Defining disasters and types relevant to peds
Disasters pertain to their effect on the environment and healthcare and are divided into two major groups: natural and man-made. Natural disasters further include volcanoes, hurricanes, earthquakes, and floods, while man-made disasters include wars, pollution, fires, explosions, and exposure to hazardous materials. These disasters lead to the destruction of infrastructure, the spread of communicable diseases, and an increase in the rate of mortality [1].
The post-disaster phase plays a crucialrole in healthcare response, particularly in disease control, resource allocation, and staff training. Effective disaster preparedness is essential for managing crises, ensuring the availability of adequate equipment, and implementing structured emergency protocols [6].
Children are affected significantly in a disaster owing to their smaller bodies, higher respiratory rate, less subcutaneous fat, and inability to effectively verbalize their needs [3]. A study by Dyregrov A et al. highlighted the dual physical and emotional toll disasters impose on children. For example, the eruption of Eyjafjallajökull in 2010 led to respiratory diseases and an earthquake in China in 2008 led to increased cases of depression and post-traumatic stress disorder (PTSD) among children. Consequently, highlighting the need to prepare to effectively manage and reduce the impact of disasters on the children [7].
Unique needs of children in disasters
Children make up about 25–30% of those hurt in disasters. During disasters, pediatric care is especially challenging due to differing biological, social, and ethical factors, requiring specific approaches to disaster handling and preparedness [2]. The Federal Emergency Management Agency (FEMA) divides these points of vulnerability into three categories: psychological, anatomy and physiology, and educational vulnerabilities [2].
Anatomical and physiological traits of children significantly influence their care during disasters. Children’s smaller circulating blood volume, thin skin, and limited body fat increase their susceptibility to fluid and heat loss compared to adults [2]. Their smaller body mass results in greater energy absorption per square inch, leading to unique injury patterns [2].
Skeletal immaturity and ligamentous laxity make children prone to different injuries. Their shorter stature and higher body surface area-to-mass ratio heighten the risk of toxin absorption and inhalation of heavy gases such as sarin and chlorine [2]. Additionally, their higher metabolic rates increase the risk of hypothermia and susceptibility to toxins [2].
Healthcare professionals who are not experienced in pediatric care may have difficulties providing adequate care to children in disasters. Due to variances in normal vital signs and dosages, it is essential to have quick access to pediatric-specific references [2]. Children were more impacted by gastrointestinal diseases than injuries, after hurricanes Katrina, Rita, and Tropical Storm Allison highlighting their vulnerability to infectious diseases in disasters [2]. Gastroenteritis can lead to srapid dehydration, shock and death. In addition, children who experience disrupted services face increased mortality from diarrheal diseases and respiratory infections, both of which are two of the leading causes of death for children under five [2].
Children’s psychological and developmental responses to disasters differ from adults, posing challenges for healthcare providers. For communication and emotional support, infants and young children rely entirely on caregivers for communication and emotional support [2]. Separation or loss of caregivers during disasters further complicates care and increases staffing demands [2].
Disasters can bewilder children, impacting their ability to cooperate with evaluations and treatments. Stress often results in developmental regression. Also, children are particularly vulnerable to an acute stress disorder, which if left without treatment can develop into PTSD. Symptoms such as withdrawal and emotional instability often go unrecognized increasing risk for mental health problems in adulthood, highlighting the necessity for pediatric tailored interventions in disaster response [2].
Children’s dependency on carers for physical and emotional needs complicates disaster response. Since they cannot care for themselves, infants and young children need safe age-appropriate resources and safe housing [2]. communication and care get interrupted when caregivers are separated from them due to injury, death, or logistical challenges [2]. Unfamiliar surroundings further distress children, hindering effective medical intervention [2].
Educational vulnerability is often overlooked in disaster response. Children’s education is severely disrupted, with many changing schools’ multiple times within months after a disaster. These disruptions negatively impact academic performance and recovery [2].
Addressing children’s unique needs in disaster preparedness and response is critical to reducing morbidity and mortality. Failure to do so exacerbates the challenges faced by this vulnerable population [2].
Pediatric disaster preparedness frameworks
International guidelines for pediatric disaster preparedness
International organizations such as UNICEF and WHO have developed frameworks to safeguard children’s health and well being during disasters. The 1990 Convention on the Rights of the Child, for instance, establishes the right of children to development, protection, and survival. International initiatives, such as the Anti-war Agenda (UNICEF, 1996), have been driven by this legal framework to advocate for the inclusion of children’s concerns in peace talks [8]. The removal of child soldiers, vaccinations during ceasefires, and the promotion of children as (zones of peace) in conflict zones are all measures central to UNICEF’s child protection strategies [8]. Child protection principles are further solidified by International Labour Organization (ILO) Convention No. 182 which forbids the use of minors under 18 in armed conflict [8]. Pediatric disaster preparedness implies that systems are in place to ensure the rapid triage and emergency management of children as patients in event of a disaster [9].
The United States has developed pediatric-specific disaster response guidelines, known as the Guidelines for Care of Children in the Emergency Department. These guidelines outline the necessary pediatric-specific equipments, medications, supplies, and readily available experienced staff, to help emergency departments (EDs) assess their readiness for disasters involving children [10]. Since their introduction in 2009, there has been a significant improvement in the number of EDs meeting these requirements and demonstrating increased preparedness [11].
Although not specifically designed for children, the World Health Organization (WHO) has developed the Health System Capacity Toolkit, which allows countries to assess their health systems’ ability to respond to various threats and identify gaps in preparedness [12, 13]. When applied in the European Union, this tool has shown that while the region’s preparedness is at an acceptable level, there remains considerable room for improvement [14].
Currently, the U.S. protocol is the only pediatric-specific tool available for assessing disaster readiness and is being adopted globally. However, a survey of EDs in Europe using these guidelines revealed that they lag behind the U.S. in pediatric disaster preparedness [15]. Studies from Europe continue to emphasize the need for national programs and pediatric-specific guidelines to enhance readiness [16,17,18].
During disasters, the needs of pediatric patients should be addressed through specialized disaster response practices. Triage systems and emergency responder training should be developed which consider the physiological and psychological features of children [8, 19]. For instance, during the 2009 H1N1 pandemic, regional variation in mortality estimates highlighted the importance of pediatric-specific response frameworks [19]. Furthermore, child-focused critical care interventions, such as oxygen concentrators and low-cost ventilation systems, have proven effective in improving pediatric outcomes in resource-limited settings, as evidenced by Papua New Guinea’s 35% reduction in pneumonia fatalities [19].
The stark differences between high and low-income nations about preparedness stand out when available tools and resources are compared. High-income countries make use of technology and initiate advanced-level instructors, while poor countries lack even the basic resources, such as staff, supplies, and basic infrastructure. Discrepancies are sought to be remedied through WHO-funded programs that build on affordable care in critical areas and include it in the disaster prevention action plan [19].
Challenges in implementing Pediatric-Specific frameworks
Resource limitations, training gaps, and ethical dilemmas remain barriers to adopting comprehensive pediatric disaster frameworks. The worldwide shortage of health workers (4.3 million doctors and nurses below requirements) worsens these challenges, particularly in resource-limited settings [19]. Most regions lack specialized pediatric care providers, including intensivists and respiratory therapists, which compromises disaster response efforts [19].
Although material resources, such as intravenous fluids and oxygen, are often available, a lack of trained personnel frequently prohibits their utilization, as was seen during the Ebola outbreak in West Africa [19]. Financial constraints also limit the application of pediatric-specific frameworks. In some cases, the daily costs of ICU in low-income settings are similar to those in high-income countries, which makes critical care appear cost-prohibitive [19]. However, short-term ICU interventions for acute but curable diseases in children can reduce mortality rates significantly, thus justifying their cost-effectiveness [19].
Ethical issues, however, further complicate pediatric disaster preparedness. Resource allocation decisions and those regarding local cultural values of global justice need to strike a balance between immediate needs and long-term goals. The child-focused framework will be further enhanced by systematically incorporating pediatric considerations in peace accords, deployment of child protection advisers, and robust monitoring mechanisms of violations against children [8, 19].
Infrastructure, training, and crisis response in pediatric emergency departments (PEDs)
Infrastructure and resource readiness
Disaster response is based on PEDs’ infrastructure and physical readiness. A spike in pediatric patients during disasters calls for more beds, adaptable treatment spaces, and specialized equipment. Reconverting non-clinical facilities into temporary patient care areas, for example, is a popular tactic, but it requires careful planning to prevent lowering the standard of treatment [20].
Equipment designed specifically for children presents special difficulties. PEDs need specialized equipment, such as ventilators that are the right size, infusion pumps, and monitoring made for babies and kids, in contrast to regular emergency rooms. In a similar vein, the accessibility of pharmaceuticals in child-friendly quantities is still a major worry during emergencies. Due to financial limitations and a lack of storage space, many PEDs struggle to accumulate these items. Patient outcomes may worsen if care is delayed due to a lack of readiness in this area [21].
PEDs frequently struggle to maintain basic operation, let al.one being disaster ready, making resource-constrained environments face substantial challenges in disaster preparedness. These difficulties include a lack of pediatric-focused training, limited personnel, and inadequate infrastructure. During emergencies, when the already constrained systems are under tremendous strain, the differences in resource distribution are most noticeable [21].
Novel adaptations have been developed to lessen these difficulties. Among the strategies used to increase capacity include mobile clinics, telemedicine platforms, and task-shifting models, in which non-specialized healthcare professionals are taught to provide critical pediatric care. In order to augment local resources, collaborations with foreign assistance groups are also essential. These modifications demonstrate the adaptability and ingenuity of healthcare professionals in environments with limited resources, but systemic investments are still necessary for long-term progress [22].
Sudden, overwhelming patient surges brought on by disasters frequently put a strain on PED staffing and resources. Three key components have being identified as necessary for efficient surge capacity management: system-wide coordination, resource mobilization, and flexible personnel. A tried-and-true method of increasing the workforce during emergencies is to cross-train medical personnel to manage pediatric situations. Establishing catastrophe response procedures and conducting frequent simulation exercises also guarantees that teams can react effectively [23].
During catastrophes, regional and interdepartmental cooperation is frequently required for resource mobilization. For example, quick resource allocation is made possible by establishing digital inventory systems, utilizing regional supply networks, and hoarding essential commodities. In order to offer comprehensive treatment in the midst of turmoil, crisis management also includes psychological support for patients and medical staff [24].
Effective crisis response by PEDs necessitates a multipronged strategy. It is crucial to address equipment and space requirements, enhance resource allocation in settings with limited funding, and fortify surge capacity through effective crisis management techniques. Even if there has been improvement, there are still large gaps, especially in areas with limited resources. Building robust PED systems that can protect juvenile populations during catastrophes would need sustained funding along with creative modifications [24].
Staff training and simulation programs
Pediatric disaster preparedness involves systems for the swift triage and emergency management of children in natural, human-made, or terrorist-related disasters. Disaster preparedness is crucial for healthcare workers, as demonstrated by Boston’s healthcare workers’ effective response to the Boston Marathon bombing [25,26,27]. Physicians, particularly PEPs who are expected to provide care for disaster victims, must be prepared for these situations. Physicians should consider their potential roles in disasters and prepare accordingly. Physicians in all specialties should consider their potential roles in a disaster and attempt to prepare for these roles.
Nevertheless, workforce readiness remains a challenge. Most emergency medical responders lack specific training in pediatric disaster care, particularly in triage protocols like JumpSTART [28]. When it comes to treating the primary causes of pediatric death during catastrophes, this training gap frequently leads to uneven use of pediatric assessment and airway management abilities. Systemic shortcomings in readiness are evident in the fact that less than 20% of U.S. emergency services questioned said they have strategies specifically for pediatric emergencies [28, 29].
One of the primary concerns during disasters is surge capacity ability to manage and handle a rapid influx of patients more than the usual patient load [30]. Disaster protocols simulating training programs should ensure bed surge capacity by marking areas for patient expansion, like waiting rooms and hallways. Training should contain both staff surge capacity involving cross-training hospital staff for emergency care, and resource surge capacity including medical supplies and equipment, emphasizing rationing during prolonged disasters [25].
Communication and coordination systems
Disaster preparedness involves a crucial step of communicating the care between the hospitals for exchange of information, coordination of care and allocation of resources. Triage is the initial step for classifying the patients by their means of needs of care. It is conducted by qualified healthcare professionals and relies on effective communication to deliver essential care to critical patients [6]. Telemedicine is another means that could be used for triaging in pediatric emergency situations to direct care to patients who need immediate care and limit unnecessary visit to optimize the use of manpower. However, this can only be achieved with a healthcare professionals trained in the care of children [31].
The study by Torab-Miandoab A et al. explains how interoperability proves to provide the effective communication and efficient care to the patients. The word itself refers to the sharing of information between the healthcare to provide care for the patients by providing thorough information about the patient data. It further highlights how interoperability is the solution for delayed care due to inaccessible health records [32]. The study by Chaichotjinda K et al. found the incidence of 22% in adverse effects when transporting critically ill patients, which could have been avoided to some extent by effective communication, inappropriate escrot and lack of equipment [33].
Communication with the families is another aspect of effective communication as families rely on the healthcare professionals to support for their children’s care. In addition, it is needed for a two-way communication as a pre-disaster preparation to equip families with necessary information of how and where to access care. This can be made possible with the help of primary care patient medical home, information regarding continuity of care and rehabilitation services to serve as a medium for disaster planning [34].
Psychosocial support and mental health considerations
Disasters expose children to traumatic experiences that can lead to anxiety, depression, or post-traumatic stress disorder (PTSD). Events like the Haiti earthquake and the Gaza conflict demonstrate the profound psychological impacts on children, including separation from caregivers, exposure to violence, and loss of community support [35,36,37]. These challenges often lead to developmental regression and hinder their ability to cooperate with medical evaluations [37, 38].
Integrating mental health care into Pediatric Emergency Departments (PEDs) is essential for mitigating these effects. Psychological first aid, combined with access to child psychologists, ensures early intervention. Establishing child-friendly spaces and delivering long-term follow-up care are critical to addressing both immediate and prolonged psychological impacts on pediatric patients [37, 38].
PED staff play a crucial role in providing not only medical care but also emotional and logistical support to families during disasters. Clear communication helps caregivers manage their child’s needs and navigate the complex disaster environment [37, 38]. Structured programs, such as family reunification protocols, caregiver education on trauma responses, and access to counseling, help families remain resilient during crises [37, 38]. UNICEF’s guidelines on child protection emphasize the importance of caregiver inclusion as a cornerstone of effective pediatric disaster response [35].
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