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AAP policy provides guidance on addressing key environmental drivers of health for children across globe

January 21, 2025

A 4-year-old patient and her family arrive at your office for her first medical exam since they came to the United States as refugees. What are key environmental exposures of concern to address during the initial visits with this family?

Pediatricians care for growing numbers of children and adolescents who have relocated to the U.S. from low- and middle-income countries (LMICs). Pediatricians and pediatric trainees from developed countries also provide care to children and adolescents in LMICs.

It is important to be aware that exposures to toxic environmental hazards such as heavy metals (lead, mercury, arsenic), pesticides and air pollution are much more prevalent and severe in many LMICs than in developed countries and that in LMICs environmental factors can account for a very high proportion of childhood disease.

Migrant and refugee children may confront additional environmental hazards after their arrival in high-income countries. For example, they may be exposed to lead-based paint and mold in substandard housing. Parents may bring home hazardous materials from work (e.g., pesticides from agricultural work), and family members may use toxic products imported from the home country (e.g., spices, cosmetics and some Ayurvedic medicines). 

An updated AAP policy statement from the Council on Environmental Health and Climate Change offers evidence-based guidance for pediatric clinicians, health care organizations and governments on addressing environmental drivers of child health in countries around the world and among children who emigrate from LMICs.

The policy statement Environmental Issues in Global Pediatric Health is available at https://doi.org/10.1542/peds.2024-070075, and an accompanying technical report is available at https://doi.org/10.1542/peds.2024-070076. Both will be published in the February issue of Pediatrics.

Global burden of environmental disease

Toxic environmental hazards are major causes of disease and death among children in all countries, especially LMICs, but the great magnitude of the environment’s impact on children’s health generally is not appreciated.

Globally, environmental pollution is responsible for an estimated 9 million deaths each year — three times as many deaths as are caused by AIDS, tuberculosis and malaria combined.

Nearly 92% of all pollution-related deaths occur in LMICs, where environmental hazards account for twice as great a proportion of deaths in children younger than 5 years than in high-income countries. Environmental threats to children’s health in LMICs are worsening: Two-thirds of global chemical and pesticide manufacturing is located there, and ambient air pollution as well as contamination by pesticides and other toxic chemicals are worsening.

In addition, the impacts of global climate change fall most severely on children in LMICs and will magnify the effects of pollution on children’s health.

Taking an environmental history

Diseases of environmental origin in children seldom have unique signatures on physical examination. Therefore, an environmental exposure history (supplemented as appropriate by laboratory testing) is the principal tool that pediatricians can use to diagnose environmentally related illness and guide treatment.

The environmental history can include questions about hazardous exposures in the home, neighborhood and other places where the child spends time. These questions can be tailored to reflect the most prominent environmental exposures in a particular country and community.

Table 2 in the policy statement outlines sources of environmental exposures among immigrant, refugee and internationally adopted children and adolescents in the United States and lists key clinical resources pediatricians can use to inform care of these patients. 

Key actions and recommendations

The policy statement includes the following recommendations for pediatric clinicians.

  • Understand the importance of environmental hazards, including climate change, and their impacts on children’s health, especially on children in LMICs and children who have come to high-income countries from LMICs.
  • Pediatricians from high-income countries who plan to work in LMICs are advised to become familiar with the environmental hazards in the region and country where they will be serving.
  • Add questions about environmental health hazards to standardized questionnaires for new patients. Ask about possible exposures to toxic materials brought into the home by parents on clothing, shoes or vehicles. 
  • Ask environmental health questions during appropriate medical encounters with existing patients who have environmentally related disease (e.g., asthma).
  • Refer patients with suspected environmental exposures to public health or environmental health agencies or community organizations for further help with exposure assessment and management. Pediatric Environmental Health Specialty Units are available to guide clinicians on the identification and management of environmentally related illness (see resources).

Additional recommendations for health organizations and governments include:

  • increasing environmental health and climate change content in education and training and
  • putting the protection of children’s health at the center of all environmental legislation and rule-making and considering potential impacts on children’s health in all environmental decision-making.

Drs. Zajac and Landrigan are lead authors of the policy statement and technical report. Dr. Zajac is chair of the AAP Council on Environmental Health and Climate Change (COEHCC). Dr. Landrigan is a former member of the COEHCC Executive Committee. 

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