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Introduction Mass casualty incidents (MCIs) strain health systems across clinical, logistical and operational domains. When children are involved, the complexity increases due to their unique physiological and psychosocial needs. Despite this, it remains unclear how the health system’s operational readiness for MCIs can be evaluated. The objective of this study was to systematically map and synthesise existing literature on health system operational readiness for MCIs involving children with a focus on identifying critical gaps, strengths and recommendations related to paediatric care.Methods A systematic search of databases PubMed, Embase, CINAHL, Scopus, Global Health, ProQuest Dissertations, PsycInfo and the Cochrane CENTRAL Register was conducted adhering to PRISMA-ScR guidelines. Studies were screened at title and abstract level and full text review by two independent reviewers. Studies were included that assessed the operational readiness of the health system for MCIs. Data extraction captured study characteristics, themes, limitations and paediatric-specific findings. Thematic analysis was applied to synthesise data and identify patterns.Results 60,229 articles were screened, of which 182 were also assessed at full text for eligibility. Analysis of these 182 studies revealed six themes affecting operational readiness: (1) Planning and logistics; (2) Governance; (3) Training deficiencies; (4) Resource and infrastructure limitations; (5) Data, monitoring and evaluation gaps; and (6) Human resources and leadership. Across all themes, paediatric-specific preparedness was consistently underrepresented. Only a minority of institutions had disaster plans that explicitly addressed children. Surge capacity, triage protocols and tracking systems were often inadequate, especially in rural settings. While paediatric hospitals showed higher levels of awareness, integration of children’s needs were lacking across the broader system.Conclusion Despite growing recognition of the challenges posed by paediatric MCIs, operational readiness remains inconsistent and often insufficient. Investment in paediatric-focused planning, workforce training and infrastructure is urgently needed. Embedding child-specific considerations into emergency preparedness frameworks is essential for effective response. *presenting author