The French Society of Disaster Medicine has just organized a session « Children and Disasters » in order to better understand the problems raised by children who are victims of a disaster.
This gave us the opportunity to review the literature on pediatric decontamination that we propose to you here.
Special vulnerabilities of children
Smaller in size than adults, he is more exposed to heavy agents that concentrate near the ground (chemical agents or biological agents);
Larger surface-to-body mass ratio, therefore greater relative absorption of toxin;
Less subcutaneous fat, therefore more sensitive to hypothermia;
Greater respiratory ventilation rate, therefore better absorption of aerosolized or gaseous toxins;
Less fluid storage and therefore more sensitive to dehydration in case of vomiting or diarrheal toxins;
Immaturity of the immune system, therefore greater sensitivity to infectious agents;
Immaturity of psychological and motor development means that the child does not easily escape dangerous situations;
The child does not spontaneously protect his face and eyes;
Post-traumatic anxiety reactions leading to significant psychological sequelae.
Disrobing. The child’s age must also be taken into account when undressing: between the ages of 8 and 18, children undress alone and do not need help with the decontamination shower. Between 2 and 8 years old they usually need help for both phases and children under 2 years old must be undressed by staff. Have both male and female caregivers available, as older children may be disturbed in the presence of the opposite sex. If possible, do not separate children from their families unless care requires it. In case of panic, children are psychologically affected by the separation of their parents.
Shower. The younger the child, the bigger the problem. Many of them are afraid of the shower and resist undressing. Parents cannot decontaminate themselves while they are helping their children. But family decontamination is recommended, so they must be assisted by a helper. In a state of fear, the child may not follow the instructions correctly.
Their skin is thinner and more permeable and therefore more sensitive to chemical agents. 36.7°C is the ideal temperature for a shower. While a lower temperature may be more effective in adults by causing vasoconstriction that reduces the absorption of toxins, it may cause hypothermia.
Babies, especially when wet, are very difficult to keep in the shower. It is advisable to place them on a stretcher, for example, to allow fluids to flow. Specific materials exist. The child can then be decontaminated by a caregiver who will not have to carry it. Care should be taken to ensure that he or she is not uncomfortable in breathing (especially if it is an infant who is not holding his or her head) and that he or she does not inhale water from the shower.
As for the water pressure, it must not exceed 413 kPa. Protection of the respiratory tract under the shower is essential. Children who are unable to protect their airways can be decontaminated with a hand spray.
It is always necessary to provide a manual shower that delivers a large volume under reduced pressure, which is more suitable for children and of which they are less afraid.
Dry and wrap the child in a blanket immediately afterwards to avoid hypothermia.
At the hospital, a paediatric ward maintains them in a pleasant environment. When they are discharged from hospital, it is important to ensure that they are handed over to the persons legally responsible. Ensure their psychological development.
The child’s skin is more permeable and has less keratin. It also has a proportionally larger surface area in relation to weight and therefore it will better absorb toxins. The immune system is still relatively immature. Decontamination is therefore particularly important. Do not use alcoholic or bleach-based products, otherwise there is a risk of systemic poisoning. Water alone is enough. In the case of oily products, a mild soap or shampoo can be used.
Unlike chemical agents, biological agents require considerable energy to be re-aerosolized from a skin or clothing. Non-volatile and non-active on the skin (except for the rare ones that penetrate healthy skin), the decontamination of a biological agent is therefore less critical than that of chemicals. Undressing and careful washing with soap and water are nevertheless necessary.
Most biological agents are aerosolized. Since children ventilate more quickly and are closer to the ground, they are more sensitive to biological agents than adults, especially if they are exposed to agents heavier than air. This should be taken into account when establishing the child’s specific antibiotic treatment.
None of the publications address this issue. The use of Fuller’s earth can be dangerous because of the re-aerosolization of the dangerous powder for the child’s eyes, nostrils and mouth. The use of Decpol ABS® wipes can be an interesting alternative before wet decontamination on the skin after undressing (or even on clothing to facilitate undressing). Suitable for children, it decontaminates an baby or even a child and does not release any harmful powder for the child’s lungs or eyes.
With regard to prevention, Ouvry provides an NH15 escape hood in size XS suitable for children.
It is encouraging to see that the problem of decontamination of children is being addressed in the various studies and congresses. Their particular physiology makes them particularly vulnerable and even if, overall, decontamination is based on the same principles, special protocols must be applied. It should be remembered that when the twin towers of New York fell, the first patient at the New York Veterans Administration Medical Center was a 5-month-old toddler covered in grey ash. This hospital does not have a pediatric ward. Nevertheless, it was provided with a minimum of child-friendly equipment and the staff had followed specific paediatric training, which is why the child and his breastfeeding mother were cared for and cared for without any difficulties.
Heon, GL Foltin, Principles of pediatric decontamination, Clin Ped Emerg Med, 2009, 10, 186-194
CW Freyberg, B. Arquilla, BS Fertel, MG Tunik, A. Cooper, D. Heon, SA. Kohlhoff, KI. Uraneck, GL Foltin. Disaster preparedness: Hospital decontamination and the pediatric patient- Guidelines for hospitals and emergency planners. Prehosp and Disast med, 2008, 23, 166-173
Henretig, TJ Cieslak. Bioterrorism and pediatric emergency medicine. Clin Ped Emerg Med, 2001, 2, 211-222
Committee on environmental health and committee on infectious diseases. Chemical-biological terrorism and its impact on children. Pediatrics, 2006, 118, 12671278
Timm, S. Reeves A mass casualty incident involving children and chemical decontamination. Disast Manag & Resp, 2007, 49-55
Scalzo, KL Lehman-Huskamp, GA Sinks, WJ Keenan. Disaster preparedness and toxic exposures in children. Clin Ped Emerg Med, 2008, 4760