LAUSR

The United States has been consumed by the news about the flooding in Texas that accompanied and followed Hurricane Harvey. Many have been comforted by the relatively low levels of morbidity and mortality seen so far compared with disasters such as Hurricane Katrina. However, we should resist complacency. Unfortunately, most of the potential harm from the storm is yet to come, and much of it will fall on children. Although flooding is one of the most deadly types of natural disasters in the United States and worldwide, floods’ full physical and mental health effects, particularly in the long term, are still not well understood. However, some data do exist and have been summarized in a 2012 systematic review on floods and human health.1 Overall, mortality rates nearly double in the year after floods. Increases in disease outbreaks of hepatitis E and gastrointestinal infections are common, fueled by breakdowns in sanitation services and the contamination of potable water with sewage. The incidence of injuries is usually focused on the short term, driven by wounds from contact with debris. However, physical and mental effects of floods on children can be especially acute and worthy of dedicated, long-term attention. As with adults, children with chronic conditions are at increased risk for problems after a flood.2 In a crosssectional study of more than 500 children following Hurricane Katrina, those with preexisting conditions were significantly more likely to have a disruption in care (58% vs 38%), miss a visit to a physician (49% vs 38%), or run out of medications (34% vs 8%). They were also more likely to experience other conditions that could exacerbate their health problems. For example, they were more likely to live with flood damage afterwards (20% vs 11%) and to have mold in their homes (24% vs 16%). The link between disasters and posttraumatic stress disorder is well established in children and can be long term. After Hurricane Katrina, studies showed that more than half of high school students experienced symptoms of posttraumatic stress disorder and reactive aggression more than a year after the event.3 Although most children’s symptoms improve over time, even 3 years poststorm, about 28% of children still experienced significant mental health problems, meeting the criteria for a mental health referral.4 Even pregnant women and the infants eventually born to them are at risk.5 Researchers followed up a cohort of 301 women from Baton Rouge and New Orleans, Louisiana, to examine the potential effects of Hurricane Katrina on outcomes of pregnancy and delivery. Low birth weight was much more common in women who had high hurricane exposure (14%) than women who did not (4.7%). Preterm birth was also more likely among women with high exposure (14%) compared with women without that exposure (6.3%). This difference was large enough for the researchers to advise that pregnant women may need earlier evacuation to minimize their exposure to severe weather events. Evidence shows that we still have work to do to protect children from storms’ long-term health effects. A 2017 study examined the performance of TexKat, a Hurricane Katrina Medicaid Emergency Waiver program for evacuees from Louisiana to Texas.6 TexKat provided Medicaid coverage to about 60 000 low-income parents, pregnant women, children, and people with disabilities displaced by the flooding in New Orleans. Even with extended coverage from TexKat, prescriptions filled for children with asthma fell, while those for control children (who experienced no disruptions) did not. There were decreases in health care use as well. The conclusions of the authors were that “children in the program may have received inadequate care.”6 This highlights a pervasive problem in the US health system: coverage alone does not guarantee adequate access to care. Although access limitations are not always problematic for healthy adults, they can be life altering for vulnerable children after a large natural disaster. There are many things we can and should do to further protect children from the worst consequences of floods and other disasters. The Centers for Disease Control and Prevention has a thorough guide with suggestions.7 Children take their cues from adults, so the Centers for Disease Control and Prevention advises that those engaging with children, particularly parents, guardians, and other caretakers, act calmly and confidently. This will help reassure children that they will be cared for. The Centers for Disease Control and Prevention also recommends that families develop a disaster plan that includes the assembly of necessary supplies, which would include important health records and emergency medications. In the case of Harvey, it is too late for advanced planning, but there is always a next time, and preparing children for potential issues can reassure them as well as limit adverse outcomes. Parents are the first line of defense in monitoring for declines in mental health. Young children may regress behaviorally, even reverting to bedwetting, as well as becoming more clingy. This may be caused by feelings of helplessness or a fear of separation. Older children may experience sadness, anger, or fear that disasters could reoccur. Children of any age who experience traumatic events can develop posttraumatic stress disorder. Teenagers can act out through high-risk behaviors such as alcohol or drug use. They may become withdrawn or have difficulty getting along with siblings, parents, or others. In all cases, children need to know that their feelings are valid. VIEWPOINT