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Pediatric Terrorism and Disaster Preparedness

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Table 11.2. Pediatric Medical Complaints After Large-scale Natural Disasters: Challenges and Adaptations Based on Post-hurricane Responses

Challenges Adaptations to usual care Decisions
Pulmonary
  • Bronchospasm is common in those with and without histories of asthma.
  • Children with bad/labile asthma present early due to stress, environmental triggers, lack of medication.
  • Stable asthmatics start showing up as triggers increase or medication runs out.
  • Children with bronchospasm due to respiratory infection start to present after the first 3-5 days.
  • October storms correspond to high allergy season and a slight peak in RSV incidence.
  • Winter storms may occur during RSV outbreaks.
  • Need adequate supplies to treat patients.
  • Premixed beta agonists for nebulizers (infant and child dosing).
  • Nebulizer capability with and without oxygen.
  • Pediatric nebulizer masks and pipes.
  • Oral and parenteral steroids.
  • Peak flow monitoring helpful but not essential.
  • Outpatient treatment:
  • Allow use of facility's electricity for families giving their own nebulization.
  • Using MDIs with spacer chambers more frequently.
  • Be liberal with steroids.
  • Counsel regarding allergen exposure.
  • Lower threshold for admission based on available resources and ongoing hazards.
  • Consider recommendation to temporarily remove child from the area to healthier environment.
  • Temper decisions with consideration of family's existing resources and demands on family members.
Gastrointestinal (GI)
  • Close living quarters may lead to transmission of GI viral illnesses,
  • Limited water and facilities for washing; limited diaper/hygiene supplies.
  • Inadequate sanitation in field kitchens/food distribution points.
  • Norovirus precautions go beyond soap and water or alcohol.
  • Erratic availability of potable water and oral rehydration solutions.
  • MREs have high sodium/high calorie content.
  • Ask about sheltering situation. Give specific infection control instructions (written if possible).
  • Health care sites can act as distribution points for hygiene items such as alcohol solution, diaper wipes, diapers, soap, garbage (biohazard?) bags/gloves, bleach.
  • Maintain contact with public health officials.
  • Ask about diet specifics, including origin of drinking water and food storage conditions.
  • Warn families of need to increase fluid intake if eating MREs.
  • Consider unusual electrolyte abnormalities in clinically dehydrated children.
  • Distribute oral rehydration solutions.
  • Focus on oral rehydration protocols unless staff and intravenous (IV) fluids are in adequate supply.
  • Limit use of antiemetics and antidiarrheals in children.
  • Minimize infant formula-switching.
  • Use fecal volume replacement techniques in cases of diarrhea.
  • Admission decisions must include consideration of shelter status.
  • Lower admission threshold if adequate outpatient management is doubtful.
  • If in doubt, schedule patient rechecks.
Infectious diseases
  • Infections will mostly follow existing community patterns.
  • "Third world" epidemics have not occurred in the U.S.
  • Isolation/segregation of infected people is difficult in the post-storm environment.
  • Children need different preparations of antibiotics, some requiring controlled environmental conditions.
  • Pharmacies and drug supplies may be limited and may focus on adult medications.
  • Skin infections are common; good hygiene is not.
  • Penetrating injuries to the foot are common; Pseudomonas must be suspected.
  • Community-acquired MRSA is an increasing problem.
  • Animal control may be problematic; may need to vaccinate patients against rabies.
  • Contact local public health or hospital officials for intelligence regarding existing infection patterns and sensitivities.
  • Cooperate with public health officials in monitoring efforts.
  • Assist in informing shelter staffs of infection patterns seen and what to look for.
  • Assist public health personnel with projects needed to protect exposed high-risk groups, such as giving VZIG to exposed immunocompromised victims or tetanus boosters to those who need them.
  • Educate patients and families about infection control issues, especially if they are shelter residents.
  • Prescribe antibiotics judiciously; use the simplest appropriate form for the shortest practical course.
  • Use alternative medication formulations (chewable tabs, crushed tabs) and those that do not require refrigeration.
  • Obtain and distribute information about pharmacies in operation.
  • Inform local pharmacies about prescribing privileges for federal responders.
  • Consider distribution of starter doses of medications.
  • Distribute hygiene and wound care supplies, insect repellant, and topical or oral medications for itching/inflammation.
  • Plan follow-up for penetrating and contaminated injuries (especially nails into feet).
  • Consider using ciprofloxacin for children with penetrating wounds into feet.
  • May use first-generation cephalosporins for most skin infections.
  • Consider adding TMP-SMX or clindamycin if community-acquired MRSA is suspected.
  • Communicate with local public health authorities about rabies exposure.
  • Recognize that most children will not need a tetanus booster.
  • Consider family's environment and mobility when making decisions about admission vs. outpatient treatment with rechecks.
  • May need to admit children with highly contagious diseases to avoid exposing others in a crowded environment.
  • Consider sending infected children out of the area if more appropriate shelter is available.
  • Maintain low admission thresholds for the very young with fever and for immunocompromised patients.
  • Use antibiotics judiciously.
Trauma
  • The post-storm environment is hazardous!
  • Children may not have adequate supervision or may be asked to perform inappropriate tasks.
  • Children are risk-takers.
  • Minor skin and musculoskeletal injuries are common.
  • Penetrating injuries by contaminated objects are common.
  • Skin foreign bodies are common.
  • Major trauma is not common.
  • Increased chance of:
    • Carbon monoxide exposure
    • Hydrocarbon and bleach ingestion/aspiration
    • Ingestion of medications
    • Drowning
    • Traffic incidents due to unregulated intersections
  • Intentional injury
  • Carefully document mechanisms of injury.
  • Be prepared to stabilize a badly injured child while arranging for transfer.
  • Identify local pediatric trauma and burn care resources.
  • Have access to poison control resources.
  • If lacking x-ray capabilities, splint the injured extremity on any child with bony tenderness, regardless of lack of deformity.
  • Emphasize elevation and splinting of an injured extremity for control of pain and swelling; ice may not be a viable option.
  • Provide the best possible initial wound care in an environment as comfortable for the patient as possible.
  • Consider delayed/no closure for contaminated wounds or possible retained foreign bodies.
  • Consider self-absorbing sutures for children with lip, finger or toe lacerations.
  • Use skin glue only if wound is clean and can be kept dry.
  • Don't forget pain management!
  • Follow-up care may be biggest issue; patients may need to go to another facility to initiate contact with follow-up caregivers.
  • Make some allowances for unusual circumstances but be alert for potentially negligent or dangerous family situations.
  • Depending on available medical resources, conscious sedation/analgesia should remain a consideration for painful or stressful procedures.
Psychosocial
  • Families may have difficulty coping with their child's illness or injury.
  • Delays in seeking care may be more common than in ordinary circumstances.
  • Families may not have had primary care resources before the disaster.
  • Compliance with treatment recommendations may be difficult for many reasons.
  • Stress may lead to higher risk for domestic and child abuse.
  • Pediatric mental health goes beyond posttraumatic stress disorder (PTSD).
  • Children with mental health issues may present with acute or prolonged nonspecific physical symptoms.
  • Parents are often not well informed about children's reactions to catastrophic stress.
  • Assume family members do not get your message the first time.
  • Write down instructions for the family.
  • Always ask, "Is there anything else we can help you with?"
  • Address children directly; let them know what they have to say is important and that they have a role in feeling better.
  • Encourage children to express their feelings.
  • Make the visit as pleasant as possible for the child.
  • Explore alternatives with the family to help ensure compliance with treatment recommendations.
  • Avoid judgmental attitudes.
  • Identify local resources for family psychosocial support.
  • Use available mental health resources.
  • Recognize risks for abuse or intentional neglect; know the local reporting mandates and procedures.
  • Try to keep family members together.
  • Remember that a child's reactions will reflect what's going on with the rest of the family. Ask!
  • Be willing to accept reasonable therapeutic compromises that help increase family coping abilities without jeopardizing patient care.

Notes: MDI = metered-dose inhaler; MRE = Meal, Ready-to-Eat; MRSA = methicillin-resistant Staphylococcus aureus; RSV = respiratory syncytial virus: VZIG = Varicella zoster immunoglobulin

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