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.
Introduction
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.
Statement of the Problem
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:
Key environmental issues in global pediatric health, with a particular focus on the major environmental hazards contributing to pediatric morbidity and mortality in LMICs.
Strategies and resources to recognize, diagnose, manage, and prevent disease in children caused by hazardous environmental exposures in LMICs.
Opportunities for increased education and training on environmental health issues for pediatricians and other pediatric health professionals.
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.
Role of governmental and nongovernmental organizations to increase resources and capacity to address children’s environmental health.
Environmental Justice
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
Diseases Caused by Hazardous Environmental Exposures Can Be Prevented
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.
The High Costs of Disease Caused by Hazardous Environmental Exposures
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 Disease Caused by Hazardous Environmental Exposures is Highly Cost-Effective
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
Key Environmental Exposures in LMICs
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
Select Key Environmental Exposures of Concern in Low- and Middle-Income Countries (LMICs)
Environmental Concern . | Sources of Exposure . | Health Impacts and Disease Burden . |
---|---|---|
Water, sanitation, and hygiene (WASH) |
| |
Ambient air pollution |
| |
Household air pollution (HAP) |
| |
Lead |
|
|
Mercury |
| |
Arsenic |
| |
Pesticides |
|
|
Hazardous wastes |
|
|
Unintentional injuries |
|
|
Environmental Concern . | Sources of Exposure . | Health Impacts and Disease Burden . |
---|---|---|
Water, sanitation, and hygiene (WASH) |
| |
Ambient air pollution |
| |
Household air pollution (HAP) |
| |
Lead |
|
|
Mercury |
| |
Arsenic |
| |
Pesticides |
|
|
Hazardous wastes |
|
|
Unintentional injuries |
|
|
PM2.5= particulate matter with aerodynamic diameter of 2.5 microns or less; also known as “fine particulate matter.”
Role of the Pediatrician and Other Health Care Professionals
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.
Sources of Environmental Exposures Among Immigrant, Refugee, and Internationally Adopted Children and Adolescents in the United States
. | Possible Sources of Exposure . | Clinical Resources . |
---|---|---|
General Environmental Health Considerations | ||
| 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:
| Obtain a blood lead level on all foreign-born children. CDC has additional guidance on testing immigrant and refugee children for lead.87 |
Mercury |
| EPA and FDA provide fish consumption guidance.88 EPA has information on mercury in consumer products.89 |
Arsenic |
| 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 |
| 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 |
| New York City Department of Health (NYCDOH) has compiled an extensive list of consumer products that may be contaminated with heavy metals.96 |
Diet |
| 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 Exposure . | Clinical Resources . |
---|---|---|
General Environmental Health Considerations | ||
| 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:
| Obtain a blood lead level on all foreign-born children. CDC has additional guidance on testing immigrant and refugee children for lead.87 |
Mercury |
| EPA and FDA provide fish consumption guidance.88 EPA has information on mercury in consumer products.89 |
Arsenic |
| 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 |
| 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 |
| New York City Department of Health (NYCDOH) has compiled an extensive list of consumer products that may be contaminated with heavy metals.96 |
Diet |
| 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
Role of Pediatric and Public Health Organizations
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.
Need for Expanded Education in Children’s Environmental Health
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.
Need for Increased Resources in Children’s 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.
Role of Governmental and Nongovernmental Agencies
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.
Summary and Recommendations
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.
Recommendations for Pediatricians and Other Health Care Professionals
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.
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.
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.
Include environmental health questions during appropriate medical encounters with existing patients who have environmentally related disease (eg, asthma).
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.
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.
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.
Recommendations for Pediatric Organizations
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.
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.
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.
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.
Recommendations for Governmental and Nongovernmental Agencies
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.
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.
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.
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.
Increase the resources directed to global public health and pollution prevention to better protect children against environmental threats to health.
Increase resources for the surveillance, analysis, and reporting of environmental exposures and environmentally related diseases.
Create channels of communication for dissemination of information among governmental and nongovernmental organizations regarding pediatric environmental exposures, effects, and management strategies.
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.
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.
Create opportunities for increased collaboration between high-income and low- and middle-income countries in achieving the above recommendations.
Lead Authors
Lauren Zajac, MD, MPH, FAAP
Philip J. Landrigan, MD, MSc, FAAP
Council on Environmental Health and Climate Change Executive Committee, 2022–2023
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
Liaisons
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
Staff
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.
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