From previous chapters, we know that disasters can and do take many forms. Both natural and man-made disasters occur in a variety of contexts and settings, from Paris to small mountaintop villages in Nepal and everywhere in between. Children are also affected by context; however, specific plans for how best to respond to a particular disaster in a particular place are beyond the scope of this chapter. The intent of this chapter is to provide general information and structures that can be adapted and applied to local planning needs and practices.

A structured, multi-agency approach to disaster management forms the basis of the preparedness and response when it comes to dealing with children in disasters as it does for dealing with disasters in general.

Planning at the local level will inevitably involve discussions with key local stakeholders. Pediatric specialists should be identified and involved early in the planning process. At a minimum, experts in pediatric pre-hospital care, pediatric emergency medicine, childhood mental health experts, and pediatric critical care experts should be involved in planning for disaster response. Ideally this planning process should be integrated with broader disaster plans to enable a response for pediatric care in disasters that dovetails with other emergency response plans.

Wherever and however disaster strikes, prior preparation and planning will enable a more coordinated and effective response to coping with and managing children involved. During the early stages of planning and preparedness, consideration of which groups of children will likely be at more risk than baseline or those children with likely the highest risk may help to focus efforts to benefit the whole community.

Understanding the ways in which children differ from adults in disasters is a first step in preparing effectively.

Amongst other medical concerns in a disaster event, children are particularly vulnerable to clinical problems like diarrheal illness, respiratory compromise, effects of environmental extremes, trauma, and burns (see Table 9.1).

Table 9.1 Pediatric risks in disasters

Illness/injury	Pediatric risk	Example of disaster event	Potential mitigation
Diarrheal illness	Age-dependent susceptibility (influenced by hygiene, crowding, water and sanitation) More susceptible to effects of dehydration More specialised knowledge and skills required for intravenous rehydration Infants and young children much more susceptible to hypoglycemia and malnutrition	Natural: any that disrupts routine sanitation and/or displaces populations into areas of high density (e.g. Nepal earthquake, Cyclone Winston in Fiji) Man-made: war (e.g. Syrian refugee crisis)	Caches and ready supply of oral rehydration solution (ORS) Access to and supply of infant formula Intravenous and nasogastric rehydration capability
Respiratory infection/ compromise	Higher minute ventilation Greater susceptibility to infectious agents Many chemical agents settle low to ground closer to children’s breathing level Smaller, narrower airways more susceptible to inflammation or inhalational agents	Natural: fires, pandemic influenza Man-made: fires, terrorist attack, nuclear accidents	Established relationships with regional pediatric centers for advice and training Oxygen supplies Specific chemical and radiological antidotes if available
Trauma	Smaller circulating volume and therefore less total volume loss required before onset of shock Inexperience in most centers dealing with pediatric trauma Pain management difficulties	Natural: floods, earthquake, major storm event Man-made: war, terrorism, major transport incident	Structured approach to pediatric trauma following APLS/ ATLS guidelines Early pharmacologic management of pain (see Table 9.3)
Burns^a	More susceptible to effects of fluid shifts in major burns Inexperience of most practitioners	Natural: fires, earthquakes Man-made: fires, war	Accuracy in estimating total body surface area (TBSA) burned using either “rule of nines” (see Figure 9.2) or other validated approach. Early initiation of fluid resuscitation based on modified Parkland’s formula^a or aiming for urine output of 1 ml/kg/h
Environmental extremes	Greater risk of hypothermia and heat illness (especially the very young)	Natural: flooding, storms Man-made: war	Early priority to dry, cover, and shelter young children
Developmental	Less capacity for independent survival High risk of impaired childhood development if displacement/trauma prolonged	All
Emotional	Less mature coping strategies Less able to process events High chance of separation from family	All	See Chapter 13