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.
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.
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.
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.
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.
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
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 1–3 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
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
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.
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.
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.