Pediatricians and pediatric trainees in North America are increasingly involved in caring for children and adolescents in or from low- and middle-income countries (LMICs). In many LMICs, hazardous environmental exposures—notably outdoor and household air pollution, water pollution, lead, pesticides, and other manufactured chemicals—are highly prevalent and account for twice the proportion of disease and deaths among young children as in North America. Climate change will likely worsen these exposures.

It is important that pediatricians and other pediatric health professionals from high-income countries who work in LMICs be aware of the disproportionately severe impacts of toxic environmental hazards, become knowledgeable about the major local/regional environmental threats, and consider environmental factors in their differential diagnoses. Likewise, pediatricians in high-income countries who care for patients who have emigrated from LMICs need to be aware that these children may be at elevated risk of toxic environmental diseases from past exposures to toxic environmental hazards in their countries of origin as well as ongoing exposures in products imported from their home countries, including traditional foods, medications, and cosmetics.

Because diseases of toxic environmental origin seldom have unique physical signatures, pediatricians can utilize the environmental screening history, supplemented by laboratory testing, as a diagnostic tool. To prepare pediatricians to care for children in and from LMICs, pediatric organizations could increase the amount of environmental health and climate change content offered in continuing medical education (CME) credits, maintenance of certification (MOC) credits, and certification and recertification examinations. Broadly, it is important that governments and international agencies increase resources directed to pollution prevention, strengthen the environmental health workforce, and expand public health infrastructure in all countries.

Pediatricians and pediatric trainees in North America are increasingly involved in providing care to children and adolescents in low- and middle-income countries (LMICs). Pediatricians in North America also care for children who have emigrated from across the globe1; their may increase in future years in consequence of climate change,2 armed conflicts, complex sociopolitical circumstances, and changing immigration policies.3 

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 is not generally appreciated.4–6 Globally, environmental pollution is responsible for an estimated 9 million deaths each year—3 times as many as are caused by AIDS, tuberculosis, and malaria combined.7 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 as in high-income countries.8 Environmental threats to children’s health in LMICs are worsening: two-thirds of global chemical and pesticide manufacturing is now located there, and ambient air pollution as well as contamination by pesticides and other toxic chemicals is growing rapidly. The impacts of environmental factors on children’s health in all countries, and especially in LMICs, will likely be magnified by climate change.

It is important that pediatricians, pediatric trainees, and other pediatric health professionals from high-income countries who plan to work in LMICs be aware that hazardous environmental exposures account for a much higher proportion of disease, disability, and death among children there than among children in high-income countries. Thus, it is important that they become knowledgeable about the major environmental threats to children’s health in the countries where they will be working and incorporate this information into their clinical practice. Similarly, it is important that pediatricians in high-income countries who care for children and adolescents who have emigrated from LMICs be aware that these children may be at elevated risk of diseases caused by hazardous environmental exposures in their countries of origin. The intent of this policy statement and the accompanying technical report9 is to provide pediatricians and pediatric trainees an overview of the following:

  1. Key environmental issues in global pediatric health, with a particular focus on the major environmental hazards contributing to pediatric morbidity and mortality in LMICs.

  2. Strategies and resources to recognize, diagnose, manage, and prevent disease in children caused by hazardous environmental exposures in LMICs.

  3. Opportunities for increased education and training on environmental health issues for pediatricians and other pediatric health professionals.

  4. Roles of the pediatricians and other clinicians practicing in the United States and LMICs in the prevention of environmental exposures and the diseases that they cause, with a particular focus on prevention of disease caused by toxic chemical hazards.

  5. Role of governmental and nongovernmental organizations to increase resources and capacity to address children’s environmental health.

Significant social, ethnic, racial, and economic inequities are evident in the global distribution of environmental hazards. Nearly 92% of all disease and death attributable globally to environmental risk factors occur in LMICs.10 In countries at every economic level, disease caused by hazardous environmental exposures is most prevalent among poor people and historically marginalized groups, an inequitable pattern of exposure and disease termed “environmental injustice.”11 

Environmental injustice is also seen in high-income countries, including the United States. Examples include the disproportionate siting of polluting industries, hazardous waste sites, and major roadways in low-income communities where the majority of the residents are people of color. Another example is the disproportionally high levels of lead found in drinking water in communities that are predominantly people of color, such as Flint, Michigan. The disproportionate exposures of Native American and Alaska Native children to high levels of household air pollution and unsafe drinking water are further examples of environmental injustice in the United States.12–27 

Toxic environmental exposures and the diseases that they cause are the result of human activity and can, therefore, be prevented. This is a key point, and it is the basis for all pollution control policy.

The strongest evidence that diseases of environmental origin can be prevented is seen in the experience of the United States and other high-income countries in controlling pollution and preventing pollution-related disease.10 In the United States, for example, air pollutant emissions have fallen by 77% since passage of the Clean Air Act in 197028; air and drinking water are now cleaner, polluted rivers no longer catch fire, and the worst hazardous waste sites have been remediated. Disease and premature death of environmental origin have been prevented.

The two factors that made possible these gains were (1) research to discover the environmental causes of disease in children; and (2) evidence-based advocacy that translated research findings into laws, policies, and prevention programs. Pediatricians are trusted advisors, uniquely well qualified to address environmental threats to children’s health. For this reason, pediatricians have repeatedly been leaders in environmental health research, and individual pediatricians and pediatric organizations have been key players in successful intervention efforts. Examples of environmental health efforts led by pediatricians include the removal of lead from gasoline, which resulted in a more than 95% reduction in blood lead levels of American children and an approximate 5-point gain in population mean IQ29; reduction in children’s exposure to urban air pollution, which resulted in improvements in lung function and reduction in childhood asthma30; bans on the use of neurotoxic insecticides such as chlorpyrifos; and reduction of arsenic levels in drinking water.

A powerful ancillary argument for the prevention of pediatric disease of environmental origin is that these diseases result in large economic costs and their prevention is highly cost-effective.31 This argument is valid in all countries and especially in LMICs, where the costs of diseases caused by hazardous environmental exposures are so great that they can undermine national economies and undercut prospects for human development.32,33 

The economic costs of pediatric diseases caused by toxic environmental exposures include health care costs as well as increased costs for special education, accommodation for disabilities, and other developmental services. In addition, environmentally related disease and disability have negative economic impacts on children’s futures, because they diminish children’s educational attainment, their lifelong earning potential, and their ability to contribute to society by reducing cognitive function, decreasing IQ, and impairing physical function.10 Globally, the economic losses attributable to pollution-related disease are estimated to amount to $4.6 trillion per year, approximately 6% of global economic output.10 

Prevention of diseases caused by toxic environmental exposures has not only improved children’s health and well-being but also benefited the economy.28 Improvements in air quality in the United States have been associated with benefits of nearly $30 for every dollar invested in pollution control since passage of the Clean Air Act in 1970.34 Removal of lead from gasoline has not only reduced childhood lead poisoning by over 95% but also returned an estimated $200 billion to the US economy each year since 1980 through the increased creativity and economic productivity of generations of more intelligent and creative children not impaired by lead.29 

Information on the cost-effectiveness of disease prevention programs provides pediatricians with another powerful argument for persuading policy makers to take preventive action to safeguard children’s health.29,34 

The key toxic environmental exposures for children in LMICs include: water pollution, ambient air pollution, household air pollution from indoor fuel-burning stoves, toxic chemical pollution including heavy metals (lead, mercury, arsenic), industrial chemicals, pesticides, and hazardous waste (Table 1). A review of the evidence on the health hazards of these exposures is presented in the accompanying technical report.9 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. The health impacts of climate change have been extensively reviewed35,36 and are addressed in a statement from the American Academy of Pediatrics (AAP) Council on Environmental Health and Climate Change focused on climate change and children’s health.37,38 

Table 1.

Select Key Environmental Exposures of Concern in Low- and Middle-Income Countries (LMICs)

Environmental ConcernSources of ExposureHealth Impacts and Disease Burden
Water, sanitation, and hygiene (WASH) 
  • Water contaminated by biological waste (human and animal) and chemical waste.

  • 2.4 billion people use unimproved sanitation facilities; 946 million people practice open defecation.10 

 
  • Acute and chronic gastrointestinal tract diseases such as diarrheal diseases, paratyphoid fever, and parasitic infections; affecting more than 1 billion people (most in LMICs).61,62 

  • Unknown impact of chemical pollution because of sparse data.63 

 
Ambient air pollution 
  • Increasing coal combustion and growing car ownership,10 along with wildfires,64 leads to higher concentrations of fine particulate matter (PM2.5).

  • 88% of urban residents globally live in cities that fail to meet WHO air quality guidelines.65 

 
  • PM2.5 exposure is linked to asthma, impaired lung function, cardiovascular disease, preterm births, low birth weight, impaired cognitive function, lung cancer.

  • PM2.5-related deaths expected to rise sharply over next 3 decades, especially in South and East Asia.66 

  • May increase morbidity and mortality from SARS-CoV-2 infection (COVID-19).67–70 

 
Household air pollution (HAP) 
  • Burning of biomass and solid fuels in unvented indoor stoves for cooking and heating, leading to exceedingly high levels of PM2.5.

 
  • Women and young children are disproportionately exposed to HAP because of traditional gender roles in many LMICs.17,71 

 
Lead 
  • Lead “hot spots”—battery recycling operations, smelters, mines, hazardous waste sites.

  • Lead paint.

  • Medicinal products (eg, Ayurveda).

  • Cosmetics (eg, Sindoor).

  • Ceramic glazes.

  • Spices, solder in food cans.

  • Contaminated soil.

 
  • Lead exposure is linked to neurocognitive impairment, anemia, kidney impairment, gastrointestinal tract effects.

  • 40% of the world’s children have blood lead levels exceeding 5 μg/dL, and 90% of these live in LMICs.72 

  • Episodes of pediatric lead poisoning in LMICs have been extremely severe or fatal.73 

 
Mercury 
  • Artisanal and small-scale gold mining.

  • Consumption of large predator fish contaminated with methylmercury is the major route of exposure.74,75 

 
  • Mercury is a neurotoxicant.

  • Methylmercury crosses the placenta, passes easily into the tissues of fetuses and young children, and causes permanent injury to the developing brain.74 

 
Arsenic 
  • Contaminated drinking water is the principal source of arsenic exposure, especially in areas with high levels of naturally occurring arsenic in bedrock.

  • Rice-based food products

 
  • Chronic exposure to inorganic arsenic is linked to several cancers (lung, bladder, skin).76 

  • Prenatal exposures are linked to late fetal/neonatal/postneonatal mortality, neurodevelopmental abnormalities, adult cancers, and bronchiectasis.77–79 

 
Pesticides 
  • Highly toxic pesticides banned in the United States are shipped or sold to LMICs and widely used.80 

 
  • 99% of all acute pesticide poisonings occur in LMICs.81 

 
Hazardous wastes 
  • Asbestos exported into LMICs (more than 2 million tons/year) to be used in construction of homes and schools.82 

  • Electronic waste (e-waste) shipped into LMICs (45 million tons per year).18 Women and young children are employed in e-waste recycling and are exposed to mixture of heavy metals and other chemicals during the process.

 
  • Asbestos exposure can cause lung cancer and malignant mesothelioma.82 

  • Children at e-waste sites can have elevated levels of multiple toxic chemicals, including lead and nickel.83 These exposures are associated with injury to children’s immune, cardiovascular, gastrointestinal, renal, endocrine, and hematological systems as well as adverse birth outcomes.18,84 

 
Unintentional injuries 
  • Road traffic accidents, drowning, falls.

  • Poisonings: household chemicals/pesticides, medications, fuels and solvents, methanol (informally produced alcoholic drinks).

 
  • Approximately 2000 children globally die from unintentional injuries each day.85 

 
Environmental ConcernSources of ExposureHealth Impacts and Disease Burden
Water, sanitation, and hygiene (WASH) 
  • Water contaminated by biological waste (human and animal) and chemical waste.

  • 2.4 billion people use unimproved sanitation facilities; 946 million people practice open defecation.10 

 
  • Acute and chronic gastrointestinal tract diseases such as diarrheal diseases, paratyphoid fever, and parasitic infections; affecting more than 1 billion people (most in LMICs).61,62 

  • Unknown impact of chemical pollution because of sparse data.63 

 
Ambient air pollution 
  • Increasing coal combustion and growing car ownership,10 along with wildfires,64 leads to higher concentrations of fine particulate matter (PM2.5).

  • 88% of urban residents globally live in cities that fail to meet WHO air quality guidelines.65 

 
  • PM2.5 exposure is linked to asthma, impaired lung function, cardiovascular disease, preterm births, low birth weight, impaired cognitive function, lung cancer.

  • PM2.5-related deaths expected to rise sharply over next 3 decades, especially in South and East Asia.66 

  • May increase morbidity and mortality from SARS-CoV-2 infection (COVID-19).67–70 

 
Household air pollution (HAP) 
  • Burning of biomass and solid fuels in unvented indoor stoves for cooking and heating, leading to exceedingly high levels of PM2.5.

 
  • Women and young children are disproportionately exposed to HAP because of traditional gender roles in many LMICs.17,71 

 
Lead 
  • Lead “hot spots”—battery recycling operations, smelters, mines, hazardous waste sites.

  • Lead paint.

  • Medicinal products (eg, Ayurveda).

  • Cosmetics (eg, Sindoor).

  • Ceramic glazes.

  • Spices, solder in food cans.

  • Contaminated soil.

 
  • Lead exposure is linked to neurocognitive impairment, anemia, kidney impairment, gastrointestinal tract effects.

  • 40% of the world’s children have blood lead levels exceeding 5 μg/dL, and 90% of these live in LMICs.72 

  • Episodes of pediatric lead poisoning in LMICs have been extremely severe or fatal.73 

 
Mercury 
  • Artisanal and small-scale gold mining.

  • Consumption of large predator fish contaminated with methylmercury is the major route of exposure.74,75 

 
  • Mercury is a neurotoxicant.

  • Methylmercury crosses the placenta, passes easily into the tissues of fetuses and young children, and causes permanent injury to the developing brain.74 

 
Arsenic 
  • Contaminated drinking water is the principal source of arsenic exposure, especially in areas with high levels of naturally occurring arsenic in bedrock.

  • Rice-based food products

 
  • Chronic exposure to inorganic arsenic is linked to several cancers (lung, bladder, skin).76 

  • Prenatal exposures are linked to late fetal/neonatal/postneonatal mortality, neurodevelopmental abnormalities, adult cancers, and bronchiectasis.77–79 

 
Pesticides 
  • Highly toxic pesticides banned in the United States are shipped or sold to LMICs and widely used.80 

 
  • 99% of all acute pesticide poisonings occur in LMICs.81 

 
Hazardous wastes 
  • Asbestos exported into LMICs (more than 2 million tons/year) to be used in construction of homes and schools.82 

  • Electronic waste (e-waste) shipped into LMICs (45 million tons per year).18 Women and young children are employed in e-waste recycling and are exposed to mixture of heavy metals and other chemicals during the process.

 
  • Asbestos exposure can cause lung cancer and malignant mesothelioma.82 

  • Children at e-waste sites can have elevated levels of multiple toxic chemicals, including lead and nickel.83 These exposures are associated with injury to children’s immune, cardiovascular, gastrointestinal, renal, endocrine, and hematological systems as well as adverse birth outcomes.18,84 

 
Unintentional injuries 
  • Road traffic accidents, drowning, falls.

  • Poisonings: household chemicals/pesticides, medications, fuels and solvents, methanol (informally produced alcoholic drinks).

 
  • Approximately 2000 children globally die from unintentional injuries each day.85 

 

PM2.5= particulate matter with aerodynamic diameter of 2.5 microns or less; also known as “fine particulate matter.”

It is important for pediatric clinicians to be alert to the possibility that any illness or exacerbation of illness in a child or adolescent may have an environmental etiology. Given the disproportionately heavy burden of environmental exposures in LMICs, environmental causation is an especially likely diagnostic possibility among children evaluated clinically in LMICs. Because diseases of environmental origin in children seldom have unique physical signatures, an exposure history, supplemented as appropriate by laboratory testing, is the principal diagnostic tool. A targeted environmental history is also an important part of pediatric care during well visits and management of an environmentally related illness (eg, asthma). The environmental screening history includes questions about hazardous exposures in the home, neighborhood, and other places the child spends time; questions can be tailored to reflect the most prominent environmental exposures in a particular country and community.39 Positive responses on the screening history can trigger deeper inquiry and/or referral to a Pediatric Environmental Health Specialty Unit (PEHSU).

Pediatricians and other pediatric health professionals in high-income countries are increasingly likely to care for foreign-born children and to have an important role in promoting these children’s health and wellness. It is important for these providers to be aware of the possibility that children who have come to high-income countries from LMICs may have been exposed to toxic environmental hazards in their countries of origin. Such exposures might include heavy metals (lead, mercury, arsenic), pesticides, and air pollution. In addition, once they arrive in the United States, immigrant children may face ongoing environmental exposures if they move into substandard housing, have parents who bring home work-related exposures (eg, pesticides with agricultural workers), or have family members who use toxic products imported from the home country (eg, Ayurvedic medicines) (Table 2). It is also important to assess the mental health of children who have come from LMICs, because these children may have been exposed to environmental stressors (eg, violence, famine) and can be referred to appropriate social services and mental health support.

Table 2.

Sources of Environmental Exposures Among Immigrant, Refugee, and Internationally Adopted Children and Adolescents in the United States

Possible Sources of ExposureClinical Resources
General Environmental Health Considerations 
 
  • For new patients, include key questions about possible environmental and para-occupational exposures

  • In patients with suspected environmental etiology of disease, consider a consultation with specialists in the PEHSU network for assistance with the diagnosis, management, or treatment of complex environmental health issues.

 
Use environmental health history forms from WHO (https://www.who.int/publications/m/item/children-s-environmental-record--green-page) or NEEF (https://www.neefusa.org/resource/asthma-environmental-history-form). In the United States, access expert guidance from the Pediatric Environmental Health Specialty Units (PEHSU): www.pehsu.net The WHO has a collaborating network of expert centers in pediatric environmental health: www.niehs.nih.gov/research/programs/geh/partnerships/network/index.cfm 
Toxic Stress 
 Violence, extreme poverty, racism, nativism, trauma in unaccompanied minors, effects of climate change AAP Immigrant Child Health Toolkit provides guidance on screening for trauma, assessing risk and protective factors for mental health and developmental outcomes.43 AAP policy statement on preventing childhood toxic stress86 provides recommendations on how to integrate relational health into pediatric care to buffer adversity and build resilience. The CDC provides guidance on health care for immigrants and refugees: www.cdc.gov/immigrantrefugeehealth 
Specific Toxicants 
Lead Upon arrival in the United States, consider:
  • Lead paint (homes built before 1978)

  • Imported consumer products, cosmetics, spices, medications, candies wrapped in lead foil

  • Glazed ceramic cookware, dishes

 
Obtain a blood lead level on all foreign-born children. CDC has additional guidance on testing immigrant and refugee children for lead.87  
Mercury 
  • Large ocean fish

  • Religious rituals (eg, Santeria, Espiritismo)

  • Skin-lightening creams/soaps

  • Exposure to small-scale gold mining

 
EPA and FDA provide fish consumption guidance.88 EPA has information on mercury in consumer products.89  
Arsenic 
  • Groundwater contamination (children from Bangladesh and other Southeast Asian countries)

  • Ayurvedic medications

  • Rice-centered diet

 
FDA has guidance to reduce arsenic in rice-based diet.90  
Pesticides Para-occupational exposure from caregivers working in agriculture Migrant Clinicians Network provides clinical tools on reducing environmental exposures among migrant farmworker families.91  
Tobacco or nicotine products Secondhand exposure to cigarette smoke, electronic cigarettes, hookahs AAP Richmond Center has extensive clinical resources on tobacco.92  
Alcohol Prenatal exposure – risk of fetal alcohol syndrome disorder (FASD) AAP provides clinical guidelines93 for diagnosis of FASD and a management toolkit.94  
Exposure Categories 
Substandard housing and asthma triggers 
  • Peeling lead-based paint (pre-1978 home)

  • Mold, pests, and other asthma triggers

  • Secondhand smoke

  • Housing instability

 
CDC recommends screening foreign-born children for lead exposure. Tools are available to screen for environmental triggers in the homes of children with asthma.95  
Contaminated consumer products 
  • Imported cosmetics (Kohl, Kajal, Surma, Sindoor, skin-lightening creams)

  • Herbal supplements, Ayurvedic medications

  • Amulets

 
New York City Department of Health (NYCDOH) has compiled an extensive list of consumer products that may be contaminated with heavy metals.96  
Diet 
  • Large ocean fish (mercury)

  • Rice-based diet (arsenic)

  • Spices purchased abroad (lead)

 
EPA and FDA provide fish consumption guidance.88 FDA has guidance to reduce arsenic in a rice-based diet.90 NYCDOH has guidance on lead-contaminated spices.97  
Possible Sources of ExposureClinical Resources
General Environmental Health Considerations 
 
  • For new patients, include key questions about possible environmental and para-occupational exposures

  • In patients with suspected environmental etiology of disease, consider a consultation with specialists in the PEHSU network for assistance with the diagnosis, management, or treatment of complex environmental health issues.

 
Use environmental health history forms from WHO (https://www.who.int/publications/m/item/children-s-environmental-record--green-page) or NEEF (https://www.neefusa.org/resource/asthma-environmental-history-form). In the United States, access expert guidance from the Pediatric Environmental Health Specialty Units (PEHSU): www.pehsu.net The WHO has a collaborating network of expert centers in pediatric environmental health: www.niehs.nih.gov/research/programs/geh/partnerships/network/index.cfm 
Toxic Stress 
 Violence, extreme poverty, racism, nativism, trauma in unaccompanied minors, effects of climate change AAP Immigrant Child Health Toolkit provides guidance on screening for trauma, assessing risk and protective factors for mental health and developmental outcomes.43 AAP policy statement on preventing childhood toxic stress86 provides recommendations on how to integrate relational health into pediatric care to buffer adversity and build resilience. The CDC provides guidance on health care for immigrants and refugees: www.cdc.gov/immigrantrefugeehealth 
Specific Toxicants 
Lead Upon arrival in the United States, consider:
  • Lead paint (homes built before 1978)

  • Imported consumer products, cosmetics, spices, medications, candies wrapped in lead foil

  • Glazed ceramic cookware, dishes

 
Obtain a blood lead level on all foreign-born children. CDC has additional guidance on testing immigrant and refugee children for lead.87  
Mercury 
  • Large ocean fish

  • Religious rituals (eg, Santeria, Espiritismo)

  • Skin-lightening creams/soaps

  • Exposure to small-scale gold mining

 
EPA and FDA provide fish consumption guidance.88 EPA has information on mercury in consumer products.89  
Arsenic 
  • Groundwater contamination (children from Bangladesh and other Southeast Asian countries)

  • Ayurvedic medications

  • Rice-centered diet

 
FDA has guidance to reduce arsenic in rice-based diet.90  
Pesticides Para-occupational exposure from caregivers working in agriculture Migrant Clinicians Network provides clinical tools on reducing environmental exposures among migrant farmworker families.91  
Tobacco or nicotine products Secondhand exposure to cigarette smoke, electronic cigarettes, hookahs AAP Richmond Center has extensive clinical resources on tobacco.92  
Alcohol Prenatal exposure – risk of fetal alcohol syndrome disorder (FASD) AAP provides clinical guidelines93 for diagnosis of FASD and a management toolkit.94  
Exposure Categories 
Substandard housing and asthma triggers 
  • Peeling lead-based paint (pre-1978 home)

  • Mold, pests, and other asthma triggers

  • Secondhand smoke

  • Housing instability

 
CDC recommends screening foreign-born children for lead exposure. Tools are available to screen for environmental triggers in the homes of children with asthma.95  
Contaminated consumer products 
  • Imported cosmetics (Kohl, Kajal, Surma, Sindoor, skin-lightening creams)

  • Herbal supplements, Ayurvedic medications

  • Amulets

 
New York City Department of Health (NYCDOH) has compiled an extensive list of consumer products that may be contaminated with heavy metals.96  
Diet 
  • Large ocean fish (mercury)

  • Rice-based diet (arsenic)

  • Spices purchased abroad (lead)

 
EPA and FDA provide fish consumption guidance.88 FDA has guidance to reduce arsenic in a rice-based diet.90 NYCDOH has guidance on lead-contaminated spices.97  

CDC, Centers for Disease Control and Prevention; EPA, US Environmental Protection Agency; FDA, US Food and Drug Administration.

Comprehensive resources on the identification, management, and prevention of environmental exposures are available to guide clinicians caring for children and adolescents in LMICs and children in the United States who have come from LMICs (for full details, see Table 2). For example, the World Health Organization (WHO) provides clinicians with a pediatric environmental health history tool called the “Green Page” to assist in the identification of critical environmental exposures, including key issues in LMICs.40 The national network of PEHSUs in the United States provides consultation, guidance, and education for health care providers, public health agencies, and communities on key pediatric environmental health issues.39,41,42 The WHO has launched an international network of Children’s Environmental Health Units, including the Unidades de Pediátrica Ambiental (UPAs) in Latin America, and has created a comprehensive training program in pediatric environmental health that can serve as a resource for clinicians. The AAP has published resources to assist providers in the clinical care of immigrant children43 and internationally-adopted children.44 

Pediatric organizations can make important contributions to protecting children against environmental threats to health by complementing and magnifying the voices of individual pediatricians. The informed and trusted voices of district, state, and national pediatric organizations can powerfully influence environmental policy decisions by reminding policy makers that almost any environmental decision has implications for children’s health and that these implications must be explicitly considered before decisions are made.

Recent decades have seen a dramatic rise in interest in environmental health among medical and public health professionals in the United States and across the globe. Gains have been made in adding topics on environmental health and climate change into medical education. These educational programs are, however, not yet comprehensive, and many of them do not fully prepare physicians to address environmental concerns among their patients, especially patients in LMICs.45–48 Environmental health training for medical personnel, public health professionals, environmental public health technicians, and community health workers could be expanded to raise knowledge of and capacity to address environmental health concerns in the clinical setting. The curricula of such training can also be structured to provide pediatricians with the knowledge and tools they will need to be effective, science-based advocates for children’s environmental health.

To fill the gap in medical education, organizations such as the AAP, the Academic Pediatric Association, and the WHO have launched initiatives to build capacity in pediatric environmental health. The Academic Pediatric Association has launched an environmental health fellowship that has trained more than 50 clinicians and scientists who have become leaders in the field49,50 and has formed an environmental health special interest group. The AAP has convened pediatric environmental health champions (including trainees), raised the national profile of the field, and published the Pediatric Environmental Health clinical handbook (known as the “Green Book”), now in its 4th edition.39 A Textbook on Children’s Environmental Health has also been published.51 However, greater integration of environmental health and climate change topics into existing educational structures (eg, medical school curricula, pediatric residency competencies, continuing education for providers) is needed to reach more providers and increase their ability to address key environmental exposures in their patients.52 A growing network of health professional schools and programs around the world have begun integrating climate change into their educational curricula,48,52,53 providing a model for replication in additional settings and covering a broader range of topics in environmental health.

Given the immense burden of disease attributable to modifiable environmental factors, increased financial support and capacity building in environmental public health and research is urgently needed in all countries, and especially LMICs. Programs such as the WHO-National Institute of Environmental Health Sciences (NIEHS) Collaborating Centers and the Fogarty International Center (of the National Institutes of Health) offer international training programs, research, capacity building, and information sharing across countries, which have reduced disease burden around the world.54,55 However, substantially more funding and investment in these types of programs is needed to fully address the complex and changing scope of environmentally related disease.

Despite the great magnitude of their effects on human health, environmental hazards in LMICs have been neglected in the international development and global health agendas as well as in the planning strategies of many countries. The foreign aid budgets of the European Commission, the US Agency for International Development, and bilateral development agencies allocate only minimal resources to the prevention and control of ambient air pollution and chemical pollution.56,57 No major foundation has made pollution control a priority. Despite the great impact of pollution on global morbidity and mortality, the average investment by international development agencies in preventing an environmentally related death (caused by ambient air pollution and chemical pollution) is $14/death compared with $1250/death for malaria, $190/death for tuberculosis, and $165/death for HIV/AIDS.58 

It is critical that governmental and nongovernmental agencies prioritize the funding of primary environmental interventions such as implementing safely managed drinking water systems, ending open defecation through installation of safe toilet facilities, increasing access to cleaner fuels and more efficient indoor cook stoves, and improving surveillance of chemical products.59 These preventive interventions produce crosscutting health, social, and economic co-benefits and support the ambitious vision of United Nation’s Sustainable Development Goals. The 17 Sustainable Development Goals aim to eradicate global poverty by 2030 by focusing on sustainable strategies to ensure healthy environments for all, especially women and children.60 

As climate change accelerates and LMICs continue their passage through the epidemiological and environmental transitions with increasing urbanization and industrialization, increased investment in research and infrastructure is needed to ensure a resilient future for all children and future generations.

The AAP provides additional details on the topics discussed in this policy statement in the accompanying technical report.9 Combined, these 2 documents provide guidance to pediatricians and trainees on recognizing, diagnosing, managing, and preventing environmentally related diseases in children and adolescents living in LMICs and those who have relocated to high-income countries from LMICs. Given the importance of environmental exposures to the health and well-being of children around the world, the AAP offers recommendations for pediatricians, trainees, and other health professionals.

  1. 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.

  2. Recognize the importance of environmental hazards and their impacts on the health of children in communities experiencing environmental injustice in areas that you serve in clinical practice and engage in appropriate needs-based collaboration with these communities to identify and reduce environmental threats to children’s health.

  3. Include environmental health in histories for new patients via standardized questions about possible environmental and para-occupational (exposures to toxic materials brought into the home by parents on clothing, shoes, or vehicles) exposures. Refer to general environmental history guides, such as the World Health Organization’s “Green Page,” the AAP’s textbook Pediatric Environmental Health (known as the “Green Book”), or tailored guidance from local health agencies if available.

  4. Include environmental health questions during appropriate medical encounters with existing patients who have environmentally related disease (eg, asthma).

  5. Refer patients with suspected environmental exposures to PEHSUs, public health or environmental health agencies, or community organizations for further help with exposure assessment and management.

  6. In patients with suspected environmental etiology of disease, consider a consultation with specialists in the PEHSU network for assistance with the diagnosis, management, or treatment of complex environmental health issues.

  7. Contact local public health and environmental health authorities about previously unknown or unrecognized community environmental exposures to allow for further community-based assessment of potential impacts on children’s health and management of the problem.

  1. Increase the amount of environmental health and climate change content offered as continuing medical education (CME) credits and in maintenance of certification (MOC) credits as well as in certification and recertification examinations.

  2. Collaborate with other pediatric and environmental organizations (national and international), as well as with the WHO, to advocate for prevention strategies and policies that protect children against environmental hazards in all countries.

  3. Collaborate with health departments and research institutions to develop standardized data sets to enhance surveillance, analysis, and reporting of environmental exposures and environmentally related diseases.

  4. Collaborate with other national or international pediatric and health organizations to prevent and ameliorate the impact of environmental factors on the health of children, and address child poverty as a determinant of health. These goals can be further achieved by supporting progress on the Sustainable Development Goals.

  1. Nations, states, territories, and cities must take action to end the exposure of all children to known toxic chemicals and to prevent the entry of untested new chemicals into markets.

  2. Nations, states, and cities must put the protection of children’s health at the center of all environmental legislation and rule making and deliberately consider potential impacts on children’s health in all environmental decision making.

  3. When setting environmental regulations, use the best available scientific evidence that adequately considers the unique vulnerabilities of children as well as the impacts on children’s health and development of cumulative exposures to chemical mixtures.

  4. When setting environmental regulations, seek whenever possible to regulate entire classes of chemicals such as the organophosphate insecticides rather than individual chemicals within such classes.

  5. Increase the resources directed to global public health and pollution prevention to better protect children against environmental threats to health.

  6. Increase resources for the surveillance, analysis, and reporting of environmental exposures and environmentally related diseases.

  7. Create channels of communication for dissemination of information among governmental and nongovernmental organizations regarding pediatric environmental exposures, effects, and management strategies.

  8. Increase opportunities and resources for training pediatric health workers in environmental and occupational health to provide the global health workforce needed to address these health problems.

  9. Create more opportunities and resources for research on global pediatric environmental health issues to include characterizations of environmental exposures and study of efficacy of interventions to evaluate, decrease, and/or prevent exposures.

  10. Create opportunities for increased collaboration between high-income and low- and middle-income countries in achieving the above recommendations.

Lauren Zajac, MD, MPH, FAAP

Philip J. Landrigan, MD, MSc, FAAP

Lauren Zajac, MD, MHP, 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

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

Grace Robiou – 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

Dr Zajac was the lead author and Drs Zajac and Landrigan were both responsible for conceptualizing, writing, and revising the manuscript and considering input from all reviewers and the board of directors, and all authors approved the final manuscript as submitted.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

FUNDING: No external funding.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2024-070076.

AAP

American Academy of Pediatrics

LMICs

low- and middle-income countries

PEHSU

Pediatric Environmental Health Specialty Unit

WHO

World Health Organization

1
Suchdev
PS
,
Howard
CR
.
The role of pediatricians in global health
.
Pediatrics.
2018
;
142
(
6
):
e20182997
. doi:10.1542/peds.2018-2997
2
Philipsborn
RP
,
Chan
K
.
Climate change and global child health
.
Pediatrics.
2018
;
141
(
6
):
e20173774
. doi: 10.1542/peds.2017-3774
3
Linton
JM
,
Green
A
,
Chilton
LA
, et al
.
Providing care for children in immigrant families
.
Pediatrics.
2019
;
144
(
3
):
e20192077
. doi: 10.1542/peds.2019-2077
4
Miller
MD
,
Marty
MA
,
Landrigan
PJ
.
Children’s environmental health: beyond national boundaries
.
Pediatr Clin North Am.
2016
;
63
(
1
):
149
165
. doi: 10.1016/j.pcl.2015.08.008
5
Landrigan
PJ
,
Fuller
R
,
Fisher
S
, et al
.
Pollution and children’s health
.
Sci Total Environ.
2019
;
650
(
Pt 2
):
2389
2394
. doi: 10.1016/j.scitotenv.2018.09.375
6
Suk
WA
,
Ahanchian
H
,
Asante
KA
, et al
.
Environmental pollution: an underrecognized threat to children’s health, especially in low- and middle-income countries
.
Environ Health Perspect.
2016
;
124
(
3
):
A43
A45
. doi: 10.1289/ehp.1510517
7
Landrigan
PJ
,
Fuller
R
.
The impact of pollution on planetary health: emergence of an underappreciated risk factor
.
UN Environment Perspective.
2017
;
29
:
1
12
8
World Health Organization
.
Inheriting a Sustainable World: Atlas on Children’s Health and the Environment
.
World Health Organization
;
2017
. Available at: https://www.who.int/publications/i/item/9789241511773. Accessed May 19,
2020
9
Zajac
L
,
Landrigan
PJ
;
American Academy of Pediatrics, Council on Environmental Health and Climate Change
.
Technical report. Environmental issues in global pediatric health
.
Pediatrics
.
2023
; in press
10
Landrigan
PJ
,
Fuller
R
,
Acosta
NJR
, et al
.
The Lancet Commission on pollution and health
.
Lancet.
2018
;
391
(
10119
):
462
512
. doi: 10.1016/S0140-6736(17)32345-0
11
Bullard
RD
,
Robert
D
.
Dumping in Dixie : Race, Class, and Environmental Quality
.
Westview Press
;
1990
12
Foote
EM
,
Singleton
RJ
,
Holman
RC
, et al
.
Lower respiratory tract infection hospitalizations among American Indian/Alaska Native children and the general United States child population
.
Int J Circumpolar Health.
2015
;
74
:
29256
. doi: 10.3402/IJCH.V74.29256
13
Singleton
R
,
Salkoski
AJ
,
Bulkow
L
, et al
.
Impact of home remediation and household education on indoor air quality, respiratory visits and symptoms in Alaska Native children
.
Int J Circumpolar Health.
2018
;
77
(
1
):
1422669
. doi: 10.1080/22423982.2017.1422669
14
Hennessy
TW
,
Ritter
T
,
Holman
RC
, et al
.
The relationship between in-home water service and the risk of respiratory tract, skin, and gastrointestinal tract infections among rural Alaska Natives
.
Am J Public Health.
2008
;
98
(
11
):
2072
. doi: 10.2105/AJPH.2007.115618
15
Smith
KR
,
Ezzati
M
.
How environmental health risks change with development: the epidemiologic and environmental risk transitions revisited
.
Annu Rev Environ Resour.
2005
;
30
:
291
333
. doi: 10.1146/annurev.energy.30.050504.144424
16
Omran
AR
.
The epidemiologic transition: a theory of the epidemiology of population change
.
Milbank Q.
2005
;
83
(
4
):
731
757
. doi: 10.1111/j.1468-0009.2005.00398.x
17
Yadama
GN
.
Fires, Fuel, and the Fate of Three Billion: Portraits of the Energy Impoverished
.
Oxford University Press
;
2013
18
Grant
K
,
Goldizen
FC
,
Sly
PD
, et al
.
Health consequences of exposure to e-waste: a systematic review
.
Lancet Glob Heal.
2013
;
1
(
6
):
e350
e361
. doi: 10.1016/S2214-109X(13)70101-3
19
Spitz
PH
.
The Chemical Industry at the Millennium : Maturity, Restructuring, and Globalization
.
Chemical Heritage Press
;
2003
20
Pronczuk
J
,
Bruné
MN GF
. Children’s environmental health in developing countries. In:
Nriagu
JO
,
Kacew
S
,
Kawamoto
T
,
Patz
JA RD
, ed.
Encyclopedia of Environmental Health
.
Amsterdam, Netherlands
:
Elsevier
;
2011
:
601
610
. https://www.sciencedirect.com/referencework/9780444522726/encyclopedia-of-environmental-health. Accessed May 19, 2020
21
Stanaway
JD
,
Afshin
A
,
Gakidou
E
, et al
.
Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017
.
Lancet.
2018
;
392
(
10159
):
1923
1994
. doi: 10.1016/S0140-6736(18)32225-6
22
Yen
C
,
Tate
JE
,
Hyde
TB
, et al
.
Rotavirus vaccines: current status and future considerations
.
Hum Vaccines Immunother.
2014
;
10
(
6
):
1436
1448
. doi: 10.4161/hv.28857
23
Florez
ID
,
Al-Khalifah
R
,
Sierra
JM
, et al
.
The effectiveness and safety of treatments used for acute diarrhea and acute gastroenteritis in children: protocol for a systematic review and network meta-analysis
.
Syst Rev.
2016
;
5
(
1
). doi: 10.1186/s13643-016-0186-8
24
Branca
F
,
Piwoz
E
,
Schultink
W
,
Sullivan
LM
.
Nutrition and health in women, children, and adolescent girls
.
BMJ.
2015
;
351
:
h4173
. doi: 10.1136/bmj.h4173
25
Landrigan
PJ
,
Sly
JL
,
Ruchirawat
M
, et al
.
Health consequences of environmental exposures: changing global patterns of exposure and disease
.
Ann Glob Health.
2016
;
82
(
1
):
10
19
. doi: 10.1016/j.aogh.2016.01.005
26
Remais
JV
,
Zeng
G
,
Li
G
,
Tian
L
,
Engelgau
MM
.
Convergence of non-communicable and infectious diseases in low-and middle-income countries
.
Int J Epidemiol.
2013
;
42
:
221
227
. doi: 10.1093/ije/dys135
27
Fuller
R
,
Rahona
E
,
Fisher
S
, et al
.
Pollution and non-communicable disease: time to end the neglect
.
Lancet Planet Health.
2018
;
2
(
3
):
e96
e98
. doi: 10.1016/S2542-5196(18)30020-2
28
Samet
JM
,
Burke
TA
,
Goldstein
BD
.
The Trump administration and the environment—heed the science
.
N Engl J Med.
2017
;
376
(
12
):
1182
1188
. doi: 10.1056/NEJMms1615242
29
Grosse
SD
,
Matte
TD
,
Schwartz
J
,
Jackson
RJ
.
Economic gains resulting from the reduction in children’s exposure to lead in the United States
.
Environ Health Perspect.
2002
;
110
(
6
):
563
569
. doi: 10.1289/ehp.02110563
30
Gauderman
WJ
,
Urman
R
,
Avol
E
, et al
.
Association of improved air quality with lung development in children
.
N Engl J Med.
2015
;
372
(
10
):
905
913
. doi: 10.1056/NEJMoa1414123
31
Galvez
M
,
Collins
G
,
Amler
RW
, et al
.
Building New York state centers of excellence in children’s environmental health: a replicable model in a time of uncertainty
.
Am J Public Health.
2019
;
109
(
1
):
108
112
. doi: 10.2105/AJPH.2018.304742
32
Barreto
M
.
The globalization of epidemiology: critical thoughts from Latin America
.
Int J Epidemiol.
2004
;
33
(
5
):
1132
1137
. Available at: https://www.researchgate.net/publication/8490293_The_globalization_of_epidemiology_Critical_thoughts_from_Latin_America. Accessed May 19,
2020
33
De Maio
FG
.
Understanding chronic non-communicable diseases in Latin America: towards an equity-based research agenda
.
Global Health.
2011
;
7
(
1
):
36
. doi: 10.1186/1744-8603-7-36
34
US Environmental Protection Agency, Office of Air and Radiation
.
Overview of the Clean Air Act and Air Pollution
.
2020
. Available at: https://www.epa.gov/clean-air-act-overview. Accessed May 19,
2020
35
Watts
N
,
Amann
M
,
Arnell
N
, et al
.
The 2019 report of The Lancet Countdown on Health and Climate Change: ensuring that the health of a child born today is not defined by a changing climate
.
Lancet.
2019
;
394
(
10211
):
1836
1878
. doi: 10.1016/S0140-6736(19)32596-6
36
Anderko
L
,
Chalupka
S
,
Du
M
,
Hauptman
M
.
Climate changes reproductive and children’s health: a review of risks, exposures, and impacts
.
Pediatr Res.
2020
;
87
(
2
):
414
419
. doi: 10.1038/s41390-019-0654-7
37
Ahdoot
S
,
Baum
CR
,
Cataletto
M
,
Hogan
P
,
Wu
CB
,
Bernstein
A
;
American Academy of Pediatrics, Council on Enviornmental Health and Climate Change, Council on Children and Disasters, Section on Pediatric Pulmonology and Sleep Medicine, Section on Minority Health, Equity, and Inclusion
.
Policy statement. Climate change and children’s health: building a healthy future for every child
.
Pediatrics
2024
;
153
(
3
):
e2023065504
38
Ahdoot
S
,
Baum
CR
,
Cataletto
M
,
Hogan
P
,
Wu
CB
,
Bernstein
A
,
Council on Enviornmental Health and Climate Change, Council on Children and Disasters, Section on Pediatric Pulmonology and Sleep Medicine, Section on Minority Health, Equity, and Inclusion. Technical report. Climate Change and Children’s Health: Building a Healthy Future for Every Child
.
Pediatrics
March
2024
;
153
(
3
):
e2023065505
. 10.1542/peds.2023-065505
39
American Academy of Pediatrics, Council on Environmental Health
.
Pediatric Environmental Health
.
Etzel
RA
,
Balk
SJ
, eds.
Itasca, IL
:
American Academy of Pediatrics
;
2018
40
World Health Organization
.
The Paediatric Environmental History Recording Children’s Exposure to Environmental Health Threats: A “Green Page” in the Medical Record
.
World Health Organization
;
2018
. Available at: https://www.who.int/news-room/questions-and-answers/item/q-a-the-paediatric-environmental-history. Accessed May 16,
2023
41
Paulson
JA
,
Karr
CJ
,
Seltzer
JM
, et al
.
Development of the pediatric environmental health specialty unit network in North America
.
Am J Public Health.
2009
;
99
(
Suppl 3
)
S511
S516
. doi: 10.2105/ajph.2008.154641
42
Wilborne-Davis
P
,
Kirkland
KH
,
Mulloy
KB
.
A model for physician education and consultation in pediatric environmental health—the Pediatric Environmental Health Specialty Units (PEHSU) Program
.
Pediatr Clin North Am.
2007
;
54
(
1
):
1
13
. doi: 10.1016/j.pcl.2006.11.001
43
American Academy of Pediatrics
,
Council on Community Pediatrics
. Immigrant Child Health Toolkit.
2020
. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Immigrant-Child-Health-Toolkit/Pages/Immigrant-Child-Health-Toolkit.aspx. Accessed December 1,
2022
44
Jones
VF
,
Schulte
EE
,
Springer
S
, et al
.
Comprehensive health evaluation of the newly adopted child
.
Pediatrics.
2019
;
143
(
5
):
e20190657
. doi: 10.1542/peds.2019-0657
45
Trasande
L
,
Schapiro
ML
,
Falk
R
, et al
.
Pediatrician attitudes, clinical activities, and knowledge of environmental health in Wisconsin
.
Wis Med J.
2006
;
105
(
2
):
45
49
46
Trasande
L
,
Boscarino
J
,
Graber
N
, et al
.
The environment in pediatric practice: a study of New York pediatricians’ attitudes, beliefs, and practices towards children’s environmental health
.
J Urban Heal.
2006
;
83
(
4
):
760
772
. doi: 10.1007/s11524-006-9071-4
47
Trasande
L
,
Newman
N
,
Long
L
, et al
.
Translating knowledge about environmental health to practitioners: are we doing enough?
Mt Sinai J Med.
2010
;
77
(
1
):
114
123
. doi: 10.1002/msj.20158
48
Philipsborn
RP
,
Sheffield
P
,
White
A
,
Osta
A
,
Anderson
MS
,
Bernstein
A
.
Climate change and the practice of medicine: essentials for resident education
.
Acad Med.
2021
;
96
(
3
):
355
367
. doi: 10.1097/ACM.0000000000003719
49
Landrigan
PJ
,
Woolf
AD
,
Gitterman
B
, et al
.
The ambulatory pediatric association fellowship in pediatric environmental health: a 5-year assessment
.
Environ Health Perspect.
2007
;
115
(
10
):
1383
1387
. doi: 10.1289/ehp.10015
50
Landrigan
PJ
,
Braun
JM
,
Crain
EF
, et al
.
Building capacity in pediatric environmental health: the Academic Pediatric Association’s professional development program
.
Acad Pediatr.
2019
;
19
(
4
):
421
427
. doi: 10.1016/j.acap.2019.01.001
51
Etzel
RA
,
Landrigan
PJ
, eds.
Textbook of Children’s Environmental Health
.
Oxford University Press
;
2024
. ISBN 978 019 766 2533
52
Goldman
RH
,
Zajac
L
,
Geller
RJ
,
Miller
MD
.
Developing and implementing core competencies in children’s environmental health for students, trainees and healthcare providers: a narrative review
.
BMC Med Educ.
2021
;
21
(
1
). doi: 10.1186/S12909-021-02921-3
53
Columbia University Mailman School of Public Health
.
Global Consortium on Climate and Health Education
.
2020
. Available at: https://www.publichealth.columbia.edu/research/global-consortium-climate-and-health-education. Accessed December 1,
2022
54
Drain
PK HK
.
The Fogarty International Center at 50: Accomplishments and Priorities for the Next 50 Years
.
Clin Infect Dis.
2018
;
66
(
9
):
1323
1325
. doi: 10.1093/cid/ciy078
55
World Health Organization
.
Collaboration between the World Health Organization and the National Institute of Environmental Health Sciences: Highlights from 30 Years of Partnership
.
Geneva
:
World Health Organization
;
2011
. Available at: https://www.who.int/publications/i/item/978924502078. Accessed June 26,
2020
56
Greenberg
H
,
Leeder
SR
,
Raymond
SU
.
And why so great a “no?” The donor and academic communities’ failure to confront global chronic disease
.
Glob Heart.
2016
;
11
(
4
):
381
385
. doi: 10.1016/j.gheart.2016.10.018
57
Nugent
R
.
A chronology of global assistance funding for NCD
.
Glob Heart.
2016
;
11
(
4
):
371
374
. doi: 10.1016/j.gheart.2016.10.027
58
Swinehart
S
,
Fuller
R
,
Kupka
R
,
Conte
MN
.
Rethinking aid allocation: analysis of official development spending on modern pollution reduction
.
Ann Glob Heal.
2019
;
85
(
1
). doi: 10.5334/aogh.2633
59
World Health Organization
.
Healthy Environments for Healthier Populations: Why Do They Matter, and What Can We Do?
Geneva
:
World Health Organization
;
2019
60
United Nations
.
Sustainable Development Goals
.
2015
. Available at: https://sustainabledevelopment.un.org. Accessed June 23,
2020
61
Forouzanfar
MH
,
Afshin
A
,
Alexander
LT
, et al
.
Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015
.
Lancet.
2016
;
388
(
10053
):
1659
1724
. doi: 10.1016/S0140-6736(16)31679-8
62
Wang
H
,
Naghavi
M
,
Allen
C
, et al
.
Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015
.
Lancet.
2016
;
388
(
10053
):
1459
1544
. doi: 10.1016/S0140-6736(16)31012-1
63
Landrigan
PJ
,
Goldman
LR
.
Children’s vulnerability to toxic chemicals: a challenge and opportunity to strengthen health and environmental policy
.
Health Aff.
2011
;
30
(
5
):
842
850
. doi: 10.1377/hlthaff.2011.0151
64
Kelly
FJ
,
Fussell
JC
.
Global nature of airborne particle toxicity and health effects: a focus on megacities, wildfires, dust storms and residential biomass burning
.
Toxicol Res (Camb).
2020
;
9
(
4
):
331
345
. doi: 10.1093/toxres/tfaa044
65
World Health Organization
.
Air Pollution
. Available at: https://www.who.int/health-topics/air-pollution#tab=tab_1. Accessed May 25,
2020
66
Lelieveld
J
,
Evans
JS
,
Fnais
M
,
Giannadaki
D
,
Pozzer
A
.
The contribution of outdoor air pollution sources to premature mortality on a global scale
.
Nature.
2015
;
525
(
7569
):
367
371
. doi: 10.1038/nature15371
67
Dettori
M
,
Deiana
G
,
Balletto
G
, et al
.
Air pollutants and risk of death due to COVID-19 in Italy
.
Environ Res.
2021
;
192
:
110459
. doi: 10.1016/j.envres.2020.110459
68
Copat
C
,
Cristaldi
A
,
Fiore
M
, et al
.
The role of air pollution (PM and NO2) in COVID-19 spread and lethality: a systematic review
.
Environ Res.
2020
;
191
:
110129
. doi: 10.1016/j.envres.2020.110129
69
Paital
B
,
Agrawal
PK
.
Air pollution by NO2 and PM2.5 explains COVID-19 infection severity by overexpression of angiotensin-converting enzyme 2 in respiratory cells: a review
.
Environ Chem Lett.
2021
;
19
(
1
):
25
42
. doi: 10.1007/s10311-020-01091-w
70
Zoran
MA
,
Savastru
RS
,
Savastru
DM
,
Tautan
MN
.
Assessing the relationship between surface levels of PM2.5 and PM10 particulate matter impact on COVID-19 in Milan, Italy
.
Sci Total Environ.
2020
;
738
:
139825
. doi: 10.1016/j.scitotenv.2020.139825
71
Balakrishnan
K
,
Cohen
A
,
Smith
KR
.
Addressing the burden of disease attributable to air pollution in India: the need to integrate across household and ambient air pollution exposures
.
Environ Health Perspect.
2014
;
122
(
1
):
A6
A7
. doi: 10.1289/ehp.1307822
72
Fewtrell
LJ
,
Prüss-Üstün
A
,
Landrigan
P
,
Ayuso-Mateos
JL
.
Estimating the global burden of disease of mild mental retardation and cardiovascular diseases from environmental lead exposure
.
Environ Res.
2004
;
94
(
2
):
120
133
. doi: 10.1016/S0013-9351(03)00132-4
73
Haefliger
P
,
Mathieu-Nolf
M
,
Lociciro
S
, et al
.
Mass lead intoxication from informal used lead-acid battery recycling in Dakar, Senegal
.
Environ Health Perspect.
2009
;
117
(
10
):
1535
1540
. doi: 10.1289/ehp.0900696
74
United Nations Environment Programme
.
Global Mercury Assessment 2018. UNEP-UN Environment Programme
.
Geneva
:
United Nations
;
2019
. doi:ISBN: 978-92-807-3744-8
75
World Health Organization
.
Mercury and health
.
2017
. Available at: https://www.who.int/news-room/fact-sheets/detail/mercury-and-health. Accessed May 25,
2020
76
Hopenhayn-Rich
C
,
Browning
SR
,
Hertz-Picciotto
I
,
Ferreccio
C
,
Peralta
C
,
Gibb
H
.
Chronic arsenic exposure and risk of infant mortality in two areas of Chile
.
Environ Health Perspect.
2000
;
108
(
7
):
667
673
. doi: 10.1289/ehp.00108667
77
Smith
AH
,
Marshall
G
,
Liaw
J
,
Yuan
Y
,
Ferreccio
C
,
Steinmaus
C
.
Mortality in young adults following in utero and childhood exposure to arsenic in drinking water
.
Environ Health Perspect.
2012
;
120
(
11
):
1527
1531
. doi: 10.1289/ehp.1104867
78
Von Ehrenstein
OS
,
Poddar
S
,
Yuan
Y
, et al
.
Children’s intellectual function in relation to arsenic exposure
.
Epidemiology.
2007
;
18
(
1
):
44
51
. doi: 10.1097/01.ede.0000248900.65613.a9
79
Wasserman
GA
,
Liu
X
,
Parvez
F
, et al
.
Water arsenic exposure and children’s intellectual function in Araihazar, Bangladesh
.
Environ Health Perspect.
2004
;
112
(
13
):
1329
1333
. doi: 10.1289/ehp.6964
80
Food and Agriculture Organization of the United Nations
.
Prevention and Disposal of Obsolete Pesticides: Pesticide Bans
. Available at: http://www.fao.org/agriculture/crops/obsolete-pesticides/why-problem/pesticide-bans/en. Accessed May 20,
2020
81
United Nations Environment Programme
.
Childhood Pesticide Poisoning: Information for Advocacy and Action
.
Chatelaine, Switzerland
:
United Nations Environment Programme
;
2004
82
Frank
AL
,
Joshi
TK
.
The global spread of asbestos
.
Ann Glob Heal.
2014
;
80
(
4
):
257
262
. doi: 10.1016/j.aogh.2014.09.016
83
Xu
X
,
Yang
H
,
Chen
A
, et al
.
Birth outcomes related to informal e-waste recycling in Guiyu, China
.
Reprod Toxicol.
2012
;
33
(
1
):
94
98
. doi: 10.1016/j.reprotox.2011.12.006
84
Heacock
M
,
Kelly
CB
,
Asante
KA
, et al
.
E-waste and harm to vulnerable populations: a growing global problem
.
Environ Health Perspect.
2016
;
124
(
5
):
550
555
. doi: 10.1289/ehp.1509699
85
Peden
M
,
Oyegbite
K
,
Ozanne-Smith
J
, et al
.
World Report on Child Injury Prevention
.
Geneva, Switzerland
;
2008
. Available at: https://www.who.int/publications/i/item/9789241563574. Accessed June 4,
2020
86
Garner
A
,
Yogman
M
;
Committee on Psychosocial Aspects of Child and Family Health, Section on Developmental and Behavioral Pediatrics, Council on Early Childhood
.
Preventing childhood toxic stress: partnering with families and communities to promote relational health
.
Pediatrics.
2021
;
148
(
2
):
e2021052582
87
Centers for Disease Control and Prevention
.
Refugees and Other Newcomer Persons Resettled to the United States
. Available at: https://www.cdc.gov/nceh/lead/prevention/refugees.htm. Accessed May 16,
2023
88
US Environmental Protection Agency, US Food and Drug Administration
.
Fish and Shellfish Advisories and Safe Eating Guidelines
. Choose Fish and Shellfish Wisely.
2020
. Available at: https://www.epa.gov/choose-fish-and-shellfish-wisely/fish-and-shellfish-advisories-and-safe-eating-guidelines. Accessed June 16,
2020
89
US Environmental Protection Agency
.
Mercury in Consumer Products
.
2019
. Available at: https://www.epa.gov/mercury/mercury-consumer-products. Accessed June 19,
2020
.
90
US Food and Drug Administration
.
What You Can Do to Limit Exposure to Arsenic
.
2019
. Available at: https://www.fda.gov/food/metals-and-your-food/what-you-can-do-limit-exposure-arsenic. Accessed June 16,
2020
91
Migrant Clinicians Network
.
Environmental and Occupational Health Screening Questions for Primary Care
.
2020
. Available at: https://www.migrantclinician.org/toolsource/288/environmental-and-occupational-health/index.html. Accessed June 16,
2020
92
American Academy of Pediatrics
,
Julius
B
.
Richmond Center of Excellence. Tobacco Control and Prevention
.
2020
. Available at: https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Richmond-Center/Pages/default.aspx. Accessed June 19,
2020
.
93
Hoyme
HE
,
Kalberg
WO
,
Elliott
AJ
, et al
.
Updated clinical guidelines for diagnosing fetal alcohol spectrum disorders
.
Pediatrics.
2016
;
138
(
2
):
e20154256
. doi: 10.1542/peds.2015-4256
94
American Academy of Pediatrics
.
The Fetal Alcohol Spectrum Disorders (FASD) Toolkit
. Available at: https://www.aap.org/en/patient-care/fetal-alcohol-spectrum-disorders/. Accessed May 20,
2020
95
National Environmental Education Foundation
.
Asthma Environmental History Form
.
2020
. Available at: https://www.neefusa.org/resource/asthma-environmental-history-form. Accessed June 19,
2020
96
New York City Department of Health
.
Hazardous Consumer Products
.
2020
. Available at: https://www1.nyc.gov/site/doh/health/health-topics/lead-poisoning-hazardous-consumer-products.page. Accessed June 16,
2020
97
New York City Department of Health
.
Hazardous Foods and Spices
.
2020
. Available at: https://www1.nyc.gov/site/doh/health/health-topics/hazardous-foods-spices.page. Published 2020. Accessed June 16,
2020