Five I’s of Climate Change and Child Health: A Framework for Pediatric Planetary Health Education

On February 15, 2013, Ella Kissi-Debrah died of a severe asthma exacerbation at 9 years of age.1 Ella lived in a traffic-congested neighborhood in London, England. A 2018 report later revealed that this area far exceeded the World Health Organization guidelines for nitrogen dioxide and other particulate matter levels, prompting the High Court to grant Ella’s mother a new inquest into the cause of Ella’s death.2,3 In 2020, an independent coroner concluded that “air pollution was a significant contributory fact to both the induction and exacerbations of her asthma,” making Ella the first person in the world to have air pollution exposure listed as a medical cause of death.1,4There are growing calls for planetary health to be incorporated into medical training to ensure that physicians are well-versed in the unique effects that climate change has on children and adolescents. Professional associations, including the American Academy of Pediatrics, have highlighted the pediatrician’s role in the fight against climate change.5 As future child health experts, it is essential that pediatric trainees understand how changes in the natural environment impact the health of our patients to inform health care decisions.The Five I’s of Climate Change and Child Health is a framework to categorize articles on climate change.Humans begin to experience the adverse impacts of climate change during fetal development. Infants born to mothers who are exposed to ambient air pollution during pregnancy are more likely to be premature, have a low birth weight, or be stillborn.6 Similar findings have been reported for maternal exposure to high temperature variability during pregnancy.7 A variety of possible mechanisms have been put forward to help explain the association between climate change and its negative effects on the developing fetus. These include epigenetic changes, the induction of oxidative stress in utero, and the effects of general hypoxemia.6 In low-resource settings, extreme temperatures may decrease harvest yields, thereby negatively impacting maternal nutrition and, consequently, raising the odds of poor birth outcomes.7 Extreme weather events, such as floods, can destroy health infrastructure, thus creating barriers for pregnant women to access adequate prenatal care.7Changes in the climate modify the dispersion and precipitation of particulate matter and amplify ambient air pollution.8 The consequent deterioration in air quality adversely impacts young respiratory systems. Children’s relatively high respiratory rates and still-developing lung tissues leave them more vulnerable to inhaled toxic particles and aeroallergens. In addition, long-term exposure to these pollutants impairs lung development, raising their risk of developing chronic lung disease in the future.9 As global temperatures increase, so do the predicted frequencies and severity of wildfires. Exposure to wildfire smoke has already been shown to cause increased emergency department visits for children with asthma.10The term climate-sensitive infectious diseases refers to those illnesses whose prevalence and transmission are closely linked to changes in weather variables. Globally, infectious diseases are a leading cause of mortality in children under the age of 5 years. In low- and middle-income countries, scientists predict that climate change will lead to an increase in the prevalence of childhood diarrheal disease as extreme flooding becomes more common.11 In sub-Saharan Africa, child mortality from malaria will also likely increase significantly as temperatures warm.12 Climate change is already significantly altering epidemiological patterns of vector-borne diseases. For example, in North America, warmer temperatures and increasing humidity are associated with the expansion of deer tick habitat and survival, leading to an increased incidence of Lyme disease.13The scope of injuries sustained by children secondary to climate change is broad and comprises the effects on both their physical and mental health. Children’s relatively small size makes them more vulnerable to physical injury and death during climate disasters (eg, drowning during floods).14 Physical injuries go beyond musculoskeletal injuries and include damage to other organ systems. Children’s relatively high surface area-to-body mass ratio compared with adults means that a greater percentage of their cardiac output is diverted to the skin to dissipate excess heat, making children more susceptible to the effects of extreme temperatures.15 High temperatures are associated with increased hospital presentations due to heat-related illnesses, such as heatstroke and dehydration.16The impacts of climate change on mental health have also garnered significant attention. “Climate anxiety” and “eco-anxiety” are terms used to describe the profound emotional response toward our changing climate and its adverse effects on human existence. Recently, a global survey revealed that most youth experience moderate to extreme levels of worry about climate change, with nearly half of respondents also stating that these feelings impair their function.17 In addition, climate catastrophes can impact mental health. For example, 1 study revealed that adolescents experience increased rates of posttraumatic stress disorder after severe floods.18Insecurity refers to the direct and indirect effects of climate change on the social drivers of health. As increased temperatures and weather shocks threaten agricultural yields, researchers predict increased rates of stunting, especially in vulnerable children.19 Thus, climate change may act to reverse the decades-long gains the world has made in combating global food insecurity and malnutrition in children. Additionally, threatened food supplies and loss of property from climate shocks change migration patterns, which in turn increases the risk of conflict as groups compete over scarce resources.20 Researchers have suggested that such climate-related factors contributed to civil unrest in Darfur in the early 2000s.21 When children are displaced, their educational attainment and financial security are adversely impacted.22,23In discussing the insecurities caused by climate change, it is important to recognize that even within the pediatric population, the impact of climate change on health is not evenly distributed. Children living in equity-deserving communities globally suffer disproportionately from health risks due to climate change despite those communities contributing the least to the rise in global temperatures in most cases.24The Five I’s framework can be used by learners in a variety of medical teaching contexts. As a mnemonic, the framework can be incorporated into didactic lectures on planetary health. The Five I’s can be scaffolded into case studies and small group learning scenarios to reinforce learning. Simulation activities, such as OSCEs, can offer an opportunity for learners to demonstrate their knowledge of pediatric planetary health. Knowledge of the Five I’s can prompt a pediatrician to consider that a child’s asthma exacerbation could be related to air pollution from a nearby wildfire or increased aeroallergen exposure on a hot and humid day. The Five I’s can also help inform medical student advocacy related to climate change and child health. The framework could form the basis for communicating to the public and policymakers about how climate change impacts child health and guide the design of specific mitigation strategies.The interactions between climate change and the health of children are complex and profound. The Five I’s can be a useful tool for communicating and teaching these relationships to pediatric practitioners and trainees. Curbing the existential threat posed by climate change requires coordinated efforts from all sectors of society. Patient stories like Ella’s highlight health care workers’ duty to understand how our changing climate impacts population health outcomes and then work to mitigate them. For pediatricians, our obligation is even clearer because climate change threatens the ethos of our work, which is to ensure that children are provided with the best chance of living healthy lives well into adulthood.We would like to thank Dr Courtney Howard for her perspective and feedback on the creation of this manuscript.

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