Improving Disaster Preparedness for Children: A 75-Year Review in Pediatrics

Commentary From the Council on Children and Disasters

After the devastation of hurricane Katrina, the American Academy of Pediatrics (AAP) leadership founded the Disaster Preparedness Advisory Council (DPAC) to assist the AAP with advocacy and promotion of disaster preparedness planning for children. Five years after Katrina, “Helping the Helpers to Help Children” was published to highlight the impact of disasters on children and the importance of prioritizing the health of children in disaster planning, which previously focused on adults. Realizing the increased risk that children and youth with special healthcare needs face during disasters, a landmark publication, “Emergency Information Forms and Emergency Preparedness for Children With Special Health Care Needs” was created to assist families in their preparedness journey with actionable tools to help families prepare for emergencies and disasters. With the increase in not only natural disasters but also manmade disasters affecting children in recent decades, DPAC worked to promote supporting children’s mental health after disasters with the publication, “Providing Psychosocial Support to Children and Families in the Aftermath of Disasters and Crises.” In 2019, AAP leadership, seeking to expand subject matter expertise in pediatric preparedness and response, launched the Council on Children and Disasters (COCD). COCD helps to encourage children’s needs to be considered and addressed in all aspects of disaster planning, response, and recovery at the national, regional, tribal, territorial, and local levels.

Improving Disaster Preparedness for Children: A 75-Year Review in Pediatrics

Shana Godfred-Cato, DO, FAAP¹; Sarita Chung, MD, FAAP^2,3; Steve Krug, MD, FAAP^4,5

Affiliations: ¹Division of General Pediatrics, Department of Pediatrics, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City; ²Division of Emergency Medicine, Boston Children’s Hospital; ³Harvard University Medical School, Boston, MA; ⁴Northwestern University Feinberg School of Medicine, Chicago, IL; ⁵Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital, Chicago, IL

Highlighted Articles From Pediatrics

• Krug SE, Tait VF, Aird L. Helping the helpers to help children: advances by the American Academy of Pediatrics. Pediatrics. 2011;128(Suppl 1):S37-S39; doi: 10.1542/peds.2010-3724O
• Schonfeld DJ, Demaria T, Disaster Preparedness Advisory Council, Committee on Psychosocial Aspects of Child and Family Health. Providing psychosocial support to children and families in the aftermath of disasters and crises. Pediatrics. 2015;136(4):e1120-e1130; doi: 10.1542/peds.2015-2861
• Chung S, Baum CR, Nyquist AC, Disaster Preparedness Advisory Council, Council on Environmental Health, Committee on Infectious Diseases. Chemical-biological terrorism and its impact on children. Pediatrics. 2020;145(2):e20193750; doi: 10.1542/peds.2019-3750
• Disaster Preparedness Advisory Council, Committee on Pediatric Emergency Medicine. Ensuring the health of children in disasters. Pediatrics. 2015;136(5):e1407-e1417; doi: 10.1542/peds.2015-3112
• American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Council on Clinical Information Technology; American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Emergency information forms and emergency preparedness for children with special health care needs. Pediatrics. 2010;125(4):829-837; doi: 10.1542/peds.2010-0186

Disasters, whether manmade or natural, have been present since the beginning of time yet have increased markedly in the past decades. Historically the US healthcare system had varying levels of disaster preparedness by state or region without much national oversight. The September 11, 2001 terrorist attacks and Hurricane Katrina (2005) brought recognition that disasters are significant public health concerns and highlighted the need for a coordinated effort to optimize health outcomes for those affected. These events also underscored the observation that children have suffered greatly in all major disasters, yet preparedness for children had lagged far behind adult readiness. After Katrina, which saw more than 5,000 children separated from their families, the American Academy of Pediatrics (AAP) prioritized ensuring the health of children impacted by disasters through the creation of the Disaster Preparedness Advisory Council, and via active collaboration with federal partners, to further pediatric preparedness on a national level.¹

Due to the profound impact of Katrina on affected communities, including the mental health and medical needs of children, Pediatrics published a supplement 5 years later that shared the experiences and lessons learned from Katrina with the aim of improving preparedness for children in future events.² Over the past 75 years, Pediatrics has published many articles, including important policy statements and technical reports, outlining the need for pediatric-centric considerations in disaster preparedness and response as well as ways to improve healthcare preparedness at local, state, territorial, tribal, and national levels. This retrospective highlights a few of the most impactful disaster preparedness publications in Pediatrics.

An early article published in 1985 addressed the psychosocial impacts of the threat of nuclear war on children.³ Barness was a leader in his time, calling out the unique impact that disasters or the threat of disasters can have on children. What is known about psychosocial impacts of disasters on children has expanded immensely over the last 30 years. In 2005, Pediatrics published “Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician,” and again in 2015, an update “Providing Psychosocial Support to Children and Families in the Aftermath of Disasters and Crises.”^4,5 These articles describe how children’s response to a disaster differs across the age and development spectrum and how children are also affected by the impact on their family unit. These authors emphasized the role pediatricians can play in helping children and families prepare for disasters and in supporting children and families after a disaster. Schonfeld discusses effective coping strategies, reviews common responses children may have, and outlines age-appropriate interventions that can be used to assist children after an event.⁵

Children spend a large portion of their lives in school or childcare settings and may be in these locations when a disaster occurs. Schools must be prepared to respond to disasters, plan for reunification of children and families, and assist with recovery after the event.⁶ Family Reunification Following Disasters: A Planning Tool for Health Care Facilities provides recommendations that schools can adopt to improve their preparedness plans without extensive funding or time and methods for integrating family, community, and medical home participation into their disaster planning and response.

Since Katrina, the AAP has championed the importance of pediatric-specific planning and emphasized that children are particularly vulnerable with unique needs. In 2015, Pediatrics published “Ensuring the Health of Children in Disasters,” a follow-up to the 2006 technical report, “The Pediatrician and Disaster Preparedness.”^7,8 These articles outline how children’s needs and responses to disasters differ from adults. When we fail to include children and their needs in disaster plans, responders may not be prepared to care for children; not only due to a lack of essential equipment and medications but also due to a dearth of clinical knowledge, both of which can lead to poor outcomes for children. Pediatricians and the medical home can serve as trusted sources of information for families and communities throughout the disaster cycle. Moreover, they can promote family readiness, assist communities to improve disaster planning for all ages of children, and improve pediatric care delivery though disaster mitigation, response, and recovery.

Children worldwide continue to be victimized by manmade events, including accidental release of chemical, biological, and radiological substances, and by violence and terrorism. In 2020, Pediatrics published an updated 2006 chemical-biological policy statement.^9,10 In 2018, Pediatrics published the technical report “Pediatric Considerations Before, During, and After Radiological or Nuclear Emergencies” as an update to an earlier 2003 report.^11,12 These extensive technical reports outlined the deleterious impact chemical, biological, and radiological agents have on children and, specifically, how pediatricians can support families and the healthcare system to improve pediatric readiness and medical, mental, and behavioral health after a disaster. The AAP has worked closely with federal partners to further pediatric preparedness for specific agents. As an example, the AAP, in collaboration with the Centers for Disease Control and Prevention, published the clinical report, “Pediatric Anthrax Clinical Management,” that focused on pediatric aspects of prophylaxis and treatment of anthrax disease.¹³

Medical countermeasures (MCM) are treatments or equipment used to treat patients during a public health emergency.¹⁴ Many MCMs are developed with adults as the targeted recipient. There are many challenges with pediatric MCMs, including the lack of testing in children and the greater expense and shorter shelf life for many pediatric formulations. This gap in available treatments for children must be addressed. This publication summarized the actions of the federal government in addressing the MCM gap and called on federal and local governments, academia, and private industry to prioritize pediatric research and development.

Children are clearly vulnerable and can experience substantial morbidity and mortality with disasters; children and youth with special health care needs (CYSHCN) are at even greater risk due to their medical and mental health conditions. Emergency planning is especially important for these children because medications, electricity, equipment, clean water, or other supplies may be required for medical care during a response. Lack of these necessities will further jeopardize outcomes of CYSHCN during disasters. The 2023 AAP joint policy statement, an enhanced update of the 2010 and 1999 version, includes a thoughtfully developed emergency information form that includes the child’s health conditions, baseline ancillary findings, treatments, specialty care providers, emergency contact numbers, and vaccination record.^15-17 An emergency plan should be developed ahead of any disaster in coordination with the child’s care team and school. The plan should be shared with all caregivers and practiced to assist with meeting the needs of CYSHCN during a crisis.

Knowledge concerning how to prepare for and respond to natural and manmade disasters affecting children has increased significantly since Barness’ 1985 article. Many of these publications are based on subject matter experts’ knowledge or are consensus-driven based on past response experience. Nonetheless, the literature lacks evidence-based methods that can be implemented within homes, schools, medical facilities, and communities. Hopefully, the recent creation of pediatric emergency and disaster networks aimed at improving pediatric emergency and disaster readiness (eg, the Health Resources Services Administration [HRSA]-funded Pediatric Pandemic Network, the Administration for Strategic Planning and Response-funded Pediatric Disaster Centers of Excellence, and the HRSA-funded Emergency Medical Services for Children Innovation and Improvement Center) will over time expand the evidence base. In addition, greater engagement of pediatricians, including those in the medical home, is vital to achieve optimal pediatric preparedness and response, and ultimately recovery. As disasters will continue to affect the lives of children, the efforts of pediatricians and others serving the needs of children may guide us toward the ultimate goal: resiliency.

References

1. Krug SE, Tait VF, Aird L. Helping the helpers to help children: advances by the American Academy of Pediatrics. Pediatrics. 2011;128(Suppl 1):S37-S39; doi: 10.1542/peds.2010-3724O
2. American Academy of Pediatrics. Hurricane Katrina’s Children: 5 Years Later. Pediatrics. 2011;128(Suppl 1):S1-S43
3. Barness LA. Will there be a tomorrow without the children? Pediatrics. 1985;76(3):459-460
4. Hagan JF, Committee on Psychosocial Aspects of Child and Family Health, Task Force on Terrorism. Psychosocial implications of disaster or terrorism on children: a guide for the pediatrician. Pediatrics. 2005;116(3):787-795; doi: 10.1542/peds.2005-1498
5. Schonfeld DJ, Demaria T, Disaster Preparedness Advisory Council, Committee on Psychosocial Aspects of Child and Family Health. Providing psychosocial support to children and families in the aftermath of disasters and crises. Pediatrics. 2015;136(4):e1120-e1130; doi: 10.1542/peds.2015-2861
6. Council on School Health. Disaster planning for schools. Pediatrics. 2008;122(4):895-901; doi: 10.1542/peds.2008-2170
7. Disaster Preparedness Advisory Council, Committee on Pediatric Emergency Medicine. Ensuring the health of children in disasters. Pediatrics. 2015;136(5):e1407-e1417; doi: 10.1542/peds.2015-3112
8. Markenson D, Reynolds S, Committee on Pediatric Emergency Medicine, Task Force on Terrorism. The pediatrician and disaster preparedness. Pediatrics. 2006;117(2):e340-e362; doi: 10.1542/peds.2005-2752
9. Chung S, Baum CR, Nyquist AC, Disaster Preparedness Advisory Council, Council on Environmental Health, Committee on Infectious Diseases. Chemical-biological terrorism and its impact on children. Pediatrics. 2020;145(2):e20193750; doi: 10.1542/peds.2019-3750
10. Committee on Environmental Health, Committee on Infectious Diseases. Chemical-biological terrorism and its impact on children. Pediatrics. 2006;118(3):1267-1278
11. Paulson JA, Council on Environmental Health. Pediatric considerations before, during, and after radiological or nuclear emergencies. Pediatrics. 2018;142(6): e20183000
12. Committee on Environmental Health. Radiation disasters and children. Pediatrics. 2003;111(6):1455-1466
13. Bradley JS, Peacock G, Krug SE, et al. Pediatric anthrax clinical management. Pediatrics. 2014;133(5):e1411-e1436; doi: 10.1542/peds.2014-0563
14. Disaster Preparedness Advisory Council. Medical countermeasures for children in public health emergencies, disasters, or terrorism. Pediatrics. 2016;137(2):e20154273; doi: 10.1542/peds.2015-4273
15. Clinical Information Technology; American College of Emergency Physicians; Pediatric Emergency Medicine Committee. Emergency information forms and emergency preparedness for children with special health care needs. Pediatrics. 2010;125(4):829-837; doi: 10.1542/peds.2010-0186
16. Committee on Pediatric Emergency Medicine. Emergency preparedness for children with special health care needs. Pediatrics. 1999;104(4):e53; doi: 10.1542/peds.104.4.e53
17. Callahan JM, Baldwin S, Bodnar C, et al. Access to critical health information for children during emergencies: emergency information forms and beyond. Pediatrics. 2023;151(3):e2022060970; doi: 10.1542/peds.2022-060970