Children under five years of age account for 40% of cases of environment-related diseases.17 There are differences between countries based on income level, but there is an overall increasing trend in the incidence of paediatric and adult chronic diseases related to early exposure to environmental hazards (Table 2).

• a)

  Respiratory diseases and asthma. Respiratory diseases are the leading cause of paediatric morbidity and mortality worldwide. They include acute and chronic diseases, most importantly those involving the lungs and bronchi, such as bronchopulmonary dysplasia, tuberculosis, congenital infections, asthma and cystic fibrosis.18 In children, these diseases and exposure to air pollution hinder lung development and predispose individuals to chronic obstructive pulmonary disease in adulthood.9,19Asthma is the most frequent chronic disease in the paediatric population, especially between ages 5 and 14 years.18 It has exhibited progressive increases worldwide, although its distribution varies widely between regions. Tobacco, the use of biomass energy, urban and industrial air pollution and malnutrition are some of the risk factors for acute and chronic respiratory disease.9,18

• b)

  Childhood cancer. Since 1980, the overall age-standardised incidence rate of childhood cancers (age 0–14 years) has increased from 124 to 140 per million person-years. In South American, it has increased from 116 to 133 per million person-years, and in Western Europe, from 132 to 160 per million person-years. In the EU, the overall 5-year survival nears 80%, with 5-year survival nearing 100% in some types of cancer.20 The populations and economies in LAC are growing rapidly, with 26% of the overall population aged 15 years or less, and 24000 new cases of childhood cancer a year. Within the LAC region, survival rates are similar to those in the EU in Chile and Uruguay, while in other countries they do not even reach 40%.21

• c)

  Endocrine disorders. In the EU, in the past century the age at menarche has decreased from 17 to 12 years, and in countries in LAC there has been a reduction in the age at onset of puberty in girls. Precocious puberty increases the risk of breast and ovarian cancer, cardiovascular disease, infertility, teen pregnancy and psychiatric disorders. There has been an increase in the incidence of urogenital malformations, poor sperm quality and testicular cancer.22The global prevalence of diabetes has doubled since 1980. An increase by 38% in the incidence of diabetes is expected in LAC by 2025 in association with increasing urbanisation, dietary changes, alcohol use and sedentary lifestyles. In recent decades, the annual incidence of type 1 diabetes has increased by nearly 3% in high-income countries. In the EU, type 1 diabetes in 10 times more frequent compared to LAC.23 Eliminating exposure to endocrine disruptors will be a challenge in the prevention of all these disorders.

• d)

  Neurodevelopmental/psychiatric disorders. Exposure to neurotoxins during childhood or in critical periods of organogenesis or cellular development during prenatal or postnatal life may produce brain damage and cause neurologic changes. These effects may manifest during childhood or in adulthood, and in some cases be permanent.24The evidence on the association of early exposure to environmental toxins, such as air pollution or alcohol, with neurodevelopmental disorders continues to grow. In the paediatric population, there is a prevalence of intellectual disability of nearly 1%, of learning disorders of 5% to 10% and of attention deficit hyperactivity disorder of 6% to 17% (1% corresponding to autism); foetal alcohol spectrum disorders affect 1.7% of children in LAC and 3.7% of children in the EU.10

• e)

  Malnutrition: globesity versus global hunger. The abuse of hypercaloric and high-protein diets results in the deaths of millions of consumers in high-income countries from diseases associated with globesity (cardiovascular and cerebrovascular diseases, diabetes or cancer), and obesity is a global pandemic in the EU-ALC. The increase in child globesity is a significant challenge in the EU–LAC. On the other hand, many poor countries are affected by undernutrition, as individuals are not given access to arable land to feed their families. Worldwide, approximately 41 million children aged 5 years and under are overweight or obese, while 540000 a year die from starvation.25 The Decade of Action on Nutrition initiative (2016–2025) seeks to redouble the efforts to free the world from malnutrition.

• f)

  Parasitic and vector-borne diseases.7 Climate change, migration and globalisation are changing the prevalence and geographical distribution of these diseases in the EU-ALC. Their prevalence is greater in countries with deficient hygiene and sanitation systems.

In all nations, the health interventions with the highest economic and social returns are those that increase the resources allocated to pregnancy, childhood and adolescence.26 A good example is childhood vaccination.

The increases in health care costs associated with the treatment of chronic diseases provide an excellent opportunity to develop health economics models based on the prevention of diseases and environmental hazards.

All children, wherever they live, are affected by environmental hazards. However, rightful access to effective diagnostic tests and treatment, technology and psychosocial care varies widely and is a source of injustice worldwide. Poverty and race are key determinants of environmental injustice and threats to paediatric health.16

Inequities in childhood are associated with the costs of economic productivity and chronic disease in adults.27 Environmental degradation and vulnerable policies contribute to the persistence of these inequities in health.16

Increases in population and human activity and the abuse of natural resources lead to the overexploitation of the planet, with an associated decline in biodiversity and the overall sustainability of life on Earth. According to the Global Footprint Network,28 the greatest ecological footprints correspond to the EU, Brazil, Chile and Argentina. In LAC there has been a dramatic 89% decrease in biodiversity relative to 1970. Twenty percent of the Amazon rain forest has been lost in only 50 years. It would take 1.7 planets Earth to produce all resources currently used by the global population sustainably.

Between 2000 and 2050, the proportion of the global population aged 60 or more years will increase from 11% to 22%. At present, this age subset amounts to 24% of the total population in the EU and 11% of the total population in LAC. The declines in birth rates and increases in life expectancy are key factors in the global population ageing, although international migration flows have also contributed to changes in age distribution in regions of the EU and LAC.

In the next 15 years, the population aged 60 years and older will grow by 71% in LAC and by 23% in the EU. The ageing index of the population (the ratio of individuals aged >60 years over those aged <15 years) in LAC was 0.44 in 2015 and is expected to rise to 1.53 by 2050, exceeding the ageing index predicted for Europe in 2075.29 The ageing of the population calls for action in the area of chronic diseases in every age group. Many chronic diseases of adulthood are subclinical during childhood. To improve the health of the ageing population, we need to optimise paediatric health, making prevention of environmental risk factors a priority among the competencies of paediatricians.

In 2015, 74% of the population of the EU and 80% of the population of LAC resided in cities, and 20% to 21% in suburban areas characterised by greater poverty and violence. Although in the last 2 decades the proportion of the population living in slums has decreased in LAC, in absolute terms the number has increased to 111 million.30Table 3 presents the most populous cities and data for some indicators.

The construct of the family varies significantly between countries and communities. Democracy and globalisation promote family health in low- and high-income countries. The integration of low-income countries in the global economy is associated with increases in education and household incomes, thus improving child health.31

The use of technology is changing how family and interpersonal relationships are conceived. The introduction of technology makes the lives of individuals easier, but also changes human relations and health with both positive and negative effects. Technology interferes with interpersonal relationships and has physical, behavioural and emotional repercussions.

The increasing awareness in society of the interrelationship of health and environment is the main drive to push for changes in global policies to give a greater priority to children.

In addition, populations are increasingly demanding democracy, participation and freedom in shaping the context of their lives, including improved environmental conditions. Paediatricians play a key role in the management of environmental diseases by identifying environmental risk factors in their patients, providing guidance about them to reduce exposure, researching these diseases and helping other professionals, parents and society develop skills for their prevention. Their participation is a must in any debate regarding PEH, as is their involvement in advocacy for policies or environmental practices that can contribute to the protection of paediatric health.32

We are immersed in the digital age, with greater access to information and improved real-time communication capabilities planet-wide, which allows the integration of distant professionals to obtain local, regional and global data for the purpose of developing integral strategies.

The changing patterns of environmental health require a more creative approach and strategy. Emerging sensing and biomonitoring technologies will improve prevention, diagnosis and treatment while reducing the burden of chronic environmental diseases in the EU–LAC by reaching remote geographical areas. Furthermore, the sensoriszation of ecosystems, clinical biomonitoring and digital platforms will lead to efficient and innovative health care models. It will be key, however, to assess how this will transform the lives of children.

We need new professionals adapted to a “child and environmental health” culture. The creation of advisory committees, structures and tools are important steps to promote science in the field of PEH.3 Many PEH-related visits involve healthy individuals concerned by environmental factors, but society in general seeks interlocutors to which to address emerging concerns. New health care investment and business models will develop based on prediction, prevention, personalisation and community participation. The integration of PEH in clinical practice will contribute to a shift by which 80% of paediatricians will act as health consultants by 2050.33,34

Some types of childhood exposure are associated to chronic diseases in adulthood. Between 90% and 95% of the mass of the human brain develops starting in intrauterine life through age 5 years. The prenatal period and childhood and adolescence are critical periods of opportunity in the development of human neuroplasticity and cellular resilience to increase paediatric and adult wellbeing (Fig. 1).

Figure 1.

The period with the highest economic returns of investment is pregnancy through age 5 years.

Source: Borrowed with the permission of Heckman & Carneiro Human Social Policy, 2003, RAND, Benefits and Costs of Early-Childhood Interventions, A Documented Briefing, Lynn A. Karoly, Susan S. Everingham, Jill Hoube, Rebecca Kilburn, C. Peter Rydell, Matthew Sanders, Peter W. Greenwood, April, 1997.

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We need to create international networks and centres of excellence devoted to research in PEH involving professionals and institutions in the EU and LAC, such as the ENSUCHICA Network on “the environment, child cancer and child survival”. We also need to establish partnerships for the effective and direct exchange of information and research coordination with the aim of improving child health and reducing social disparities and pollution.3,35

The WHO and the EU have promoted the creation of paediatric environmental health speciality units (PEHSUs).32,36 These units, also known as children's environmental health units (CEHUs), are clinical units staffed by paediatricians and biomedical professionals with expertise in PEH in cooperation with other health professionals (obstetricians, toxicology specialists) and professionals in other fields (engineers, environmental workers, educators, psychologists, chemists …). Their purpose is to identify and assess environmental risks and diseases affecting the paediatric population, and to engage in education, training, research and school- and community-based health interventions. The PEHSU is a useful strategy in PEH to apply the precautionary principle in clinical practice. Networks of PEHSUs in the United States and Spain are helping launch similar initiatives in Mexico, Argentina and Uruguay.32,37

The Green Page (GP) for EU–LAC is a tool designed in the context of health care policies delivered at the primary care level and consists of a basic screen for environmental factors that are relevant to paediatric health, to be accompanied by guidance and brief interventions in PEH. The GP includes basic questions regarding prenatal and postnatal life that explore different types of exposure: community-based (neighbourhoods and schools), domestic, related to parental occupation and related to lifestyle. There are different GP models, and they need to be adapted to each specific environment.

The GP is a useful tool in primary care. Its integration in check-up visits or prenatal or routine paediatric visits in the EU and LAC can identify risks associated to environmental pollution in pregnant women and children, increase the awareness and sensitivity of health care professionals and families in regard to environmental issues and improve prevention and quality of life at the community level. A GP form for pregnancy designed in the EU (including a mobile health version) is currently undergoing transcultural adaptation for its use in LAC.33,38

The paediatric environmental history (PEHi) is part of the standard health record. It comprises a series of questions to assess individual risk to identify environmental risk factors and prevent their effects. The role of PEHSUs in training paediatricians on the use of this tool is key. Table 4 summarises the differences between the GP and the PEHi.

We need to advocate for the inclusion of environmental health items in the national budgets of the EU and LAC to fund and properly equip PEHSUs or CEHUs and to introduce PEH as a subject in the curricula of undergraduate and postgraduate degrees in health care and the biomedical sciences.36Table 5 proposes tasks through which paediatricians could become involved in PEH.

We need to better educate resident physicians and nurses in training in the fields of paediatrics, obstetrics and family medicine in the integration of PEH in clinical practice.

Paediatrics societies will form committees on PEH32,39 to develop guidelines and programmes for training on specific competencies like the fellowship programmes in the United States.37

Children spend 40h a week in schools and child care centres. These settings raise concerns in parents regarding the exposure to pollutants. At the same time, fields concerned with education (education, teaching and learning) must take into account environmental pollutants (Table 6) and their adverse effects on health and natural ecosystems. The development of a guideline on school-based environmental health will help develop specific skills in school nurses.