Climate Change and Children’s Health: Building a Healthy Future for Every Child

The warming of our planet matters to the health, well-being, and future of every child. Climate conditions stable since the founding of modern pediatrics in the mid nineteenth century have shifted, and old certainties are falling away.¹ Climate change causes profound shifts in temperature, precipitation, and ecosystems. These effects on earth systems compromise air and water quality, increase food insecurity, change the incidence of infectious diseases, intensify allergy seasons, and result in more devastating wildfires and hurricanes and more dangerous and frequent heat waves. The fundamental nature of climate change also presents risks to child health that may not yet be recognized or foreseen.

Appreciation of the unique vulnerability of children has placed pediatricians at the forefront of the response to climate change. The American Academy of Pediatrics (AAP) was the first medical organization in the United States to recognize the health consequences of climate change. The publication of the AAP policy statement² and technical report³ on global climate change and children’s health in 2007 marked a watershed moment in medicine, whereby a leading medical society acknowledged that its members must care for the planet to care for our patients. As signposts of the progress that has been made over the past 15 years across the fields of medicine, leading medical journals, such as The Lancet and the New England Journal of Medicine, have initiatives dedicated to climate and health; medical schools, often at the behest of their students, are more often teaching about climate and health⁴; and the nation’s leading medical societies joined together in 2016 to form a consortium⁵ dedicated to climate and health, with the AAP as a founding member. Across the nation, pediatricians are leading local, state, and national climate change advocacy campaigns aimed at curtailing greenhouse gas emissions in clinical practice, in their states, and nationally.

The scientific basis and current knowledge pertaining to the effects of higher concentrations of greenhouse gases (GHGs) on earth systems, as well as the child health impacts of climate change, are detailed in the technical report⁶ accompanying this policy statement. This policy statement addresses 3 subjects.⁷ 

1. Children’s physical and mental health are threatened by climate change through its effects on temperature, precipitation, extreme weather (eg, heat waves, wildfires); ecological disruption; and community disruption.

2. Climate change disproportionately burdens children in socially disadvantaged groups.⁸ Climate change exposes and amplifies existing inequities and creates an unprecedented intergenerational injustice.

3. Climate change solutions, advanced through the collaborative work of pediatricians, health systems, communities, corporations, and governments, provide a new framework for child health promotion.

Having been trained to understand child health through the lens of a stable climate, pediatricians must now learn to recognize, predict, and prevent child health risks that result from climate change. To this end, the following sections provide an overview of relevant intersections of climate change and child health.

Rising atmospheric concentrations of GHGs have resulted in average US warming and more extreme weather, including severe heat events.⁹ Extreme heat is projected to increase even more than average temperature.⁹ Heat exposure can have broad child health effects that begin in the prenatal period. Maternal heat exposure is associated with adverse birth outcomes including preterm birth, with higher risk observed in Black mothers, although causal relationships have not been identified.¹⁰ Studies from numerous countries including the United States have found infants to be at particularly elevated risk of heat-related mortality.^11,12 Heat mortality risk generally is region specific and has been correlated to average regional temperatures, demonstrating adaptation to local climates.¹³ 

All children are at risk for heat-related illness, which describes a continuum from mild illness (heat cramps, stress, and syncope) to potentially fatal heat stroke. Extreme heat exposure also contributes to excess health care utilization for a variety of causes among children.¹⁴ Children who exercise outdoors in the summer months are at high risk for heat-related illness, particularly football players,¹⁵ young military recruits,¹⁶ and child agricultural workers.¹⁷ Exposure to higher temperature has been associated with reduced cognitive function¹⁸ and educational achievement. The effect of heat on achievement was found to be roughly 3 times larger for Black* and Hispanic students than for white students, likely associated in part with unequal investment in school air conditioning.¹⁹ The built environment strongly influences heat exposure. Less green space and more dark, synthetic surfaces contribute to greater absorption of heat and higher temperatures within cities, known as the “urban heat island” effect.²⁰ Varying degrees of tree cover and building density associated with the historically racist housing policy of redlining can cause temperatures to vary within a single urban region by as much as 7.4°C.²¹ 

Extreme weather events, including severe storms, floods, and wildfires, cause child injuries and, rarely, death. The harms of such events extend well beyond these immediate risks. Flooding events have resulted in greater exposure among children to toxicants, including carbon monoxide poisoning²² and infectious pathogens in contaminated waters.²³ Hurricane Harvey, for example, delivered the highest total rainfall in US history, when 19 trillion tons of water, equivalent to 1 year of rainfall, fell in the Houston area over a few days.²⁴ This storm overwhelmed wastewater facilities for an extended period, leading to unprecedented sewer overflows and hazardous material spills.²⁴ 

Climate change also fuels catastrophic wildfires, a rising global health concern. Less precipitation, longer warm seasons, and more heat extremes all promote wildfire risk.²⁵ Exposure to wildfire smoke is a well-established cause of respiratory health effects including asthma exacerbations.²⁶ Particulate matter less than 2.5 microns (PM_2.5) from wildfire smoke has been found to be as much as 10 times more harmful to children’s respiratory health than PM_2.5 from other sources, particularly for children younger than 5 years.²⁷ Wildfire smoke exposure has been associated with adverse birth outcomes including preterm birth and reduced birth weight.²⁸ Higher temperatures also promote ground-level ozone formation. Ozone is a potent lung irritant that causes asthma exacerbations and reduced lung function in children.²⁹ Fossil fuel combustion, which emits most of the world’s GHG emissions, also is responsible for air pollutants that have broad child adverse health effects with racial and socioeconomic disparities in exposure.³⁰ 

Wildfires and other weather disasters are life-altering and traumatic events that exact mental health and learning harms.³¹ Native American populations have particularly elevated wildfire risk associated with historical forced concentration onto reservation land with greater wildfire hazard and higher social vulnerability.³² Exposure to natural disasters represents significant trauma that, in the absence of supportive caregivers, can contribute to toxic stress. This toxic stress may lead to a range of negative psychosocial and physical health effects that can extend into adulthood.³³ Extreme weather events widen existing social and health disparities. Households with lower wealth and people in minoritized racial/ethnic groups may experience greater physical and mental health effects and displacement after disasters as a result of poor-quality housing; lack of access to emergency communications; reduced access to transportation and resources for relocation, health care services, and medications; and limited or no health and property insurance.³⁴ Children dependent on medical technologies powered by electricity are particularly vulnerable to events that interrupt power supplies.³⁵ 

Climate change alters natural systems that support children’s health. Rising atmospheric carbon dioxide (CO₂) concentration, increasing temperature, and earlier growing seasons are causing an advancement and intensification of the pollen allergy season. The onset of pollen season has advanced by approximately 20 days in North America since 1990. Approximately 50% of this advancement can be attributed to human-caused warming.³⁶ Very early spring onset has been associated with increased asthma hospitalizations.³⁷ 

Elevated CO₂ also can reduce the iron, protein, and zinc content of plants, including rice, wheat, and soybean, thus increasing the risk of nutrient deficiency in vulnerable regions.³⁸ Climate change poses risks to food security via other pathways including extreme heat, drought, and severe storms, which can affect crop growth, food safety, and food transport. These factors threaten increases in global child malnutrition, which remains a profound child health concern.³⁹ 

Warming temperature has been associated with range expansion, disease spread, and earlier incidence for diseases transmitted by vectors, including tickborne infections, such as Lyme disease and spotted fever group rickettsioses.^40,–42 Between 2004 and 2016, the number of annual reports of tickborne bacterial and protozoan diseases in the United States more than doubled, with Lyme disease accounting for 82% of all tickborne disease reports.⁴³ The Aedes aegypti and Aedes albopictus mosquitoes and the diseases they carry, including dengue and chikungunya, have rapidly expanded their range in the past decade and currently inhabit the widest global distribution ever recorded.⁴⁴ The influence of climate change on mosquitoborne diseases has been heavily debated. Climate influences the ecology of mosquitoborne diseases, as well as land-use patterns, vector-control measures, and socioeconomic factors.

Elevated temperature has also been associated with increased incidence of enterovirus-mediated hand, foot, and mouth disease,⁴⁵ and disease caused by Escherichia coli,^46,Salmonella species,^47,Campylobacter species,⁴⁸ and Vibrio species.⁴⁹ 

Healthy child development relies on stable and supportive relationships for children with their families, schools, and neighborhoods. Extreme weather, sea level rise, food and water insecurity, and degraded ecosystems put community economic welfare, health care access and delivery,⁵⁰ education,⁵¹ and mental health at risk.⁵² At a broader scale, these weather extremes can lead to population displacement and migration⁵³ and threaten global security.⁵⁴ 

In the United States, climate change stands to worsen child health disparities. Harms from heat, air pollution, and extreme weather disproportionately affect children in Black and ethnically and racially diverse communities.⁸ Investigating why a given group is more or less likely to live in a climate-sensitive area is beyond the scope of this report. Regardless of race, children and families who have low wealth have fewer resources to prepare for and respond to climate-related shocks. Weather extremes or chronic environmental stressors associated with climate change can lead to loss of basic resources, including food, water, and shelter, as well as economic hardship, forcing people to relocate. For families with limited means and those affected by decades of structural racism, such losses can widen disparities. The voices of marginalized children and families are often excluded from decisions surrounding the adaptation and mitigation policies necessary to address climate change.⁵⁵ Furthermore, those who are most harmed by climate change in the United States and across the world are least responsible for the problem.⁵⁶ For example, temperature variability in tropical countries in coming decades will be greatest in Southeast Asian, Amazonian, and Southern African Nations, which have contributed very little to global GHG emissions.⁵⁷ 

The disproportionate risks to Native American children warrant particular attention. Native American populations often have greater exposure to environmental hazards, because resource extraction and transportation (eg, pipelines), dump sites, and weapons-testing facilities have been sited on their lands.⁵⁸ Centuries of trauma, displacement, and discrimination have led to increased underlying health comorbidities that increase vulnerability to climate hazards.⁵⁹ Climate change is destroying first foods (those foods that were eaten by Indigenous people before contact with outside civilizations) that are essential to traditional nutritious diets, as well as the spiritual health of Native American people.⁵⁸ Historical and contemporary land rights and sovereignty conflicts have led to increased environmental injustice.⁶⁰ 

Fossil fuel extraction and combustion cause harm today and reach centuries into the future, jeopardizing the health, safety, and prosperity of today’s children and future generations. Many young people view themselves as betrayed by governmental policies that inadequately protect the planet or their future, a source of widespread youth distress⁶¹ and the foundation for the rising youth climate movement.⁶² 

Climate change solutions are child health and equity solutions. Policies that promote cleaner air, facilitate walking and bicycling, encourage more sustainable diets, increase access to nature, and develop more connected communities can lead to enormous gains in child health and equity (Fig 1). Climate actions matter most to disadvantaged children such as those with chronic medical conditions, those living in low-wealth households, or children experiencing discrimination.

Fossil fuel-related air pollution is a major, underappreciated cause of noncommunicable disease in the United States and the world.⁶³ For children, air pollution from burning fossil fuels contributes to asthma, hypertension, and neurocognitive disorders, among other harms.³⁰ Air pollution exposure during pregnancy has also been associated with adverse birth outcomes.¹⁰ Neonates born to parents living in areas where oil and gas extraction is occurring may have lower birth weights and increased risk of preterm birth.^64,65 An analysis of US census tract data and all sources of PM_2.5 pollution found significant differences in exposure, with people of color experiencing overall 14% greater exposure than the population average.⁶⁶ 

Electricity generation and transportation are the 2 largest contributors to air pollution and GHG emissions in the United States.⁶⁷ Approximately 60% of US electricity is produced from combustion of fossil fuels, 20% from nuclear, and 20% from renewable energy sources, primarily hydroelectric, wind, and solar energy.⁶⁸ To limit warming to less than 2°C, deep reductions in CO₂ and other GHG emissions are required in the coming decades.⁶⁹ This requires rapid replacement of fossil fuel use in electricity production with low- or no-carbon energy sources such as wind, solar, hydropower, and nuclear, and likely the implementation of CO₂ removal.⁷⁰ 

Transportation-focused climate actions can reduce traffic-related air pollution and promote child physical activity and the many benefits that come from healthier body weights. Improving access and safety of bicycling, walking, and other modes of active transportation may promote healthier BMIs and cardiorespiratory fitness.⁷¹ Public transportation can decrease traffic congestion and time spent sitting in vehicles and improve air quality.⁷² 

Green building design can improve energy efficiency and indoor environmental quality and provide a range of climate and child health benefits. Buildings require energy for heating, cooling, and electricity, contributing nearly one-third of GHG emissions in the United States.⁷³ Lower energy consumption reduces outdoor air pollution, as well as utility costs. The lower operating costs of more energy-efficient, low-income residential buildings can buffer against housing insecurity that contributes to more health care use.⁷⁴ Green buildings often have better air quality indoors because of the building materials used and ventilation systems installed, and are associated with improved occupant health.⁷⁵ 

Childhood diets are a major cause of the obesity epidemic that now afflicts nearly 1 in 5 children on average, with higher rates in Hispanic and non-Hispanic Black children.⁷⁶ Expert guidance on healthy childhood diets emphasizes eating plants, especially vegetables, whole grains, healthy proteins, and fruits, with reduced emphasis on meats.⁷⁷ Such diets can contribute to healthier body weights, have substantially lower carbon footprints than the average obesogenic diet that tends to have high amounts of processed sugars and meats, and be achieved while preserving cultural acceptability, affordability, and nutritional adequacy.⁷⁸ 

Food production accounts for approximately 10% of GHG emissions in the United States (Fig 2).⁶⁷ About half of these emissions are derived from the application of nitrogen-based fertilizers to soil and another quarter are from ruminant livestock, primarily cows. Inventories of the carbon intensity of diets show that, pound for pound, the mean GHG emissions for beef production globally are 4.5 times higher than for cheese, 8.7 times higher than for poultry, 25 times higher than for tofu, and 167 times higher than for nuts. In the United States, where per-capita meat consumption is 3 times the global average, dietary change has the potential to reduce emissions from food production by 61% to 73%.⁷⁹ 

Livestock also contributes to air and water pollution. Agricultural air pollution near livestock farms can affect children who may be exposed to a host of other toxicants.⁸⁰ A shift from current diets to diets high in plant-based and low in animal-based foods would both reduce sources of pollution and promote health.⁸¹ 

Adaptation to climate change can also benefit child health. Urban green space, for example, can reduce the urban heat island effect. Areas of cities that have more dark surfaces absorb more heat and become hotter than greener ones.⁸² These heat islands are more often found in communities of color and those with low income.²¹ Planting trees, rooftop gardens, and other greenery in these areas can reduce heat exposure. Exposure to green space has also been associated with profound child mental health benefits.⁸³ Indigenous ecological knowledge^† can provide innovative and novel approaches to protect from climate-related hazards.⁸⁴ 

Pediatricians have a long history of advocating for policies that protect the health and welfare of children. Informed by an understanding of the threat that climate change poses to their patients, pediatricians serve as a voice for children in the societal response to this global challenge. The following are recommendations to help achieve this goal.

1. Incorporate climate change counseling into clinical practice. Assess climate risks and recommend climate solutions when screening for and addressing social determinants of health such as energy, food, and housing security.⁸⁵ Educate families on regional climate and health risks and protective strategies. Use existing anticipatory guidance as a framework for discussing climate change solutions. For example, encourage active modes of transport or promote consumption of plant-based proteins to reduce carbon emissions and promote health. Encourage family choices that reduce fuel consumption and promote mobility, such as utilization of public and active transportation, and fuel-efficient vehicles.

2. Incorporate climate, health, and equity curricula into medical school, residency, continuing education, and board examinations to prepare pediatricians to adequately provide health care for children.

3. Reduce carbon emissions from the health sector through operating facilities on carbon-free energy sources; improve energy, water, and other resource efficiency in health care buildings and health care product manufacture; transition to zero-emission vehicles and promote active and public transportation for patients and employees to hospitals and clinics; minimize medical waste, including pharmaceutical waste; serve sustainably grown food and eliminate food waste; use telehealth when appropriate; include climate resilience in facility design and disaster preparedness efforts; and invest in climate and health innovation.⁸⁶ On the basis of accepted clinical performance measures, incentivize decarbonization through incorporating the carbon intensity of services into value-based health care metrics.⁸⁷ US health sector GHG emissions exceed those of any other nation in both absolute and per-capita terms, and are projected to increase significantly without climate action within and outside the health sector.⁸⁶ 

4. Serve as a role model in your personal and professional community for practices that promote sustainability. For example, embrace active transportation, reduce home energy use, transition to clean electricity sources, reduce air travel, and adopt a more plant-based diet.⁸⁸ Actions to reduce personal carbon footprint can increase the efficacy of messaging and advocacy efforts.⁸⁹ 

5. Advocate for equitable climate solution policies at the local, state, national, and international level. Pediatricians are ideal advocates with whom to partner and uplift youth and community voices working to advance zero-carbon energy policy and climate justice.⁹⁰ Educate elected officials and health insurance entities on the risks that climate change poses to child health and the benefits of local solutions, including improved air quality, safe streets, tree canopy and green space, and access to affordable fresh fruits and vegetables. Engage with the community by speaking at public hearings, providing expert testimony, and writing letters to the editor. Maximize impact by working with other health care professionals in an organization focused on climate and health.

6. Bring the child health voice to coalitions working to address climate change. Pediatricians are well positioned to collaborate with health departments, universities, and research facilities to enhance surveillance, analysis, and reporting of climate-sensitive health effects and vulnerable communities. Develop local, regional, and national preparedness measures that protect the best interests of children from current and future harm. Prioritize engagement with members of communities at highest risk as a result of historical underinvestment and racist policies.

Consistent with scientific assessments of the United States’ responsibility to meet our obligation under the Paris Agreement, policies should be put in place that reduce GHG emissions to net-zero by 2050.⁹¹ Policies also must be enacted that promote climate resilience, especially for children. Stakeholders can act to:

1. Promote energy efficiency and renewable energy production at the federal, state, and local levels. Preserve essential public health protections in the Clean Air Act. Establish an effective and equitable carbon pricing regimen that reflects the health costs of fossil fuel reliance and ensures a positive impact on communities affected by environmental injustice and energy sector dependence. End federal subsidies and tax incentives for production and consumption of carbon-intensive fuels.

2. Establish laws or regulations that transition on road vehicles, the leading source of GHG emissions in the United States,⁶⁷ to zero carbon emission at a rate consistent with attaining our obligations under the Paris Agreement. Expand public transportation, increase construction of safe bikeways and walkways, and support urban planning designs that reduce dependence on automobile transit.

3. Promote more plant-based diets with reduced red meat and sugar consumption in line with current dietary guidelines and associated with reductions in both GHG- and diet-related disease risks in children.⁸¹ Improve food security through incentivizing crop and soil resilience, regenerative agriculture, and reduced GHG contributions from livestock.

4. Increase urban green space, safe routes for walking and biking, and access to mass transit where appropriate. Invest in strategies that reduce heat islands in communities that experience higher temperatures. Prioritize support for communities that have experienced historical underinvestment.

5. Positively incentivize the health care sector through payment reforms, grants, value-based initiatives, or other mechanisms to improve energy efficiency, reduce waste, and increase reliance on clean energy. Support resilience of hospitals and health systems to climate shocks.

6. Expand and develop pediatric research and climate change related public health adaptation, mitigation, and resilience measures to protect children, with a focus on vulnerable communities and environmental justice.⁹² Deploy early-warning systems for extreme weather events that include health care professionals and that reflect the specific needs of children. Improve surveillance of climate-associated infectious diseases, including new and emerging pathogens.

7. Promote enhanced, localized community resilience with active engagement and support of impacted communities. Promote environmental justice through investments in communities that have historically been overburdened by pollution. Direct public housing and school infrastructure funding to incorporate green building design.

8. Advance global actions to decarbonize through setting sound domestic climate policies and supporting international efforts to reduce greenhouse gas emissions among all nations.

Samantha Ahdoot, MD, FAAP

Carl R. Baum, MD, FACMT, FAAP

Mary Cataletto, MD, FAAP, FCCP

Patrick Hogan, MD

Christina B. Wu, MD, MPH, FAAP

Aaron Bernstein, 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

Steven E. Krug, MD, FAAP, Chairperson

Sarita Chung, MD, FAAP, Vice Chairperson

Carl R. Baum, MD, FACMT, FAAP

Deanna L. Dahl-Grove, MD, FAAP

H. Dele Davies, MD, MS, MHCM, FAAP

Eric J. Dziuban, MD, DTM, CPH, FAAP

Aaron H. Gardner, MD, MS, FAAP

Stephanie E. Griese, MD, MPH, FAAP

Scott M. Needle, MD, FAAP

David J. Schonfeld, MD, FAAP

Joelle N. Simpson, MD, MPH, FAAP

Stephanie Smiley, MA

Richard M. Kravitz, MD, FAAP, Chairperson

Rajeev Bhatia, MD, FAAP

Theresa W. Guilbert, MD, FAAP

Brooke Gustafson, MD FAAP, Fellowship Trainee

Binal Kancherla, MD, FAAP

Benjamin Kopp, MD, FAAP

Susan L. Millard, MD, FAAP, FCCP

Rebekah J. Nevel, MD, FAAP

Andrew G. Sokolow, MD, FAAP

Kristin Van Hook, MD, FAAP, Past Chairperson

Laura N. Laskosz, MPH

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

AAP

American Academy of Pediatrics

CO₂

carbon dioxide

GHG

greenhouse gas

PM_2.5

particulate matter less than 2.5 microns