September 2019

Cleaner air for healthier children

In October/November 2018 WHO will convene the ‘First Global Conference on Air Pollution and Health’, which willbring authorities, policy makers, health professionals and other relevant entities together in a global effort to improve the quality of our air and combate climate change. The conference will highlight the links between air pollution and the global epidemic of noncommunicable diseases and aim to enhance pro-health policies on clean household energy, transport and waste.

Current situation

This global conference is important as air pollution from both outdoor and indoor sources represents the single largest environmental risk to health globally. According to WHO, ambient and household air pollution cause some 6.5 million deaths annually of which 627,000are children under 5 years of age. Recent data confirms that most cities exceed recommended WHO Air Quality levels of pollution. The burden of disease attributable to air pollution is not evenly distributed across Europe with higher prevalence in low- and middle-income countries compared to high-income countries. Household air pollution is a leading cause of morbidity and mortality in poor rural and urban homes.

How are children affected by air pollution?

Children are especially vulnerable to the negative effects of air pollution because of their unique behaviours and physiology. Children often play in the dust or crawl on the ground. They spend much more time outdoors than adults do, increasing their exposure to air pollutants, and they also have fewer biological defences compared to adults.

Evidence suggests[i] that current levels of ambient air pollutants may cause deficits in lung function growth in children.  Ambient air pollution has been associated with increased respiratory symptoms among non-asthmatic children, as well as increased respiratory hospital admissions and paediatric visits to the emergency department.

Less well-known but as important are the effects of air pollution on allergic rhinitis in children. Allergic rhinitis is a very common disease in children and adolescents which is often undervalued and underdiagnosed. It is an inflammatory disease of the nasal mucosa caused by exposure to allergens, most commonly domestic dust mites, pollens and pet dander. Viral infections are also an important trigger. At face value allergic rhinitis may seem to be a trivial disease, however it does cause a lot of morbidity and affects the quality of life of the individual. When untreated, it can limit physical activity, and intellectual and social life. Paediatricians do not only have a role in evaluating, investigating and treating children with allergic rhinitis, but also in advocating for cleaner air, both indoors and outside.

The symptoms can occur minutes after exposure and last for days. The treatment consists of avoidance of allergens and risk factors, like tobacco smoke or air pollution, drug relief therapy with oral antihistamines and/or intranasal steroids or allergen immunotherapy. It is important that paediatricians know how to evaluate pediatric patients with rhinitis, investigate the pattern of allergens sensitisation and initiate appropriate therapy. This control will not only improve the quality of life but also prevent possible comorbidities, like allergic conjunctivitis, ear infections, sleep disturbances and asthma. Active and passive exposure to tobacco smoke is related not only to worsening but also to the onset of rhinitis symptoms. Anti-smoking policies, as reviewed in our previous blog about tobacco, are essential to protect and improve the prognosis of these hyper-reactive patients.

Air pollution including cigarette smoke compromises natural pulmonary defence mechanisms by disrupting both mucociliary function and macrophage activity. Exposure to cigarette smoke therefore increases the risk for pneumonia in infants younger than one year of age. According to WHO, approximately a million children die from pneumonia each year worldwide. Half of these are linked to air pollution. There is a growing body of evidence that second-hand smoke exposure is also associated with the development of asthma.

Clean air is critical for children′s health and well-being. Many samples from children populations are showing an array of adverse short and long-term health outcomes, which include some of the most detrimental effects on brain development . However, most of current research and policy efforts link air pollution to respiratory and cardiovascular disease, and the effects on children’s central nervous system are still not broadly recognised.

What should be done

Air pollution in the home should be identified, and its sources eliminated or reduced. Common sources of pollutants like chemical cleaners should be used responsibly and with care. In addition, the house should be regularly maintained and cleaned to eliminate dust and mould. Air pollutants like dust, mould, smoke and particulate matter can be harmful to children, so it is important to remove these pollutants from indoor air. High-efficiency air filters can remove substantial amounts of the air pollutants which threaten the health of children and adults alike. Paediatricians have a role in informing parents about these pollutants and on measures to eliminate or reduce exposure.

Our Recommendations

Air pollution does not recognise borders. Improving air quality requires sustained and coordinated action at all levels. The former Bulgarian Presidency of the Council of the EU had designated air quality improvement as one of its top environmental priorities. Young EAP encourages  the current Austrian Presidency and European governments to continue to work together on solutions for sustainable transport; renewable, efficient energy production and usage; and waste management across Europe.

Because of the impact of air pollution on health, Young EAP also encourages paediatricians to underline the importance of the paediatric environmental health history when speaking to children and their parents. This history should therefore include screening questions whenever applicable, directed toward describing their home or other environments frequented by the child. This would allow for earlier detection of diseases associated with air pollution, such as allergic rhinitis. Furthermore, earlier detection would mean earlier management and control of disease progression for the overall well-being of children.

About the authors

Sian Copley is a 3^rd year resident from the UK working in the North East of England and representing UK paediatric trainees within Young EAP and paediatric trainees/Young EAP within the EAP Advocacy Group.

Veronica Said Pullicino is a 4^th year paediatric trainee in Malta, and she represents the Maltese paediatric trainees within the Young EAP.

Lenneke Schrier is the European Junior Doctor Representative to the European Academy of Paediatrics, and the Chair of Young EAP. She is a 4th year paediatric trainee at the Leiden University Medical Center in the Netherlands.

Ana Neves is a Professor of Paediatrics and the Coordinator of the Paediatric Allergology Unit at the University Hospital of Santa Maria in Lisbon, and the Vice-President of the European Academy of Paediatrics.

References

[I] ESPOSITO ET AL. IMPACT OF AIR POLLUTION ON RESPIRATORY DISEASES IN CHILDREN WITH RECURRENT WHEEZING OR ASTHMA. BMC PULMONARY MEDICINE 2014 14:130

ALL OTHER REFERENCES PROVIDED IN THE FORM OF HYPERLINKS THROUGHOUT THE TEXT.