Children Are Not Little Adults

This post was written by Steven E. Krug, MD, FAAP, and Yae Sul “Hazel” Jeong, MD, MS, FAAP. Dr. Krug is the Chairperson for the American Academy of Pediatrics (AAP) Council on Children and Disasters. He is a Professor of Pediatrics at the Northwestern University Feinberg School of Medicine, and the prior Head of the Division of Emergency Medicine at the Ann & Robert Lurie Children’s Hospital of Chicago. Dr. Jeong is a member of the AAP Council on Children and Disasters; Assistant Professor in the Section of Pediatric Emergency Medicine at The Ohio State University; and an Attending Physician in Pediatric Emergency Medicine at Nationwide Children’s Hospital.

Girl hugging her dad's leg

Imagine it. An earthquake shakes a California community, waking people whose homes have caught fire; responders must treat multiple children whose brief inhalation of smoke has rendered severe airway injuries. Or imagine a tornado rips through a town during the school day, and dozens of children need medical attention, but they’ve been separated from their identification and medical records. These are just two of the many disaster scenarios that pediatricians can help respond to—and also help others to plan for – so that the distinct medical needs of children are met.

Children have distinct healthcare needs in regard to their anatomic, physiologic, developmental, and psychological characteristics. These differences make them among the most vulnerable of all “at-risk populations” during a disaster. There are also social and environmental needs that should be considered in preparing to care for children and their families during a disaster.

For example, children are more likely to sustain greater damage from smoke inhalation or from an aerosolized biological or chemical agent. Due to their physiology, they are at a higher risk of absorbing dangerous amounts of chemicals or radiation through their skin. They are closer to the ground, where contaminants may be more concentrated and are at a substantially greater risk for hypothermia, which can happen from decontamination washes or exposure to cold temperatures in the field or disaster site, or even at a healthcare facility.

In addition, children are more susceptible to the development of shock due to smaller blood volume and smaller fluid reserves. Compared with adults, they are more likely to sustain a serious injury with blood loss from blast injuries, as the force of the blast is distributed over a smaller body. Children are also much more likely to sustain head trauma from blasts or other blunt injury mechanisms due to their unique body proportion.

Equipment and supplies are another important consideration. The wide range of ages and body sizes within the pediatric population requires advance preparation to assure there will be appropriately sized medical equipment and supplies, and acceptable medication formulations to support the care of young people of all ages.

Developmental immaturity can also place children at a greater risk during a disaster. Youngsters lack the cognitive abilities and self-preservation skills to know how to respond to a dangerous situation. The youngest may also lack the necessary motor skills to escape from a dangerous environment. They may also be unable follow the directions of a “stranger” who is trying to help them; imagine how a preschooler would perceive emergency responders in biohazard gear giving them instructions.

Planning for Children Without an Adult Present

Kicks with backpacks entering school

During a disaster, children may present to a healthcare facility without a parent or adult family member. Because children are highly dependent upon the support of parents and family, this poses a profound source of distress for children, their parents, and care givers. A primary goal when caring for unaccompanied minors in a disaster situation should be to reunite them with family members as quickly as possible. This may be further complicated for infants and preverbal children. In addition to providing necessary acute care, healthcare institutions must plan for key processes, including identification, tracking, and secure sheltering. Means for communication and interaction with local public safety and social service agencies should be established as part of disaster planning. Click here for more information from the American Academy of Pediatrics (AAP) reunification tool kit.

How Pediatricians Can Help Their Patients and Community to Be Prepared

Pediatricians can play a vital role in helping local communities to be better prepared to address the emergency care needs of children. Firstly, the medical home—the place where a child regularly receives care– is an essential component of a community’s resiliency and recovery framework. Pediatricians should work with staff to ensure that there is a disaster plan for their practice– one that is regularly rehearsed, and one that will support continuity of operations when a disaster strikes.  Next, pediatricians are in a unique position to educate patients and families about emergency planning.  This is especially important for families whose children have special health care needs.

Pediatricians also can improve emergency plans within their communities by advising schools, child care facilities, local health care facilities and emergency planners about the unique considerations for children.

Because disaster events are impossible to predict, plans should be broad in scope and flexible in nature; pediatric surge capacity and care capabilities should be considered and practiced in both ambulatory and inpatient settings. And once those plans are activated during an emergency, pediatricians can partner with public health and emergency management leaders in conveying consistent messaging to patients and families.

As part of the effort to improve preparedness for children, the National Advisory Committee on Children and Disasters  was established under the Pandemic and All-Hazards Preparedness Reauthorization Act of 2013. Pediatric care subject matter experts are well represented on this important advisory committee.

For more information about special considerations for children in disasters, visit the AAP Disasters and Children page.