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Abstract:This article is part of a collaborativeeffort by experts in the field ofemergency preparedness to com-plete an overview begun by the lateMichael Shannon, MD, MPH, on thecurrent challenges and future direc-tions in pediatric disaster readiness.This particular article, "ChallengesFacing Pediatric Preparedness," willreview some of the major challengesfacing current efforts to enhancepediatric readiness.
Pediatric Critical Care Fellowship Pro-
gram, Division of Pediatric Pharmacology
and Critical Care, Rainbow Babies and
Children’s Hospital, Cleveland, OH; Uni-
versity Hospitals of Cleveland, Cleveland,
OH; Division of Pediatric Critical Care,
Rainbow Babies and Children’s Hospital,
Cleveland, OH.
Reprint requests and correspondence:
Katherine Mason, MD, Pediatric Critical
Care Fellowship Program, Division
of Pediatric Pharmacology and Critical
Care, Rainbow Babies and Children’s
Hospital, 11100 Euclid Ave, Cleveland,
OH 44106.
1522-8401/$ - see front matter
© 2009 Elsevier Inc. All rights reserved.
CHALLENGES FA
Challenges FacingPediatric
Preparedness
CING PEDIATRIC PREPAREDNESS /
Katherine Mason, MD,*Michael R. Anderson, MD†‡
t has become increasingly evident that there is a need forpediatric expertise in the development of comprehensive
Iand cohesive systems for disaster management. In bothnatural disasters and acts of terrorism, children are likelyto be affected in numbers at least proportional to theirrepresentation in the population at large. It is also possiblethat children will be affected in numbers exceeding theirproportion in the population because of their unique vulner-abilities and patterns of localization within schools and childcarecenters. In the setting of a large-scale disaster, pediatric victimsrequire more supervision, higher staffing, specialized equipment,and resources. In a mass casualty event, it is likely that youngchildren and infants will be cared for by providers and systemsthat do not have significant pediatric experience, mandating thedevelopment of policies and procedures for emergent pediatriccare that are readily accessible, straightforward, and focus onhigh-impact assessment and interventions. Challenges facingpediatric preparedness include the determination of what isneeded for the care of affected children, the determination ofhow care and resources are allocated, and the determination ofhow the required training, research, equipment, and resourcesare paid for.
CHALLENGE I: WHAT IS NEEDED?The identification and procurement of requisite resources and
expertise for the optimal treatment of children in disasters are aformidable task. Neonatal and pediatric-sized bag and masksetups, ventilator circuits, intravascular catheters, and equip-ment are essential for optimal care and need to be available topersonnel treating children. The most recent multiagency policystatement on equipment for ambulances is an example of a
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160 VOL. 10, NO. 3 • CHALLENGES FACING PEDIATRIC PREPAREDNESS / MASON AND ANDERSON
“stock list” of equipment required for the treatmentof children.1 Medical countermeasures to bioha-zards are essential to the successful treatment ofmass exposure to toxins or infectious agents.Children represent 22% of the US population andare more susceptible than adults to many bioha-zards, yet readily available countermeasures appro-priate for use in pediatric patients are nearlynonexistent. Retrospective reviews of inadvertentadministration of adult formulated auto injectorscontaining oximes or atropine as treatment fornerve gas exposure suggest that these doses are welltolerated in children.2 The potential benefit of rapidantidote administration may outweigh the risk ofrelatively minor side effects. Pharmacokinetic dataon the use of such adult formulated therapies inchildren are lacking, and a large percentage of thedrugs routinely used as antidotes and treatmentsfor children are most often off-label for use in thepediatric population. These factors prevent thewide-scale preparation and distribution of pediatricantidote kits for biohazards. Current recommenda-tions for pediatric dosing of antidotes are notuniform and leave much margin for inconsistencyand error.3 The recent H1N1 epidemic highlightedthe potentially expeditious emergency use author-ization process; however, the current absence ofFood and Drug Administration approval for mostdrugs used on a day-to-day basis in children wouldgreatly slow the process unless well-established andaccepted dosing recommendations were already inplace. Given the lack of adequate and well-controlled clinical trials in children, consensusstatements from pediatric expert panels are asource of recommendations that can be broadlyapplied to pediatric care in disasters. Defining theprocesses by which this should happen is an area ofactive investigation. One promising method is theuse of the Delphi consensus process, as outlined ina recent article by Kanter, et al4 in which theallocation of limited personnel and equipment wasapplied to a scenario of pediatric disaster care.Whether for pandemic flu, nerve gas exposure, orany other biologic agent, the goal of simplifiedadministration of medical countermeasures tochildren in the event of a mass biohazard exposurehas not been met.
Pediatric disaster preparedness extends beyondthe provision of appropriate equipment and med-ications. Children present unique challenges inregard to shelter, nutritional, transportation, andcommunication needs. Systems for identifying,transporting, and reuniting children with theircaregivers are of paramount importance. A large-scale disaster scenario is likely to require the
transport of affected individuals to distant sites tomake use of resources that have been locallyoverwhelmed. The safe transport of childrenunder adequate supervision and with an effectivemeans of tracking pediatric patients is a significantchallenge. It should be assumed that children mayact in ways counter to their own best interest in adisaster scenario. Hiding, running away, beinguncooperative with caregivers, and attempting toremove restraints and medical equipment aredevelopmentally appropriate responses to stressfulsituations in young children. The recruitment ofnonmedical personnel to supervise and providecare to young children may better provide for theirpsychosocial and emotional needs, minimizingstress and freeing up medical staff for needsrequiring their expertise. Procedures by whichthese ancillary caregivers would be identified,vetted, and supervised need to be in place beforethe realization of an actual disaster scenario.
Parents and adult caregivers who have beenseparated from their children are likely to befrantic for reunification and may inadvertentlyintroduce more chaos into a disaster scenario andimpede efforts to care for patients. Communitypreparedness requires the dissemination of infor-mation to caregivers about the process for reunifi-cation with their children in the event of a disasterand, ideally, the confirmation that the informationhas been reviewed.
Effective immediate care requires pediatric train-ing and expertise. Young children make up a smallfraction of emergency medical service runs; thus, itis difficult to retain best-practice pediatric-specificskills in first responders. Pediatric triage guidelinesremain in the early stages of development. TheTherapeutic Intervention Scoring System, Jump-START, Pediatric Triage Tape, and Careflight haveall been evaluated with no consensus on the bestinstrument and no consistency in their use by firstresponders or medical centers. The ability to triagepediatric patients in a consistent and meaningfulway across all levels of care delivery is a necessaryfoundation of pediatric disaster preparedness.Pediatric patient assessment and airway manage-ment skills are particularly critical because mostpediatric arrests are due to respiratory embarrass-ment rather than hemodynamic compromise. Com-pounding the paucity of pediatric experience andtraining for most acute care providers is the lack ofspecific training in pediatric mass casualty events.In a 2005 survey of nearly 4000 emergency medicalservices, only 13.3% had pediatric-specific masscasualty plans and only 19% had a pediatric-specifictriage plan.5 It may be appropriate to develop a
CHALLENGES FACING PEDIATRIC PREPAREDNESS / MASON AND ANDERSON • VOL. 10, NO. 3 161
system whereby personnel without extensive pedia-tric training or experience can provide care usingalgorithms and care paths under the direction andsupervision of pediatric acute care providers.
CHALLENGE II: DISTRIBUTION OF LIMITEDCARE AND RESOURCES
Changing the paradigm of medical treatment inpediatric disasters is a potentially enormous chal-lenge. Disasters are characterized by an overwhelm-ing increase in the medical, social, and psychologicneeds of a population in the face of inadequate orlimited resources. The provision of care in a disasterscenario requires consideration of the allocation oftherapies, staffing, and supplies in a manner thatprovides the most benefit to the largest number ofpatients. It is not clear how the most benefit is to bedefined and by whom. A multilevel comprehensivesystem including bedside clinicians and local andfederal agencies is likely to be unduly complex andmay not be sufficiently streamlined to permiteffective care in a crisis. The importance ofidentifying, training, and authorizingmedical leader-ship during a disaster is not to be underestimated.
The shift from current standards of care with afocus on optimizing individual outcomes to astandard that optimizes population outcomes is aradical change. In adults, several strategies for theallocation of resources have been proposed.6-10 Thedecision to limit, withhold, or withdraw resourcesthat are to the benefit of a particular child to bettergarner resources for the larger pediatric populationis problematic on ethical, social, and legal grounds.The fact that best practices of resource allocationunder one paradigm are contradictory to bestpractices in another mandates clear, consistent,and readily available guidelines for priorities andlimitations of care to children in disasters. Healthcare providers are vulnerable to short- and long-term stress, burnout, fatigue, and threats to theirown psychologic health under any setting ofdisaster care, but the stress of limiting, withholding,or withdrawing treatment to injured or sickchildren is likely to pose an increased threat toprovider well-being.
A final but no less important challenge topediatric disaster preparedness is the need forfinancial resources. Care facilities, equipment,staffing, transport, and other requisite factors areall dependent on financial support. The Stafford Act(Public Law 93-228) is one source of federal disasterfunding, but it is clearly not enough. Optimizing the
use of available community resources is a potentialmeans to reduce costs but requires a great deal ofcoordination between schools, daycares, theiremployees, private physicians, civic leaders,families, community centers, retail stores, andhospitals. Community support of care and resourcesfor children is generally quite strong, and theintegration of community resources would be, withhealth care resources, a powerful alliance forpediatric disaster preparedness.
The challenges for pediatric preparedness rangefrom drug development to safe transportation, fromthe identification of funding strategies for facilitiesand equipment to the provision of resources for themanagement of situational stress in children andcaregivers. Strong pediatric leadership, governmen-tal support, and community investment are the besttools available to provide optimal care to childrenin disasters.
REFERENCES1. American College of Surgeons Committee on Trauma,
American College of Emergency Physicians, National Asso-ciation of EMS Physicians, Pediatric Equipment GuidelinesCommittee-Emergency Medical Services for Children(EMSC) Partnership for Children Stakeholder Group, Amer-ican Academy of Pediatrics. Equipment for ambulances.Pediatrics 2009;124:e166-71.
2. Kozer E, Mordel A, Haim SB, et al. Pediatric poisoning fromtrimedoxine and atropine autoinjectors. J Pediatr 2005;146:41-4.
3. Baker M. Antidotes for nerve agent poisoning: should wedifferentiate children from adults? Curr Opin Pediatr 2007;19:211-5.
4. Kanter RK, Andrake JS, Boeing NM, et al. Developingconsensus on appropriate standards of disaster care forchildren. Disaster Med Public Health Prep 2009;3:27-32.
5. Shirm S, Liggin R, Dick R, et al. Prehospital preparednessfor pediatric mass-casualty events. Pediatrics 2007;120:e756-61.
6. Health Systems Research Inc. Altered standards of care inmass casualty events. AHRQ publications, 05-0043. Rock-ville (Md): Agency for Healthcare Research and Quality;2005.
7. White DB, Katz MH, Luce JM, et al. Who should receive lifesupport during a public health emergency? Using ethicalprinciples to improve allocation decisions. Ann Intern Med2009;150:132-8.
8. Strikas RA, Wallace GS, Myers MG. Influenza pandemicpreparedness action plan for the United States: 2002 update.Clin Infect Dis 2002;35:590-6.
9. Christian MD, Hawryluck L, Wax RS, et al. Development of atriage protocol for critical care during an influenza pandemic.CMAJ 2006;175:1377-81.
10. Devereaux AV, Dichter JR, Christian MD, et al. Definitive carefor the critically ill during a disaster: a framework forallocation of scarce resources in mass critical care. Chest2008;133:51S-66S.
