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The vision of the American Board of Pediatrics (ABP) is to inspire a lifetime pursuit of learning to improve child health. We recognize the importance of educating pediatricians on how children are vulnerable to the impact of climate change, despite this topic likely not being the first that comes to mind when thinking about child health. As outlined in the American Academy of Pediatrics' (AAP) Policy on Global Climate Change and Children's Health, the effects of climate change on temperature, air quality, food insecurity, and extreme weather events uniquely impact the physical and mental health of our children.1
To help pediatricians learn more about this critically important topic and the potential consequences on child health, the ABP partnered with several subject-matter experts to publish a new Maintenance of Certification (MOC) Part 2 article-based self-assessment: Impact of Climate Change on Pediatric Health Care. This activity contains 20 questions linked to recent, open-source articles.
Global Climate Change and Children's Health
Rising global temperatures are causing major physical, chemical, and ecological changes in the planet. There is wide consensus among scientific organizations and climatologists that these broad effects, known as “climate change,” are the result of contemporary human activity. Climate change poses threats to human health, safety, and security, and children are uniquely vulnerable to these threats. The effects of climate change on child health include: physical and psychological sequelae of weather disasters; increased heat stress; decreased air quality; altered disease patterns of some climate-sensitive infections; and food, water, and nutrient insecurity in vulnerable regions. The social foundations of children's mental and physical health are threatened by the specter of far-reaching effects of unchecked climate change, including community and global instability, mass migrations, and increased conflict. Given this knowledge, failure to take prompt, substantive action would be an act of injustice to all children. A paradigm shift in production and consumption of energy is both a necessity and an opportunity for major innovation, job creation, and significant, immediate associated health benefits. Pediatricians have a uniquely valuable role to play in the societal response to this global challenge.
Ahdoot S. AAP Policy Statement: Global climate change and children's health. Pediatrics. 2015;136(5):992-997. doi:10.1542/peds.2015-3232.
Policy Statement—Climatic Heat Stress and Exercising Children and Adolescents
Results of new research indicate that, contrary to previous thinking, youth do not have less effective thermoregulatory ability, insufficient cardiovascular capacity, or lower physical exertion tolerance compared with adults during exercise in the heat when adequate hydration is maintained. Accordingly, besides poor hydration status, the primary determinants of reduced performance and exertional heat-illness risk in youth during sports and other physical activities in a hot environment include undue physical exertion, insufficient recovery between repeated exercise bouts or closely scheduled same-day training sessions or rounds of sports competition, and inappropriately wearing clothing, uniforms, and protective equipment that play a role in excessive heat retention. Because these known contributing risk factors are modifiable, exertional heat illness is usually preventable. With appropriate preparation, modifications, and monitoring, most healthy children and adolescents can safely participate in outdoor sports and other physical activities through a wide range of challenging warm to hot climatic conditions.
AAP Policy Statement: Climatic heat stress and exercising children and adolescents. Pediatrics. 2011. doi:10.1542/peds.2011-1664.
Heat Waves and Cause-specific Mortality at All Ages
Background: Mortality has been shown to increase with extremely hot ambient temperatures. Details on the specific cause of mortality can be useful for improving preventive policies. Infants are often identified as a population that is vulnerable to extreme heat conditions; however, information on heat and infant mortality is scarce, with no studies reporting on cause-specific mortality.
Methods: The study includes all deaths in the Catalonia region of Spain during the warm seasons of 1983-2006 (503,389 deaths). We used the case-crossover design to evaluate the association between the occurrence of extremely hot days (days with maximum temperature above the 95th percentile) and mortality. Total mortality and infant mortality were stratified into 66 and 8 causes of death, respectively.
Results: Three consecutive hot days increased total daily mortality by 19%. We calculated that 1.6% of all deaths were attributable to heat. About 40% of attributable deaths did not occur during heat-wave periods. The causes of death that were increased included cardiovascular and respiratory diseases, mental and nervous system disorders, infectious and digestive system diseases, diabetes, and some external causes such as suicide. In infants, the effect of heat was observed on the same day and was detected only for conditions originating in the perinatal period (relative risk = 1.53 [95% confidence interval = 1.16-2.02]). Within the perinatal causes, cardiovascular, respiratory, digestive system, and hemorrhagic and hematologic disorders were the causes of death with stronger effects.
Conclusions: Heat contributes to an increase in mortality from several causes. In infants, the first week of life is the most critical window of vulnerability.
Basagaña X, Sartini C, et al. Heat waves and cause-specific mortality at all ages. Epidemiology. 2011;22(6):765–772.
Association of Air Pollution and Heat Exposure With Preterm Birth, Low Birth Weight, and Stillbirth in the US: A Systematic Review
Importance: Knowledge of whether serious adverse pregnancy outcomes are associated with increasingly widespread effects of climate change in the US would be crucial for the obstetrical medical community and for women and families across the country.
Objective: To investigate prenatal exposure to fine particulate matter (PM2.5), ozone, and heat, and the association of these factors with preterm birth, low birth weight, and stillbirth.
Evidence Review: This systematic review involved a comprehensive search for primary literature in Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, PubMed, ClinicalTrials.gov website, and MEDLINE. Qualifying primary research studies included human participants in US populations that were published in English between January 1, 2007, and April 30, 2019. Included articles analyzed the associations between air pollutants or heat and obstetrical outcomes. Comparative observational cohort studies and cross-sectional studies with comparators were included, without minimum sample size. Additional articles found through reference review were also considered. Articles analyzing other obstetrical outcomes, non-US populations, and reviews were excluded. Two reviewers independently determined study eligibility. The Arskey and O'Malley scoping review framework was used. Data extraction was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.
Findings: Of the 1851 articles identified, 68 met the inclusion criteria. Overall, 32 798 152 births were analyzed, with a mean (SD) of 565 485 (783 278) births per study. A total of 57 studies (48 of 58 [84%] on air pollutants; 9 of 10 [90%] on heat) showed a significant association of air pollutant and heat exposure with birth outcomes. Positive associations were found across all US geographic regions. Exposure to PM2.5 or ozone was associated with increased risk of preterm birth in 19 of 24 studies (79%) and low birth weight in 25 of 29 studies (86%). The subpopulations at highest risk were persons with asthma and minority groups, especially black mothers. Accurate comparisons of risk were limited by differences in study design, exposure measurement, population demographics, and seasonality.
Conclusions and Relevance: This review suggests that increasingly common environmental exposures exacerbated by climate change are significantly associated with serious adverse pregnancy outcomes across the US.
Bekkar B, Pacheco S, et al. Association of air pollution and heat exposure with preterm birth, low birth weight, and stillbirth in the US. JAMA Network Open. 2020;3(6):e208243. doi:10.1001/jamanetworkopen.2020.8243.
Extreme Water-related Weather Events and Waterborne Disease
Global climate change is expected to affect the frequency, intensity and duration of extreme water-related weather events such as excessive precipitation, floods, and drought. We conducted a systematic review to examine waterborne outbreaks following such events and explored their distribution between the different types of extreme water-related weather events. Four medical and meteorological databases (Medline, Embase, GeoRef, PubMed) and a global electronic reporting system (ProMED) were searched, from 1910 to 2010. Eighty-seven waterborne outbreaks involving extreme water-related weather events were identified and included, alongside 235 ProMED reports. Heavy rainfall and flooding were the most common events preceding outbreaks associated with extreme weather and were reported in 55·2% and 52·9% of accounts, respectively. The most common pathogens reported in these outbreaks were Vibrio spp. (21·6%) and Leptospira spp. (12·7%). Outbreaks following extreme water-related weather events were often the result of contamination of the drinking-water supply (53·7%). Differences in reporting of outbreaks were seen between the scientific literature and ProMED. Extreme water-related weather events represent a risk to public health in both developed and developing countries, but impact will be disproportionate and likely to compound existing health disparities.
Cann KF, Thomas DR, et al. Extreme water-related weather events and waterborne disease. Epidemiology and Infection. 2012;141(4):671-686. doi:10.1017/s0950268812001653.
Associations Between Historical Residential Redlining and Current Age-adjusted Rates of ED Visits Due to Asthma Across Eight Cities in California
Background: Asthma disproportionately affects communities of colour in the USA, but the underlying factors for this remain poorly understood. In this study, we assess the role of historical redlining as outlined in security maps created by the Home Owners' Loan Corporation (HOLC), the discriminatory practice of categorising neighbourhoods on the basis of perceived mortgage investment risk, on the burden of asthma in these neighbourhoods.
Methods: We did an ecological study of HOLC risk grades and asthma exacerbations in California using the security maps available for the following eight cities: Fresno, Los Angeles, Oakland, Sacramento, San Diego, San Jose, San Francisco, and Stockton. Each census tract was categorised into one of four risk levels (A, B, C, or D) on the basis of the location of population-weighted centroids on security maps, with the worst risk level (D) indicating historical redlining. We obtained census tract-level rates of emergency department visits due to asthma from CalEnviroScreen 3.0. We assessed the relationship between risk grade and log-transformed asthma visit rates between 2011 and 2013 using ordinary least squares regression. We included potential confounding variables from the 2010 Census and CalEnviroScreen 3.0: diesel exhaust particle emissions, PM2·5, and percent of the population living below 2 times the federal poverty level. We also built random intercept and slope models to assess city-level variation in the relationship between redlining and asthma.
Findings: In the 1431 census tracts assessed (64 [4·5%] grade A, 241 [16·8%] grade B, 719 [50·2%] grade C, and 407 [28·4%] grade D), the proportion of the population that was non-Hispanic black and Hispanic, the percentage of the population living in poverty, and diesel exhaust particle emissions all significantly increased as security map risk grade worsened (p<0·0001). The median age-adjusted rates of emergency department visits due to asthma were 2·4 times higher in census tracts that were previously redlined (median 63·5 [IQR 34·3] visits per 10 000 residents per year [2011–13]) than in tracts at the lowest risk level (26·5 [18·4]). In adjusted models, redlined census tracts were associated with a relative risk of 1·39 (95% CI 1·21–1·57) in rates of emergency department visits due to asthma compared with that of lowest-risk census tracts.
Interpretation: Historically redlined census tracts have significantly higher rates of emergency department visits due to asthma, suggesting that this discriminatory practice might be contributing to racial and ethnic asthma health disparities.
Nardone A, Casey JA, et al. Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study. The Lancet Planetary Health. 2020;4(1):e2
Multiple Threats to Child Health from Fossil Fuel Combustion: Impacts of Air Pollution and Climate Change
Background: Approaches to estimating and addressing the risk to children from fossil fuel combustion have been fragmented, tending to focus either on the toxic air emissions or on climate change. Yet developing children, and especially poor children, now bear a disproportionate burden of disease from both environmental pollution and climate change due to fossil fuel combustion.
Objective: This commentary summarizes the robust scientific evidence regarding the multiple current and projected health impacts of fossil fuel combustion on the young to make the case for a holistic, child-centered energy and climate policy that addresses the full array of physical and psychosocial stressors resulting from fossil fuel pollution.
Discussion: The data summarized here show that by sharply reducing our dependence on fossil fuels we would achieve highly significant health and economic benefits for our children and their future. These benefits would occur immediately and also play out over the life course and potentially across generations.
Conclusion: Going beyond the powerful scientific and economic arguments for urgent action to reduce the burning of fossil fuels is the strong moral imperative to protect our most vulnerable populations.
Perera FP. Multiple threats to child health from fossil fuel combustion: impacts of air pollution and climate change. Environmental Health Perspectives. 2017;125(2):141-148. doi:10.1289/ehp299.
Providing Psychosocial Support to Children and Families in the Aftermath of Disasters and Crises
Disasters have the potential to cause short- and long-term effects on the psychological functioning, emotional adjustment, health, and developmental trajectory of children. This clinical report provides practical suggestions on how to identify common adjustment difficulties in children in the aftermath of a disaster and to promote effective coping strategies to mitigate the impact of the disaster as well as any associated bereavement and secondary stressors. This information can serve as a guide to pediatricians as they offer anticipatory guidance to families or consultation to schools, child care centers, and other child congregate care sites. Knowledge of risk factors for adjustment difficulties can serve as the basis for mental health triage. The importance of basic supportive services, psychological first aid, and professional self-care are discussed. Stress is intrinsic to many major life events that children and families face, including the experience of significant illness and its treatment. The information provided in this clinical report may, therefore, be relevant for a broad range of patient encounters, even outside the context of a disaster. Most pediatricians enter the profession because of a heartfelt desire to help children and families most in need. If adequately prepared and supported, pediatricians who are able to draw on their skills to assist children, families, and communities to recover after a disaster will find the work to be particularly rewarding.
Schonfeld DJ, Demaria T. Providing psychosocial support to children and families in the aftermath of disasters and crises. Pediatrics. 2015;136(4):e1120-e1130. doi:10.1542/peds.2015-2861.
Additional Reading: Ngo, NT. Climate change and health equity. AMA J Ethics. 2021;23(2):E202-203
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