Core Content Lecture 1

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Pediatric Disaster Life Support

• Core Content Lecture 1
• Fundamentals of Pediatric Disaster Medicine
• Andrew L. Garrett, MD

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The Need is Clear

• We have established that disasters affect
  children at the same time as the rest of the
  community
• We know that children have needs that are
  different than adults
• What tools do we need to properly prepare to
  treat them?

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An Approach to Taking Care of Children in
Disaster

• Taking care of children is a complex process
• Multiple factors must be considered
• PDLS uses a bio-psycho-social approach

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The Bio-Psycho-Social Model
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The Bio-Psycho-Social Model

• No one component is the most important
• Excellent care of children requires that all
  three components be addressed

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Biological
Care of the Child During Disaster
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Biological Needs

• Children have unique anatomy and physiology
• This creates specific vulnerabilities during
  disasters

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Anatomic Differences

• The youngest children have relatively larger and
  heavier heads
• Relatively larger and less protected abdomens
• Penetrating injuries
• Primary and secondary impact from objects or
  blast wave
• Predisposition to more serious traumatic damage
  during disasters compared to adult for the same
  injury

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Relative Body Proportions
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Anatomic Differences

• Smaller mass may cause children to be thrown
  further and faster, resulting in greater
  secondary injuries upon impact

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Surface to Body Ratio

• Higher surface area and thinner skin
• Risk of exposure-related injuries
• Burns
• Hypothermia after decontamination
• Toxic exposure to the skin
• Dehydration

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Higher Baseline Metabolism

• Faster Respiratory Rate
• Dehydration
• Ingestion of toxins, smoke, dust
• Lower Blood Volume
• Shock from bleeding
• Greater risk from dehydration
• Greater relative metabolic needs
• Higher risk for malnutrition sooner than adults

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Behavior

• Live Closer to the Floor
• Risk of exposure to debris and water
• Greater chance of exposure to chemical or
  radioactive residue
• Example Infant contracts cutaneous anthrax on
  arm after visiting ABC television studios
  targeted during the 2001 attack

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Behavior

• Hand-to-Mouth Activity
• Children routinely place hands and objects in
  mouth, increasing risk of exposure to chemicals,
  toxins
• Increases risk of contracting vomiting and
  diarrheal illness during unsanitary conditions
  such as in a shelter or with exposure to
  contaminated water supply

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Immune Systems

• Young children do not have the same capacity as
  adults to respond to infectious disease
• Biological agents
• Routine infections during sheltering

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How Children Decompensate

• Differently than adults
• Children rarely have primary cardiac event
• Pathway is predictable
• Focus is on respiratory problems and shock
• To know it is to prevent decompensation
• Recognize early signs and symptoms of respiratory
  distress and shock

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Care of the Child During Disaster
Psychological
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Psychological Issues

• PDLS will review general concepts, not
  age-specific details
• The psychological impact of disasters on children
  as victims
• Focus on what to expect and how to help

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General Principles

• Children are at a high risk of experiencing
  psychological consequences before, during, and
  after a disaster
• Many factors that affect this
• There is some controversy about these

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What to Expect?

• Everyone is affected by a disaster in some way

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Expected Changes

• Anxiety, Fears, and Worries about safety of self
  and others
• Worries about re-occurrence or consequences such
  as war
• Hyperactivity, decreased concentration,
  withdrawal, outbursts, absenteeism
• Increased body complaints
• Headache, Stomach-ache, Pains

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Expected Changes

• Changes in school performance
• Recreating Event through talk, play
• Increased sensitivity to sounds
• Sirens, thunder, aircraft
• Questions about death and injury
• Changes in sleep
• Denial of impact
• Hateful or angry statements

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Specific Symptoms Aggression

• Seen across all age groups
• Verbal and/or physical outbursts towards
  siblings, adults

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Specific Symptoms Regressive Behavior

• Seen across all age groups
• Crying, clinginess, helplessness
• Regression of toileting habits
• Bedwetting
• Diaper dependence

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Specific Symptoms Post-traumatic stress

• Post-traumatic stress symptoms include
• Nightmares
• Flashbacks
• Emotional detachment or numbness
• Insomnia
• Hypervigilance
• Irritability
• Memory Loss

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Common Symptoms Post-traumatic stress

• The best studied psychological effect
• Factors affecting development of PTSD
• Age (older gt younger)
• Gender (females gt males)
• Race (black gt white)
• Parental coping skills and capabilities
• Childs perception of risk (media role?)
• Duration of and distance to the danger

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Examples

• Buffalo Creek Dam Collapse (1972)
• 179 children screened 2 years after
• 37 given probable diagnosis PTSD

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Examples

• Flooding in Bangladesh (1993)
• 162 children screened 2 years later
• Aggressive behavior went from 0 to 10
• 34 new onset of enuresis in previously
  toilet-trained children

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Examples

• Wildfires in Australia
• 808 children screened
• 2, 4, 26 months after surviving
• Prevalence of post-disaster PTSD did not change
• Prevalence is present in population tested
• Predicting factors
• Mothers response to disaster more predictive
  compared to patients direct exposure

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Examples

• Reactions studied in preschoolers exposed to a
  severe hurricane
• After 14 months, when compared to unexposed
  children
• Higher levels of anxiety and withdrawal
• Other behavioral issues resolved slowly over 6
  months post-disaster
• Again, mothers response predictive of resilience
  in child

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Examples

• 9/11 terrorist attacks
• National sample 3-5 days after attacks
• 35 parents reported one child or more with
  anxiety-related symptoms
• Half of children worried about their safety
• Factors
• Parental response
• Amount of media viewed on the attacks

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Suicide?

• Development of PTSD symptoms a link to suicidal
  behavior
• In cross-population study of multiple federally
  declared disasters
• 25 increase in suicide in age group 10-29 years
  old
• Hurricanes, floods, and earthquakes highest risk
• Data suggest young men at highest risk

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How to Help

• Understand the high rates at which these
  psychiatric disorders appear in children after
  disaster
• Understand the time frame
• Many behavioral problems will resolve over weeks
  to months
• Anxiety/PTSD symptoms may persist over years

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Planning

• Incorporate Psychologic First Aid information and
  providers in your planning at all levels
• Utilize the expertise and advice of mental health
  professionals before, during, and after
• Preparation and pre-positioning resources
• Expertise in screening, therapy

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Care of the Child During Disaster

• Social

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Overview

• Children need to be viewed as an integral part of
  the population, not a special circumstance to
  be dealt with separately
• What happens to adults happens to children
• Planning, Response, and Recovery must acknowledge
  this principle to be effective

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Influences

• It is established that outside factors greatly
  affect a childs post-disaster psychiatric
  recovery, especially
• How parents (especially mother) reacts in the
  post-disaster environment
• Media

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Influences

• Exploring the parent-child relationship a little
  bit more
• Child Abuse
• Substance Abuse
• In general, parental stress and a lack of social
  services are linked to an increase in child abuse
  reports
• Is this true after a disaster too?

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Examples

• Loma Prieta Earthquke (1989)
• Hurricane Hugo (1989)
• Hurricane Andrew (1992)
• Data suggest that child abuse rates increased in
  the 3 and 6 month period after these disasters

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Examples

• Hurricane Floyd (1999) in North Carolina
• Inflicted traumatic brain injury increased in the
  6 months following the hurricane in the most
  affected counties
• After 6 months rates of inflicted injury returned
  to baseline
• Accidental injury rates remained the same

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Examples

• A 2001 café fire in the Netherlands wounded 250
  adolescents, and killed 14
• Compared to a control group
• Increased rates of anxiety, depression, and
  alcohol use
• Marijuana, Ecstasy, and sedative use did not
  increase

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Expectations

• Disasters are stressful events to all members of
  the community
• Anticipate problems such as
• Increased child abuse
• Increased substance abuse

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Media and Society

• What has been the role of media in recent
  disasters?
• Hurricane Katrina
• Indian Ocean Tsunami
• 9/11 Terrorist Attacks
• How did children respond to this information,
  based on what we have already discussed?

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Media and Society

• Many children feared for their own safety, and
  that of their parents
• Media viewing of disturbing images may exacerbate
  anxiety, aggression, regression, PTSD
• What is the responsibility of the media?
• What is the responsibility of parents?

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Suggestions

• Acknowledge that children do not benefit from the
  repeated viewing of frightening images

Photo National Geographic Channel
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Suggestions

• Helping parents in need?

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School

• The re-establishment of routine may prevent the
  worsening of symptoms in children and speed the
  recovery
• The ability to recover after a disaster and
  return to normal is termed resiliency

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School

• School provides much of what is taken away during
  a disaster and may be an important part of
  resiliency
• Order
• Rules
• Consistency
• Friends
• Role Models and Teachers

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Coping Techniques at Home and School

• Reinforce the idea of safety and security through
  self-realization
• Maintain a routine schedule
• Listen to childrens discussions of the events
• Discuss how media may be affecting their feelings

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Coping Techniques at Home and School

• Validate feelings of anger but discuss how
  developing hatred towards groups of people does
  not help
• Encourage children to talk about how they have
  been affected, and explain how these reactions
  are normal

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