Pick up almost any magazine or newspaper these days, and you'll probably see a story about environmental health. Your patients are reading the same stories and may come to the clinic with questions about the effects of environmental hazards on their child's health. Many pediatricians feel ill-equipped to answer these questions, largely because few of us learned much about environmental health during residency and fellowship training.
Recognition that the environment may have an effect on health is not new. More than 150 years ago, Florence Nightingale was a pioneering champion of environmental health. Her famous "Canons of Health" included ventilation and warming, light, cleanliness of rooms and walls, health of houses, good food, and observations of the sick. She also named the six D's of disease - dirt, drink, diet, damp, drafts, and drains. The early history of public health and its major advances depended on reforms in housing, sanitation, and sewage.
Although the basic tenets of environmental health go back more than a century and a half, environmental pediatrics (or pediatric environmental health) is relatively new. We have learned a great deal in the past 40 years about the effects of radiation, lead, pesticides, and outdoor air pollution on the health of children. Perhaps more importantly, we now clearly recognize that the overall social, economic, and environmental conditions in homes and neighborhoods function synergistically to create health risks for children.
Nonetheless, practice changes occur very slowly. Before the 1980s, for example, few doctors acknowledged that passive exposure to tobacco smoke was hazardous. But in the past 20 years a large body of evidence unequivocally documents that passive smoking increases infants' risk of lower respiratory tract illnesses, middle ear effusions, and sudden infant death syndrome. As a result, a slow but steady societal change occurred with regard to smoking behavior, and pediatricians now seek to protect children from exposure to tobacco smoke. It may take many years before the prevailing medical theories change, even when the evidence is strong.
This issue of Pediatrics Annals has a special focus on environmental health. A variety of papers have been included to demonstrate the range of environmental issues that may have an effect on children's health. Although our precise understanding about how environmental exposures produce illness in infants and children remains incomplete, we do know about the consequences of acute and chronic exposure to arsenic and mercury, the relation between infant bronchiolitis and air pollution, and useful techniques to reduce disease, such as the appropriate use of DEET and other insect repellants and housing interventions.
Therefore, knowledge and counseling about environmental health issues must be an integral part of pediatrics. If we don't ask about the child's environment and the potential exposure pathways that link exposures to health outcomes, we may miss key information needed to make a diagnosis or deliver anticipatory guidance. Hence, we need to stay abreast of new developments in this emerging field to ensure that we ask the right questions about the context of children's everyday lives that will strengthen our ability to advise parents.