AUTHOR: David H.

Rothstein, MD, MS
Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital of
Chicago, Chicago, Illinois and Department of Surgery, Northwestern Feinberg
School of Medicine, Chicago, Illinois
Address correspondence to David H. Rothstein, Division of Pediatric Surgery, Ann
& Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Box 63,
Chicago, IL 60611. E-mail: drothstein@luriechildrens.org
Accepted for publication Jun 27, 2013
KEY WORDS
disasters, emergency aid, developing countries
ABBREVIATION
NGO—non-governmental organization
doi:10.1542/peds.2013-1691

Pediatric Care in Disasters

Natural and man-made disasters bring
harm to children throughout the world
on a regular yet unpredictable basis. Dr
Rothstein describes the nature of such
disasters and how we can prepare to
meet the challenges of providing med-
ical assistance. As pediatricians, we
know children have unique vulner-
abilities and will have more optimal
outcomes when we are attentive to
systematic approaches that recognize
those needs. In recent years, there has
been significant progress in our un-
derstanding of how to prepare to in-
tervene on behalf of children. The
American Academy of Pediatrics Di-
saster Preparedness Advisory Council
has served to mobilize efforts related to
pediatric preparedness planning and
response. The Council has recom-
mended that children’s issues be
addressed early on in the development
of disaster preparedness programs
and activities, encouraging community
planners to include pediatric experts in
all levels of disaster planning and re-
sponse.
—Jay E. Berkelhamer, MD, FAAP
Section Editor
In an internally displaced persons camp
in war-torn eastern Democratic Repub-
lic of Congo, hundreds of refugee chil-
dren run around in torn clothes and
mismatched flip-flops, their fragmented
health care administered by multiple
non-governmental organizations (NGOs).
The Haiti earthquake of 2010 killed more
than 220 000 people and displaced more
than a million, nearly half of whom were
children.1 Houston received hundreds
of pediatric patients in the days after
Hurricane Katrina, straining medical
care providers and facilities alike. In
Beijing, air quality is so dismal that
pediatric rates of respiratory infections
and inflammatory diseases are sky-
rocketing.2 In Chicago, scores of children
are victims of street violence each year.
These natural and man-made disasters
are only a few examples from the past
decade that have challenged health care
professionals and systems alike. They
share common themes and have in-
dividual nuances, representing typical
and perhaps non-typical ideas of what
a disaster is and how difficult it can be
to take care of children affected thereby.
Disasters are broadly defined as man-
made or natural causes that trauma-
tize a population, exceeding its capacity
to deal with that trauma.3 There is often
a change in provider-to-patient ratios
that proves overwhelming. The arche-
typal disaster is a natural one, such as
an earthquake, tsunami, or flood. But
war and civil conflict, pollution and
environmental changes, famine and
urban violence each precipitate marked
changes in how children receive main-
tenance and emergency care. The ex-
tremes of perturbation are felt most by
vulnerable populations in vulnerable
times.
WHERE TO BEGIN
Multiple NGOs and transnational or-
ganizations have defined priorities in
initial disaster response (Table 1).
These can be generalized to all pop-
ulations, but pediatric patients have
specific needs that require additional
care. Fifty percent of victims in man-made
and natural disasters are children.4
In low- and middle-income countries,
where 95% of disasters occur, children
are particularly vulnerable, subjected
to high rates of malnutrition and sus-
ceptibility to communicable diseases,
psychological frailty, and risk for dis-
rupted family environments. By some
estimates close to 200 million children
per year are affected by disasters.5
In addition to responding to immediate
needs (usually traumatic injuries)
specific to a given disaster, providers
of pediatric care must address major
causes of pediatric morbidity and
mortality, which include diarrheal dis-
eases, acute respiratory tract infections,
measles, malaria, severe bacterial in-
fections, malnutrition and micronutrient
deficiencies, injuries, burns, and poi-
soning.6,7 Children born during disasters
require attention and their needs are

602 ROTHSTEIN
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easily ignored or underappreciated in
the midst of a crisis.8,9 Adapting to lo-
cal disease prevalence, providers may
also discover the need to prevent and
treat meningococcal meningitis, yellow
fever, hemorrhagic fever, typhoid fever,
leishmaniasis, trypanosomiasis, and
plague.6,7,10 Because external emer-
gency responders are often poorly
versed in care of tropical and, to the
resource-rich provider’s eyes, “atypical”
diseases, coordination with local health
care providers and ministries of health
is essential, albeit difficult, owing to
disruptions inherent to disaster envi-
ronments. Lastly, pediatric patients are
singularly vulnerable to exploitation,
abuse, and trafficking, particularly
when they are separated from families.
LESSONS LEARNED
The past 2 decades have seen in-
creasing amounts of medical literature
dedicated to analyses of disaster re-
sponse, with several themes emerging.
 Coordination: Well-intended but un-
organized responses can do more
harm than good. Although there can
be no monopoly on good intentions,
careful coordination between volun-
teer groups is essential to prevent
duplication of resources and mini-
mize strains placed by an influx of
providers. This coordination is par-
ticularly important between large
NGOs, international relief agencies,
and local authorities.11 Inclusion of
a hospital administrator has been
cited as a key element of response
coordination.12
 Involvement of local resources: Al-
though local resources and providers
are often eliminated or displaced by
the disaster itself, their contribution
can be invaluable.
 Planning for changing patient de-
mographics: The evolution of injury
patterns and patient needs is pre-
dictable. The Haiti earthquake, Indian
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Ocean tsunami, and others showed
that initial waves of injured patients
are soon followed by patients with
medical problems typical for the
local region, exacerbated by delays
to care and further fragmented health
care systems.12–17
 Planning for transition and after-
care: Paradoxically, initial health
care response is no more impor-
tant than planning for aftercare
and transition. What happens when
external providers leave? When do-
nated resources fade away? Who is
responsible for long-term care of
patients operated on during an
emergency? Who will care for
patients newly burdened with
post-traumatic stress disorder and
exacerbations of pre-existing condi-
tions? These are difficult questions
with complex answers.
 Disease surveillance and quality
control: The rush to treat immedi-
ate victims of major disasters can
obscure the need to set up disease
surveillance systems to identify
outbreaks (particularly important
for measles, dysentery, cholera,
and meningitis), as well as to per-
sist with efforts to maintain quality
control, by standardizing diagnostic
and treatment protocols, providing
essential drugs, and providing staff
training and monitoring.
 Welling et al, in writing about med-
ical volunteerism in 2010, described
“seven sins of humanitarian medi-
cine” to be avoided.18 These are no
less apropos in disaster situations
(Table 2).
FUTURE DIRECTIONS
The events of Hurricane Katrina and
the World Trade Center bombings
brought a sense of urgency and clarity
to the need for disaster preparedness
in the United States.19 The Helping the
Children Taskforce of the American
Academy of Pediatrics recently adopted
MONTHLY FEATURE
TABLE 1 Top 10 Priorities in the Emergency
Phase35,36
1. Initial assessment
2. Measles immunization
3. Water and sanitation
4. Food and nutrition planning
5. Shelter and site planning
6. Health care in emergency phase
7. Control of communicable diseases and
epidemics
8. Public health surveillance
9. Human resources and training
10. Coordination
TABLE 2 The 7 Sins of Humanitarian
Medicine18
1. Leaving a mess behind
2. Failing to match technology to local needs
3. Failure of NGOs to cooperate with each other
4. Failing to have a follow-up plan
5. Allowing politics or training to trump service
6. Going where we are not wanted or needed
7. Doing the right thing for the wrong reason
a Pediatrics in Disasters course that
provides teaching modules to help
train pediatricians and specialists in
disaster relief.20
Along with greater recognition of the
global needs specific to pediatric di-
saster victims and greater resources
marshaled by governments and NGOs
alike comes greater responsibility. Good
intention or action is necessary, but not
sufficient. Just as providers seek quality
assurance and improvement in their
own institutions, they have an obligation
to do the same in resource-poor areas
and even in the midst of disaster
zones.21,22 This serves not only a moral
purpose, but allows reflection on im-
provement initiatives for the future.
Information technology has played an
ever-increasing role in disaster man-
agement, from cell phone-based social
networking as a means to identify vic-
tims and danger zones, to computeri-
zation of records, to image-based tools
to help reunite families with missing
children.23–25 Reflections by responders
to recent disasters have spawned
many recommendations for simulation
exercises, national deployment teams,
and responder certification.12,16,21,26–28
603
With regional instabilities rampant and
climate change predicted to increase
the number of natural disasters world-
wide, the United Nations Children’s Fund
and the Office for Disaster Risk Reduc-
tion have focused on disaster risk re-
duction through educational campaigns
principally in counties and regions with
high risks for disaster.29–32 They have
also advocated for the inclusion of
children’s voices in planning, in an ef-
fort to fulfill the United Nations mandate
for patient independence.33
More work, lastly, is needed in the
arena of ethics. Early responders are
faced with unusually difficult decisions
regarding allocation of resources, often
in a manner they have never faced in
their own countries. Pediatric-specific
triage systems are being developed
that may simplify this task, but only to
an extent, and can only serve to inform
difficult decision-making.34
CONCLUSIONS
The most important task of medical re-
sponse in pediatric disaster care is to
provide a framework whereby order can
be made out of disorder, and normative
care can be restored as quickly as
possible. Although first responders are
usually tasked with providing extraordi-
nary care for the extraordinarily injured,
this demand is usually transient and
quickly replaced by the more pressing
need to provide care that mimics as fully
and rapidly that of children in times of
peace and safety. Disasters often occur
suddenly but end excruciatingly slowly,
and careful coordination between aid
agencies, emergency medical respond-
ers and local authorities, and medical
infrastructures is critical in treating
disaster victims, both the immediate
trauma phase and the longer-term re-
covery phase.
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FINANCIAL DISCLOSURE: The author has indicated he has no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.

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 Pediatric Care in Disasters
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DOI: 10.1542/peds.2013-1691
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Pediatric Care in Disasters
David H. Rothstein
Pediatrics 2013;132;25; originally published online September 2, 2013;
DOI: 10.1542/peds.2013-1691

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/132/4/25.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org at Univ Of New Orleans on June 4, 2015