10 Pediatric Priorities Through the Disaster Management Cycle: Integrating Children’s Needs in Mitigation, Preparedness, Response and Recovery

Authors

Christine Raj, MD, MPH(c), Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California

Lorraine Schneider, MSc, The Resiliency Initiative

Mikey Latner, Project:Camp

Ozzie Baron, Project:Camp

Rita V. Burke, PhD, MPH, Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California; Department of Pediatrics, Keck School of Medicine, University of Southern California

 

Keywords

children, disaster management, pediatric, preparedness, mitigation, recovery, response

 

Abstract

Despite children being at especially high-risk during disasters, there is a lack of information and focus on children’s disaster preparedness. Following a scoping review of the literature on children’s disaster preparedness, we identified several gaps and found that many people do not have adequate pediatric disaster training or plans to comfortably manage a disaster situation. Additionally, there was scant literature on health disparities, children with special needs, childcare, and international disaster preparedness. We found several areas in need of improvement but very few recommendations on how to address these concerns. Areas of pediatric focus in the future should prioritize including children in disaster plans (particularly, children with access and functional needs), addressing health disparities, and training those who work with children on disaster preparedness.

 

 

Introduction and Problem Statement

In Maslow’s hierarchy of needs, which provides an order to human needs, the three most basic categories are physiological needs, safety needs, and love. For children to grow and develop, these needs must be met. Societies strive to create policies, laws, and societal expectations with the goal of helping children fulfill these needs. However, when a disaster strikes, these needs may not be met. Disasters may severely impact basic needs like obtaining food, shelter, and water. Safety may not be guaranteed, and children may not be able to be with loved ones. When these needs are not met, it can have a lasting psychological and physical impact on a child.

As can be seen, children tend to be overly impacted by disasters and are forced to carry much of the health burden because of poor preparation for disasters (Hoey et al., 2020). By focusing on the needs of children from the most basic to the hardest to achieve, we can create plans to help children through disasters. Children have different needs than adults because of their emotional maturity and physiology. Therefore, children need to have distinct plans when it comes to preparing for disasters. Unfortunately, there is scant information on pediatric disaster preparedness. Although our primary objective is to showcase the current information on pediatric disaster preparedness, we also uncover a number of gaps in the literature itself.

Literature Review

After Hurricane Katrina and 9/11, children were disproportionately displaced and suffered the consequences long after the disaster event. It became apparent that more focus needed to be placed on protecting children during a disaster. To address the need, the United States created the National Commission on Children and Disasters to investigate previous disaster preparedness laws, policies, and programs and find any gaps that needed to be covered (Sen. Dodd, 2007). In 2010, this commission published their recommendations finding 11 areas requiring additional focus. This included disaster management and recovery, mental health, child physical health and trauma, emergency medical services and pediatric transport, disaster case management, childcare and early education, elementary and secondary education, child welfare and juvenile justice, sheltering standards, housing, and evacuation (National Commission on Children and Disasters. 2010 Report to the President and Congress, 2010). In 2013, the National Pediatric Readiness Project launched with the aim of promoting pediatric readiness in emergencies (Remick et al., 2018). However, when the five-year report card came out on the National Commission on Children and Disasters, it was found that 79% of the recommendations remained unfulfilled.

The United Nations Office for Disaster Risk Reduction created the Sendai Framework to showcase their goals for disaster risk reduction from 2015-2030. In it, children are only briefly mentioned as a vulnerable population that needs more attention. Despite noticing the gap, the Sendai Framework failed to focus on the needs of children in disasters in detail (Sendai Framework for Disaster Risk Reduction 2015 – 2030, n.d.).

Through the efforts of the commission and the United Nations, it has become apparent that there are concerted efforts being made to promote children’s disaster preparedness. However, there remains a gap between policy and actions as minimal changes have occurred.

Methods

To address our primary question (“what are the gaps in international pediatric disaster preparedness?”), a scoping review of the current literature was performed. Due to the broad nature of the question, a scoping review was identified as the best methodology as it allows for an overview of a substantial and diverse body of literature. It also creates a framework in which a large amount of literature can be synthesized into a palatable form for those trying to understand the fundamental needs of pediatric disaster preparedness.

For our scoping review of pediatric disaster preparedness, we searched multiple databases in January 2024, including PubMed, Ovid, CIHNAL, and Google Scholar. The search terms used were “pediatric disaster preparedness,” “pediatric fire preparedness,” “pediatric flood preparedness,” “pediatric hurricane preparedness,” “pediatric earthquake preparedness,” and “pediatric typhoon preparedness” and the same terms replacing “pediatric” with “children” for each database.

Next, we screened the articles and included all that were peer-reviewed, full-text articles written in English, and published after 2017. Incorporated articles needed to focus on children, be specifically about disasters resulting from natural hazards, and discuss any phase of the disaster management cycle. An article was excluded from the study if it was a duplicate, case study, editorial, or position statement. Articles were also eliminated if the focus was on medical management or medical countermeasures of children. Included articles were read thoroughly and qualitative information was extracted from each. They were reviewed for common themes and ideas that were repeated within multiple articles.

Finally, as our work was exclusively a review and did not require interaction with human or animal subjects, approval by an Institutional Review Board (IRB) was not necessary.

Findings and Solutions

In this section, we report our findings on the current state of international pediatric disaster preparedness. The total number of articles reviewed for this scoping review was 513. We drew our findings from 161 articles and excluded 352 articles. The articles that were included were divided into subcategories based on what part of the disaster cycle they address. The disaster cycle covers mitigation, preparedness, response, and recovery. Mitigation is defined as system-level preparedness strategies that prepares groups for any disaster and implements policies and regulations to promote safety and wellbeing. Preparedness is defined as the planning and action steps taken before a disaster that help to successfully deal with the emergency. Response is the initial emergency response that occurs after a disaster happens while recovery is the long-term efforts employed to return to normal. Each subsection focuses on one aspect of the disaster cycle, providing an overview of what was found in the scoping review.

Mitigation

The first part of the disaster cycle is mitigation. This covers long-term preparedness strategies. One group in need of mitigation strategies are children with access and functional needs. Children with access and functional needs (defined by FEMA as “individuals who may have additional needs before, during and after an incident in functional areas, including but not limited to: maintaining independence, communication, transportation, supervision, and medical care”) are at an increased risk during disasters. They have more requirements and needs that must be met, making disaster planning for them especially important. However, 85% of parents of children with special needs do not have a disaster plan and 65% do not have a copy of their child’s medical emergency plan (Chin et al., 2020). Some barriers families reported to making a disaster plan were coping with their child’s disability, poor communication, difficulty with knowledge acquisition, social cognitive factors, which determine how people process, store, and apply information about others and social situation, and other external factors. When surveyed on measures they had taken to prepare for a disaster, parents of children with disabilities had taken less than half of the previously published recommended 11 action steps to prepare for a disaster (Mann et al., 2021). In our scoping review, families with children with disabilities feeling underprepared emerged as a common theme. However, in this review Griffin et al. (2023) found that families who received training, at least in the short-term, had increased self-efficacy, skills, and health outcomes for their child (Griffin et al., 2023). Families with children dependent on parenteral nutrition received education on disaster preparedness as well as how to make an emergency kit for their specific needs. After the education, there was significant improvement in having an emergency plan for the family (P < 0.0001), basic emergency kit (P < 0.0001), completed emergency information form (P < 0.0001), and confidence in their ability to cope with a disaster (P < 0.0001) (Toor et al., 2018). Another study focused on families with children dependent on technology and gave the families an eight-item preparedness assessment and education about preparing for power outages when their child was admitted to the pediatric intensive care unit (PICU). Every follow-up interval saw a significant increase in the number of items checked off, with an average of 7 out of 8 after six months implying that these families were better prepared for power outages (Gillen & Morris, 2019).

There have also been positive results in training children on emergency preparedness directly. Children with developmental disorders were tested on whether they could use behavioral skills training to practice earthquake safety. Researchers found all students were able to acquire, maintain, and generalize skills to prepare an earthquake kit, drop-cover-hold, and share their location through an app (Olcay et al., 2024). This could be an effective model to use in the future.

Neonates in the intensive care unit also are especially vulnerable in disasters, as they are dependent on technology for warmth, nutrition, medication administration, life-sustaining physiologic support, and more. It is important for Neonatal Intensive Care Unit (NICU) teams to be part of hospital emergency planning and involved in drills to address the needs of NICU patients. Understanding the many supplies neonates might need, Gray et al. (2019) created a list of supplies for nurses to pack and rated them from most to least essential. The researchers identified the most useful skills nurses need during an evacuation of neonates, including maintaining thermoregulation, avoiding infection, respiratory support, and monitoring vital signs (Gray et al., 2019). Planning to successfully maintain capacity for 10 days for three times the normal critical care volume also emerged as a priority (Barfield et al., 2017).

Specificity in educational resources available is also very important for pediatric disaster planning. Koeffler et al. (2019) found that disaster preparedness resources rarely distinguish between ages, and teachers and principals of different age groups were given the same materials (Koeffler et al., 2019). Disaster preparedness for an elementary school teacher should be different from a high school teacher, but studies often do not differentiate between age ranges, and instead, broadly encompass schools in disaster resources.

Along with trainings for caretakers, there are also trainings for children on how best to stay safe during disasters. At the 2018 UN World Conference on Disaster Risk Reduction, the United Nations Office for Disaster Risk Reduction stated that comprehensive school safety consists of safe school facilities, effective school disaster management and disaster risk reduction.. From these, the Mentawi Islands in Indonesia created a school preparedness plan called SekolahSiaga Bencan. All student participants were able to correctly answer the majority of questions on disaster preparedness questionnaire after taking the course (Sujarwo et al., 2018). The course isn’t currently mandatory in Indonesia, but if integrated into the schools’ curriculum, it potentially could drastically increase the preparedness of the islands’ students. Another program, the Emotional Prevention and Earthquakes in Primary School (PrEmT) developed in Italy, aimed to increase children’s physical and psychological preparedness for earthquakes. In tests, those who took the PrEmT course had better knowledge about earthquakes, safety behaviors, emotions, and coping strategies than those who did not (Raccanello et al., 2023). This model attempts to mitigate the potential emotional impact of a disaster and prepare children to cope with effects on their physical and mental health.

From a mitigation perspective, significant gaps remain in international pediatric disaster preparedness. The lack of tailored disaster plans for children, along with insufficient training and educational resources, highlights the critical need for more children-focused and inclusive strategies. There is also a notable disparity in preparedness levels among families, particularly those with children reliant on medical technologies or with special needs, underscoring the urgency for widespread, accessible training programs. Addressing these gaps requires a concerted global effort to develop and implement comprehensive, age-appropriate, and needs-specific mitigation measures to reduce the effects of disasters on children.

Preparedness

While mitigation strategies are important, we must also consider short-term disaster preparedness. One way is to analyze the results of previous disasters and drills. When asked how they would prepare better in the future, those who managed the evacuation of neonates during California wildfires in 2018 responded that having both horizontal (within the hospital evacuation) and vertical (out of the hospital evacuation) emergency plans, getting as many supplies as they could, particularly formula, and having multiple strategies for infant identification would be helpful for future evacuations (Ma et al., 2020). Challenges they encountered included not having access to patient records at a receiving hospital, and difficulty communicating to the receiving hospital that patients were coming (Ma et al., 2020). In an evaluation of NICU emergency preparedness, it was noted that tabletop exercises were done but there remained a need for more evacuation simulations in different disasters (Eskandar-Afshari et al., 2020) A drill in El Paso, Texas, that evacuated multiple NICUs simultaneously encountered several problems. One problem they noted was a lack of communication between hospital staff and incident command, so first responders often lacked information. This led to first responders being unsure of what their role was and they were therefore slow to assist. The drill also highlighted the inability to resume full care at a designated safety site due to lack of equipment (Tullius et al., 2022).

Healthcare workers and hospitals must be ready for disasters as they play a key role in taking care of those who are hurt during disasters. Despite this, healthcare workers have very little knowledge about what to do in disasters. A study done by Boggs et al. (2021) discovered that pediatric residents had decreased confidence in hospital protocols as they progressed further into their residency. They also noted that low confidence in disaster medicine and skills was consistent through every year of residency (Boggs et al., 2021). Another study (Kuppanda et al., 2021) of pediatric residents determined that 86% felt ill-prepared for an evacuation and 80% felt that they were underprepared for a patient surge. This same study also noted that none of the participants had ever been trained in NICU surge or evacuation procedures and only 8% had taken any disaster preparedness courses (Kuppanda et al., 2021). Physicians in France self-estimated that their ability to cope with a disaster was a 5 out of 10 on the Likert scale (Mortamet et al., 2019). A disaster training exercise with pharmacists noted that prior to the exercise 40% felt minimally prepared, 50% felt somewhat prepared and only 10% felt moderately prepared to handle a disaster (Marks et al., 2022).

It is not surprising that there are low levels of knowledge on pediatric disaster preparedness as not all healthcare settings have a pediatric disaster plan. Primary care physicians are necessary for disaster response as they are the main point of contact within the healthcare system for most people. Needle et al. (2021) stated that small or solo pediatric practices were less likely to be prepared than hospital-based practices. Only 48% of study respondents stated they had a written disaster plan. When looking into how many hospitals have a pediatric disaster plan, 78% had them and 63% had someone specifically responsible for pediatric disaster planning. Those with someone specifically in charge of pediatric disaster planning were statistically more likely to address both children with special needs and pediatric decontamination processes (Ketterhagen et al., 2018). When making a disaster plan structure, staff, stuff (resources), and space are the four elements that need to be addressed according to Anthony et al. (2017). A prime example of this is the importance of having a reunification process in place. Many hospitals have a written reunification plan (63.6%) but most professionals do not believe that their hospital is prepared to reunify unidentified patients (Rebmann et al., 2021). In France, the national disaster plan does not include pediatric considerations, instead leaving it up to each hospital to create their own pediatric disaster plan. While each pediatric center in the study population that took in trauma patients had a pediatric disaster plan, each plan widely varied from center to center. Mortamet et. al (2019) argue for standardized national guidelines to help increase pediatric readiness. On the other hand, there is an argument that due to heterogeneity of regional environments and resources, national guidelines should be implemented in ways that allow for variation in order to address these differences (Anthony et al., 2017). Navis et al. (2023) also noted that understanding communities’ pre-existing medical, social, and economic needs are critical for disaster planning in those areas in order to try and minimize health disparities.

One theme that emerged in the scoping review was the focus on emergency preparedness outside of the hospital setting. For example, families in São Miguel, an island in the North Atlantic, reported 75.6% of them had plans for what to do in case of an earthquake but only 9.2% of them had plans specifically for how to handle their children (Pacheco et al., 2021). In Michigan, most childcare programs had a written disaster evacuation and relocation plan but 40% of these plans did not address the relocation of children with special needs (M. T. Chang et al., 2018). Areas that needed improvement in childcare disaster plans were family reunification, addressing needs of toddlers and infants, and appropriate supplies and resources for transportation (Chang et al., 2018). When comparing childcare centers with residential family childcare, it was found that childcare centers were more likely to have a written disaster plan and to inform parents of what would happen if a disaster occurred. On the other hand, residential family childcare centers were more prepared to keep children for over 24 hours; though they were less likely to have a plan for restocking supplies. All childcare centers were best prepared to deal with a fire and less prepared for other disasters (Leser et al., 2019). In the Philippines, teachers surveyed had positive attitudes and intentions toward disaster preparedness, but due to low perceived threat of disasters, were unmotivated to exhibit excellent disaster preparedness (Salita et al., 2021). A study (M. Chang et al., 2017) on disaster preparedness at summer camps noted large gaps in their preparedness levels. Most respondents stated their camp lacked specific plans and were unsure of plans for specific emergencies. It was also noted that most camps did not have a disaster plan for children with special needs and were not equipped with emergency supplies (Chang et al., 2017).

Despite the high risk for disasters, many people have little knowledge of what to do to appropriately train and prepare for one. In a review of childcare programs in Michigan, 45.9% of programs reported no disaster or emergency training for their staff before the pandemic (Budnik et al., 2023). In a post-hoc analysis after hurricane season in Florida, in 2017, parents reported that their pediatricians or education providers rarely or never talked to them about local disaster resources or recommendations for disaster plans (Scott et al., 2022). Internationally, a study done in the Mentawi Islands showcased that 73.4% of primary school students never had disaster training (Sujarwo et al., 2018).

Along with having educational sessions on disaster plans, tabletop exercises are necessary to ensure people can implement what they have learned. A tabletop exercise is a discussion-based exercise where select team members meet to discuss their role and proposed response to a possible emergency scenario. Playing out scenarios in such low-pressure, no-fault environments helps organizations highlight gaps in their preparedness level and identify ways to improve their plans, policies, and infrastructure. For example, in Connecticut, the Connecticut Coalition for Pediatric Disaster Preparedness conducted a tabletop exercise of a school bus turnover to see if a checklist was useful in guaranteeing that all needs were met. During the exercise, they found that each region handled expanding and generating surge capacity differently (Cicero et al., 2019). For them, this was an area that needed more focus within their regions. One barrier to performing tabletop exercises is the time and money it takes to bring people together in one space, but one study (So et al., 2019) found that a virtual tabletop exercise performed over Zoom had similar benefits and allowed for multistate participation in drills. After the exercise there was an increase in interdisciplinary work between pediatricians and the public health workers and their scores in a Strategic Alliance Formative Assessment Rubric, a tool for evaluating collaborative goals and strategies across sectors, were significantly higher than before the exercise. Six months after the tabletop exercise, the majority of attendees were still making progress on creating these partnerships in their own areas (So et al., 2019). Another study regarding a tabletop exercise also noted that the most beneficial component of the exercise was the partnerships formed between the pediatricians and the public health officials (Chung et al., 2018).

Disasters can often reveal gaps in our public health system and shine a light on existing health inequities. The perception of risk from disaster and preparedness levels were higher in children from wealthier cities of Nepal and Turkey when compared to cities with lower socioeconomic status (Yildiz et al., 2023). A study looking into the best resources for pediatric disaster preparedness noted that almost all the resources were only in English and if there was a translation, it would be Spanish (Koeffler et al., 2019). Focus groups in a study by Navis et al. (2023) also noted the need for information to be disseminated in different languages and using basic terminology to ensure health literacy is not a barrier to receiving public health information. These groups also advised providing children’s resources as well as having community-centered care by utilizing community leaders in disaster preparedness (Navis et al., 2023). Some social workers found that they were unable to fully help families put together emergency kits or feasible evacuation plans due to financial barriers the families had (Scott et al., 2022).

Similar to tabletop exercises, drills help staff ingrain steps required for an effective disaster response and have the added benefit of highlighting potential gaps. In Japan, one drill identified a need for transport to be available to a wide area as few hospitals in the region would be specialized enough to handle critical care for children (Toida et al., 2019). Another drill focused on having a single nurse evacuate a neonatal intensive case unit (NICU) patient and found that a disaster checklist the size of an ID card could be helpful for nurses to use as a “cheat sheet” on what their patient will need for a disaster evacuation (Thomas et al., 2020). As is often the case, this same drill and another two-hour pediatric emergency department drill incorporating all personnel in a healthcare setting both showed that communication was a weak point (Thomas et al., 2020; Li et al., 2022). Specifically, in the NICU evacuation drill, nurses had trouble with situation, background, assessment, recommendation (SBAR) communication during the mass casualty exercise and emergency department (ED) administrators had difficulty with patient identification within their registration system (Thomas et al., 2020; Li et al., 2022).

The more staff get to practice their disaster preparedness plan, the more intuitive the steps become. However, one barrier to performing a drill for some hospital systems may be the worry that patients will get upset and not cared for in time while a drill is being conducted. This idea was challenged by Asenjo et al. (2022) in a study that showcased that waiting times and length of pediatric ED stay was not negatively impacted on the day of a drill and some wait times were even shortened.

In summary, from a preparedness perspective, there is a clear need for more comprehensive disaster plans that specifically address the needs of children, particularly those with special needs. Additionally, there is an urgent need for more training and education to raise awareness and understanding of disaster preparedness among childcare providers, teachers, and parents. Activities like tabletop exercises emerge as a valuable tool for identifying gaps in preparedness and fostering collaboration between different stakeholders. As part of any preparedness efforts, it is essential to address the socioeconomic disparities in disaster preparedness, as children from lower socioeconomic backgrounds are often more vulnerable to disasters. Addressing these gaps is crucial to ensuring the safety and well-being of children in the face of potential disasters.

Response

Immediately after a disaster, efforts must be made to ensure the safety and wellbeing of those affected by the disaster. If there must be an evacuation, plans need to be put in place to provide shelter and evacuation routes for those in need, including children. In a study (La Greca et al., 2019) evaluating the stressors of families choosing to evacuate or remain at home when facing Hurricane Irma, families who evacuated said they felt much safer but were more stressed before and after the disaster. A considerable stressor for them was transportation and worrying about the ability to get vehicle fuel. Those who stayed behind had similar stressors as those who were not in evacuation zones, but there was more stress around “finding and being able to get into a shelter” for those who were in a mandatory evacuation zone (La Greca et al., 2019). Another study by Yamazaki and Nakai (2023) showed stressors that would increase a mother’s anxiety regarding whether she should evacuate her children included: not having an emergency kit, having no social support, having children under the age of three, or having children with allergies (Yamazaki & Nakai, 2023). These are also concerns that should be addressed in disaster plans.

Evacuation and sheltering specifically poses a significant challenge for children with access and functional needs. After hurricanes in Florida, families with children with special needs were unsure whether their children qualified for a local special needs shelter or whether the general shelters would have the specific accommodations their children needed (Scott et al., 2022). Even if these children were admitted to local special needs shelters, only one caregiver was allowed to go with them to the shelter leading to family separation during a disaster (Scott et al., 2022). In Japan, it was also noted that the cost for opening and maintaining emergency shelters for vulnerable populations, including children with special needs, is not covered by municipalities, creating yet another hurdle for families (Nakai et al., 2021). Another issue for families with children with special needs is physically being able to get to the shelters that have been set up. A study using geographic information systems (GIS) investigated how children with neurodevelopmental disorders would be able to make it to planned evacuation centers that could accommodate their needs in the event of a tsunami. They found that many of the fastest evacuation routes may be flooded or destroyed by landslides and these children should focus on moving to higher ground rather than putting themselves at risk by going through a dangerous area to get to the evacuation center (Nakai et al., 2021). How people get to shelters is important to consider and should be thought out beforehand with multiple different evacuation options in case certain routes are no longer feasible. The same study also found that for the 33 children with neurodevelopmental disorders in the study area, they would need 135.9 m² of personal space as well as five professional supporters at the shelter (Nakai et al., 2021). This is more space and personnel than most shelters for vulnerable populations have available.

Financial stressors are yet another significant cause of health disparities during disasters. When schools shut down for a hurricane in Mississippi, most parents reported loss of pay and difficulty finding childcare as some of their top concerns during the closure. The median household income lost was $150. The highest average daily cost of a child staying home from school resulted when a child was left home alone, was taken to work, and when a working adult stayed home, in that respective order (Zheteyeva et al., 2017).

In essence, from a response perspective, it is important to improve sheltering and evacuation procedures to account for the needs of children. The financial implications of disasters can have a significant impact on families, often leading to loss of pay and difficulty finding childcare. The challenges of accommodating children with special needs in emergency shelters are also significant, with issues such as inadequate space, lack of professional support, and difficulty in physically reaching the shelters.

Recovery

Disaster can exacerbate existing social disparities and challenges, particularly in low and middle-income countries. In India, child safety was compromised by stressors caused by flooding. Many children, primarily girls, have been seen discontinuing their education due to financial constraints, and child marriages increasing to decrease parents’ financial burdens (Krishna et al., 2018). Aid is also not equally distributed. People from lower castes generally received less aid post-flooding. People of lower castes and class also had a harder time finding shelter as people from higher castes were unwilling to share shelters with them (Krishna et al., 2018). Similar disparities have been found in the United States, with households with individuals with disabilities and lower socioeconomic statuses experiencing higher barriers to receive aid from government agencies, non-governmental organizations (NGOs), private businesses, and social networks (Mann et al., 2021).

Disasters also challenge access to existing resources, particularly when they are already scarce. For example, resources set up to address sexual and reproductive health have difficulties reaching the needs of the population during disasters. There have been rises in sexual and gender-based violence in Fiji and Tonga following disasters (Murphy et al., 2023). Due to the increase in violence, it is even more important to ensure resources to sexual and reproductive health remains available despite damage to communication and transportation networks. One way in which this problem was addressed by local humanitarians and citizens was through relying on community advocates and peer mentors to promote sexual and reproductive health through their social networks (Murphy et al., 2023). In Fiji and Tonga, systems were established so community members would be accompanied by someone when they were going to access safe water, sanitation, or hygiene. Similar peer networks were used to create safe spaces for people to deal with trauma and get access to help (Murphy et al., 2023). This is one way that communities addressed health care needs after a disaster and could be replicated with other health needs.

Time and time again, we see disasters contribute to hunger. In flood-impacted districts of Pakistan, children were more likely to be malnourished if they were younger, had younger mothers, only had access to untreated water sources, and were located within districts hit harder by the flooding for a longer time (Haq et al., 2022). There was an 8% and 27% higher risk of having a child with low birth weight or very low birth weight, respectively, in flood-impacted areas of India as compared to areas that were not experiencing floods. When low economic status is matched, there is a 5% higher risk of having a child with a low birth weight in flood hit areas as compared to areas unaffected by the floods (Biswas et al., 2024).

Lastly, disasters can often have a negative impact on healthcare access, further exacerbating large disparities. In Mozambique, after Cyclones Idai and Kenneth in 2019, healthcare accessibility coverage for children in one district dropped from 78.8% to 52.5% meaning approximately 136,941 children under the age of five were unable to reach a clinic in under two hours (Hierink et al., 2020). Coverage losses were mostly attributed to damaged transport networks and reduced travel speeds resulting from the cyclones (Hierink et al., 2020). Flooding in Bangladesh resulted in many community clinics and village doctors having to close their clinics (Shah et al., 2019). There was about a 30% reduction in how many children under the age of five community clinics and village doctors treated in the months after the floods despite sending out more referrals due to an increased number of sick children during these months (Shah et al., 2019). Due to flooded, destroyed, or damaged roads, children who needed a higher level of care often were not able to get to the sub-district hospital and the supply of medicine to the clinics decreased. In the months after the flood, there were medication shortages because of the high demand and the difficulty in replenishing supplies. Some solutions the community healthcare providers came up with were to set up their clinics in areas like schools or a home, and using community boats to visit patients at home (Shah et al., 2019).

In conclusion, the road to recovery for children affected by disasters is particularly challenging in low and middle-income countries. These gaps are evident in the disparities in aid distribution, access to resources, unmet basic needs, and healthcare access. Common consequences of this are risks of violence, malnourishment, and health issues due to a lack of resources and support. There is an urgent need to address these gaps in order to better protect and support children in disaster-affected areas.

Case Study 1 provides an example of how to integrate children into all phases of the disaster management cycle.

 

Discussion of Implications

During the process of trying to answer the research question of what the gaps in international pediatric disaster preparedness are, some roadblocks presented themselves. While trying to find gaps in the implementation and the process of pediatric disaster preparedness, it became clear that there were gaps in the literature itself that made it challenging to analyze the gaps in the implementation of disaster preparedness. As a result, this section discusses both the gaps in international disaster pediatric preparedness based on the literature as well as gaps in the literature itself. Furthermore, we proceed to making key scholarly recommendations and show what implications our findings have on international emergency management.

The first gap in the literature that needs to be filled is prioritizing solution-driven initiatives for at-risk populations in future research. Although there were many papers that discussed at-risk populations, there were few that had solutions on how best to manage them. Many papers display the extra layers of difficulties children with special needs face in an emergency such as access to medicine, understanding what is going on, and dependency on machines. Children with chronic illnesses also tend to be those who need hospital resources the most during disasters and will need access to care. Despite laying out these difficulties, few provided solutions on how to address these challenges and those that did lay out solutions are not widely implemented. This presents an opportunity for cross-disciplinary collaboration amongst emergency managers, pediatric healthcare professionals, disability advocates and other child-facing professionals to call for regulations and standardize preparedness and response processes. Effective practices in one country could be tested and applied in another. Children and children with access and functional needs specifically are often an afterthought in disaster management when they should be a key consideration in disaster planning. This chapter discusses children with access and functional needs at the beginning of each section as we aim to change the narrative of them being included as addendum.

Overall, more focus needs to be placed on protecting children in disasters. Though the National Commission on Children in Disasters (2010) laid out over 80 specific guidelines for how to best prepare for a pediatric disaster, in 2015, an organization found that only 17 of these recommendations had been met. They also stated that for $10 distributed to emergency planning funding, only a single cent would be dogeared for children specifically (Dziuban et al., 2017). This exemplifies how pediatric disaster preparedness has been ignored and how we need more focus on it now.

An area that was also very sparse in the literature was health care disparities in times of disasters. The Covid-19 pandemic has highlighted large inequities in our healthcare system and the way that emergency situations can exacerbate them. Despite the obvious impact disasters have had on perpetuating health inequities, there were very few papers that addressed this topic.

Along with health disparities, there was also little focus on pediatric emergency preparedness in the international literature. Most of the literature on pediatric disaster preparedness came from the United States with a small percentage focusing on other countries. The few papers that studied disaster preparedness in other countries often had to be eliminated as they did not focus on pediatrics. France and Germany do not record age-stratified disaster data so there is no information in their emergency databases on the pediatric population (Ries et al., 2019). Many of the other international papers were post-hoc analyses of how disasters affected an area and where resources needed to be utilized in the future. While this is helpful in identifying future planning needs, there seems to be little effort to implement the identified solutions to these problems. Moreover, the analyses are very area- and disaster- specific and are less generalizable to planning for various types of pediatric disasters.

With little information, it is hard to gather targeted disaster responses that work with different countries and consider the differences between their systems and the United States. There may be cultural or policy differences that change the way pediatric disaster planning would be considered in other countries. Much of the post-hoc analyses on disaster that were observed in the literature were from low-income countries. Due to the differences in infrastructure between these countries and the United States, it does not seem like the priorities in the United States would be like the low-income countries as the infrastructure already in place would be different.

Another common theme within the scoping review was the need for more training and exercises in support of meeting children’s needs during a disaster. Hospital personnel in positions of leadership in a disaster generally have very low confidence in what to do in disaster situations. Most of these personnel have stated that they would like more disaster preparedness training to better understand their role and responsibilities during a disaster. Not only is it necessary to have more trainings, but the trainings should be repeated and tested to ensure retention of knowledge. Trainings have been seen as very effective in increasing the confidence of personnel, but that confidence tends to decline over time. As for repetition, it has been seen that childcare teachers who participate in two or more disaster preparedness sessions report significantly better preparedness than those who attend just one session (Uhm & Oh, 2018). It is also important that the training incorporates all personnel which can be difficult in the hospital setting as there are various shifts of workers. Training, and knowledge specifically, has been shown to have a significant positive correlation with preparedness in students which is why it is important to incorporate it into disaster preparedness (Sujarwo et al., 2018).

Training and education also needs to be expanded outside of the hospital setting. Parents, childcare workers, teachers, pediatricians in office settings, and many more can all be utilized in a disaster setting where they are best suited to help children. It is essential that we have a broad idea of who needs to have disaster training and education. It is important for hospitals to be prepared for a disaster as they need to be able to manage a surge of patients and be able to give patients proper care in the aftermath of a disaster. On the other hand, people outside of the hospital setting need to be equipped with disaster preparedness awareness and knowledge so that they can do their best to protect and support children during disasters and prevent the need for hospitalization. A program in Canada called the EnRiCH Youth Research Team allows youth to have a platform to promote disaster risk reduction and incorporates an “all-of-society” approach (Pickering et al., 2021). The all-of-society approach emphasizes that everyone within the community has a part to play in disaster preparedness.

There are many caregivers that need disaster training and education. To ensure this, anyone working with children should be required to take a training module on disaster preparedness. As we saw, online modules were effective in training non-medical personnel in disaster preparedness (Pham et al., 2018); therefore, creating a similar module specific for caregivers could address the gap in caregiver disaster trainings. This module would need to be created by an interprofessional group that includes public health workers, social workers, mental health professionals, physicians, nurses, and others. The interprofessional collaboration on disaster preparation and sheltering and evacuation is important as it is one of the recommendations from a post hoc analysis of the Florida hurricanes in 2017 (Scott et al., 2022). One such module was created in 2019 (Mar et al., 2019) and can be accessed here: https://vimeo.com/95673229. Similar trainings that meet the specific needs of other daycare providers are needed.

Another population that needs disaster training and education are parents. One idea for how to ensure parents are better equipped to handle disasters is incorporating disaster preparedness into well-child visits at their pediatrician’s office. It was already noted that physicians, nurses, and many other public safety officers would want to incorporate emergency preparedness into their bedside care once they became aware that this is desired by families with children with disabilities (Flanagan et al., 2023). It is reasonable to believe that these same groups would be able to do this for all children not just for children with disabilities. Although many groups volunteered to have these preparedness meetings, pediatricians are one of the few groups that get the time to have a yearly visit focusing on health and safety which is why we recommend addressing these concerns in this way. Physicians will need to be trained on emergency preparedness and this should be created by a similar interdisciplinary group as the one that created the trainings for caregivers.

Along with training, it is essential that there is a good pediatric disaster plan in place that people can work to implement in a disaster. Although many places do address pediatric patients in their disaster plans, there are still places that believe that pediatric patients do not need special considerations. One example of an element that is specific to children is addressing children with special needs. Children with special needs are an especially at-risk population during a disaster and plans must ensure that they have the equipment and resources necessary. Another component that many pediatric disaster plans fail to incorporate is reunification planning. Many pediatric disaster plans have either flawed reunification strategies or lack them entirely. Learning can take place from proven reunification strategies devised by certain American schools and airline companies, the latter of which is mandated by law to have such plans in place. More thought needs to be put into how children will be reunited with their caretakers in disaster plans.

Another key element of disaster plans is how to evacuate and where to shelter if an evacuation is needed. There were no papers within our review that focused on where children should congregate when a disaster strikes and only five papers, Matsumoto et al. (2022), Thomas et al. (2020), Yamazaki et al. (2023), Nakai et al. (2021), La Greca et al. (2019), that discussed evacuation for children. These five papers were focused on evacuation of children with disabilities or special medical needs and how they may not have their needs met at a standard evacuation center so are unable to evacuate. There may not be significant literature on evacuation due to the inclusion criteria we have set for this scoping review. Evacuation and sheltering during a disaster tend to be a decision made by parents or guardians of children rather than children themselves. Therefore, since the focus of these papers was on caretakers and not children, those papers might have been excluded from our dataset. However, this is an important area that needs more focus as parents who evacuate report more stress before and during disasters (La Greca et al., 2019). During a disaster, there will also be plenty of children that are unable to contact their parent or guardian. This is why it is important to also have plans in place for where these children should go when their caretakers are not around to guide them.

Along with evacuation, there is very little attention given to childcare during a disaster. When schools were closed in Mississippi, parents stated finding childcare was one of the biggest stressors they had. Yet, even though this was one of the biggest stressors during a disaster, there is no literature on it. In our review, we did not come across a single study that focused on where children are supposed to go during and after a disaster. Disasters can be a heavy financial burden on families as there can be unexpected housing costs, replacement costs, medical costs, and more. At this time, adding the extra burden of paying for childcare or having an adult lose pay for missing work may be too much for a family to manage. Also, after a disaster children may have trauma from the experience that they need to manage. They need a safe space and resources available to them to be able to handle the impact of the disaster effectively.

An example of an approach to addressing preparation for and response to an event can be found in Project:Camp (https://projectcamp.co). Their focus is providing free, trauma-informed childcare during disasters when regular childcare services, such as school and care facilities, are disrupted by a natural hazard. Their model involves using the format of a summer day camp and including local youth professionals, a trauma-informed care training for those professionals, and locating their camps near evacuation centers and natural gathering points, such as hotels and motels, where people have been displaced. In response to a disaster, their model seeks to re-establish a sense of safety and normalcy for children while also providing necessary support for parents. In preparation for natural hazards, Project:Camp builds agreements and networks between emergency services, schools, afterschool programs, hospitals, and others to create the relationship frameworks so that response protocols can be built, incorporated multiple facets of a community, and be implemented should the need arise.

Another problem in international disaster management was the influence of humanitarian aid on the countries. While aid was helpful and greatly appreciated in areas where a disaster had occurred, the aid was instantaneous and sometimes did not consider sustainability required to revitalize the communities. Aid that was given to these areas often brought in increased healthcare, food, shelter, and mental health services that were not sustainable to maintain once funding ran out and the humanitarian agencies had to leave. International aid should focus on finding ways for the communities to become self-sufficient as well as providing basic living needs right after a disaster. One way that the positive influence of international NGOs could increase would be to work closely with the local NGOs that know the community and have expertise in that area. As the local NGOs have been working in the locations prior to the disaster, they can help with more long-term recovery solutions.

Of note, there has been recent emphasis on pediatric disaster readiness. In 2017, the Administration for Strategic Preparedness and Response (ASPR) funded two pediatric disaster care centers of excellence (PDCOEs) to improve local pediatric response capacity and capability. A third center was funded in 2022 (NDMS | Pediatric Disaster Care Centers of Excellence Cooperative Agreement, n.d.). The three centers are located throughout the US. WRAP-EM (Western Regional Alliance for Pediatric Emergency Management) is comprised of western states. Region V for KIDS covers a region in the Midwest and G7 (Gulf-7) is found in the gulf states of the US. While the foci of each of the PDCOEs may differ, the goal is the same: to generate and make available resources and capabilities that will ensure the safety of children during all phases of a disaster.

In addition, the Administration of Strategic Preparedness and Response convened three advisory group for priority populations in 2022. One of those groups includes the National Advisory Committee on Children and Disasters (NACCD) The NAACD is comprised of national experts in pediatric disaster preparedness. The role of the NAACD is to provide expert recommendations to the Secretary of the US Department of Health and Human Services on the medical and public health needs of children during disasters.

Some limitations of this study are the fact that we only included papers that were in English. There may have been more international papers if we included other languages into our inclusion criteria. Another limitation of this study is that international articles tend to focus broadly on disaster preparedness rather than children specifically. Although they referred to children at times throughout these articles, we did not include them into our study as they were not focused on children. We also chose not to focus on mental health needs within this chapter as it is such a large need for the pediatric population and would have derailed the focus from pediatric disaster planning. It is an area that needs more focused research on as it has a significant, consequential long-term impact on the population we are trying to serve.

Conclusion

This chapter has investigated many of the aspects of pediatric disaster preparedness and considered progress in the field and other opportunities for improvement. Within our review, we identified some key implementation flaws that should be prioritized in future preparedness strategies and policy. First, children with special needs should be prioritized in disaster preparedness and must be included in all disaster planning preparation. Second, there are many health disparities that both are created and widened during a disaster. More resources and thought needs to be placed into eliminating these inequities. Finally, there needs to be more training throughout all personnel and community members that work with children.

This review also identified that certain important aspects of child disaster preparedness had very little research. Some of the topics that need more research are also the same as what needs improvement within our preparedness system. These areas include the need for more research on disaster preparedness strategies for children with special needs as well as research on health disparities. Another area that has been overlooked in research has been children disaster preparedness in the international community. There are many post-hoc analyses of poor disaster outcomes in other countries, but we should be working to prevent them rather than trying to learn lessons from them. The final area of research that needs to be addressed is childcare during a disaster. While there are many more ways in which children’s disaster preparedness can be improved, if these few areas are addressed, we will be in a much better state to protect the life and wellbeing of our children.

 

 

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