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 Table of Contents    
CONSENSUS STATEMENT  
Year : 2021  |  Volume : 14  |  Issue : 3  |  Page : 153-172
The 2021 toolkit for emergency preparedness and mitigation to combat surge of pediatric COVID-19 patients in India: The world health organization collaborating center for emergency and trauma in South East Asia recommendations


1 Florida State University Emergency Medicine Residency Program Sarasota Memorial Hospital, Sarasota, Florida
2 Department of Pediatrics, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
3 Department of Pediatric Critical Care Medicine, SUNY Downstate Health Sciences University, Brooklyn, NV, USA
4 Department of Emergency Medicine, University of Nevada, Las Vegas School of Medicine, Las Vegas, NV, USA
5 Department of Emergency Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Udupi, Karnataka, India
6 State University of New York Health Science Center, Downstate Medical Center, New York, USA
7 Department of Pediatrics, Lady Hardinge Medical College, Kalawati Saran Children's Hospital, New Delhi, India
8 WHO Collaborating Center for Emergency and Trauma, AIIMS, New Delhi, India
9 WHO Collaborating Center for Emergency and Trauma; JPN Apex Trauma Center, AIIMS, New Delhi, India
10 Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India

Click here for correspondence address and email

Date of Submission17-Aug-2021
Date of Acceptance23-Aug-2021
Date of Web Publication30-Sep-2021
 

   Abstract 


The authors of this toolkit focus on children under the age of 18 comprising approximately 41% of the total population in India. This toolkit has been created with an objective to prepare, mitigate the effects of any surge of COVID-19 in our communities, and help to optimally utilize the scarce resources. The toolkit design suggests the manpower, equipment, laboratory support, training, consumables, and drugs for a 10-bedded pediatric emergency room, 25-bedded COVID pediatric intensive care unit, and 75-bedded COVID pediatric high dependency unit/ward as defined for a 100-bedded facility. A dedicated and detailed chapter is included to address the psychological needs of the children. These data can be modified for other department sizes based on the facilities, needs, local environment, and resources available.

Keywords: COVID-19, disaster, pediatric toolkit, preparedness

How to cite this article:
Galwankar S, Shah D, Gist RE, Shah AP, Krishnan S V, Arquilla B, Batra P, Saha A, Bhoi S, Sinha TP, Agrawal A. The 2021 toolkit for emergency preparedness and mitigation to combat surge of pediatric COVID-19 patients in India: The world health organization collaborating center for emergency and trauma in South East Asia recommendations. J Emerg Trauma Shock 2021;14:153-72

How to cite this URL:
Galwankar S, Shah D, Gist RE, Shah AP, Krishnan S V, Arquilla B, Batra P, Saha A, Bhoi S, Sinha TP, Agrawal A. The 2021 toolkit for emergency preparedness and mitigation to combat surge of pediatric COVID-19 patients in India: The world health organization collaborating center for emergency and trauma in South East Asia recommendations. J Emerg Trauma Shock [serial online] 2021 [cited 2021 Dec 1];14:153-72. Available from: https://www.onlinejets.org/text.asp?2021/14/3/153/327084





   Introduction Top


Welcome to this unique document that focuses on the youngest, most vulnerable members of our society. The authors of this toolkit recognize that children under the age of 18 comprise 41% of the total population of 1.39 billion in India, amounting to nearly 570 million.[1] At the same time, there are scarce resources and an urgent need to plan for an influx of children who will need medical care in combating COVID-19. Extrapolating the infectivity rates from previous waves, we assume that 10% of the total population might get infected with COVID-19 during the 3rd wave, which will amount to 57 million pediatric cases. Assuming that 10% of these will need hospital admission and 5% will need intensive care unit (ICU) care, there shall be an anticipated need to be ready with resources to cater to 5.7 million hospital admission and 2.8 million ICU patients. Indian Academy of Pediatrics and Ministry of Health and Family Welfare have provided management guidelines for children with COVID-19.[2],[3] Our focus is to provide a broad toolkit for pediatric COVID-19 preparedness in India. The toolkit can be used by health facilities for preparing for COVID care facilities and may be modified as per their requirements. The inspiration for this document comes from the New York City Department of Health and Mental Hygiene's 2006 pediatric disaster tool kit. We wish to thank and acknowledge those authors (Pediatric Disaster Toolkit).[4]


   How to Use Tool Kit Top


The tool kit is designed for 100 beds in the facility devoted to pediatrics in the facility to which should have 25% beds reserved for COVID pediatric ICU (PICU) and 75% as COVID high dependency unit (HDU)/wards. The tool kit design suggests the manpower, equipment, consumables, and drugs for a 10-bedded pediatric emergency room, 25-bedded COVID PICU, and 75-bedded COVID pediatric HDU/ward as defined for a 100-bedded facility. These data can be modified for other department sizes based on the facilities planning objectives. We recommend that the facility have a 10-bedded pediatric emergency area. Each chapter in this tool kit is meant to stand alone to be used as a checklist and helpful reference for facilities that either have a limited pediatric inpatient service and or no critical care capabilities. We urge you to take each chapter and discuss it with your administrations and other clinical services and adjust it as your environment dictates. The details of infrastructure, personnel, equipment, drugs, laboratory, radiology support, and training needed for such a facility are included in the subsequent chapters.


   Process of Development of Tool Kit Top


In anticipation, the World Health Organization Collaborating Center for Emergency and Trauma (WHO-CCET) of South East Asia and the World Academic Council of Emergency Medicine recognized a need for a comprehensive guide for planning and mitigation for pediatric patients during the COVID-19 pandemic. The WHO-CCET appointed a team of subject matter experts from the field of Pediatrics, Pediatric Emergency Medicine, Disaster Medicine, Emergency Medicine, and Hospital Administration. This team met regularly through virtual conferences and identified specific topics to be addressed based on the previous experience with COVID patients. A literature search was then conducted and recommendations were developed which are reflected in this tool kit. This tool kit reflects the opinions drafted by content experts for which consensus was sought to identify areas of agreement and disagreement. In contrast to clinical practice guidelines, which are based primarily on high-level evidence, consensus statements are more applicable to situations where evidence is limited or lacking, yet there are still opportunities to reduce uncertainty and improve the quality of care. This manual describes the planning measures needed by every health care facility. The authors have identified categories of institutions these tool kit recommendations are designed to assist in planning for a surge of pediatric COVID patients.

Preparation, mitigation, and assignment of in-patient bed space for hospitals without pediatric intensive care unit

  1. Ideally sick patients should be promptly transferred to a hospital that can provide pediatric critical care. Until the transfer is completed, patients should be managed by Pediatric Staff in areas where beds with multipara monitors are available (example; postoperative recovery room, beds in the pediatric ward, adult medical, or surgical ICU
  2. Moderately ill children requiring admission should be admitted to the pediatric ward until all beds are utilized. Anticipating a surge, the hospital should increase pediatric ward beds and assign the older pediatric patients (we suggest all aged more than 14 years) to the adult wards. Whenever possible, all children should be admitted to the same adult ward for ease of nursing care and to improve the children's psychological well-being.


Assignment of in-patient bed space for hospitals without a pediatric service

The following is a suggested plan for the distribution of pediatric cases upon arrival at a hospital without both PICU capability or pediatric inpatient wards. Hospitals must consider their resources and personnel when creating a specific pediatric disaster surge plan. All pediatric patients requiring admission should be stabilized ideally in the emergency department. Capacity should be expanded for initial stabilization. Arrangements for the safe transport of sick patients to a higher level of care should be made as soon as it is medically and technically possible.


   Space Considerations Top


When planning for COVID-19 pediatric management the facility should have well-defined areas before a surge in patient volume in the form of the triage area, PICUs, pediatric HDUs, and pediatric step-down wards. Ideally, all the beds should have the capability to deliver oxygen. Details of the ideal infrastructure recommended are in [Table 1]. The use of adult beds may be considered if the following actions are taken:
Table 1: Recommended infrastructure

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  • Children who have to be boarded in adult beds that have side rails
  • The bed should be set at the lowest possible height from the floor
  • In the case of electronic controls on the beds, the beds should be unplugged so the buttons do not function.



   Personnel Top


The details of the personnel to be deployed in each area with their specialty areas of experience are depicted in [Appendix I]. However, these are suggestions and the individual job responsibilities may be modified depending upon the facility's need and availability of personnel [Table 2].
Table 2: Summary showing provider level and training program/course

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   Equipment Tool Kit Top


The number after each item is the recommended number for a 10 bedded pediatric emergency room, 25 bedded COVID PICU, and 75 bedded COVID pediatric HDU/ward as defined for a 100 bedded facility. [Table 3] shows a list of the ideal items the facility should assure are available for use whenever possible. The authors understand that this may not always be possible but urge facilities to make efforts to achieve these goals. Consumables are calculated for a duration of 1 month for a 100-bedded facility with 100% occupancy. The equipment have been categorized as essential (E) and desirable (D) as per the priority and feasibility [Appendix II].
Table 3: Important training courses and link to the website

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   Drug Tool Kit Top


The authors want to stress to tool kit users who may not be familiar with pediatric patient care that all drug dosing is weight-based. In addition, we want to stress that failing to estimate the correct dosing may result in either underdosing the child and then not getting the results desired or overdosing which could lead to drug toxicities. We also acknowledge that during an influx of patients during a surge of any pandemic, each patient's weight may be difficult to estimate. We strongly recommend the length to a weight-based system. There are many of these on the commercial market. We do not recommend one over the other but have included links to explore. The hospital's pharmacy should be encouraged to be ready with drugs needed for a surge of Pediatric patients. A drug tool kit can be used as a reference for the preparation of a 100-bedded facility [Appendix III].




   Laboratory and Testing Checklist Top


It is anticipated that each facility has an investigation policy including a list of investigations [Appendix IV] and a communication plan to educate laboratory and other investigational facility personnel (including radiology) on the testing and reporting process along with specific to laboratory personnel protective equipment (PPE) training. A facility-wide communications plan for public/patients data sharing also needs to be in place; who will be tested for accessing/collecting laboratory results in concordance with the hospital policies. In case an alternative facility is needed for laboratory/radiology support, we recommend that the alternative facility be identified in advance and modalities for transport of samples and collection of reports can be defined and communicated with all involved personnel. Interim review reports can be communicated to hospital administration and at the regulatory level.




   Training Top


The authors have identified the ideal course in the table 3 below but want to also note that equivalent courses approved by the Government of India may be substituted based on the facilities preferences. It is important to remember that children are not young adults. They have anatomic and physiologic peculiarities and thus all the doctors, nurses, and support staff should be trained in the assessment of pediatric patients, skills required in pediatric care, equipment use, and attitude required for handling pediatric patients, especially during pandemics. This section compiles training recommendations for healthcare workers and provides links to the courses recommended. The recommendations are based on the settings and scope of practice. In the Indian context, broadly they are divided into three sections below. Please note that the authors discuss just in time training modules. These are meant to educate and empower all staff in reaching out of their comfort zone to provide care to the pediatric patient. Every hospital should provide the following recommended training regardless of its current scope of service.

Please refer to chapters on the following topics which are delegated to training:

  1. Plan for expanding existing space through surge (including the use of adult-in-patient space if/when available). Identification of the potential space where a temporary PICU could be established and service provided
  2. Formulating just-in-time training modules relevant to the hospital. Just-in-time training for COVID-19 management provides staff with competencies and encourages the attitude required to safely work in the facility during the COVID-19 pandemic, as well as understanding the basic principles of public health emergency care and their role in the facility
  3. Escalation plan for disaster duty roster with existing staff
  4. Identification of personnel who can be placed in surged spaces after just-in-time training and reinforcement of basic disaster training protocols
  5. Pediatric-focused disaster drills at regular intervals. A drill is a coordinated and supervised activity testing a specific operation in a facility.



   Infection Control Considerations of COVID-19 in the Pediatric Setting Top


This section reviews the infection control measures in the pediatric setting specific to COVID-19 disaster. Links to resources that provide information to facilities treating COVID-19 patients are included. We recommend using them in conjunction with the institutional guidelines for reinforcing best practices for infection control during the COVID-19 in the pediatric setting.


   General Guidelines Top


The infection control measures in the pediatric setting do not differ from the measures in other clinical care areas designated in the facility. Appropriate PPE should be worn during cleaning as well as all procedures. Careful attention should be given to maintain complete records of all persons who were present during these activities (refer “cleaning and sanitation” section[5]).


   Environment Top


Environmental hygiene includes flooring, walls, spacing (distancing), and ventilation. Cleaning and disinfection measures of surfaces should follow institutional protocols based on the national guidelines. The authors of this tool kit recommend a mandatory institutional policy for cleaning, sanitation, and disinfection.

Adequate ventilation can reduce the risk of the spread of the virus and subsequent infection. Different ventilation systems exist and there is a need for healthcare facilities to adopt an optimal approach based on their climate and geography.

Ensure optimal treatment space and adequate spacing between beds in different settings (Ward/ICU) to prevent the transmission of infection. In the PICU there should be 100–150 sqft spacing between beds refer to the section on PICU[9]).


   Hand Hygiene Top


The importance of hand hygiene has been emphasized for years and reinforced since the beginning of this pandemic. Following the guidelines-based hand washing, and hand rub strategies are strongly recommended. The WHO's 5 moments of hand hygiene provides a summary of hand hygiene in healthcare settings.[10] The details of hand-washing procedure have been described by experts in the link provided.[11]


   Equipment Top


Routine surface disinfection, targeted strategies based on the equipment/device used need to be practiced.[12]


   Biomedical Waste Management Top


Ensure the implementation of guidelines for handling, treatment, and disposal of waste generated during the management of COVID-19 patients.[13] This is particularly important for the safety of health care workers (HCWs) and the prevention of the iatrogenic spread of infection. Training HCWs and ancillary staff in biomedical waste management are mandatory the facilities guidelines should be updated based on the governmental guidance and communicated with all stakeholders.[3] The video for the safe management of biomedical waste in COVID-19 describes the details of the procedure.[14] Proper sanitation, hygiene, and waste management guidelines should be followed in all healthcare settings.[15]


   Additional Links Top


  • Infection prevention and control guidelines for 2019-nCoV (COVID-19) by the All India Institute of Medical Sciences, India[12]
  • COVID-19 IPC Sameeksha is a compilation of scientific reviews and guidelines from WHO and the Government of India intended for clinical and public health professionals in India[16]
  • Operational guidelines for strengthening facility-based pediatric care by National Health Mission, Child Health Division, Ministry of Health and Family Welfare, India[17]
  • Preparedness for the management of surge of COVID-19 in children, Number 33/31/F2/2020/H and FW dated June 2, 2021 by COVID-19 outbreak control and prevention state cell, Health and Family Welfare Department, Government of Kerala[18]
  • Online courses on COVID-19 Infection prevention and control measures


  • Infection prevention and control for COVID-19[19]
  • Standard precautions - Environmental cleaning and disinfection[20]
  • Infection prevention and control core components and multimodal strategies.[21]



   Emergency Triage and Surge Considerations Top


This section reviews the recommended approach to pediatric triage. The users will find substantial detail in the section since it has been evident during this COVID-19 pandemic that the identification through the triage of the very sick patients who need intervention and those who can have delayed treatment is essential to the best outcomes for our patients and the functioning of facilities.


   Triage and Screening before Treatment Top


The clinical presentation in children with COVID-19 is nonspecific such as fever, cough, runny nose, diarrhea, abdominal pain, and irritability, and mimics many other illnesses. Thus, local epidemiology is important for deciding the level of the index of suspicion of COVID-19 in children with these manifestations.


   Triage and Classification of Severity for Management Top


As children present with nonspecific symptoms, general guidelines for assessing the severity of illness in neonates and children at the community level such as those outlined in Integrated Management of Childhood Illnesses, should be valid criteria for triage at the community and primary healthcare level. As respiratory manifestations and diarrhea are the most common manifestations in children, integration of disease severity classification of these two conditions into the COVID triage algorithm should suffice. Moreover, with the easy availability of pulse oximetry, it can be integrated into the triage algorithm for the early detection of hypoxia. Children with Multisystem Inflammatory Syndrome in Children (MIS-C) require expert care for the proper diagnosis and management; and it being a rare complication of COVID-19 in children, we recommend putting it under “severe disease” criteria so that such children are managed in hospitals with the availability of pediatricians. Children who are unresponsive and floppy, unconscious, convulsing, cyanosed, or grunting should be immediately put in the “very severe category” by the triage team for immediate management of airway, breathing, and circulation. [Table 4] describes triage and classification of severity of COVID-19 disease in children.
Table 4: Classification of Severity of Disease


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   Initial Screening Criteria During a COVID-19 Surge Top


Any fever with

  • Clinical features suggestive of shock (poor peripheral pulses, drowsiness, cold hands, and feet, not passing urine)
  • Respiratory symptoms such as cough/runny nose/sore throat/difficulty in breathing
  • Diarrhea ± abdominal pain or discomfort ± vomiting
  • Myalgia/irritability
  • Skin rash/conjunctival congestion
  • Neonate born to mother with suspected/confirmed COVID-19
  • The presence of a recently confirmed COVID-19 case in the household or among close contacts.


Children presenting with the above features in an epidemiological background suggestive of high risk of COVID-19 infection should be tested for COVID-19 by reverse transcription-polymerase chain reaction (RT-PCR) or a rapid antigen test (please note that the rapid antigen test cannot be used to rule out disease; therefore, all infection control measures must be maintained until a negative RT-PCR report is available in symptomatic children).


   Additional Considerations - Upgradation of Risk Category Top


It may be considered for children with[22],[23],[24],[25]

  • Cancers
  • Chronic kidney diseases
  • Type 1 diabetes
  • Chronic hematological diseases
  • Known immunodeficiencies
  • Immunosuppressive therapy
  • Chronic liver disease
  • Obesity/Type 2 diabetes
  • Severe malnutrition (weight for height Z-score <−3 or mid-upper-arm circumference <11.5 cm).



   Criteria for Pediatric Intensive Care Unit Admission for COVID-19 Top


  • All respiratory or cardiac arrest
  • Unstable airway
  • Inability to oxygenate (O2 saturation <90% on >50% oxygen requirement)
  • Inability to ventilate with rising PCO2 levels with respiratory insufficiency
  • Septic or other severe forms of shock
  • Glasgow coma scale score <8 or sudden fall in score by >2 points
  • Status epilepticus
  • Acute renal failure
  • Multiple organ dysfunction syndrome.



   Multisystem Inflammatory Syndrome in Children Top


During the initial outbreak of the COVID-19, it was noted that most patients impacted were adults. In some instances, pediatric hospital volume was so low that some units and their staff were incorporated into the adult surge plan. However, 4–8 weeks after the pandemic struck, children began to present with a mysterious systemic inflammatory illness. This illness would come to be known as Multisystem Inflammatory Syndrome in Children or MIS-C. MIS-C has a variety of phenotypes, ranging from a Kawasaki-like illness to hypotension/shock with some patients requiring outpatient follow-up and others vasopressor support in the PICU. Despite the various ways in which it can present, MIS-C almost always occurs in the setting of exposure to SARS CovV-2 within the past 2–8 weeks. To date, there is no singular case definition, workup, or proven treatment regimen for MIS-C. This is largely due to the relatively small number of cases and lack of randomized controlled trials. A quick reference guide is in the appendix of this toolkit that provides the clinician with suggestions on identifying, evaluating, and managing children with suspected or proven MIS-C [Appendix V].




   Inter and Intra-facility Transport Top


Children with COVID-19 disease may need inter and interfacility transport. The interfacility transfer might be needed for the purpose of investigations, if not available at the treating center, or for treatment to a higher level of care facility than is available at the diagnosing institution. In addition, the transfer of patients within the facility will be needed for investigations such as the radiology department for computed tomography scan or to cardiology for echocardiography. Safe transport with the patient in a stable condition should be the aim when such a requirement exists. It is suggested that all COVID-19 treating hospitals develop a transport team, with orientation and training in the safe transport of patients. See [Box 1] for the personnel and equipment requirements for the transport of patients within and outside of the facility.




   Transport of Pediatric Patients within the Hospital Top


General guidelines for transporting pediatric patients between hospital units or diagnostic testing areas.

Transport personnel

All transport personnel should be oriented to the special needs of pediatric transport and patients should never be left alone/unattended at any time. Additional staff skilled in pediatric airway management and familiar with pediatric resuscitation ideally should accompany the patient on the transport.

Unstable patients

Unstable patients require continuous 1:1 observation during transport. In addition, parents or adult caregivers should be encouraged to stay with children.

Transport equipment

Airway management and resuscitation supplies are available which are appropriate for all age groups (see equipment recommendations). For long distance, intrahospital transport ambulance should be available. For small distance or short time in transport expected the use of adult stretchers may be appropriate for children >8–10-year-old, smaller children may require a crib, additional transport personnel, and/or converting an adult stretcher by adding padding to inside rails to assure safety during transport.


   The Psychosocial Needs of Children during a Disaster Top


To properly care for children in hospitals it is necessary to consider both their physical and mental health needs and treating them in the context of the family unit. Children's responses to disaster and hospitalization may share some aspects of adult responses but are distinguished by the developmental contexts in which children of varying ages experience, mediate, and communicate the impact of associated events and procedures. An unfamiliar environment such as a medical setting can be made to feel safer for pediatric visitors and patients by including familiar people, familiar things, and routines. Hospitals need also note the cultural differences that may cause a group of children exposed to the same trauma to react differently and must ensure that mental health staff is sympathetic to each of these variances. Lastly, there are legal concerns regarding the treatment and release of children which each hospital should consider when creating the pediatric response portion of its disaster plan.

General guidelines

  1. When describing the hospital experience to children of any age, it is important, to be honest in your description and in answering any questions they may have. However, it is important not to give preconceived notions about what a child may feel. Caregivers should avoid the use of the words “pain” and “scary” in describing experiences the child may have since everyone feels pain and emotions differently
  2. Since young children (preschool through school-age) learn best by experience, provide as much information as you can to help the child learn about their upcoming experience. Describe what the child may smell, hear, touch, and feel using as many tangible items as possible, such as dolls and books
  3. Children's reactions and symptoms can be expressed through behavior, thoughts, emotions, and physical reactions. Children's fears about their own safety can contribute to symptoms of anxiety and depression and may also lead to oppositional and aggressive behavior. This may be an attempt to reassert some sense of control and should be recognized as such
  4. Do not leave children unaccompanied in front of a television, for example, with the news on, but allow them to talk about what is going on if they choose. Clarify misconceptions with simple, truthful explanations
  5. Refrain from having conversations about the disaster in front of the children or within hearing distance. This can lead to misunderstandings and misconceptions
  6. Gather unit staff and develop language for describing events of disaster. Ensure that all staff is educated accordingly and then communicate this information consistently to avoid adding to the children's confusion
  7. Opportunities for play are important for learning, expression of feelings, normalcy, escape, and mastery. Age-appropriate toys and diversionary activities are helpful to have on hand. This may include puzzles, books, simple art supplies, and video and audiotapes. If possible, allow children to interact in groups and monitor for misconceptions
  8. Try not to separate them from their primary caregivers for extended periods of time. Allow a parent/caregiver to accompany the child to procedures as much as possible. To encourage feelings of safety and familiarity try to limit the number of staff caregivers (i.e. assign the same nurse to care)
  9. Parents will be most helpful when they are/feel informed-if they are upset from not knowing what is going on that tension is going to affect the child
  10. Assess for any underlying mental health disorder that may require immediate psychiatric consultations such as trouble sleeping, lack of appetite, and physical complaints with no medical basis
  11. Gather information about varying cultural responses to trauma and death
  12. Gather a list of community resources (counseling services, etc.) for distribution to parents/caregivers upon discharge
  13. Identify staff within the hospital who can assist with addressing the emotional and psychological issues i.e. social workers, psychologists, psychiatrists, chaplains, psychiatric nurses, and have an on-call list available for unit staff
  14. Identify resources for staff support to cope with the impact of seeing injured and/or dying children
  15. Identify community resources that may be able to donate services, supplies, and specifically for the children.



   Development Specific Guidelines for Treating Children in the Hospital Top


Infants

  • Try to let a parent/caregiver stay with the baby during medical procedures
  • Use familiar objects from home such as a stuffed animal, blanket, music box, or toy to help comfort the baby before, during or after a procedure.


Toddler and preschool

  • Try not to have conversations about your child's care in their presence unless you are including them in the conversation. Children overhear much more than adults think and without any explanation, the information may seem frightening
  • Let a parent/caregiver stay overnight with the child if possible. If appropriate, let other family members, including brothers and sisters, come and visit. With the understanding that these family members must follow all COVID-19 guidelines of the institution
  • Reassure the child that the hospitalization is not a punishment. Try to avoid using good/bad labels particularly during a procedure. For example, instead of saying “See, you were so good, the doctor only had to do this once,” you can say, “You did such a good job of sitting still, I know that was hard”
  • Children learn best through play and “medical play” can be particularly useful. Allow them to handle some medical equipments such as a stethoscope, and blood pressure cuff. Allow them to practice the procedure on a doll
  • Allow the child to make choices whenever possible but do not offer a choice when none exist. For example, do not say, “Would you like to come into the treatment room now so the doctor can look at you?” It would be better to say, “Do you want to bring your bear or blanket with you to the treatment room?”


School-age

  • School-age children can be given more specific information about what is going to happen to them. Many medical terms can be confusing for children. For example, the term “I.V.” could be confused with the word “ivy” or “dye” with “die.” Give simple, specific explanations for procedures
  • This is a great age for medical play (communicating understanding, and fearsthrough play with medical equipment). Allow the child the opportunity to reenact events through play with different kinds of toys or art materials. This is an important way for school-age children to express their feelings and gain a sense of control over what is happening to them
  • Respect the child's privacy and encourage others to do the same by knocking before entering the room and being sensitive to who is around when examinations are being conducted
  • Sometimes children at this age regress, or start up with behaviors that they had grown out of (thumb sucking and bed wetting), when in a stressful situation like being in the hospital. Do not berate (come on, you're a big girl now…) or punish for this behavior. Encourage the child to express his feelings and discharge emotions through play.


Adolescents

  • Try not to have conversations about the teen's care in his/her presence unless you are including him/her in the conversation. Adolescents can understand much more about their bodies and what is happening to them and may resent not being included in discussions about their condition or treatment
  • Do not assume that teens manage their emotions the same way as adults do. Give them opportunities to discuss what is happening with staff both with and without the parent/caregiver being present so they can ask questions
  • Respect a teen's privacy and encourage others to do the same by knocking before entering the room and being sensitive to who is around when examinations are being conducted.



   How Children Can React to a Disaster Top


Children react differently to stressful events than adults. Their response can often be delayed and may be hard to detect. They may find it hard to talk about how they have been affected.

  • Staff needs to be aware of changes in children's behaviors such as extra clinging or a change in appetite. parents, teachers, and other caring adults who know the child are in the best position to notice these changes
  • Don't wait for them to come to you, ask questionssuch as: Are they having trouble sleeping? Are they feeling less safe than before?
  • Some children are more likely to have emotional reactions to the events:


  • Children who witnessed the event first hand or whose parent, a relative, or friend was killed or injured
  • Children who are displaced from their home or schools
  • Children who have a past history of emotional problems
  • Children who have a past history of trauma, either as a victim or a witness to violence or abuse
  • Children with an adult in their life who is having difficulty with their emotions, a witness to violence, or victim of domestic violence.


Emotional responses also vary by development stages and may include the following.

Children aged 5 and younger may

  • Have fears of being separated from a parent
  • Be unusually fearful, “fussy,” clingy, and have crying bouts
  • Return to outgrown behavior, such as bed-wetting or baby talk
  • Have nightmares or problems sleeping
  • Have stomach aches, headaches, or other physical complaints that do not have a medical base
  • Startle easily
  • Have a loss or increase in appetite.


Children aged 6–11 may

  • Have appetite changes
  • Headaches, gastrointestinal problems
  • Loss of interest in social activities
  • Sadness or depression
  • Feelings of inadequacy and helplessness
  • Feelings of anger and aggression
  • Isolation from others, fewer interests in friendships
  • Repetitive behaviors such as hand-washing.


Children aged 12–18 may

  • Have appetite changes
  • Headaches, gastrointestinal problems
  • Loss of interest in social activities
  • Sadness or depression
  • Feelings of inadequacy and helplessness
  • Feelings of anger and aggression
  • Isolation from others, fewer interests in friendships Repetitive behaviors such as hand-washing.


Not all children exhibit all symptoms and their reactions may change over the 1st days or weeks following a crisis.


   Helpful Hints to Assist Children during and after a Disaster Top


For children under age 5

  • Try to keep to normal routines and favorite rituals as much as possible
  • Limit exposure to TV programs and adult conversations about the events
  • Ask what makes them feel better
  • Give plenty of hugs and physical reassurance
  • Provide opportunities for them to be creative and find other ways to express themselves.


For children older than age 5

  • Do not be afraid to ask them directly what is on their mind and answer their questions honestly
  • Talk to them about the news and any adult conversations they have heard
  • Make sure they have opportunities to talk with peers if possible
  • Set gentle but firm limits for acting out behavior
  • Encourage verbal and play expression of thoughts and feelings
  • Listen to the child's repeated retelling of the event.



   When to Consult a Mental Health Professional Top


Consultation with a mental health professional may be useful at any of these times. However, psychiatric consultation should be sought if any of the following is exhibited:

  • Excessive fear of something terrible happening to their parents or loved ones
  • Excessive and uncontrollable worry about things, such as unfamiliar people, places, or activities
  • Fear of not being able to escape if something goes wrong
  • Suicidal thoughts or the desire to hurt others
  • If the child has hallucinations
  • Expressing feelings of being helpless, hopeless, and worthless.



   Legal Considerations Top


The following are legal questions and issues that may arise during a disaster. Having policies and procedures in place before an event should be considered:

  • For unaccompanied children during a disaster, consent is not needed to treat for a life or limb-threatening situation. Is parental consent needed to treat a child victim with minor injuries? With psychological injuries?
  • Is parental consent required to decontaminate an unaccompanied child? What if the child is asymptomatic? What if the child is refusing?
  • What medical or social information can be released and to whom during a disaster?
  • Check Health data privacy and security rules and your legal counsel concerning the unidentified patient locator protocols such as posting Polaroid photographs of unidentified children
  • Who can children be released to and if not the parent or caregiver, what permission or information is needed? What is your protocol for releasing children if no legal guardian or parent can be found or if no permission document is provided?



   Cultural Differences About Death and Dying Top


Every culture has its own rituals and manner of mourning. Given that India is such a diverse society, mourning patterns of ethnic groups are going to be equally different. Clinicians should be careful about definitions of “normality” in assessing families' responses to death. The patient's response may be very different from the physicians' cultural beliefs and expected response. In addition, health care providers should remember not to assume people within any particular cultural group fit a pattern when mourning. Each family unit, as each individual, needs to be treated and assessed on an individual case-by-case basis.

  • It is important for staff to appreciate an ethnic group's particular attitudes about mourning and to find out from a family what its members believe about the nature of death, the rituals that should surround it, and the expectations of the afterlife
  • Often a failure to carry out death rituals contributes to a family's experience of unresolved loss
  • Helping family members deal with a loss often means showing respect for their particular cultural heritage and encouraging them actively to determine how they will commemorate the death of a loved relative
  • While it is generally better to encourage families toward openness about death, it is also crucial to respect their cultural values and timing for dealing with the emotional aftermath of a loss
  • Staff may inquire about:


    • What are the prescribed rituals for handling dying, disposition of the body, rituals to commemorate the loss
    • What are the group's beliefs about what happens after death
    • What do they believe about appropriate emotional expressions
    • What are the gender rules for handling the death


  • Staff should identify personnel in their setting who may be able to provide more details regarding specific cultural groups such as pastoral care, social work, or even particular staff members from various cultural groups.



   Obtaining Mental Health Services in the Community Top


Every child experience emotional difficulty from time to time, but at some point, a child's problems may warrant professional attention.


   Fact Sheet after a Disaster: A Guide for Parents and CareGivers Top


From the National Institute of Mental Health.[28]

Natural disasters such as tornados, or man-made tragedies such as bombings, can leave children feeling frightened, confused, and insecure.

Whether a child has personally experienced trauma or has merely seen the event on television or heard it discussed by adults, it is important for parents, caregivers, and teachers to be informed and ready to help if reactions to stress begin to occur.

Children respond to trauma in many different ways. Some may have reactions very soon after the event; others may seem to be doing fine for weeks or months, then begin to show worrisome behavior. Knowing the signs that are common at different ages can help parents and teachers to recognize problems and respond appropriately.

Preschool age

Children from 1 to 5 years in age find it particularly hard to adjust to change and loss. In addition, these youngsters have not yet developed their own coping skills, so they must depend on parents, family members, and teachers to help them through difficult times.

Very young children may regress to an earlier behavioral stage after a traumatic event. For example, preschoolers may resume thumb sucking or bedwetting or may become afraid of strangers, animals, darkness, or “monsters.” They may cling to a parent or teacher or become very attached to a place where they feel safe.

Changes in eating and sleeping habits are common, as are unexplainable aches and pains. Other symptoms to watch for are disobedience, hyperactivity, speech difficulties, and aggressive or withdrawn behavior. Preschoolers may tell exaggerated stories about the traumatic event or may speak of it over and over.

Early childhood

Children aged five to eleven may have some of the same reactions as younger boys and girls. In addition, they may withdraw from playgroups and friends, compete more for the attention of parents, fear going to school, allow school performance to drop, become aggressive, or find it hard to concentrate. These children may also return to “more childish” behaviors; for example, they may ask to be fed or dressed. Do boys and girls act differently?

Adolescence

Children 12 to 14 are likely to have vague physical complaints when under stress and may abandon chores, school work, and other responsibilities they previously handled. While on the one hand, they may compete vigorously for attention from parents and teachers, they may also withdraw, resist authority, become disruptive at home or in the classroom, or even begin to experiment with high-risk behaviors such as drinking or drug abuse. These young people are at a developmental stage in which the opinions of others are very important. They need to be thought of as “normal” by their friends and are less concerned about relating well with adults or participating in recreation or family activities they once enjoyed.

In later adolescence, teens may experience feelings of helplessness and guilt because they are unable to assume full adult responsibilities as the community responds to the disaster. Older teens may also deny the extent of their emotional reactions to the traumatic event.


   How to Help Top


Reassurance is the key to helping children through a traumatic time. Very young children need a lot of cuddling, as well as verbal support. Answer questions about the disaster honestly, but do not dwell on frightening details or allow the subject to dominate family or classroom time indefinitely. Encourage children of all ages to express emotions through conversation, drawing, or playing and to find a way to help others who were affected by the disaster.

Try to maintain normal routines and encourage children to participate in enjoyable activities. Reduce expectations temporarily about performance in school or at home, perhaps by substituting fewer demanding responsibilities for normal chores.

Finally, acknowledge that you, too, may have reactions associated with the traumatic event, and take steps to promote your own physical and emotional healing.


   When to Seek More Help Top


Consultation with a mental health professional may be useful at any of these times. A list of online resources is provided in [Table 5]. However, psychiatric consultation should be sought if any of the following is exhibited:

  • Excessive fear of something terrible happening to their parents or loved ones
  • Excessive and uncontrollable worry about things such as unfamiliar people, places, or activities
  • Fear of not being able to escape if something goes wrong
  • Suicidal thoughts or the desire to hurt others
  • If the child has hallucinations
  • Expressing feelings of being helpless, hopeless, and worthless.
Table 5: Important training courses and link to the website

Click here to view



   Childline India Foundation Top


Supported by the Ministry of Women and Child Development. Contact for any child-related emergency, 24 h a day. Counseling professionals provide free, confidential information, and referral services, 24 h a day. They have the latest information and where to go for help. Anyone can call. Help is available in several languages. Dedicated resources are also available for the ongoing COVID-19 pandemic [See [Box 1] and [Appendix VI].



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Top
Correspondence Address:
Prerna Batra
Department of Pediatrics, University College of Medical Sciences, Guru Teg Bahadur Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jets.jets_112_21

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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