By Frank Rando
Frank Rando highlights the most important considerations in pediatric CBRN care with reference to historical case studies from Japan, Italy, and elsewhere.
One of the many words that describe newborns and children is “innocence”. Infants, children, and adolescents are not expected to know or experience the harshness of the world or the evils of humankind. The idea of an infant, child, or adolescent being injured or dying in a motor vehicle accident, drive-by shooting, or even of natural causes, is anathema to being caring, nurturing adults.
Sadly, thousands of young innocents have been maimed or perished and continue to die in wars, acts of terrorism, and natural catastrophes of the largest and severest magnitude. We must dispel the myth that children are just “little adults”. The reality is that despite their youth and purported resilience, pediatric age children – from newborn to 15 years old – are more vulnerable to mechanisms of harm such as physical trauma, chemical exposures, and ionizing radiation. Futhermore, the deleterious effects of environmental hazards in utero have been well studied and documented for years, and it is also important to consider the special needs of the unborn.
Minamata Disease
Between 1932-1968, the Chisso Chemical Corporation, formerly known as Shin Nichitsu and Shin Nihon Chisso Hiyro, was responsible for discharging wastewater containing mercury from its acetaldehyde plant into Minamata Bay, Japan, via Hayakken Harbor.
Mercury wastes, including methylmercury and other highly toxic pollutants, were absorbed by fish and shellfish populations, and as bioaccumulative toxicants, were able to concentrate and undergo “biomagnification” in the food chain. As the inhabitants of the Kumamoto prefecture depended on fish and seafood for their livelihood and sustenance, many sold and ate the contaminated flesh and absorbed highly elevated and toxic doses of mercury, including pregnant women and children. Village residents noticed that cats who had consumed contaminated fish were displaying bizarre signs, such as running blindly into objects, seizures, tremors, and acting aggressively.
Chisso’s own company hospital medical director, Dr. Hajime Hosokawa, officially reported “an epidemic of an unknown disease of the central nervous system” on May 1, 1956, and dubbed it “Minamata disease”. As the mercury contamination of this aquatic ecosystem and the sale and consumption of toxic fish and seafood continued, in 1963 physicians at Kumamoto University concluded that Minamata disease was caused by mercury toxicity.
It is well established that mercury can both cross the placental barrier and concentrate in fetal cells, and that children are highly vulnerable to mercury poisoning. In the Minamata Bay region, several children developed severe neurological disease, such as cerebral palsy and toxic brain injury leading to mental retardation. Children are also vulnerable and susceptible to inhalation of mercury vapor and, due to hand-to-mouth behaviors, oral intake of mercury and other heavy metals such as lead.
Potential Pediatric CBRN Incidents
In crisis, emergency, and disaster planning, we must remain open-minded, and we should always think outside the box. Could a toxic heavy metal, toxic industrial chemicals, radionuclides, or a biological agent be used to target children via the food chain? Can we model a past event such as the Minamata Bay chemical disaster and extrapolate key elements and lessons learned from the event to apply them to a potential terrorism event using mercury compounds or some other heavy metal?
What if the terrorist element decided to contaminate a local milk supply with a biotoxin such as botulinum? Or place a gamma source allowing for consistent irradiation somewhere where young children congregate? In communities with nuclear power facilities, is there a viable emergency operational plan that addresses pediatric exposures to radionuclides?
The possibility of such or similar incidents is not far-fetched. Indeed, past episodes of mass chemical poisoning have occurred in various areas of the world and have involved infants and children.
On July 10, 1976, an industrial chemical disaster occurred at the ICMESA plant in Meda in Seveso, Italy. The disaster was caused by a runaway exothermic reaction that took place in a chemical reactor vessel, resulting in the release of an aerosol cloud that included sodium hydroxide, ethylene glycol, sodium trichlorophenate, and an estimated 15-30 kilograms of one of the world’s most toxic substances, dioxin.
Post-explosion, many children displayed chloracne, which indicated significant exposure to dioxin. Some children exhibited elevated liver enzyme levels, demonstrating that liver injury had occurred or heightened detoxification mechanisms were activated. Furthermore, because dioxin is known to be highly mutagenic and teratogenic – potentially inducing in utero developmental abnormalities – many pregnant women in the area pursued abortions.
Furthermore, edible oils can easily be targeted for adulteration using a variety of toxicants and widely distributed to unsuspecting populations. The contamination of rice oil in Japan in 1968 and Taiwan in 1979 with polychlorinated biphenyls and polychlorinated dibenzofurans is evidence of this.
Chemical Terrorism
Industrial or chemical terrorism disaster scenarios could cause mass chemical exposures via multiple routes and environmental pathways, and infants and children would be at heightened risk due to their unique vulnerabilities. For example, toxic gases with low vapor pressures can permeate home, daycare, and school environments and “hug” low-lying areas, disproportionately affecting infants and toddlers exhibiting crawling behaviors.
Irritant gases such as ammonia, chlorine, and phosgene can cause profound tissue damage to the airways and lungs of infants and children as their airway structures are not fully developed and are narrower and more collapsible. As infants and children require larger quantities of oxygen to meet their metabolic needs, the loss of functional red blood cells will significantly decrease oxygen transport and delivery to developing cells of various bodily systems. Inhalation exposures, direct inhalational injury, and systemic absorption via respiratory epithelial tissue and the alveolar–capillary membrane may also be facilitated by respirable particles and aerosols.
What is clear is that, in the context of an intentional CBRN attack incorporating the use of weapons of opportunity and convenience such toxic industrial chemicals and materials or chemical warfare agents, infants and children would suffer greatly.
Pediatric Disaster Planning
Pediatric disaster planning and response efforts must be able to address and readily provide specialized age-specific and agent-specific plans, protocols, and procedures for pediatric populations.
Devastating inhalational injury due to inhaling vesicant (blister agent) vapors is also possible, resulting in inflammation, tissue necrosis, epithelial sloughing, and airway obstruction, which will require providing advanced airway adjuncts and mechanical ventilation. Because of the relatively large body surface area of a child and increased skin permeability leading to fluid losses and dermal absorption, chemical burns will have to be addressed in conjunction with pediatric intensive care and burn specialists.
Furthermore, vesicants like sulfur and nitrogen mustard agents can lead to profound bone marrow failure, and age-specific protocols and procedures must be in place to be able to properly assess and treat pediatric victims for bone marrow failure and its sequelae. The pathophysiology associated with vesicant exposures may affect other rapidly dividing cells, such as fetal and gastrointestinal cells.
Vesicants are also alkylating agents that can damage DNA and lead to mutagenesis and carcinogenesis. These characteristics are very significant for the evaluation, treatment, and ongoing medical surveillance and monitoring of the developing child.
Increased Susceptibility and Special Needs
Due to the unique anatomic and physiological variances of infants and children, increased susceptibility, and special needs, there is no doubt that pediatric casualties would be among the first to be severely affected and die from the effects of a chemical terrorism attack, battlefield chemical warfare, or an industrial chemical disaster.
Significant data on increased morbidity and mortality of infants and children from chemical exposures may be derived from literature on real-world events such as the 1986 Bhopal methyl isocyanate release, the chemical agent attacks against the Kurdish population by the former Saddam Hussein regime, as well as the more recent chemical attacks in Syria which left a multitude of children dead. Biological agents, such as select bioterrorism pathogens and emerging infectious diseases, could also impact children greatly, especially if they are less than two years of age.
Children have immature immune systems and coexisting diseases such as asthma can be exacerbated by severe febrile respiratory illnesses. They will also suffer from severe diarrhea and vomiting from a gastrointestinal illness such as cholera, leading to severe dehydration and associated electrolyte abnormalities. For this reason, antimicrobial agents and vaccines must be available to administer to the pediatric population.
Increased sensitivity and susceptibility to ionizing radiation and its health effects are factors that must be incorporated into pediatric disaster planning and operational response. Over several decades, there has been a myriad of research projects involving the biological and medical effects of ionizing radiation conducted in military radiobiology research institutes, universities, governmental biomedical institutes, and other entities. In addition, there was a darker period in U.S. history where human subjects were intentionally exposed to radionuclides and external irradiation.
In 1954, errant fallout from a nuclear weapons test on Bikini Island, an atoll of the Marshall Islands, caused acute burns from beta radiation to develop in neighboring islanders. Subsequently, severe hypothyroidism developed in two children exposed to radioactive fallout prior to one year of age. Of 28 children exposed before ten years of age, 14 developed thyroid neoplasia and one developed leukemia.
This incident and others prompted the American Academy of Pediatrics to establish the Committee on Radiation Hazards and Congenital Malformations to formulate policy on exposure of children to ionizing radiation.
Following the atomic bombings of Hiroshima and Nagasaki, blood cancers developed in adults who were exposed to ionizing radiation as children. Children also received both radiation and thermal burns from the nuclear detonations, and they also developed thyroid abnormalities, including cancer, due to the incorporation of the radionuclide iodine-131. Hundreds of the children exposed to the fallout from the Chernobyl reactor accident also developed thyroid neoplasia and thyroid dysfunction, cancers, and possibly decreased immune responses.
The knowledge gained from survivors of catastrophic nuclear events such as Hiroshima and Chernobyl indicates that, when controlled for exposure level, radiation-induced cancers occur more frequently in children than adults. Therefore, when planning and preparing for radiological and nuclear events, protective countermeasures should include evacuation and shelter. Special considerations for infants and children must be incorporated into those plans.
Potassium iodide with appropriate pediatric dosing must be an integral part of pediatric disaster planning and preparedness, as thyroid blockade is an essential medical countermeasure in the management of radiological and nuclear casualties.
Traumatic Injury, Decontamination, and Mental Health
Infants and children are at greater risk of morbidity and mortality due to traumatic injury. Relative to the adult, a child has a larger head, which translates to a higher frequency of head injuries in children with its attendant sequelae. Because traumatic force is transmitted to underlying organs through the relatively plastic pediatric skeleton, children are more likely to develop pulmonary contusions and other serious internal injuries.
Because of their smaller blood volume, infants and children can exsanguinate very quickly, meaning that severe blood loss must be controlled immediately, and adequate blood replacement resources must be at the ready to save lives.
Cognitively, children have limited reasoning capabilities. They are dependent on adults to recognize danger and avoid hazards. Their psychological immaturity places them at great risk because they have limited coping skills. Mental health resources must be in place for the injured or ill child and for those who may have been orphaned in the aftermath of a disaster or catastrophic event.
We must also consider decontamination and PPE for children at every phase of postnatal development. For example, decontamination procedures can lead to hypothermia quickly in children. Every measure, including heating and water temperature, must be carefully taken into consideration. Respiratory protection including for infectious diseases and PPE for chemical agent exposures must also be offered.
Training in and further development of pediatric disaster response tools are essential, such as the JumpSTART system helping the undertriage of seriously ill or injured children.
In conclusion, the special considerations and needs of the pediatric population in CBRNe exposure scenarios, as well as technological and natural disasters, must be incorporated into all-hazards disaster plans and operations. Indeed, children, at any age, are unique organisms that present with unique challenges, and should not be considered “little adults”. During crises and contingencies, their health, safety, wellbeing, and survival depend on us all.
Frank Rando currently serves as an allied health programs educator, lead instructor, healthcare emergency preparedness, medical readiness, public health preparedness and tactical, operational, disaster medicine and homeland security subject matter expert, educator, instructor, and curriculum designer. He has served in instructional, guest speaker, and consultative roles for DHS-FEMA, various components of the National Domestic Preparedness Consortium, Department of Defense, industry, academia, health, safety and regulatory entities, emergency services organizations, and healthcare.
