Pediatric Annals

Feature Article 

The COVID-19 Pandemic and Children's Environmental Health

Alan D. Woolf, MD, MPH; Hema Pingali, BS; Marissa Hauptman, MD, MPH

Abstract

The coronavirus disease 2019 pandemic has dramatically altered the health and well-being of children, particularly as they have been isolated indoors and in their homes as a result of social distancing measures. In this article, we describe several of the environmental threats that are affecting the health of children during the pandemic. These include increased exposure to household cleaning products, chemicals and lead in dust, indoor air pollutants, screen time, family stress, and firearms, as well as decreased availability of food, social supports, and routine childhood screenings. Importantly, many of these threats disproportionately affect children of racial or ethnic minorities or who have low socioeconomic status. Pediatric health care providers will need to screen and treat children and counsel their parents and/or other caregivers during well-child visits with an eye for these new or worsened environmental threats. [Pediatr Ann. 2020;49(12):e537–e542.]

Abstract

The coronavirus disease 2019 pandemic has dramatically altered the health and well-being of children, particularly as they have been isolated indoors and in their homes as a result of social distancing measures. In this article, we describe several of the environmental threats that are affecting the health of children during the pandemic. These include increased exposure to household cleaning products, chemicals and lead in dust, indoor air pollutants, screen time, family stress, and firearms, as well as decreased availability of food, social supports, and routine childhood screenings. Importantly, many of these threats disproportionately affect children of racial or ethnic minorities or who have low socioeconomic status. Pediatric health care providers will need to screen and treat children and counsel their parents and/or other caregivers during well-child visits with an eye for these new or worsened environmental threats. [Pediatr Ann. 2020;49(12):e537–e542.]

Since March 2020, people in the United States have been caught in the grip of severe acute respiratory syndrome coronavirus 2, also known as coronavirus disease 2019 (COVID-19). The pandemic has upended nearly every aspect of daily life. Clinic visits and elective surgical procedures were initially suspended as health care workers were redeployed to combat COVID-19. For the first several months of the pandemic, states issued “stay-at-home” orders to reduce the risk of community spread by limiting physical contact between people. As a consequence, most children were no longer physically in school, preschool, or organized day care. They were staying home all the time. Over the summer, as some states were opening up gradually while continuing to battle persistently high transmission rates, some children were returning to daycare and preschools. In the fall, some older children returned to school in person or via virtual learning or some hybrid of both. As we enter the early winter months, another steep climb in the number of infections throughout the country has mandated new restrictions. There is variability in local, municipal, and statewide responses. Some communities are “closing down” some commercial businesses again and urging families to “stay at home” amidst new fears of contagion. Despite initial attempts to reinstate in-person school, now, as states combat subsequent surges of the pandemic, states and cities are reimposing stricter social distancing guidelines and kids are returning to virtual learning. Because the health of children is, in part, dependent on the quality of their environment, the increased time indoors and in the home has brought into play unanticipated new threats to their health. Pediatric health care providers, whose offices and clinics have reopened to provide well-child services and who may now also be offering telehealth visits, should be aware of these heightened environmental risks, particularly as many children likely will have to spend more time in their homes in the coming months. Providers should adjust their clinical practice and advocacy efforts accordingly.

Increased Environmental Exposures

With increased time inside the home, children have been at higher risk of exposure to certain household dangers.

Disinfectants

The advice of infectious disease experts has been to reduce contact with the virus by frequently disinfecting surfaces that are touched often (eg, doorknobs, tabletops, keyboards, smartphones). Disinfectants certified by the US Environmental Protection Agency as effective against coronavirus, such as isopropyl alcohol, activated hydrogen peroxide, and hypochlorite, are also toxic irritants.1 Inadvertent exposure of children to these disinfectants may result in acute poisoning. From January 1 through March 31, 2020, poison control centers in the US had taken 62.1% more calls about bleach products, 36.7% more calls about hand sanitizer, and 108.8% more calls about all disinfectants compared with the same period in 2019, with the majority of pediatric exposures occurring in children age 0 to 5 years.2 As these products will likely continue to be used frequently, pediatricians should counsel families to store household disinfectants safely and keep them away from children. Objects that are likely to be put into the mouth may require an extra step of rinsing after disinfection; parents should adhere to manufacturer guidelines for their specific products. In addition, children with asthma should not be present while the disinfectants are in use, as they may trigger an asthma exacerbation.

Dust

Children spend much of their time closer to the floor than adults, putting them into contact with chemicals such as flame-retardants (eg, polybrominated diphenyl ethers) or perfluoroalkyl substances in house dust. Hazardous substances such as pesticides intended to kill roaches, ants, fleas, or other insects are often sprayed along baseboards and in cabinets accessible to young children. Additionally, families may engage in do-it-yourself renovations, potentially increasing lead-based paint dust contamination if conducted in homes built prior to 1978. Children have higher respiratory rates and inhale such chemicals at a higher concentration in their breathing zone.3 Their hand-mouth exploratory behaviors include the attendant risks of ingesting paint chips or chemical-containing dust. Health care providers should share best practices with parents to avoid these ingestions, including not using these chemicals in play areas and encouraging children to play outdoors. Parents should also be encouraged to regularly change heating, ventilation, and air conditioning filters and increase indoor ventilation by opening windows and screened doors.

Inhalants

The connection between housing-related exposures and children's health has been well-established.4 Homes can accumulate high levels of radon, one of the biggest environmental risk factors for lung cancer. Poorly vented appliances can generate carbon monoxide. Water leaks and high humidity promote growth of mold and biofilm, which release allergy-provoking spores into indoor air and pathogens onto infected surfaces. The Institute of Medicine has previously warned about the untoward health effects associated with living in damp spaces.5 Families should be counseled on the importance of mold inspection and abatement (as necessary) and removal of water intrusion. Indoor second-hand tobacco or marijuana smoke and the “cloud” associated with vaping/e-cigarettes additionally pose significant inhalation exposures and consequently pose health risks to infants and children.

Increased Screen Time

With the introduction of “virtual” schooling and the cancellation of extracurricular activities, children are spending even more time on computers, smartphones, and other digital devices, possibly exceeding American Academy of Pediatrics' guidelines that recommend limiting screen-time for children.6 Risks associated with increased screen time, particularly for entertainment, include unhealthy habits (lack of exercise, overeating, and obesity), internet gaming disorder, associated eye strain, exposure to harmful websites, cyberbullying, disrupted sleep, and withdrawal symptoms of depression; therefore, pediatricians should underscore to families the importance of limiting screen time if possible.

Increased Family Stress

The seclusion of families limits social interactions and engenders health risks from prolonged exposure to isolation and toxic stress. The pandemic has fostered the shutdown of entire industries, resulting in job losses on an unprecedented scale. The initial short-term moratorium on evictions and the stimulus packages supplied by the federal government have ended, and now evictions and foreclosures are increasing and some families may be facing homelessness. These stressors, among others, can have major psychological consequences, including feelings of helplessness, confusion, hopelessness, and/or anger. Careful screening for mood disorders and suicidal ideation during the pandemic is crucial.

Children are also likely at higher risk of abuse or of witnessing abuse. In disasters, social factors (eg, reduced access to resources, increased stress due to job loss or strained finances, social isolation, and disconnection from social support systems) have historically led to higher rates of both intimate partner violence and child abuse.7 Moreover, children are having less contact with conventional mandated reporters such as teachers and health care professionals who would otherwise identify concerns of child maltreatment.8 There are calls for increased community supports to reduce the potential for family violence during the pandemic.9 During this prolonged pandemic, children need to be reassured of their own security and that they can count on parental or caregiver love and protection.

Guns

Gun sales in the US have gone up during this pandemic, as some people have increased concerns about their family's personal security.10 Firearms stored unsafely in the home, in the context of curious children, heightened stress, and family violence, can lead to tragic events,11 so pediatricians should offer recommendations on safe storage of firearms.

Decreased Screening

In the initial months of the pandemic, many doctor's offices were closed and families were concerned about going to a health care facility for illness, let alone for routine well-child care. Rates of vaccination dropped precipitously in March 2020, when the US government declared a national emergency.12 Other screenings, including blood testing for lead, have suffered the same fate. In Massachusetts, preliminary data suggest testing children for lead exposure between March and May 2020 was down by 75% from the same period in 2019.13

Food Availability

Many people with low incomes live in communities with “food-deserts,” in which there are a lack of local, affordable grocery stores and supermarkets. The pandemic has magnified this issue, as those who have lost jobs and financial stability are now contending with higher food prices and a scarcity of staples due to pandemic-associated disruptions in the food supply chain. Children dependent on school-sponsored meals may have reduced food access due to school closures and the switch to virtual learning, although some districts have found innovative ways of delivering meals to children from low-income households. Screening for food insecurity and connection with local support services is critical.

Decreased Community-Level Supports

Access to community-level supports (eg, social workers, developmental specialists, housing inspectors, and lead abatement contractors may be affected by the pandemic). Moreover, families may be more reluctant than usual to allow visitors from helping agencies such as lead inspectional services or early intervention programs into their home due to a heightened perceived risk of infection transmission.

Disparities and Environmental Justice

For decades, there have been clear racial and class disparities in environmental exposures and associated outcomes.14 This includes exposures to toxic chemicals, unsafe air and water, and a built environment not conducive to health. The pandemic has accentuated these disparities of health and environmental injustices in immigrant and indigenous communities and in urban and rural neighborhoods with multiracial or racial/ethnic minority populations. Chen et al.15 found that the surge in COVID-19 death rates was greater in city/towns and zip codes with higher rates of poverty, higher household crowding, higher percentages of racial and ethnic minority populations, and higher economic segregation based on race.15 These disparities are, in part, driven by unequal exposures to poor environmental conditions. For example, people experiencing housing instability and homelessness are suffering from disproportionately high rates of infection given the close quarters and high density of residents in shelters.16

In addition, there are clear disparities with respect to how children are experiencing the pandemic. For example, largely due to unequal access to technology, children from families with lower incomes may not have been able to participate to the same degree in remote learning activities offered by their school during the pandemic.17 On the other hand, returning to school may be a higher risk for those children, who often live in communities with higher rates of COVID-19 infection. Moreover, children from racial or ethnic minority groups or from less-affluent families often have less access to safe outdoor space where they can exercise and play in a socially distant manner. Parents living in poverty-stricken areas may have real concerns about the safety of their children if they allow them to go to outdoor play areas. This has implications for the family's physical and mental health.

Health Care Solutions

The arc of the COVID-19 pandemic will span an unknown length of time. Despite the many unknowns, it is clear that children will have to spend more time indoors and at home as long as the pandemic continues. The in-home environmental dangers and other detrimental effects of the pandemic described here have the potential to significantly affect the long-term health of children. Primary care practitioners should incorporate the additional screening and treatment practices mentioned above into their clinical work, along with new anticipatory guidance to families related to the health implications of the pandemic. This is true particularly once stay-at-home orders are relaxed, retail shops and public spaces are re-opened, and children return to school that is a hybrid of virtual and in-person learning.

Clinicians should be comfortable asking about the environmental exposures described here and offering relevant management strategies, including referral to community supports and provision of necessary supplies. Tables 13 provide tips for what to include during telehealth visits, websites to consult, and some suggestions for interviewing topics and questions related to environmental health issues created by the pandemic. Given the exposures highlighted in this article, the following themes should be explored in routine well-child visits.

Children's Environmental Health in a Pandemic: Tips for Clinicians

Table 1.

Children's Environmental Health in a Pandemic: Tips for Clinicians

Local, State, or Federal Health Department Websites to Consult for Children's Environmental Health During a Pandemic

Table 2.

Local, State, or Federal Health Department Websites to Consult for Children's Environmental Health During a Pandemic

Questions and Considerations to Incorporate into a Well-Child Visit

Table 3.

Questions and Considerations to Incorporate into a Well-Child Visit

Primary Care Mental Health Screening

As communities reopen, we must be concerned about the lurking risks of post-isolation mental illness, including depression, anxiety, suicidal ideation, and posttraumatic stress syndrome affecting children and their families. Families may need to be referred to community-level mental health agencies and supports. We must also be vigilant for signs of child maltreatment and notify the appropriate state agencies as mandated reporters.

Home-Related Health Concerns

We must ask families about guns in the home and provide education on safe storage as necessary. We must ask about their housing situation and their food security and refer to social services if relevant. Parents should be counseled about safe practices such as frequent disinfecting of high-touch surfaces, frequent dusting of furniture, damp-mopping of tile or wood floors, the need for careful and frequent handwashing, and safe storage of cleaning products.

Primary Care Catch-Up

We must consider environmental exposures when grappling with postpandemic health concerns and encourage parents to seek appointments with their child's primary care provider to “catch up” on missed immunizations, lead testing, and other important screenings. We are experiencing recurrent spikes in COVID-19 infection rates with increased needs for testing and contact tracing. We must all do our best to honor our obligations to children and their families to provide well-child care, preventive health counseling, and anticipatory guidance, even in these turbulent and uncertain times.

Health Disparities

Finally, this pandemic has given us the opportunity to address long-standing issues of health disparities and environmental racism; we should add our voices to the growing dialogue. The pandemic has only exacerbated disparities in environmental exposures, with potentially serious and long-lasting consequences. Increased efforts to address these disparities will be crucial as the country slowly recovers from the pandemic. Many children are able now to engage in outdoor activities, exercise, and return to preschool or daycare, thus combating some of the social isolation damage done during the initial months of the pandemic. However, children in racial or ethnic minority populations or those from communities with low socioeconomic status may have limited access to these resources, further exacerbating the environmental injustices suffered by these families.

Conclusion

The future health of our children is imperiled on many fronts. As a consequence of being indoors and socially distanced during the pandemic, children face many threats to their health and well-being. This is particularly true for children from racial or ethnic minority populations or those from communities with low socioeconomic status. As pediatric care providers, we must respond with renewed determination, careful screening, strong education, and provision of medical and social services to make a difference, to meet the urgent health challenges, and to be the agents of change with compassion, kindness, and understanding.

References

  1. Environmental Protection Agency. List N: disinfectants for use against SARS-CoV-2 (COVID-19). Accessed November 11, 2020. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19
  2. Chang A, Law R, Bronstein AC, et al. Cleaning and disinfectant chemical exposures and temporal associations with COVID-19 - National Poison Data System, United States, January 1, 2020 – March 31, 2020. Morb Mortal Wkly Rep (MMWR). 2020;69(16):496–498. doi:10.15585/mmwr.mm6916e1 [CrossRef] PMID:32324720
  3. Bateson TF, Schwartz J. Children's response to air pollutants. J Toxicol Environ Health. 2008;71(3):238–243. doi:10.1080/15287390701598234 [CrossRef] PMID:18097949
  4. Weitzman M, Baten A, Rosenthal DG, Hoshino R, Tohn E, Jacobs DE. Housing and child health. Curr Prob Pediatr Adolesc Healh Care. 2013;43(8):187–224. doi:10.1016/j.cppeds.2013.06.001 [CrossRef] PMID:23953987
  5. Institute of Medicine. Damp Indoor Spaces and Health.The National Academies Press; 2004. doi:10.17226/11011 [CrossRef]
  6. Council on Communications and Media. Media use in school-aged children and adolescents. Pediatrics. 2016;138(5):e20162592. doi:10.1542/peds.2016-2592 [CrossRef] PMID:27940794
  7. Cerna-Turoff I, Fischer HT, Mayhew S, Devries K. Violence against children and natural disasters: a systematic review and meta-analysis of quantitative evidence. PLoS One. 2019;14(5):e0217719. doi:10.1371/journal.pone.0217719 [CrossRef] PMID:31145758
  8. Humphreys KL, Myint MT, Zeanah CH. Increased risk for family violence during the COVID-19 pandemic. Pediatrics. 2020;146(1):e20200982. doi:10.1542/peds.2020-0982 [CrossRef] PMID:32317306
  9. Campbell AM. An increased risk of family violence during the Covid-19 pandemic: strengthening community collaborations to save lives. Forens Sci Int Rep. 2020;2:100089. doi:10.1016/j.fsir.2020.100089 [CrossRef]
  10. Pane LM. Gun background checks smash records amid coronavirus fears. Accessed November 11, 2020. https://apnews.com/64b328e6d0559e13dd7ef6e2ee0663f9
  11. Fowler KA, Dahlberg LL, Haileyesus T, Gutierrez C, Bacon S. Childhood firearm injuries in the United States. Pediatrics. 2017;140(1):e20163486. doi:10.1542/peds.2016–3486 [CrossRef] PMID:28630118
  12. Santoli JM, Lindley MC, DeSilva MB, et al. Effects of the COVID-19 pandemic on routine pediatric vaccine ordering and administration – United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(19):591–593. doi:10.15585/mmwr.mm6919e2 [CrossRef] PMID:32407298
  13. Massachusetts Department of Public Health, Childhood Lead Poisoning Prevention Program. Encouraging lead screenings during the Covid-19 pandemic. Accessed November 11, 2020. https://www.mass.gov/news/encouraging-lead-screenings-during-the-covid-19-pandemic
  14. Landrigan PJ, Rauh VA, Galvez MP. Environmental justice and the health of children. Mt Sinai J Med. 2010;77(2):178–187. doi:10.1002/msj.20173 [CrossRef] PMID:20309928
  15. Chen JT, Waterman PD, Krieger N. COVID-19 and the unequal surge in mortality rates in Massachusetts, by city/town and ZIP Code measures of poverty, household crowding, race/ethnicity, and racialized economic segregation. Accessed November 11, 2020. https://cdn1.sph.harvard.edu/wp-content/uploads/sites/1266/2020/05/20_jtc_pdw_nk_COVID19_MA-excess-mortality_text_tables_figures_final_0509_with-cover-1.pdf
  16. Stewart N. ‘It's a time bomb’: 23 die as virus hits packed homeless shelters. New York Times. April13, 2020. Accessed November 11, 2020. https://www.nytimes.com/2020/04/13/nyregion/new-york-coronavirus-homeless.html accessed 08162020
  17. Toness BV. One in five Boston public school children may be virtual drop-outs. The Boston Globe. May23, 2020. Accessed November 11, 2020. https://www.bostonglobe.com/2020/05/23/metro/more-than-one-five-boston-public-school-children-may-be-virtual-dropouts/

Children's Environmental Health in a Pandemic: Tips for Clinicians

Telehealth visits <list-item>

Watch children's behavior in their environment

</list-item><list-item>

Ask childen to show you their favorite activity, drawing, book, or toy

</list-item><list-item>

Observe the home environment for health or injury hazards

</list-item>
Coronavirus precautions: general guidance for providers and families <list-item>

Use only disinfectants approved by the US Environmental Protection Agency

</list-item><list-item>

Remind that disinfectants need to be used safely (ie, wear gloves when applying, let surface dry)

</list-item><list-item>

Frequent handwashing (>20 seconds each time)

</list-item><list-item>

Keep children with asthma away from areas that are being disinfected

</list-item><list-item>

Rinse items that are likely to be licked/put in mouth by children after disinfection

</list-item><list-item>

Always use cloth face coverings, especially when social distancing cannot be maintained (children age 2 years and older should wear a cloth face covering as long as they do not have trouble breathing, or they are not unconscious, incapacitated, or otherwise unable to remove the mask without assistance)

</list-item>

Local, State, or Federal Health Department Websites to Consult for Children's Environmental Health During a Pandemic

Healthy Homes, Boston Children's Hospital Pediatric Environmental Health Center <ext-link ext-link-type="uri" xlink:href="http://www.childrenshospital.org/centers-and-services/programs/o-_-z/pediatric-environmental-health-center-program/helpful-links/healthy-homes" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">http://www.childrenshospital.org/centers-and-services/programs/o-_-z/pediatric-environmental-health-center-program/helpful-links/healthy-homes</ext-link>
Prescriptions for Prevention, New York State Children's Environmental Health Center <ext-link ext-link-type="uri" xlink:href="https://nyscheck.org/RXP/NYS/rx_english_SaferDisinfecting_NYS_WEB.pdf" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://nyscheck.org/RXP/NYS/rx_english_SaferDisinfecting_NYS_WEB.pdf</ext-link>
<ext-link ext-link-type="uri" xlink:href="HealthyChildren.org" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">HealthyChildren.org</ext-link> <ext-link ext-link-type="uri" xlink:href="https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/2019-Novel-Coronavirus.aspx" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/2019-Novel-Coronavirus.aspx</ext-link>
US Centers for Disease Control and Prevention: COVID-19 and Children <ext-link ext-link-type="uri" xlink:href="https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/protect-children.html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/children/protect-children.html</ext-link>
Talking to Kids about the Coronavirus <ext-link ext-link-type="uri" xlink:href="https://kidshealth.org/en/parents/coronavirus-how-talk-child.html" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://kidshealth.org/en/parents/coronavirus-how-talk-child.html</ext-link>
Environmental Protection Agency <ext-link ext-link-type="uri" xlink:href="https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2-covid-19</ext-link>
American Academy of Pediatrics Guidance Related to COVID-19 <ext-link ext-link-type="uri" xlink:href="https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/" xlink:type="simple" xmlns:xlink="http://www.w3.org/1999/xlink">https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/</ext-link>

Questions and Considerations to Incorporate into a Well-Child Visit

Questions and considerations Possible interventions
Home stressors and mental health   Screen for depression, anxiety, suicidal ideation, posttraumatic stress syndrome in kids and their families   Screen for extreme social isolation   Screen for child maltreatment Are kids having behavior problems or sleep disturbances? Consider referral to mental health services and family counseling Consider referral to Child Protective Services if necessary
Home environment   Are there environmental dangers in the home? These include radon, pests, water intrusion, mold, asbestos-wrapped pipes or furnaces Counsel families on safe home remediation measures and community-based resources Consider referral to legal services or social work to advocate on tenants' behalf for safer housing conditions
Educational resources   How much time are kids spending on screens (outside of classes)?   Do the kids have books at home?   Are parents reading to kids? Offer parents guidance about the need for daily “screen-free” activities Keep books in office to provide to patients (wash hands prior to providing them to families) Encourage family reading, particularly given school closures
Home safety   Are smoke and carbon monoxide detectors working?   Is there periodic testing of drinking water for harmful chemicals if supplied from a private well?   Has your pre-1978 home been inspected for lead hazard?   Cleaning routine: are they dusting and damp-mopping regularly?   Are firearms in the home safely stored?   Home furnace annual inspection and cleaning?   Are HVAC filters regularly changed? Offer batteries to families for household detectors Remind parents to periodically test well water. Run the faucets for several minutes in the morning before using tap water Referral to community agencies (eg, lead or radon inspection, well-water testing) Educate on cleaning techniques and safe storage of firearms Offer parents handouts on household cleaners that are less toxic Educate parents on methods of increasing in-home ventilation
Family resources   Is the family eligible for public housing subsidy?   Are the parents eligible for unemployment resources?   Does family qualify for SNAP or WIC? Consider referral to social work to navigate housing, unemployment, SNAP, and WIC applications (keep applications on-site to offer to families) Provide list of local food pantries
Screening and vaccinations   Blood lead screening and/or testing, as per state and CDC guidelines   Nutrition: iron deficiency anemia per AAP guidelines   Development/cognitive-early intervention assessment, autism screening, other special learning needs   Adherence to vaccine schedule Manage elevated blood lead levels or childhood lead poisoning and its sequelae Treat iron and vitamin D deficiencies Consider referral to early intervention programs or HeadStart (a federally funded education program) Inquire about additional educational assessment and/or services at school Ensure immunizations are up to date
Authors

Alan D. Woolf, MD, MPH, is the Director, Pediatric Environmental Health Center and the Director, Region 1 New England Pediatric Environmental Health Specialty Unit (PEHSU), Division of General Pediatrics, Boston Children's Hospital; and a Professor of Pediatrics, Harvard Medical School. Hema Pingali, BS, is a Medical Student, Harvard Medical School. Marissa Hauptman, MD, MPH, is an Assistant Director, Pediatric Environmental Health Center, and an Environmental Health Specialist, PEHSU, Division of General Pediatrics, Boston Children's Hospital; and an Instructor of Pediatrics, Harvard Medical School.

Address correspondence to Alan D. Woolf, MD, MPH, Pediatric Environmental Health Center and PEHSU, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston MA 02115; email: alan.woolf@childrens.harvard.edu.

Grant: ADW and MH are supported by the cooperative agreement award (1 NU61TS000296-01-00) from the Agency for Toxic Substances and Disease Registry (ATSDR). The US Environmental Protection Agency (EPA) supports the PEHSU by providing partial funding to ATSDR under inter-Agency Agreement number DW-75-95877701. ADW and MH are also funded (in part) by the cooperative agreement award number 6 NU61TS000296-02-02 and award number 6 NU61TS000302 from the ATSDR.

Disclaimer: The content of this article is the responsibility of the authors and does not necessarily represent the official views of the ATSDR. Neither the EPA nor the ATSDR endorse the purchase of any commercial products or services mentioned in PEHSU publications.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/19382359-20201111-01

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