REVIEW

C URRENT
OPINION Climate change impacts on children's respiratory
health
Olivia Kline and Mary Prunicki

Purpose of review
This review examines the impact of climate change on the respiratory health of children, with a focus on
temperature, humidity, air pollution, and extreme weather events. Climate change is considered the
greatest health threat of our time, and children are especially at risk. This review is timely and relevant as it
provides an overview of the current literature on the effects of climate change on children’s respiratory
health, and the implications of these findings for clinical practice and research.
Recent findings
The findings of this review suggest that climate change has a significant impact on children’s respiratory
health, with temperature, humidity, air pollution, and extreme weather events being key contributory
factors. Increases in extreme weather events such as heatwaves, wildfires, floods, droughts, hurricanes and
dust storms all cause the health of children’s respiratory system to be at increased risk.
Summary
The findings of this review suggest that climate change has a significant impact on children’s respiratory
health, and that mitigation and adaptation strategies are necessary to protect children from the harmful
effects of climate change and improve their respiratory health. Overall, a comprehensive and integrated
approach is necessary to protect children from the increasing impacts of climate change.
Keywords
air pollution, children’s respiratory health, climate change, extreme weather, respiratory disease, wildfires

INTRODUCTION aeroallergen inhalation. Their airways are narrower

Climate change is considered the greatest health which amplifies the untoward effect of epithelial
threat of our time, with children especially vulner- inflammation and airway reactivity. Further, both
able to the rise in temperature and extreme weather the lungs and immune system continue to develop
conditions. From 1990 to 2000, climate-related during childhood so that any insult may have sub-
extreme weather events affected over 66 million stantial longitudinal effects. In addition, infants and
children [36]. Though the impact of climate on children are more vulnerable to severe heat due to
childhood is broad, the present chapter primarily their decreased thermoregulatory function at
focuses on the effects on child respiratory health. extreme temperatures [38]. Climate-related impacts
Worldwide, as many as one in three children can also be more pronounced in children as children
experience untoward sequelae from at least four are wholly dependent on adults to mitigate the
climate change factors daily, conferring substantial effect of temperature extremes. Thus, the relative
cumulative health effects [18]. The increasing fre-
quency of extreme weather events such as heat-
waves, wildfires, floods, droughts, hurricanes, and
Sean Parker Center for Allergy and Asthma Research, Stanford School
dust storms augment the risk to respiratory health of
of Medicine, Stanford, USA
children (Fig. 1).
Correspondence to Mary Prunicki, MD, PhD, Biomedical Innovations
The lungs of children may be more susceptible Building, 240 Pasteur Drive, AREA/ROOM 1700, Palo Alto, CA 94304,
to the effects of climate change than adults owing Mailing Code: 5136, Building code 07-600, Stanford University School
physiologic, anatomic, and developmental differ- of Medicine, Stanford, CA 94305-5427, USA.
ences. Compared to adults, in children, respiratory Tel: +1 650 521 7237; e-mail: [email protected]
rate and minute ventilation are higher for any given Curr Opin Pediatr 2023, 35:350–355
weight which increases the risk of pollutant and DOI:10.1097/MOP.0000000000001253

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 Climate change impacts on children’s health Kline and Prunicki

to adults, climate change may pose an even great

KEY POINTS threat to child respiratory health.

Climate change is considered the greatest health threat The effects of climate change on respiratory
of our time, with children especially vulnerable to the health may be more profound on children from
rise in temperature and extreme weather conditions. lower income countries and communities, as well
as those from ethnic minority groups. Currently,

Air pollution, wildfire smoke, temperature, flooding,
children of low socioeconomic status have an esti-
and humidity are all associated with increased risk of
respiratory infections in children. mated increase of 15% in asthma diagnoses in com-
&&
parison to other children [13 ]. Within the United

Synergistic effects of climate change, air pollution, and States alone, Hispanic and Black children are dis-
allergenic pollens significantly impact respiratory health proportionately exposed to air pollution and to the
in children.
effects of climate change [7]. As atmospheric temper-

Mitigation and adaptation strategies are necessary to ature increases, current modeling suggests 1.3-fold
protect children from climate hazards, such as reducing relative risk for Blacks. compared to whites, to live in
emissions, shifting to renewable energy, boosting a neighborhood with the highest projected increases
natural carbon sequestration, and strengthening the in childhood asthma due to increased concentra-
social safety net. &&
tions of particulate matter (PM) pollution [12 ].

Indoor air pollution exacerbated by climate change is
also a significant concern for children’s respiratory
health, and portable air purifiers are effective in AIR POLLUTION
lowering indoor pollutant concentrations. Climate change has caused a marked increase in
greenhouse gases. Currently, more than 90% of

FIGURE 1. Selected climate change and respiratory health impacts in children.

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Pulmonology

children in the world breathe polluted air and this is enough to enter the lungs and cross over into the
responsible for approximately 1 in 10 deaths in bloodstream at the alveolar sacs.
children under five years of age [47]. The 6 ‘‘criteria’’ There is strong evidence associating wildfire
air pollutants used to determine whether a region is smoke exposure with increased asthma visits in
meeting air quality standards include PM, carbon children. In a study examining smoke exposure over
monoxide, ground-level ozone, lead, nitrogen diox- a 4-year period in Indonesia, children under the age
ide, and sulfur dioxide. Air pollution, as defined by of five had increased mortality from chronic respi-
the criteria above, has adverse effects on children’s ratory disease at a rate of 2 deaths per 100,000 per
lung function. For example, in 2016, approximately year [44]. A study in California found that when
600,000 children worldwide died of acute lower children are exposed to the same level of PM2.5 from
respiratory infections resulting from indoor and wildfire smoke versus traffic emissions, there was an
outdoor air pollution [47]. estimated 10-fold increase in respiratory hospital-
Air pollution is associated both with the devel- izations, especially for children ages 0 to 5 years [1].
opment of asthma and asthma exacerbations in Another study in Canada found that there was an
children. Pollution exposure is also associated with increased risk for asthma, acute bronchitis, and
immune dysregulation through various mecha- respiratory infection, especially in children between
nisms, such as increased deoxyribonucleic acid newborn and 9 years of age, with a 10 yg/m3 increase
&
methylation of the transcription factor Foxp3, in PM2.5 [27 ]. Studies have consistently found
which is responsible for the expression of regulatory increases in emergency room visits and hospitaliza-
T cells and critical for regulating allergic disease. tions for respiratory outcomes in children with a
Foxp3 methylation is proportional to risk of asthma similar increase in PM2.5 and increased asthma res-
&
diagnosis at age 7 and asthma severity [33 ]. cue inhaler medication prescriptions [2,14,24]. For
Elevated air pollution levels increase the risk of example, the strongest relationship between wild-
respiratory viral infections, including influenza, fire smoke and asthma in a Southern California
measles, mumps, rhinovirus, and respiratory syncy- wildfire study was found in ages 0 to 5 years old
tial virus (RSV). Moreover, SARS-CoV-2 infection with an 8% increase in hospital admissions [10]. A
and COVID-19 mortality are positively correlated study from San Diego, California, also found that
with increased exposure to air pollution and wildfire body mass index (BMI) was a modifying factor for
&&
smoke [52 ]. worsening of asthma symptoms when children were
Atmospheric ozone concentration is increasing exposed to wildfire smoke, with obese children
with climate change. Ozone exposure causes epithe- receiving more short-acting beta-agonist medica-
lial damage and inflammation in the upper and tions [44]. Overall, young age and elevated BMI
lower airways, increasing airway reactivity and com- may put children at even greater risk for asthma
promising lung function [26]. A multicenter case- exacerbation from wildfire smoke exposure.
crossover study examining almost 4 million emer-
gency room visits for respiratory complaints found
that acute ozone exposure was associated with TEMPERATURE
asthma, acute respiratory infections, pneumonia, Temperature alone has a significant impact on res-
COPD, and upper respiratory tract inflammation piratory infections in children. Studies have shown
[28]. Chronic exposure is associated with increases that a 18C increase in temperature is associated with
in asthma exacerbations and decreased lung func- a 1.9% increase in hospital admissions for respira-
tion with chronic exposure. tory infections in children under five years old in the
tropical area of the Mekong River Delta [35]. Tem-
perature variability and the difference between the
WILDFIRES daily maximum and minimum temperature were
The increasing severity and duration of wildfires is a also risk factors for respiratory infections, especially
notable cause of the rising atmospheric PM levels in children. Temperature extremes and temperature
concomitant with climate change. Wildfire smoke change between in consecutive days are indicators
consists of approximately 80% PM, which is a mix- of global climate change and are expected to
ture of solid particles and liquid droplets, and in increase in the future, which may lead to an
addition many other toxic components, with the increased incidence of bacterial pneumonia in many
exact composition dependent on what is being parts of the world [21] Heat stress and temperature
burned. Particles with a diameter of 10 micrometers variations may be more challenging for children
in size (PM10) irritate the nose and throat but are too than adults. Sharp temperature drops from one
large to enter the respiratory tract. However, par- day to the next are associated with increased emer-
ticles 2.5 micrometers or less (PM2.5) are small gency visits for childhood pneumonia [46,48]. A

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 Climate change impacts on children’s health Kline and Prunicki

study in South Korea found that the risk of emer- of infectious diseases into new regions and hosts
gency room visits for childhood pneumonia [17].
increased by 3.8% with a temperature change
between two neighboring days of less than or equal
to 28C [39]. In addition, temperature is a risk factor INFECTIONS
for decreased lung function, lung development, Viruses: The relationship between climate change
bronchitis and other respiratory infections [31]. and viral respiratory diseases such as influenza and
RSV is of concern. Influenza is affected by temper-
ature change, with warm winters associated with
FLOODING severe and early-onset influenza incidence in the
Climate change causes increases in heavy precipita- following season [9,41]. Modeling studies demon-
tion and storms, which can result in flooding that strated a positive association between influenza out-
poses a significant risk to children. Flooding breaks and geographical differences in minimum
increases the risk of infectious diseases, especially temperature and specific humidity [9]. In children
water and food-borne illnesses like malaria and res- ages 0 to 17 years in Guangzhou, China, high
piratory infections, which disproportionately affect humidity conditions RR 1.45 (1.39, 1.51) and low
children. For example, relative risk increased by 1.66 humidity conditions RR 1.28 (1.11, 1.47) have been
(95% CI: 1.57, 1.74) for hospital admissions in chil- associated with increased risk for influenza [16].
dren ages 0 to 15 years due to acute lower respiratory Increases in atmospheric carbon dioxide concentra-
infections in the Mekong River Delta area during tion are associated with an increase in the incidence
pluvial flooding [35]. This increased risk is com- of confirmed human cases of avian influenza [25]. In
pounded by the impact of flooding on the overall contrast to influenza, warmer winters have been
nutrition status of children. Increased precipitation shown to decrease the RSV seasonality pattern, ter-
is associated with higher mortality rates and long- minating the RSV season earlier [11]. Studies have
term effects on children’s health due to lack of also found an inverse correlation between monthly
proper nutrition and the spread of communicable RSV detection rates and mean monthly air temper-
diseases. Also, mold spores, a major asthmatic trig- ature, total monthly sunshine duration, monthly
ger, increase with flooding. rainfall, monthly relative humidity, and mean
monthly wind velocity [51].
Fungi: Climate change is linked to an increase in
HUMIDITY respiratory fungal infections due to inhalation of
Humidity, driven in part by climate change, is particles in soil. Natural disasters, such as storms and
increasing and linked to increased respiratory earthquakes, can increase the incidence of these
viruses such as RSV, influenza A, and rhinovirus infections by releasing microbes and fungal spores
[29,30]. In an urban area of Italy, the incidence of into the air. For example, outbreaks of coccidioido-
RSV-positive infants was associated with relative mycosis occurred in California after a dust storm
humidity and negatively associated with temper- and an earthquake [37,46]. Moreover, climatic
ature [32]. The combination of climate factors along mechanisms like flooding can increase the inci-
with humidity is also associated with increased risk, dence of respiratory fungal diseases by creating con-
as rainfall, air temperature, and wind speed show a ditions favorable to fungal growth in normally dry
relatively high correlation with hospital admissions soil and housing materials. Epidemiological studies
for pneumonia in children (R2 ¼ 68.4%) and infants have shown that respiratory infections increase after
(R2 ¼ 71.8%) in Brazil [40]. flooding in Mozambique, Bengal, and Bangladesh
[23,50]. Fungal infections caused by aspiration of
flood waters have also been reported with dissemi-
VECTORS nated fungal infections, such as aspergillosis. These
The emergence and spread of viral diseases in recent infections can lead to severe respiratory distress and
years, including zoonotic and vector-borne infec- even death, as seen in victims of the Japanese earth-
tions, have highlighted the significant impact of quake and tsunami of 2011 and the Indonesian
environmental factors such as climate, ecology, earthquake and tsunami of 2004 [22].
and geography on viral activity and transmission.
Climate change is expected to alter habitats and
bring wildlife, crops, livestock, and humans into SYNERGISTIC EFFECTS
contact with pathogens. The challenge of novel There are synergistic effects with air pollution and
pathogens includes the absence of immunologic global warming. For example, the increase in tem-
memory which potentially will foster the spread peratures resulting from climate change accelerates

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Pulmonology

the production of ozone and other pollutants, such climate change and improve their respiratory health
as fine PM and polycyclic aromatic hydrocarbons. [6,43,45,49].
Increased temperature from climate change poten-
tiates the untoward effects of air pollution, resulting CONCLUSION
in increased hospitalization rates in children with
Climate change significantly affects the respiratory
asthma [15].
health of children, with temperature, humidity, air
Pollen grains can also absorb heavy metals,
pollution and extreme weather events being key
nitrates, and sulfur, while particles can agglomerate
contributory factors. Further research is needed to
on the surface of pollen grains [5,19,20]. This pollen-
fully understand the health implications and to
particle interaction may modulate allergen release
develop effective strategies to prevent and manage
and the absorption of pollen proteins to airborne
the impact of climate change on the respiratory
particles, contributing to the increase in pollen
health of children.
allergies and asthma in highly polluted areas [42].
These synergistic effects of climate change, air pol-
Acknowledgements
lution, and allergenic pollens significantly impact
respiratory health and suggest a complex interplay None.
among them.
Financial support and sponsorship
None.
MITIGATION AND ADAPTATION
To combat the impact of climate change on respi- Conflicts of interest
ratory health in children, both mitigation and adap- There are no conflicts of interest.
tation strategies are necessary. Mitigation efforts
must focus on reducing greenhouse gas emissions REFERENCES AND RECOMMENDED
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to protect children from the harmful effects of climate.

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