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Briefing
Protecting children’s health is frequently cited as a key objective in major policies on climate and the environment such as the zero pollution action plan (European Commission, 2020). Though most children across EEA member countries are healthy (Eurostat, 2019; WHO, 2023), there are reasons for concern regarding environmental risks to their health. Children and adolescents are more susceptible than adults to most adverse environmental factors; in some cases they may be more exposed than adults too (Valent et al., 2004); and they can do little to change the situation or protect themselves. That is especially true for air pollution, the largest environmental risk for children in Europe.
There are many factors that make children and adolescents especially vulnerable to air pollution. Children’s breathing rates are higher than those of adults and they also take in more air per kilogram of body weight. Because of their lower physical height, they breathe air closer to the ground where some pollutants, especially from traffic exhausts, are emitted and become concentrated. Their acquired dose of pollution is also elevated since they breathe faster and are often more physically active (Osborne et al., 2021). Moreover, children inhale a larger fraction of air through their mouths than adults. Due to this increased oral breathing, pollution penetrates deep into the lower respiratory tract, which is more permeable (US EPA, 2019). Children’s bodies and organs, including their lungs, are also still in development (Chen et al., 2015), which further increases risk. Furthermore, children’s developing immune systems are weaker than those of adults, strengthening the effects of pollution (WHO, 2018). Figure 1 illustrates key characteristics of children’s and adolescents’ vulnerability and exposure to air pollution.
Air pollution is the contamination of indoor or outdoor air by any agent that modifies its natural characteristics. It comes from both natural and, particularly, man-made sources, which include everything from road traffic and residential heating exhausts, through to factory chimney stacks and a wide variety of other sources (EEA, 2022a, 2022c). Air pollution affects urban and rural areas, and comes in many forms, from ambient air particles, ozone and nitrogen oxides, to second-hand smoke (SHS), smoke from the burning of biomass in households, mould spores, mites and allergens, and toxic chemicals like formaldehyde (Trasande et al., 2016; Carreras et al., 2019; Rojas-Rueda et al., 2019; WHO, 2022). Some of the aforementioned pollutants and sources are more frequent or found at higher concentrations indoors. They are the subject of ongoing research at the EEA and findings will be summarised in forthcoming publications. Boxes 1 and 2 in this briefing provide some highlights on indoor air pollutants.
This briefing however focuses on outdoor ambient air pollution, a term that is used interchangeably with ‘air pollution’ hereafter. Depending on the pollutant, different sources of ambient air pollution are the main drivers of exposure, as illustrated in Figure 2 below (EEA, 2022b).
Source: EEA (2022a)[2]. NMVOC: non-methane volatile organic compounds; NOX: nitrogen oxides; PM2.5: particles with a diameter smaller than 2,5 microns; PM10: particles with a diameter smaller than 10 microns; SO2: sulphur dioxide.
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Children’s and adolescents’ exposure to air pollutants partly mimics that of adults, but it also differs in specific ways. Children are already exposed to air pollution while in their mothers’ wombs, and after birth they are typically exposed to air pollution in child-centric settings such as: outside in the grounds of schools and kindergartens; in classrooms where ambient air pollution worsens indoor air quality; and during activities like commuting to school and afterschool activities. Smaller children are also exposed to air pollution closer to the ground, where the concentrations of some pollutants are higher. Children and adolescents tend to spend more time outdoors and are more physically active than adults, potentially increasing their exposure to ambient air pollution. In addition, as is the case with other environmental risks, poorer children tend to be systematically more exposed to and affected by air pollution (Fairburn et al., 2019) than their better-off counterparts.
Children are affected by ambient air pollutants from the womb through to adulthood. Every year in EEA member and collaborating countries, air pollution is estimated to cause over 1,200 deaths and the loss of over 110,000 disability-adjusted life years (DALYs, a measure of the burden of disease caused by a risk factor) among those aged under 18 (GBD Collaborative Network, 2020). These deaths, along with a significant burden from non-fatal diseases, are caused by air pollution through a variety of mechanisms and health outcomes, which are explored below.
Before birth, ambient air pollution increases the risk of babies being smaller during pregnancy (a condition known as ‘small for gestational age’, or SGA) (Pun et al., 2021; Health Effects Institute, 2022; Nyadanu et al., 2022), having a low birth weight (Yang et al., 2020; Ghosh et al., 2021) as well as having an increased risk of pre-term birth (US EPA, 2020; Nyadanu et al., 2022; Yu et al., 2022). All of these can increase the risk of different health problems later in life. Though the evidence is less clear, particulate matter has also been linked to an increased risk of spontaneous abortion and still births (Grippo et al., 2018; Zhang et al., 2021; Zhu et al., 2022). Despite solid epidemiological data, the biological mechanisms are not fully understood for most of the pre-natal risks of air pollution.
After birth, ambient air pollution increases the risk of several types of adverse health outcomes for children and adolescents. For example, it increases the risk of respiratory infections in children, including acute lower respiratory infections, pneumonia, upper respiratory infections and otitis media (ear infections) (Mehta et al., 2013; Nhung et al., 2017; Bowatte et al., 2018; King et al., 2018; Låg et al., 2020; Lee et al., 2020; Health Effects Institute, 2022; Ziou et al., 2022). Short-term exposure to air pollution may also exacerbate allergies, including allergic rhinitis (runny nose), eczema and conjunctivitis (itchy eyes) in children (US EPA, 2015, 2017, 2019, 2020).
Children’s lung function and lung development are also affected by ambient air pollution, especially by ozone and nitrogen dioxide (NO2) in the short term, and by fine particles (PM2.5) in the long term. This effect can be seen both in healthy children and also in children with asthma, which can be exacerbated by pollution (US EPA, 2010, 2017, 2019, 2020; WHO, 2018, 2021a; Garcia et al., 2021; Holm and Balmes, 2022).
Asthma affects over 9% of children in the EU (Selroos et al., 2015), placing a large burden on children, their families and societies. The risk of developing asthma itself and asthma-like symptoms is clearly linked to long-term exposure to air pollution (US EPA, 2010, 2015, 2017, 2019, 2020; Zu et al., 2018; Låg et al., 2020; Yan et al., 2020; Bettiol et al., 2021; Han et al., 2021; Health Effects Institute, 2022). This has been observed both in epidemiological studies and in the laboratory, where the mechanisms for this effect have been studied and confirmed. Asthma symptoms can range from mild to very severe, even life-threatening. Exposure to short term increases in air pollution increases the risk of asthma hospitalisation and emergency department visits for children (Mustafić et al., 2012; Lim et al., 2016; US EPA, 2015, 2017, 2019, 2020; Huang et al., 2021; Zheng et al., 2021; Health Effects Institute, 2022).
Ambient air pollution may also be linked to other types of health problems in children. For example, there is growing evidence that air pollution affects children’s brain development, contributes to cognitive impairment, and that it may play a role in the development of some types of Autistic Spectrum Disorders (US EPA, 2015, 2019, 2020; Dutheil et al., 2021; Health Effects Institute, 2022; Lin et al., 2022). Some studies have also observed a link between traffic-related air pollution, with benzene playing a key role, and leukaemia in children (Orsini et al., 2012; Filippini et al., 2019; Wei et al., 2021).
In addition to ambient air pollution from traffic, heating, industry, etc., children’s health is also threatened by other airborne pollutants, like second-hand smoke and chemicals. Children can be exposed to these pollutants both outdoors and indoors.
Indoor air pollution (IAP): European children spend most of their time indoors, and indoor air pollution can significantly affect their health and well-being. Sources of IAP include: some building products and furnishings that release toxic chemicals; materials like some mineral fibres and legacy-asbestos still remaining in buildings; natural pollutants like radioactive radon. Outdoor air pollution also contributes to indoor air pollution, as does smoking, burning candles, allergens and dust, among others. Two types of air pollutants are of particular importance indoors: mould, and several types of toxic chemicals. Mould is a frequent indoor health hazard for adults and children alike, for whom it increases the risk of developing asthma, asthma exacerbation, wheeze, allergic rhinitis, and respiratory infections (Gern et al., 1999; Dick et al., 2014; Tham et al., 2014; Kanchongkittiphon et al., 2015; Sharpe et al., 2015; Hurraß et al., 2017; Fakunle et al., 2020, 2021). The concentrations of certain chemicals that are toxic for adults and children, such as formaldehyde and other volatile organic compounds (VOC), flame retardants, and per- and polyfluoroalkyl substances (PFAS) tend to be much higher in indoor air. However, our knowledge of the sources, concentrations, status of, and trends in indoor air pollution in Europe lags far behind that of outdoor air pollution.
Second-hand tobacco smoke (SHS): there is no safe level of SHS exposure, and children are particularly vulnerable to it both before and after birth (Öberg et al., 2010). About 12% of European children are regularly exposed to SHS at home (Carreras et al., 2020), and socially disadvantaged children and adolescents are also more likely to be exposed to SHS at home (59%) than children of parents with high socioeconomic status (21%) (Kuntz and Lampert, 2016). In children, SHS is estimated to cause up to 13% of all new cases of asthma, 20% of lower respiratory infections, 15% of cases of otitis media, and over 20% of Sudden Infant Death Syndrome (Öberg et al., 2010, 2011; Hänninen et al., 2011; Carreras et al., 2019, 2020; GBD Collaborative Network, 2020).
The exposure of children to toxic chemicals in Europe, mould, SHS, and poor indoor air quality are the subject of current work at the EEA, to be released in forthcoming publications. Additional information on indoor air quality is available as part of the EEA’s zero pollution monitoring assessment and the WHO guidelines for indoor air quality concerning dampness and mould, selected pollutants, and household fuel combustion.
Good progress has been made towards reducing air pollution from industry, transport, and homes — thereby reducing the number of deaths of all ages linked to air pollution as a result. In the EU-27, total emissions of all pollutants have consistently declined from 2005 to 2020 (the latest year with validated data). Figure 3 shows the trend in total emissions of particularly harmful air pollutants, indexed as a percentage of their value in the reference year 2005. Though the decline of all pollutants is good news, the decline of particulate matter, both PM10 and PM2.5, is of special importance, given their overall impact on the health of Europeans.
Source: EEA (2022b)[3].
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Declining emissions have resulted in a decrease in concentrations. However, while ambient air pollution concentrations are decreasing in Europe, they continue to be unsafe, and 91% of the urban population is still exposed to air pollutant concentrations above the 2021 WHO air quality guidelines (EEA, 2022c). Taking action to protect European children from air pollution is thus urgent, and it is the responsibility of adults to do so. While the need for a proactive stance on the part of adults to protect children against air pollution may seem obvious, it is worth considering some key underlying reasons:
These facts were already highlighted by the EEA and WHO Europe 20 years ago (EEA and WHO Europe et al., 2003) and are still true today.
Policies and interventions targeting air pollutants can be categorised according to whether they aim at reducing emissions (prevention), reducing concentrations (mitigation) or avoiding individual exposure (avoidance) (Public Health England, 2019). There are entire catalogues of existing and proposed policies and interventions within these categories (Burns et al., 2020), including those mentioned in this briefing.
To ensure that air pollution policies and interventions adequately protect children and adolescents, it is important that they explicitly acknowledge and integrate the different exposures and biology of these groups, rather than treating them implicitly as little adults. Ideally, air pollution decisions and policies should be informed by specific risk assessments to children’s health, while also setting out a clear framework to protect children and adolescents from polluted air at the places and settings where they are most at risk, including prenatally. Involving the groups and institutions involved in childcare, education and health, as well as encouraging the engagement of parents and/or caregivers can promote buy-in and foster success.
Reducing the concentration of air pollutants will help protect all Europeans, including children. However, until air pollution is reduced to safer levels, preventing exposure is the most effective way of protecting children’s health. Ultimately, all air pollution policies designed to reduce exposure ought to be implemented down to local levels of government, where the exposures actually occur. The examples of good practices listed in this briefing are only a subset of possible policies, focused mostly on avoidance (i.e. reducing exposure to air pollution). They are highlighted because they are highly local and actionable, and they focus on an easily identifiable context where children are exposed to air pollution: within care and educational settings.
Locally, where exposures occur, certain good practices can be considered to reduce exposures in children. Frequently, these good practices focus on the different microenvironments where children spend most of their time: home, schools/kindergartens (including school gates, drop-off zones, classrooms and playgrounds), indoor and outdoor activities which are neither at home nor at school, and transport including school commutes. Air pollution concentrations in school grounds, playgrounds and drop-off points are heavily influenced by proximity to nearby roads, traffic density and traffic flow (Rivas et al., 2018; Boniardi et al., 2021; Osborne et al., 2021). For example, in a recent study the concentration of PM2.5 was found to intensify by approximately a factor of three at the school entrance during drop-off hours, as cars queued (Kumar et al., 2020). Reducing ambient air pollution around schools can contribute significantly to reducing the dose of air pollutants inhaled by schoolchildren daily. This reduction can be achieved in various ways.
Installation of clean air zones around schools. Establishing ‘clean air zones’ around schools can reduce the concentration of pollutants found around them. Lower pollution levels can be achieved through restrictions on traffic, such as no-idling zones around schools (Ryan et al., 2013; Rumchev et al., 2021; Mendoza et al., 2022), ‘school streets’ (i.e. with a traffic ban at the start and end of the school day in the immediate vicinity of the school), or relocation of drop off/pick-up points away from school entrances (Davis, 2020; Den Hond et al., 2020; Koppen et al., 2020; van Poppel et al. 2020 Huertas-Delgado et al., 2022).
Siting of new schools and commuting modes. If a school is still in the planning stage, children’s exposure to air pollution can be reduced by placing the school away from pollution sources or hotspots of high air pollution, as already mandated in various European countries (NICE, 2017; Rijkswaterstaat Environment, 2022; Senatsverwaltung für Umwelt, Mobilität, Verbraucher- und Klimaschutz, 2022). This principle should be applied cautiously, however, as the location of a school influences the primary modes of travel to and from it (An et al., 2021). A school built at a site with better air quality might be further away from housing areas, thus requiring a commute by motorised transport which could in turn lead to higher exposure levels at the school. A school located closer to the children’s housing, meanwhile, may be reachable on foot or by bike, reducing traffic and leading to better air quality in the vicinity. Commuting modes and routes are another area of action where good practices can reduce exposure. For example, when the same home-school route is taken by children walking and commuting by car, the pedestrians experience a higher dose of pollutants. However, by taking an alternative background route or avoiding proximity to traffic queues, pedestrians can lower their dose. In fact, studies show that pedestrians may be willing to change their route when presented with pollution information (Dirks et al., 2016; de Nazelle et al., 2017; Rafiepourgatabi et al., 2021; Wolfe et al., 2021), switching to alternative routes with less exposure (‘background routes’).
More children walking to school also reduces motorised traffic and the resulting pollution from private vehicles. Placing schools away from high-volume roads and within a walkable distance from home can benefit children’s health via a lower exposure to air pollution (An et al., 2021), particularly when background routes are used. It can also benefit children’s health through increased physical activity (Chillón et al., 2015) — an important consideration given that in most situations the benefits of physical activity outweigh the risks of air pollution (Tainio et al., 2021). Ultimately however, economic, social, and other considerations may preclude altering the siting of schools or changing commuting modes.
Design of schools. The design of school and childcare facilities can contribute to minimising the exposure of children to air pollution while onsite. This may entail locating the most frequented rooms or areas as far away from road traffic as possible, shielding the playground behind buildings, walls or green infrastructure (i.e. using plants), and allowing natural ventilation patterns that promote pollutant dispersion (An et al., 2021). At the same time, care must be taken to avoid unfiltered ventilation when there are high pollution levels outdoors near the school. Green infrastructure can filter some air pollutants and alter the airflow — thus changing pollution concentrations in local microenvironments (Abhijith et al., 2017). The type, height and porosity of vegetation heavily influences this cleaning effect, but various solutions from ivy screens to hedge fences have proved effective locally (Tremper et al., 2015: Tremper and Green, 2018; Tomson et al., 2021; Redondo-Bermúdez et al., 2022). Beyond their air quality enhancing effect, green infrastructure in and around schools provides multiple social and environmental co-benefits, including cooling, sun protection, opportunities for physical activity, water storage, habitat conservation, etc. (Redondo-Bermúdez et al., 2022). Nevertheless, the level of greening around schools in urban areas in Europe is low. On average, just over 10% of the area within a 300m radius of educational facilities is green, and only 6% is covered by trees (EEA, 2023). Schools with the greenest surroundings tend to be in northern Europe (Figure 4).
Source: EEA (2023)[4].
Children spend many hours indoors at school and kindergartens, so measures to reduce indoor air pollution in those spaces are crucial to reduce their overall exposure. Reducing toxic chemicals and mould is crucial for good indoor air quality in schools.
Establishing regulations to improve indoor air quality and limit values for common air pollutants in places where sensitive populations gather is a crucial start (Vlaamse Regering, 2004; Lowther et al., 2021; UBA, 2023; Gouvernement de France, 2022). Clear sources of exposure to indoor air pollutants such as cleaning, painting, etc. should be organised to minimise children’s exposure, by scheduling them to take place after school hours, using low-emission cleaning products and materials, prioritising wet cleaning, fitting vacuum cleaners with HEPA filters, minimising the use of toxic chemicals, and using technologies like sorptive boards (surfaces engineered to trap certain pollutants) and CO2 monitoring in classrooms as an indicator of indoor air quality. In most school settings, outdoor air quality can be better than indoor air quality on several parameters, and ventilation is a prime tool to improve indoor air quality in classrooms and laboratories. It lowers CO2 levels and the risk of aerosol-transmitted diseases, removes moisture (and associated mould risks — see below), as well as odours and toxic chemicals from construction products, furniture and cleaning agents (Fisk, 2017; Aguilar et al., 2022). Ventilation of buildings can be improved by: (1) opening windows and doors to bring in ambient air, (2) using heating, ventilation, and air conditioning (HVAC) devices, and ensuring exhaust fans in bathrooms and kitchens are working properly, and (3) communicating necessary background knowledge and instructions to students, parents, faculty and staff (Beregszaszi et al., 2013; European Commission et al., 2014; Baldauf et al., 2015; Jhun et al., 2017; Rivas et al., 2018; Thevenet et al., 2018; Brand et al., 2019; WHO Europe, 2022).
Mould only grows when there is sufficient moisture, so detecting sources of moisture is the first step to controlling it. Leaking pipes, overflows, rain seeping through cracks or gaps in roofs, spills from blocked gutters, leaky window frames and rising damp are frequent causes of excess moisture, often leaving ‘tidemarks’ that should be interpreted as warning signs for mould. Another typical source of moisture is condensation, due to high humidity indoors and worsened by low temperatures and poor ventilation. Such sources of moisture should be eliminated, and any dampness removed via ventilation, dehumidifiers, etc. Thereafter, mould should be removed from affected areas. If the mould-affected area is large, or mould is present in the building structure and materials, removal should be done by qualified professionals, according to local and national standards. Finally, to stop mould and dampness from reoccurring, basic prevention measures should be undertaken including opening windows daily, using fans in bathrooms and kitchens, maintaining mechanical ventilation where installed, watching for and repairing leaks, and avoiding condensation on cold surfaces (WHO Europe, 2009; WHO, 2022).
Preventing smoking in or around schools. The reduction of smoking in all its forms, especially in child-centric settings such as in and around schools and kindergartens, is of key importance to reduce children’s overall exposure to SHS, despite the fact that it can also occur at home, in vehicles and elsewhere. Exposure to SHS has been observed to be significantly reduced by implementing smoking bans in all public places (Liang et al., 2016; El Sharkawy et al., 2021; Laverty et al., 2021; Nogueira et al., 2022). A recent study in Germany (Burkhardt et al., 2023) measured an 82% decline in a biomarker of tobacco smoke in the urine of non-smokers from 1995 to 2019, and largely attributes this to smoking bans and regulations limiting SHS following European legislation. Bans can benefit children when implemented with a special emphasis and consistent enforcement in and around schools and kindergartens. Interventions establishing family rules for smoke free vehicles (e.g. when commuting to school), smoking counselling to parents or caregivers, strict enforcement of complete tobacco bans in and around schools, and awareness campaigns against SHS have all shown to work in reducing children’s exposure to SHS (Blaakman et al., 2013; Bunik et al., 2013; Sharifi et al., 2014; Collins et al., 2015, 2020; Hoehn et al., 2016; Mason et al., 2016; Caldwell et al., 2018; Collins et al., 2018; Turner et al., 2020). More evidence on SHS impacts on children and good practices to reduce exposure will be published in forthcoming EEA products.
In addition to the good practices considered above, there is a wide range of local measures that can help protect the general population against air pollution. Well-informed residents are generally in a better position to demand action on air pollution and protect themselves from it. Two key EEA products can help citizens understand more about the air quality where they live. The European Environment Agency’s European Air Quality Index gives near-real time assessments of air quality for more than 3,500 air quality monitoring stations across Europe. The European city air quality viewer allows citizens to check how the air quality was in their city over the past 2 years and to compare it with air quality in other cities across Europe.
While reducing European children’s and adolescents’ exposure to air pollution is crucial and urgent, the surest way to keep them safe in the long term is by making the air we all breathe cleaner. The EU bases its clean air policy on three main pillars: (1) the National Emissions reduction Commitments (NEC) Directive (EU, 2016); (2) source-specific legislation for key sources of air pollution (European Commission, 2022a); and (3) the Ambient Air Quality Directives (EU, 2004, 2008), which set air quality standards (EEA, 2021). In October 2022, the European Commission published a proposal for a revision of the Ambient Air Quality Directive, including the following key measures (EEA, 2022a):
The above measures are aligned with other legislative proposals, such as the revision of the Industrial Emissions Directive and recent proposals on Euro 7 emission standards for road vehicles, which will support the achievement of stricter air quality standards. They are key to achieving one of the goals of the zero pollution action plan: reducing by 2030 the number of premature deaths caused by exposure to PM2.5 by at least 55% compared with 2005 levels (European Commission, 2022b). In the international context, the EU Member States work closely with other UN Economic Commission for Europe (UNECE) member countries to control international air pollution under the UNECE Convention on Long-Range Transboundary Air Pollution.
It should be noted that achieving the goals and air pollution levels set forth by current EU policies and regulation will still not mean that the air in Europe is safe for children and adolescents. For example, there is no evidence of a safe level or a threshold of exposure to PM2.5 below which no adverse health effects occur, and in the past research has tended to detect health impacts of air pollution at progressively lower levels. This notwithstanding, air in Europe which is cleaner overall will significantly contribute to making our children and adolescents healthier.
[1] https://www.eea.europa.eu/en/countries
[2] https://www.eea.europa.eu/publications/air-quality-in-europe-2021/sources-and-emissions-of-air
[3] https://www.eea.europa.eu/data-and-maps/daviz/trend-in-eu-27-emissions#tab-chart_3
[4] https://portal.discomap.eea.europa.eu/arcgis/apps/experiencebuilder/experience/?id=ddcba7a8599c4b4e8fa1e5fb51ef0f42&page=page_22
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Briefing no. 07/2023
Title: Air pollution and children's health
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