The Built Environment and Pediatric Health

Community design is a social determinant of health and includes elements such as buildings, parks, and roads (all part of what is called “the built environment”), which influence children’s physical and mental health, as well as health equity. Assessing social determinants of health in clinical practice is now recognized as essential to providing comprehensive patient- and family-centered health care. Community design solutions can address root causes of social and environmental factors that contribute to health outcomes and disparities in children.

The built environment further contributes to mitigating and adapting to climate change, an urgent health threat that disproportionately affects children.¹  Transportation, commercial and residential buildings, and land use all contribute substantially to US greenhouse gas emissions.²  Adaptive design features can promote resilience to climate change-related extreme weather events such as storms, heat waves, flooding, and wildfires. Climate-smart community design practices (including strategies that are described below to reduce sprawl and increase walking, biking, and public transportation, and to mitigate heat exposure, manage stormwater, and withstand natural disasters) can confer immediate child health benefits, reduce greenhouse gas emissions, and bolster climate change resilience.

Understanding the links between the built environment and children’s health can help pediatricians gain a better appreciation of the social and environmental context of their patients’ health concerns. Equipped with this knowledge, pediatricians can be more effective advocates for community design solutions that promote children’s health and health equity.

This policy statement will outline health-promoting community design solutions (Table 1), and its accompanying technical report³  details the child health harms (including, for example, risks of injury, respiratory illness, infectious diseases, mood disorders, obesity, and poor birth outcomes) influenced by community design elements.

Because the preponderance of research in this area addresses urban settings and cities and metropolitan areas are where most children live, these documents focus on urban design, although unique aspects of the rural built environment are identified that affect child health and deserve further study. Indoor environments, including homes and schools, will be addressed in 2 separate reports and will not be covered here. Of note, lead poisoning will be addressed in these separate reports and is addressed in detail in the American Academy of Pediatrics (AAP) policy statement⁴  “Prevention of Childhood Lead Toxicity,” so it is not addressed at length here.

Discriminatory systems underlie disparities in child health outcomes associated with the built environment and community design.^5–8  For example, racist housing and lending policies, known as “redlining” (from New Deal-era neighborhood maps outlining areas considered high risk for investment—largely Black neighborhoods, as well as other neighborhoods with historically marginalized populations—in red), resulted in systematically disinvested, disadvantaged, segregated neighborhoods that continue to bear disproportionate exposures to environmental health hazards including air pollution, water pollution, and extreme heat.⁹  Racial discrimination in mortgage lending and racial disparities in homeownership persist today.^10,11 

Systemic discrimination has resulted in unequal access to health-promoting community design features and infrastructure. Children in lower-income households and from marginalized racial groups are less likely to have access to safe, well-maintained playgrounds, parks, and trails. Historically redlined neighborhoods are associated with increased risk of adverse birth outcomes.^12,13  Between 2007 and 2014, Black children were about twice as likely to have elevated blood lead levels than white children¹⁴ ; systematic disinvestment in Black neighborhoods is associated with an increase in neighborhood-level lead hazards related to age and maintenance of infrastructure, including housing and water service lines containing lead.¹⁵ 

Neighborhood gentrification, another important equity issue, describes demographic and economic neighborhood changes that may occur as a result of the relocation of wealthier residents to lower income neighborhoods.¹⁶  Although mixed-income residential development can provide benefits for safety, community resources, and shared amenities, gentrification of neighborhoods can result in displacement of low-income families and other challenges that can affect child health.¹⁷  The negative effects of gentrification may be decreased by mixed-income requirements for housing developments, cooperative land use agreements, and community inclusion in planning decisions.¹⁸ 

Safety and accessibility are important equity concerns for children with disabilities and special health care needs. Children with disabilities are at disproportionate risk of traffic-related injuries,¹⁹  individuals with disabilities experience barriers in access to public transportation and safe pedestrian routes,²⁰  and outdoor play spaces may not be accessible for children with a range of physical abilities.²¹  Complete streets²²  (an approach to urban design that promotes safety and mobility for all²³ ), well-maintained roads and sidewalks, and accessible transportation and recreational infrastructure are built environment elements that improve the safety and accessibility of essential amenities for all children. Increasing neighborhood walkability (measured by residential density, street connectivity, and land use mix) improves public transit accessibility, because walkability is associated with increased public transit use in general, especially for individuals with disabilities.²⁴ 

Public libraries are uniquely positioned as community assets that can contribute to health equity: They are used by diverse populations, offering the opportunity to foster social connections across intergenerational, intercultural, and interracial groups that may typically be segregated from one another. Libraries can also offer health-promoting programming and resources, such as adult literacy classes, health education, and employment services.²⁵ 

The coronavirus disease 2019 pandemic accentuated inequities related to the built environment—contributing to grocery store closures, affordable housing shortages, and economic constraints limiting community development. At the same time, the pandemic underscored the importance of built environment features that support outdoor recreation, social cohesion, safe housing, and healthy air quality. Investment in healthy, equitable community design is an important aspect of promoting child health in our pandemic recovery.

Children are at higher risk than most adults of being injured by a motor vehicle while walking, and children who live in low-income households, as well as Indigenous, Black, and Hispanic children, are much more at risk than white children to be killed while walking or bicycling.²⁶  Getting struck by a vehicle is more likely at night, in cities, and when either the driver or pedestrian is intoxicated.²⁷  Traffic-calming measures directed at providing safe passage for pedestrians across streets and slowing cars down when they are in areas with pedestrians can help safeguard child pedestrians. These measures can include physical interventions such as speed humps and raised intersections, as well as reduction in the width or number of lanes.²⁸  Children with disabilities are at higher risk of being struck by a motor vehicle.²⁹  Children with and without disabilities report similar challenges with traffic safety, including “too few or missing sidewalks,” being “unsure when it’s safe to cross,” and “unaware drivers.”¹⁹  The presence of sidewalks and crosswalks can help address these concerns and are protective of all children.

Designing urban areas for multimodal transit can also facilitate safer transportation for everyone. Complete street design may include protected bike lanes, dedicated bus lanes, and well-marked crosswalks, and are most needed in low-income communities and those with historically marginalized populations, where they are least available today.²⁶  The design and maintenance of complete streets infrastructure should specifically consider accessibility for people with disabilities, including those with impaired mobility and visual and auditory impairment.²² 

Active transportation refers to modes of transportation that involve nonmotorized, human energy-powered motion. Improving active transportation access and safety can promote children bicycling, walking, and using other means of transport that involve exercise. Active transportation may promote healthier body weights³⁰  and mental health.³¹ 

Traffic-related air pollution has been associated with the incidence and severity of childhood asthma,^32,33  preterm birth,^34,35  hypertension,^36,37  and neurocognitive disorders.^38–40  Fossil fuel-based vehicular traffic emissions in cities can be a primary source of ozone and particulate matter air pollution, both of which have far-reaching health effects on children, especially low-income Black and Hispanic children, who are more likely to live in areas with high emissions.⁴¹  Reducing traffic-associated air pollution improves child health and health equity.⁴²  This can be accomplished by reducing use of fossil fuels in transportation systems. Increasing active transit and public transportation can decrease traffic congestion, a major source of pollution.⁴³  Strategies to reduce traffic-related pollution also include limiting urban sprawl (the uncontrolled geographic expansion of cities and towns into surrounding undeveloped land, creating suburbs and less densely developed and distant exurbs), and zoning rules that allow amenities and employment centers to be located in close proximity to residential areas. Transportation-related greenhouse gas emissions are a driver of climate change,²  and measures to reduce vehicular pollution significantly contribute to climate change mitigation.^44–46 

Noise from vehicles and planes may affect child learning, neurodevelopment, and possibly health more broadly. Urban traffic and airplane noise may impair learning and reading comprehension,⁴⁷  attention,^48,49  and mental health.⁵⁰ 

Progress has been made in reducing aircraft noise,⁵¹  and further reductions in exposure are expected with improved technology.⁵²  Automobile and road construction noise has been abated in many cities through ordinances that limit the use of horns, revving of engines, and other vehicular noise sources. Many cities and states have put forward transportation noise mitigation plans that include construction of barriers, planting of vegetation, restrictions on hours (eg, for construction), and traffic-calming measures.

The average commuting time to work has steadily increased over the past 15 years.⁵³  Longer caregiver commute times are associated with less contact time between caregivers and their children, less access to healthy foods, and worse developmental outcomes.^54,55  The rise in travel times reflects at least in part growing costs of living in cities and peri-urban areas, forcing more people to live further from work and where there may be less access to public transportation. Additionally, for many individuals, public transit is slow and inefficient compared with commuting by car.⁵⁶  Some cities have considered congestion pricing on cars entering the city.⁵⁷  These policies are intended to reduce urban traffic. The funds raised from congestion pricing can be used to improve the efficiency of public transit⁵⁸  and subsidize costs for low-income households, either by direct payments, preloaded transponders for tolls, or investment in multimodal transit.

Zoning rules described above as solutions that reduce traffic-related air pollution also help to address the issue of long commute times.

An estimated 1 in 25 children miss a health care appointment each year because they lack access to transportation.⁵⁹  These children tend to be from low-income households or live in more rural areas.⁵⁹  Addressing these challenges requires a multifaceted response, including changes to transportation infrastructure. Improved public transportation access, greater investment in Medicaid-supported transportation services, augmentation of paratransit that can coordinate with other transportation systems, and improved coordination and use of existing nonprivate transportation vehicles all may increase health care access.⁵⁹  Access to high-speed Internet and telehealth technology are addressed elsewhere, in a dedicated AAP policy statement.⁶⁰ 

Green spaces, including parks, gardens, and urban tree canopy, are linked with multiple benefits for children and their families, including physical activity (via organized and unorganized recreation), lower BMI and obesity,^61–64  and mental health and social development. The term “biophilic design” is used to describe a design approach that includes natural elements and promotes people’s contact with nature. Biophilic design can include green spaces such as parks, but can also include urban trees, organic elements in streetscapes, and ecological restoration.⁶⁵ 

Children associate open natural spaces with calmness and relaxation.^66,67  Exposure to green spaces is associated with decreases in blood pressure and cortisol, physiologic markers of stress.⁶⁸  Access to neighborhood green spaces including parks and playgrounds may reduce hyperactivity and inattention, internal/externalizing behavior, and depression.^69,70  Outdoor exposure has been linked to decreased myopia.⁷¹  Moreover, exposure to green spaces is linked with improved self-regulation, cognitive outcomes, and school performance.^72,73  Green spaces are areas where children may interact socially, with caregivers at a distance, thus promoting autonomy and self-efficacy. They may also serve as places for caregivers to congregate and develop supportive relationships and share knowledge.^74,75 

The maintenance and perceived safety of green spaces are important to achieving health benefits. Community infrastructure, such as painted and marked crosswalks, lighting, and landscaping, can influence the perception of safety of these spaces. Areas that are not perceived as safe are less likely to be used by families with children. Poorly maintained, unclean, or unkept outdoor spaces are associated with impaired child functioning, depression, and adolescent risk-taking behavior.^76–78  High-quality community infrastructure is associated with a reduction in adolescent homicides, perhaps because of an interplay of factors including greater physical activity and social interaction.⁷⁹ 

Tree canopy and green spaces also help to mitigate urban heat islands (cities may be warmer than surrounding areas, because they have darker surfaces that absorb heat), thereby reducing children’s exposure to extreme heat and ozone air pollution (ozone formation is temperature dependent).^80,81  Trees and other vegetation planted in cities should be chosen on the basis of their water demands, as well as whether they produce allergenic pollen. Lists of drought-tolerant and low-pollen plants are available from several botanical gardens and universities.^82,83 

Many families lack ready access to affordable healthy food, including fruits, vegetables, and minimally processed foods.^84,85  Lower-income families, rural populations, and communities of color tend to have fewer grocery stores and more fast food and corner stores, leading to limited access to healthy foods and higher risk of obesity.^86–88  In addition, access to healthy food supports healthy neurodevelopment, cognition, and learning.^89,90  Government incentives for grocery store placement in areas of need, community farmers markets that accept Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women, Infants, and Children benefits, and programs that add fresh produce to corner store offerings are all potential strategies that may improve access to healthy food and promote the health of vulnerable families.^91,92  Urban agricultural initiatives are a growing, innovative strategy to increase access to healthy food while also providing job training.⁹³  Ensuring robust public transit access to grocery stores and other food outlets can also improve access to healthy food for all families.

“Green landscaping” minimizes the use of chemical herbicides, to which children can be exposed in places where they walk and play. Pesticide-free fertilizers and mulch and planting green spaces with a diversity of species (as opposed to a monoculture of grasses) are examples of green landscaping that can be employed in parks; athletic fields; the grounds of schools, child care centers, and community centers; residential yards; and along roadways.

Integrated pest management describes the use of a combination of chemical and nonchemical methods to minimize the human toxicity of pest control while achieving effective control of pests that can be health hazards. Nonchemical methods include physical and mechanical barriers, and pest-restricting agricultural planting strategies. Chemical treatments are chosen and timed to maximize efficacy while minimizing hazards to people and the environment. Studies have shown that integrated pest management is superior in efficacy to conventional pest control methods and reduces exposure to chemical pesticides.⁹⁴ 

Conventional zoning practices divide a community into zones where specific land uses are permitted or prohibited. Although this can have benefits in separating residential neighborhoods from sources of industrial pollution, it has contributed to housing shortages, racial segregation, and urban sprawl, which can affect commute times, land use, and air quality. Zoning approaches such as “form-based codes”⁹⁵  emphasize the form of buildings and their relationship to each other and the public, rather than land use. This approach supports mixed-use development, a range of housing options (including a variety of types and price points), compact development, and ecological restoration,⁹⁶  and can decrease segregation and increase housing availability, active transportation, social cohesion, air quality, climate change mitigation, and equity.⁹⁷ 

Climate change has made heat waves, floods, wildfires, and hurricanes more likely, and these disasters put at risk essential services and utilities that are vital to child health.

Power outages have become more frequent in the United States, with extreme weather being a primary cause.⁹⁸  Loss of electricity has been shown to increase health care needs and poor health outcomes, especially for low-income households and people with chronic medical problems.^99,100  The use of backup power generators can be a cause of carbon monoxide poisoning.¹⁰¹ 

Many major electric utilities in the United States have not taken the full scope of climate risk into consideration.¹⁰²  The US Department of Energy published a resiliency planning guide for the electricity sector.¹⁰³  Resiliency measures include “hardening” existing infrastructure to risks (eg, fire or flood), improving energy efficiency in homes and buildings that can prevent blackouts from summer air conditioning demand, smart grids that can more effectively dispatch electricity, and power system redundancy. Many communities in the United States have used local renewable energy sources as a means to decentralize power supplies.

Focus on low-wealth communities for renewable energy may benefit resilience. In 2016, only 15% of solar photovoltaic panels were installed for households with <200% of the federal poverty line income. Although this percentage has been increasing over time, low-wealth communities may benefit most from renewable energy because they tend to have the largest share of their income going to utilities.^104,105  Community-based solar, which serves individuals who cannot install rooftop solar, is incentivized in 22 states¹⁰⁶  and may make solar more accessible to low-wealth households.

Heavier downpours, along with more intense hurricanes and sea level rise in coastal areas, increase flood risks. Floods can contribute to power outages, unsafe drinking water, mold infestation, waterborne disease, injuries and drownings, destruction of buildings, toxic exposures, and population displacement.¹⁰⁷ 

The built environment influences flood risks. In urban areas, impervious surfaces, such as most roads and buildings, contributes to runoff that can pollute local water bodies. Suburban developments are often built on watersheds and reduce the ability of the watershed to filter and absorb water. Rural areas, especially those near or on river flood plains, may be vulnerable to flooding from engineered river systems that were designed on the basis of historical, less intense rainfall patterns. Many rivers in the Midwest, for example, have been engineered to protect farms and homes that are sited in the river’s flood plain. Heavier rainfall events in recent decades and greater runoff resulting from sprawl have compromised flood barriers and resulted in increased flooding.

To reduce flood risk, impervious surfaces can be replaced with more porous ones or vegetation. Some municipalities employ tax incentives or penalties to encourage property owners to decrease impervious surfaces on their land. Rainwater that falls on roofs can be harvested, and, where appropriate, vegetation can also be planted on roofs to absorb water. In cities with combined sewer systems, in which stormwater and sewage share a common pipe, mitigating runoff is particularly important to reduce risk of sewage backup into buildings or discharge of untreated sewage into water bodies.

There is increasing concern about the effects of extreme heat on child health. Heat can affect birth outcomes,¹⁰⁸  learning and school performance,¹⁰⁹  and mental health.¹¹⁰  Redlined and systematically disinvested neighborhoods, which are more likely to include predominantly Black and Hispanic residents, have been shown to experience disproportionate exposure to heat.¹¹¹  In addition to green spaces, trees, and vegetation, the use of building materials that are less heat-absorptive can also help to mitigate urban heat islands. Areas of respite such as cooling centers can also help to protect children from extreme heat waves.

Health care institutions are often major employers, purchasers, and drivers of economic activity—locally, regionally, and nationally. An “anchor institution” is a nonprofit, mission-driven organization that is rooted in place¹¹²  and typically has significant economic power and impact. Health care institutions and universities (often called “eds and meds”) are common examples of anchor institutions and are part of a growing trend of leveraging their economic power to achieve targeted community benefits.

These community benefits can include neighborhood revitalization, housing investments, workforce development, and more. For example, a group of health care, university, and municipal anchor institutions in Cleveland, Ohio, convened in a collaborative effort by the Cleveland Foundation, jointly established worker-owned cooperative businesses called the Evergreen Cooperatives.¹¹³  These businesses provide essential services to participating anchor institutions, employ and train worker–owners from local neighborhoods, and aim to advance sustainable and inclusive community development and wealth building in historically redlined and disinvested Cleveland neighborhoods.¹¹³ 

A growing number of health care institutions, including children’s hospitals, are leaning into their roles as anchor institutions in their communities.¹¹⁴  Their strategies include increasing local purchasing of goods and services, creating workforce opportunities for local residents, and working with local partners to catalyze community development projects including mixed-income housing, parks, transportation infrastructure, and attracting investment from other nonprofit and private sector employers.¹¹⁵  Pediatricians can play a role as advocates and collaborators in health care anchor institutions’ efforts to leverage their economic investments to improve child health and advance health equity.¹¹⁶ 

Persistent place-based health inequities are a product of community design practices that perpetuate disparities in access to clean air, safe housing, and essential amenities and services. Community design solutions can ameliorate several conditions highlighted as key priorities for child health by the AAP and the US Department of Health and Human Services Healthy People 2030 objectives, such as obesity, asthma, and mental health disorders, and child health equity.^117,118  The built environment plays a critical role in climate change mitigation and resilience, which are urgent child health imperatives. Pediatricians’ clinical practice can be better informed by understanding the effects of the community design and the built environment on their patients’ health, and pediatricians can help to advocate for communities designed to protect and enhance the health of all children.

1. Counsel families about active transportation. Where available, encourage participation in local programs¹¹⁹  that promote walking or cycling safely to school.

2. Understand how elements of the built environment and community design influence families’ ability to adhere to health recommendations (eg, healthy eating and exercise), and, when possible, counsel patients and families on specific health-promoting practices that are achievable within the context of local community amenities.

3. Advocate for health-promoting community design practices that incorporate accessibility for individuals with disabilities and special health care needs, developed in partnership with community members (including children and youth) and pediatric health professionals, such as: Parks and tree canopy, sidewalks, bike paths, public transportation, mixed-use and mixed-income development, limiting urban sprawl, equitable development practices, and climate- and weather-resilient infrastructure.

4. Advocate for shared-use agreements between schools and other organizations with recreational facilities, particularly in areas where safe recreational spaces are sparse, limiting opportunities for physical activity. School playgrounds and athletic fields are key resources that can provide access to safe spaces for outdoor and indoor recreation.

5. Develop health care “anchor institution” strategies that aim to leverage health care institutions’ economic power to increase sustainable and inclusive community development and wealth building in local communities, including local purchasing, workforce development, community partnerships, neighborhood investments, and policy advocacy.

1. Design, implement, and maintain complete streets that include traffic calming measures, support safe walking and bicycling, accessibility and safety for individuals with disabilities, and equitable access to efficient public transit (including prioritization of access to schools, public libraries, health care, and other essential amenities for children and families).

2. Employ zoning practices that permit mixed development (eg, residential, office, retail, recreational), prioritize affordable housing, support compact development and minimize urban sprawl, and incentivize ecological conservation.

3. Establish equitable access to high-quality parks, playgrounds, and green spaces, and increase natural elements in cities and streetscapes.

4. Promote equitable access to healthy, affordable food by incentivizing grocery stores, farmers markets, and community gardens in underresourced, low-income communities.

5. Develop climate-resilient infrastructure, including for storm water management, heat mitigation, and utilities.

6. Incorporate community perspectives (including children and youth) into community planning decisions, including zoning, transportation, and housing, and in the design and ongoing evaluation of shared spaces for recreation and play.

7. Employ equitable housing and lending practices, and prioritize development and investment in historically disinvested neighborhoods.

8. Minimize the displacement of individuals because of socioeconomic status and/or race/ethnicity in areas vulnerable to gentrification. Potential solutions include affordable housing requirements, community investment funds that allow residents to benefit from property development, and community land trusts that allow community members to maintain control of land.

9. Include pediatric health considerations and expertise in planning, transportation, and zoning decisions. Develop longitudinal health impact assessments for these decisions that include child health outcomes.

10. Support research on impacts of community design on child health, particularly in rural areas, via targeted funding mechanisms and training opportunities.

• 880 Cities (https://www.880cities.org/)

• America Walks (https://americawalks.org/)

• Blue Zones (https://www.bluezones.com/community/)

• AARP Livable Communities (https://www.aarp.org/livable-communities/)

• Healthy Streets (https://www.healthystreets.com/)

• League of American Bicyclists (https://www.bikeleague.org/)

• National Association of City Transportation Officials (https://nacto.org/)

• People for Bikes (https://www.peopleforbikes.org/)

• Rails to Trails Partnership (https://www.railstotrails.org/partnership-for-active-transportation/)

• Safe Routes to School (https://www.saferoutesinfo.org/)

• Transportation for America (https://t4america.org/)

• Trust for Public Land (https://www.tpl.org/)

• Vibrant Cities Laboratory (https://www.vibrantcitieslab.com/)

Aparna Bole, MD, FAAP

Aaron Bernstein, MD, MPH, FAAP

Michelle J. White, MD, MPH, FAAP

Aparna Bole, MD, FAAP, Chairperson

Sophie J. Balk, MD, FAAP

Lori G. Byron, MD, FAAP

Gredia Maria Huerta-Montañez, MD, FAAP

Philip J. Landrigan, MD, FAAP

Steven M. Marcus, MD, FAAP

Abby L. Nerlinger, MD, FAAP

Lisa H. Patel, MD, FAAP

Rebecca Philipsborn, MD, FAAP

Alan D. Woolf, MD, MPH, FAAP

Lauren Zajac, MD, MHP, FAAP

Kimberly A. Gray PhD – National Institute of Environmental Health Sciences

Jeanne Briskin – US Environmental Protection Agency

Nathaniel G. DeNicola – MD, MSc, American College of Obstetricians and Gynecologists

CDR Matt Karwowski – MD, MPH, FAAP, Centers for Disease Control and Prevention National Center for Environmental Health and Agency for Toxic Substances and Disease Registry

Mary H. Ward, PhD – National Cancer Institute

Paul Spire

Nia Heard Garris, MD, MSc, FAAP, Chairperson

Kimberly Brown, MD, FAAP

Nathan Chomilo, MD, FAAP

Nathaniel Jones, MD

Patricia Rodriguez, MD, FAAP

Valencia Walker, MD, FAAP

Ngozi Onyema-Melton

We thank Mr David Jurca, an urban designer, whose expertise and insight informed the research and development of this manuscript.

AAP

American Academy of Pediatrics