New Guidance on Managing Environmental Threats to Children

A large proportion of childhood diseases worldwide results from environmental causes and climate change magnifies the effects on children, the American Academy of Pediatrics (AAP) noted in its policy statement and technical report released in the February issue of Pediatrics.

Pediatricians and pediatric trainees in North America are increasingly caring for young people in or from low- and middle-income countries (LMICs), where toxic environmental exposures are much more prevalent. The recommendations also target pediatricians who choose to practice in those environments.

Question Patients About Toxicities in Home

New recommendations are meant to raise awareness of the environmental hazards to children and to explain how the threats should spur new questions in the patient’s visit and, in some cases, alter care. Among examples of questions to ask new patients and their families, the AAP said, is what toxic materials may be brought into the home by parents on clothing, shoes, or vehicles.

“The environment has a far greater impact on children’s health than what is generally known or appreciated,” said Lauren Zajac, MD, MPH, a lead author of the AAP policy statement. “While some children may be treated for a condition readily associated with the environment, such as asthma, others may not show any signs of exposure to a hazardous environment. This is why it is important for pediatricians to ask families about their environmental history” and include those factors in diagnosis when appropriate.

In lower-income countries, exposures may include lead, mercury, arsenic, pesticides, and air pollution. The proportion of deaths from environmental hazards in LMICs for children younger than 5 years old is significantly higher than for their counterparts in high-income countries — 26% vs 17%, according to the technical report. Pollution is responsible for an estimated nine million deaths each year in people of all ages, three times as many as the number of deaths from AIDS, tuberculosis, and malaria combined, the authors wrote.

“Nearly 92% of all pollution-related deaths occur in low- and middle-income countries,” they noted.

Targeted Questions Are Important

Diseases of environmental origin in children seldom have unique physical characteristics, so an exposure history, with laboratory testing, if appropriate, is the primary diagnostic tool. A targeted environmental history is also important and may include questions about hazardous exposures in the home, neighborhood, and other settings the child frequents. 

Positive responses on the screening for history of exposures can trigger further discussion and/or referral to a Pediatric Environmental Health Specialty Unit (PEHSU), the report stated. The national network of PEHSUs in the United States provides consultation, guidance, and education for healthcare providers, public health organizations, and communities on pediatric environmental health issues.

Also important is assessing the mental health of children who have emigrated from LMICs, because they may have been exposed to poverty, famine, complex sociopolitical circumstances, war, and other forms of violence and may require referral for appropriate support, the report authors wrote.

Additional tools are available to guide pediatricians in assessing environmental exposures including the World Health Organization pediatric environmental health history tool called the “Green Page.” The Centers for Disease Control and Prevention also offers guidance on immigrant and refugee health.

“We need to develop environmental policies that put children’s health first,” Zajac said in a statement. “There are many steps we can take to reduce children’s exposure to toxic environments — whether in the doctor’s office, at a city council meeting, or when developing global policy.”

The authors reported no relevant financial relationships.