Five years after the World Health Organization declared COVID-19 a global pandemic, infectious disease experts continue to draw on its lessons for future disasters.

Yvonne Maldonado, MD, the Taube Professor in Global Health and Infectious Diseases, led Stanford Medicine’s COVID-19 response. More recently, Maldonado, a professor of pediatrics and of epidemiology and population health, co-edited a special issue of Pediatric Clinics of North America on pandemic readiness planning, which is focused on the specific needs of children during such emergencies. The issue contains 13 invited reviews from more than three dozen experts throughout North America on how to plan for kids’ needs during this type of medical disaster.

“We learned during COVID that everything in a disaster response tends to be one-size-fits-all,” Maldonado said. Out of necessity, pandemic preparedness at every level – from plans made in a single hospital or county to those of state and federal governments – relies on pre-set protocols that enable fast, large-scale responses. But those protocols may overlook children.

“A quarter of the U.S. population is under age 18; they have distinct needs,” Maldonado said. “Children are vulnerable because they’re dependent on adults. We want planners to make sure they think about children and families when they build emergency response policies.”

Kids are unique

One of the silver linings during the COVID-19 pandemic was that the virus didn’t affect children as severely as it did adults. Still, even though they were much less prone to need hospitalization with COVID-19, kids were harmed by a variety of downstream effects of the pandemic: educational losses, mental health challenges, and medical problems such as missing routine immunizations or delays in care for chronic diseases such as diabetes and asthma.

The COVID-19 experience of young people underscores a variety of issues that experts must consider while planning for future pandemics, Maldonado said.

On the medical front, it’s rare for infectious diseases to spare children as COVID-19 did. A more common scenario is for young children, the elderly, and pregnant women to be the most severely affected by circulating germs. For instance, during the “tripledemic” winter of 2022 – when influenza, COVID-19, and respiratory syncytial virus all surged simultaneously – RSV hit small children especially hard. Many became sick enough to need hospitalization.

Their smaller size and inexperienced immune systems contribute to kids’ vulnerability.

“The epidemiology of infectious diseases in kids is very different: Young children may not have been exposed to a lot of organisms,” Maldonado said. “They may have more than one infection at once. They are smaller and can become sick or deteriorate much more rapidly than adults. They may not be able to explain their physical symptoms, medical history or risk factors, and in some disaster scenarios there may not be an adult around to tell the story for them.”

Preparing for surges of sick kids requires both trained personnel and physical facilities.

“Whoever is at the front door of the health care system may not always be a pediatrician, but they need to know how to deal with children,” Maldonado said, noting that pediatric services in community and rural hospitals have been shrinking for decades.

Even routine care, such as administering medications or fluids, is more complex for kids. Children may need smaller medical equipment. Drugs that have one dose for adults typically have pediatric dosages that change with the patient’s weight and age, and kids need multiple formulations, such as liquid for those who can’t swallow capsules. “The supply of medications for children is not quite as flexible,” Maldonado said. “We need to build in some backup plans.”

Beyond hospital walls

As COVID-19 forcefully demonstrated, a pandemic that causes few severe cases in children can still have profound effects on their lives.

“One of the most shocking things around kids was that we just fell flat on our faces when it came to school preparedness,” Maldonado said. California public school children were in remote learning for a year during COVID-19, for example, which caused mental health problems and learning losses, as well as widening achievement gaps between well-resourced and disadvantaged kids.

In the future, it would be better to have shorter or no school closures, she said. Keeping schools open will require local government and public health officials to quickly supply them with materials and know-how to follow evidence-based infection control practices. “That’s a big issue we need to keep dealing with now, offering the right things to offset the challenges of bringing vulnerable populations together in a safe way.”

Schools may need help addressing a wide variety of problems, from building low-cost air filters for classrooms that lack modern ventilation systems to implementing policies that make it easier for students to stay home from school when they are ill.

“One example is that free COVID testing was so useful, something we really needed, yet some school districts couldn’t afford it,” Maldonado said. “For the future, how do you integrate them with the public health infrastructure to make sure that happens?”

It’s also important for those engaged in preparedness planning to realize that a pandemic or other disaster won’t affect all children equally.

“People who don’t have resources are the hardest hit: They may not have caregiving for their kids, and they may have to work several jobs, with greater risk of disease exposure,” Maldonado said. “They may live in smaller homes where someone who is sick is not able to isolate.”

Finally, pandemic response plans need to consider families as units, Maldonado said: “If children are affected, parents are going to be affected.” Even if a specific disease doesn’t tend to cause serious illness in adults, when large numbers of children get sick, it affects the entire workforce.

“It can really amplify the impact on society when kids are ill,” Maldonado said. “We need to think these challenges through in advance to get ready.”