Impact of Natural Disasters on Children: Key Considerations for Pediatricians

Natural disasters have dramatic negative impacts on children, both physically and psychologically; pediatricians need to be able to appreciate the risks of the specific natural disasters to which the community they serve is vulnerable and to offer mitigation strategies during these times of need.After completing this article, readers should be able to: Describe the negative impacts of natural disasters on children’s physical and mental well-being.Identify disaster-related stressors that families may experience and provide resources and needed support.List demographic and socioeconomic factors of children and families associated with vulnerability and resiliency during disasters.Natural disasters, defined as catastrophic events triggered by the Earth’s natural processes, can profoundly disrupt human lives, communities, and ecosystems. These events include hurricanes, floods, earthquakes, tsunamis, wildfires, blizzards, and volcanic eruptions, among others. Accelerated by climate change, the frequency and severity of these disasters are on the rise, posing an increased threat to global health and stability. The impact of natural disasters extends beyond the immediate physical injuries and fatalities, leading to a cascade of secondary health detriments and a host of socioeconomic challenges.1Children, with their unique physiologic, psychologic, and developmental needs, are particularly vulnerable to the consequences of natural disasters. Effective management strategies must extend beyond the acute phase to integrate immediate and sustained medical, psychologic, and social support, mitigation, and preventive and preparation measures. By emphasizing preventive measures, acute care, and comprehensive long-term recovery processes, pediatricians play a pivotal role in ensuring that the needs of children are prioritized amidst the increasing frequency and severity of natural disasters.1In the aftermath of natural disasters, children face a myriad of health and welfare challenges that span physical, psychologic, and social spectrums. This section gives an overview of the consequences children face after natural disasters.Children are particularly susceptible to physical injuries during natural disasters, including fractures, lacerations, contusions, and head injuries due to falling debris or evacuation efforts. Crush injuries and traumatic brain injuries may occur secondary to collapsing structures, particularly in the setting of earthquakes.2 The risk of drowning incidents escalates significantly in the case of floods and tsunamis, leading to potential hypoxia and long-term neurologic, respiratory, and other end-organ consequences. Burn injuries, eye injuries, and inhalational injuries can be seen, particularly in the context of wildfires. Injuries frequently encountered in specific types of disasters are shown in Table 1.3–10The displacement of populations after a natural disaster often results in overcrowded living conditions in shelters, facilitating the spread of respiratory and gastrointestinal tract infections. The spread of viruses such as rotavirus, enterovirus, and norovirus are markedly increased under these conditions.Rotavirus causes severe diarrhea, particularly dangerous for young children in these stressful environments. Enteroviruses can lead to various symptoms, from mild respiratory issues to severe neurologic conditions, worsened by the close quarters in shelters. Norovirus, highly contagious and known for causing outbreaks of gastroenteritis, can sweep through displaced populations quickly when hygiene and sanitation are compromised.After hurricanes and floods, surges of waterborne diseases including cholera and leptospirosis may be seen due to contaminated water. For example, the extreme weather conditions caused by Hurricanes Irma and Maria in 2017 disrupted water sanitation practices in the US Virgin Islands, which is believed to have contributed to the first reported cases of human leptospirosis in the region.11 Standing water can also escalate the incidence of vector-borne diseases, including malaria and dengue fever. Vaccine-preventable diseases may be encountered with increasing frequency due to the breakdown of normal sanitation and health care services in combination with overcrowding.12Natural disasters can cause disruptions at any point in the food supply chain, including production, handling and storage, processing, and distribution. These disruptions can lead to food insecurity, hunger, and malnutrition.13 Protein-energy malnutrition is an existing problem in many low- and middle-income countries that may be exacerbated by the occurrence of natural disasters, resulting in more severe and widespread cases. Specific phenotypes of protein-energy malnutrition may be encountered, including marasmus (featuring abdominal protuberance) and kwashiorkor (notable for generalized edema). Micronutrient deficiency may become more prevalent in the wake of natural disasters secondary to the lack of diversified food sources and may result in various diseases, including iron-deficiency anemia, zinc deficiency, vitamin A–deficiency blindness, beriberi, pellagra, edema, and goiters.14 The long-term impacts of such are significant and can have profound effects on a child’s physical health, mental health, and development.Natural disasters adversely impact the mental health of children. Posttraumatic stress disorder, anxiety, depression, and other mental health issues are commonly seen in the aftermath of all disaster types. Further, displacement and the loss of caregivers, family, or other loved ones contributes to a sense of instability and insecurity.15 In the 2023 Maui wildfire’s aftermath for instance, many children faced severe anxiety and trauma from the destruction of their homes and communities, coupled with the emotional toll of losing loved ones and the stress of displacement. This and similar events have led to a heightened need for mental health support services to help children cope with the profound impacts of disasters.16One tool used during the Maui wildfires that may be helpful in the wake of other disasters is the Psychological Simple Triage and Rapid Treatment (PsySTART) triage system. This tool, which is a means for performing rapid mental health triage, aims to identify children at risk for traumatic stress and other mental health issues after disasters. By rapidly assessing the psychologic impact on children, PsySTART may help allocate mental health resources effectively, ensuring timely and appropriate support for those affected.17,18Children with chronic health conditions, such as sickle cell disease, diabetes, or congenital heart disease, may experience exacerbations due to the stress of the disaster itself, interruptions in treatment, or exposure to environmental triggers. Infrastructure breakdown can lead to challenges with accessing medications or medical equipment.19 Particularly vulnerable children include those reliant on dialysis and infusions for health maintenance. Likewise, children with asthma are at risk of exacerbation if they lack access to controller and rescue medications, especially if other precipitants, such as smoke exposure, are present during the natural disaster. For example, the Canadian wildfires in 2023 led to a significant increase in emergency department (ED) visits for asthma exacerbations. According to a US Centers for Disease Control and Prevention report that analyzed data from the National Syndromic Surveillance Program, ED visits for asthma were 17% higher than expected during 19 days of wildfire smoke from April to August 2023.20Natural disasters often result in prolonged school closures, interfering with education and social development. For example, the Huffington Post reported that “In the aftermath of Hurricane Katrina, approximately 118 000 school-aged children in Louisiana and 20 000 school-aged children in Mississippi were displaced.”1 Many children did not attend school for multiple years after displacement.21,22 The loss of routine, social isolation from peers, and the interruption of learning contribute to emotional distress and can have long-term implications for academic achievement and developmental milestones.Addressing the multifaceted impact of natural disasters on children requires a focused, multidisciplinary approach that integrates pediatric health care, mental health support, and social support. Effective disaster response must prioritize these elements to ensure equitable recovery and build resilience among the most vulnerable.The disaster cycle describes the steps taken in preparation, response, recovery, and mitigation for a disaster (Figure 1).When a pediatrician is part of the initial disaster response team, the immediate priority is to ensure the safety of the responding team. The pediatrician should coordinate with local authorities whenever possible. In areas with robust infrastructure and planning, oftentimes, an Incident Commander and a Safety Officer (SO) will be appointed, and the pediatrician should relay any concerns regarding safety to the SO. Oftentimes, the pediatrician will not be deployed directly into any search and rescue efforts and will instead be stationed nearby to provide medical care for victims who self-present or are rescued. In many disaster response situations, a pediatrician may be called on to care for both child and adult disaster survivors.The next step is to triage victims of the disaster. Various models for how to quickly triage patients in a mass casualty incident exist, such as the Simple Triage and Rapid Treatment system (START/JumpSTART, Figure 2), in which patients are tagged green (the “walking well”), yellow (significantly injured and requiring urgent medical attention), red (patients with life- or limb-threatening injuries requiring emergent attention), or black (cardiac arrest or deceased).23 Any critically ill children will need to be rapidly assessed and stabilized. A plan should be made for identifying any unidentified children and to reunify them with parents or other family when possible (see Initial Aftermath section). At the very least, a plan needs to be enacted for how to communicate with family members regarding the safety of their children.In the immediate aftermath of a natural disaster, efforts should be made to ensure access to clean water, food, and shelter while simultaneously working to reunite children with their families. Ideally, infection prevention measures should be enacted to reduce the likelihood of disease outbreaks.One challenge that responders often face is identifying pediatric patients and contacting their parents or family members. For example, after Hurricanes Katrina and Rita, the National Center for Missing and Exploited Children received more than 34 000 calls. Reunification describes efforts made to voluntarily return children to their family or another trusted guardian after they have been separated.24Federal Emergency Management Agency (FEMA) has prepared a guide to help reunify children after disasters. Table 2 provides strategies for identifying family members.Of note, some pitfalls of which the pediatrician should be aware include the following: Trafficked, exploited, or runaway children may not accurately self-identify.Unaccompanied children are at risk for exploitation; therefore, only authorized persons should be permitted access to sheltered children.Children requiring additional assistance or who have barriers to communication may require appropriately trained staff.25Previous work has demonstrated that when a disaster occurs during school hours, 63% of parents and guardians would go directly to a child’s school to reunify with their children despite receiving direct orders to evacuate.25Common practices within the disaster response include conducting a needs assessment, incorporating local medical staff into the disaster response, implementing a clear chain of command, and ensuring that patients and medical staff have sufficient access to food and clean water throughout the disaster response. Larger-scale events require a plan for integrated, efficient response without convergent volunteerism, especially when there is external or even international response; such well-intentioned response can quickly exhaust local resources and add additional victims.The pediatrician should monitor patients for delayed health effects and psychologic trauma, including depression and acute stress disorder. In young children, depression can present with regression, clinginess, withdrawal, crying, and somatic symptoms, such as abdominal pain. Older children may present with similar symptoms and acting out. In addition to these symptoms, adolescents may present with suicidal ideation and self-harm. Delayed presentation of posttraumatic stress disorder is also possible. The pediatrician should work with local mental health services to connect children and their families with counseling as needed.Children with preexisting chronic health conditions or disabilities will often need extra attention to ensure that they have access to essential medications and equipment. Pediatricians may need to coordinate with local authorities to source these items.Pediatricians should be prepared to help children who were physically injured during the disaster to access subspecialty care when needed, as well as physical therapy and rehabilitation.Pediatricians may engage with schools and community organizations to help facilitate community-based interventions that promote recovery and foster resilience. Likewise, pediatricians can help advise local authorities and community outreach agencies how to support vulnerable children within the community who may be disproportionately impacted due to social determinants of health.One way that pediatricians can help prepare their patients and communities for a disaster is to engage in community preparedness initiatives and to develop a disaster response plan, particularly if their community is known to be more susceptible to specific types of disasters, such as hurricanes, floods, or wildfires. In these cases, pediatricians can provide anticipatory guidance to parents and children during well-child visits regarding topics such as the importance of having an emergency evacuation plan and emergency kits, a reunification plan, and how to enroll in local alert systems. For suggested contents of an emergency kit, please see Table 3. Teaching children how to recognize a possible impending emergency and seek shelter or help increases the likelihood of positive outcomes in disasters. Likewise, pediatricians can help families with children who have specific needs with advance preparedness, such as an awareness of local generator programs for children who use mechanical ventilation.Pediatricians should consider having parents and guardians sign waivers during well-child visits, so that in the event of a disaster, emergency consent for treatment is already in place. An example waiver, from the FEMA guidelines for the Post-Disaster Reunification of Children, is below: “In the event of an emergency requiring medical treatment, I, [parent’s name], hereby grant permission for all medical and/or dental attention to be administered to my child/children, in the event of an accidental injury or illness, until such time as I can be contacted. This permission includes, but is not limited to, the administration of first aid, the use of an ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel.”26Pediatricians should consider ways to ensure that medical records of patients within their panel can be rapidly accessed by emergency personnel in the event of an emergency.24There are many ways that pediatricians can become more knowledgeable about disaster preparedness. Additional training is available through FEMA (https://www.fema.gov) and can be accessed through the agency website. Pediatricians asked to respond during the acute phase of a natural disaster should be familiar with the National Incident Management System (NIMS) (https://www.fema.gov/emergency-managers/nims). Pediatricians should ensure that the facilities in which they practice have plans to operate in the event of problems such as water damage or power interruption. Such plans include redundancy for patient health care information, business financial services, and predesignated alternate care sites.Pediatricians can serve as powerful community advocates. Pediatricians can invite those who are most at risk or have social factors contributing to their vulnerability to community meetings about disaster planning to ensure that they have a voice in the development of plans for a disaster response (Table 4). For example, the parents of children who use wheelchairs should be encouraged to meet with school authorities to help plan evacuation routes for children in a fire.Hurricane Maria, a Category 5 hurricane, tore through Puerto Rico and the Caribbean in September 2017. An estimated 3059 people died due to the hurricane, and its lasting impact continues to be felt even today.27One of the most important takeaways from Hurricane Maria is how a lack of adequate preparation and infrastructure set the stage for catastrophic devastation. As an additional precipitating factor, the island had not recovered from Hurricane Irma, which made landfall on September 6, 2017, only 14 days before Maria struck on September 20. Nearly the entire island lost power, so radar, weather stations, and cell service were all disrupted, which complicated efforts to assess the emergent need for assistance. Wind gusts, rainfall, flash flooding, and landslides caused 97% of the island’s roadways to become impassable during and immediately after the storm.28Given that Puerto Rico is an American territory, not a state, and its residents are US citizens, significant criticism has brought to light the disparities in how the US response to Maria was hampered by institutionalized inequity, and the federal government released a 936-page report contrasting the differences in response to Hurricanes and Maria, as well as how in both disasters, those who are living in people who are those with and people who are and had access to assistance and These data serve as an that pediatricians should their response efforts to children who may be at risk of how were able to care for the local during and after the can to the example set by the were made so that and were that in the for at The food and for the staff to of the residents were permitted to close family members to the so that work that their children were cases were and medical residents were with for patients with the such as in the and care were also made to in education for medical residents during For example, for the American of to the of the to in were made available for disasters, and were they not require to cell takeaways for the medical residents and regarding preparation and response are in Table these in preparation for the initial recovery of people were without of Puerto Rico did not have or cell of people had been without water These for was not to the island until after the the in American is important to that many children who Hurricane Maria were and approximately 000 children Puerto Rico with their families. pediatricians the care of Maria of Puerto schools did not 2 after the disaster, and a after the Many had from the The were to help with and were for families such as of the for and children The resulting disruptions in social and safety a need for care for children and their the specific disaster risks in community and families on preparedness, including evacuation plans and emergency in identifying physical and psychologic impacts on children after disaster, immediate care and long-term support. available resources for mental health support, and ensure of care for those with chronic health for and in efforts to food and support for engage in community preparedness initiatives and for comprehensive disaster response plans that consider pediatric additional training in disaster preparedness and response, with the and ensure practice is prepared for infrastructure that children from or families may face barriers to recovery and require additional support and to access health care, and social play a pivotal role in disaster preparedness, response, and recovery, with a on the unique needs of children. By incorporating these into pediatricians can contribute significantly to the resilience and recovery of the pediatric after natural disasters significant challenges to the of children, both their physical and mental Pediatricians should be aware of injury and mental seen in the aftermath of various natural on and play a role in disaster response, an of local disaster risks and in prevention and on some and disaster management requires a multidisciplinary approach to ensure of a vulnerable on some and

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