United States
Environmental Protection
^1 m \ Agency
Climate Change
and Children's
Health and
Well-Being in the
United States
APRIL 2023
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Climate Change arid Children's Health and Well-Being in the United States
Front Matter
ACKNOWLEDGEMENTS
This report was developed by EPA's Office of Atmospheric Protection (OAP) and contains modeling
contributions from Federal agency analysts, academic experts (including Aaron Bernstein, Patrick
Kinney, Jisung Park, Keith Spangler, and Gregory Wellenius), and consultants (including Industrial
Economics, Inc.). Support for the report's production was provided by Industrial Economics, Inc.
PEER REVIEW
The methods of the climate change impacts analyses described herein have been peer reviewed in
the scientific literature. In addition, this report was peer reviewed by four external and independent
experts in a process independently coordinated by Eastern Research Group, Inc. EPA gratefully
acknowledges the following peer reviewers for their useful comments and suggestions: Samantha W.
Ahdoot, Rupa Basu, Timothy W. Collins, and Kari C. Nadeau. The information and views expressed in
this report do not necessarily represent those of the peer reviewers, who also bear no responsibility
for any remaining errors or omissions. Appendix G provides more information about the peer review.
RECOMMENDED CITATION
EPA. 2023. Climate Change and Children's Health and Well-Being in the United States. U.S.
Environmental Protection Agency, EPA 430 R 23 001.
CONTACT US
cira@epa.gov
DATA AVAILABILITY
Data generated from the analyses of this report can be accessed on the following website:
http://www.epa.gov/cira/climate-change-and-childrens-health-and-well-being-united-states-report
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I
Climate Change arid Children's Health and Well-Being in the United States
Table of Contents
4
Executive Summary
10
Glossary
13
Chapter 1. Introduction
17
Chapter 2. Approach
24
Chapter 3. Extreme Heat
35
Chapter 4. Air Quality
46
Chapter 5. Changing Seasons
56
Chapter 6. Flooding
67
Chapter 7. Infectious Diseases
76
Chapter 8. What You Can Do
82
References
Appendices
Appendices with additional
analytic details, information on
data sources, and supplemental
results are provided online at
http://www.epa.gov/cira/clim.ate-
change-and-childrens-health-and-
well-being-united-states-report
A final appendix covers the peer
review process and information
quality procedures undertaken.
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Climate Change and Children's Health and Well-Being in the United States
EXECUTIVE SUMMARY
Introduction
Our climate is changing, and the health and well -being
of children will continue to be affected in many ways.
Children are uniquely vulnerable to climate change in part
because of the natural physiology of developing and
growing bodies. Exposures to climate-related stressors
can occur in a variety of ways, some of which are distinc-
tive to children, including through outdoor play and at
school. Children, and young children especially, have less
control over their physical environments, less knowledge
about health effects from climate change, and less ability
to remove themselves from harm. Climate impacts
experienced during childhood can have lifelong conse-
quences stemming from effects on learning, physical
development, chronic disease, or other complications.
This report investigates five climate-related environmental
hazards associated with children's health and well-being in
the contiguous United States (U.S.): extreme heat, poor
air quality, changes in seasonality, flooding, and different
types of infectious diseases. It provides national-scale
quantification of risks to children for a subset of key
impacts, in addition to reviewing a broad set of pathways in
which climate stressors affect children's health. The analy-
ses presented in this report are part of the EPA's Climate
Change Impacts and Risk Analysis (CIRA) project, a frame-
work using consistent inputs to enable comparison of
impacts across time and space. The infographic below
shows some examples of ways children can be exposed to
harmful conditions in a changing climate.
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Climate Change and Children's Health and Well-Being in the United States
EXECUTIVE SUMMARY
Analysis Approach
The analyses in this report rely on existing
evidence establishing links between environmental
conditions and impacts on children to project
what our changing climate may mean for future
generations. Results are summarized by degree of
global warming relative to recent conditions. Each
detailed analysis follows three main steps:
1 Establish current risks to children:
Existing literature and data are used to
document or model conditions for children
during a baseline period of 1986-2005.
2 Project future environmental conditions:
The rich array of climate data provided in general
circulation models (GCMs), or climate models, are
employed to project future climate hazards.
3 Estimate future impacts on children:
Statistical relationships from peer-reviewed,
relevant literature are leveraged to project impacts
on children's health resulting from exposures to
climate change-associated hazards.
Risks are documented for all children in the contig-
uous U.S., with additional consideration for effects
at local and regional scales. The analyses also
examine the extent to which certain groups of
overburdened children (Black, Indigenous, and
people of color, or BIPOC; low income; limited
English speaking; and children without health
insurance) may be disproportionately exposed to
the most severe impacts.
The report also highlights recent literature docu-
menting other pathways in which the five climate
stressors of interest may affect children, including
potential future magnitudes of each outcome.
Finally, some health outcomes from climate change
can be prevented or reduced through well-timed
and appropriate action; see Chapter 8 of this report
for more information on ways to minimize health
impacts to children.
FIVE DETAILED ANALYSES
[j Heat and learning: Heat negatively impacts
ALk children through learning, among other path-
ways. This analysis quantifies how heat experi-
enced during the school year reduces learning, values
those learning losses in terms of lost future income, and
demonstrates the important role of air conditioning (A/C)
in schools and homes in facilitating effective learning.
Air quality and children's health: Existing
evidence clearly links poor air quality with various
adverse health effects in children, including
asthma. This analysis considers how a warming climate will
change childhood exposures to particulate matter (PM25)
and ozone (03), and then quantifies the related effects on
respiratory diseases and related outcomes.
Pollen and children's health: Climate change
can increase children's pollen exposures as
seasons lengthen and temperatures warm. This
analysis examines how changes in oak, birch, and grass
pollen may lead to more visits to healthcare facilities,
prescriptions filled for allergy medications, and emergency
department (ED) visits for asthma among children.
Coastal flooding and children's homes: During
.—flooding events, children experience safety
risks, psychological stress associated with
displacement and loss, as well as health risks from
water-borne pathogens and mold in flooded structures.
This analysis estimates the number of children who may
experience temporary or permanent displacement from
their homes because of coastal flooding.
Lyme disease: Varying temperature and
toy precipitation patterns are likely to alter the
habitat, range, and density of pathogens,
vectors, and hosts that can cause disease among chil-
dren. Lyme disease, carried by blacklegged (deer) ticks,
is one such disease. This analysis projects the number
of new Lyme disease cases in parts of the country.
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Climate Change and Children's Health and Well-Being in the United States
EXECUTIVE SUMMARY
Key Findings
Results of the detailed analyses are presented
for increases in global average temperature
of 2°C and 4°C above levels observed
in 1986-2005. For the flooding analysis,
analogous results for 50 cm and 100 cm of
global sea level rise are described. Average
impacts across climate models are highlight-
ed, in addition to the minimum and maxi-
mum estimates projected by the models. In
situations where overburdened children
may be disproportionally exposed to the
most severe impacts, those findings are
provided as well. The summary below also
discusses other key pathways through which
children are likely to be affected by climate
change in the future.
Temperature increases of 2°C and 4°C of global
warming are associated with, on average, 4% and
7% reductions in academic achievement per child,
respectively, relative to average learning gains
experienced each school year. Across each cohort
of graduating students, the total lost future income
attributable to these learning losses may reach $6.9
billion ($1.9 to $12.7 billion) at 2°C and $13.4
billion ($8.9 to $18.3 billion) at 4°C. In contrast,
installing A/C in schools is less costly, although this
action only partially mitigates these effects, and
may further induce GHG emissions that contribute
to climate impacts. Black, Hispanic or Latino, and
low income students report the lowest rates of
current A/C in schools, and therefore are likely to
experience these impacts disproportionately.
Another way to measure the magnitude of heat's
effects on children's health is the number of ED
visits associated with high temperature days.
Existing evidence suggests the number of ED visits
among children are expected to increase between
May and September each year as summer
temperatures continue to rise.
EXTREME HEAT
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Climate Change and Children's Health and Well-Being in the United States
EXECUTIVE SUMMARY
Key Findings
AIR QUALITY fj^
New diagnoses of asthma associated with PM>.., and 03
exposure are estimated to increase by 34,500 (27,900 to
42,800) per year at 2°C of global warming up to 89,600
(74,100 to 108,000) at 4°C. On average, this represents a 4%
and 11% increase relative to baseline incidence. ED visits and
hospital admissions due to general respiratory conditions are
projected to increase, as are school days lost because of these
effects. The analysis further projects additional premature
deaths among newborns. Most impacts stem from climate-in-
duced changes in weather conditions that worsen concentra-
tions of PM2i5 and O,, although wildfires and ground-level
dust in the arid Southwest also play a role. BIPOC children are
more likely to experience new asthma diagnoses associated
with PM2;5 exposure, specifically.
Wildfire smoke is comprised of numerous air pollutants that
pose significant human health impacts, including adverse
birth outcomes. New research documents the association
between exposure to wildfire smoke and risk of preterm
birth, suggesting a dramatic potential increase in this
outcome as wildfire activity continues to increase.
At 2°C of global warming, an additional 5,800
(4,800 to 8,000) asthma-related ED visits in children
are anticipated annually from exposures to oak,
birch, and grass pollen, increasing to approximately
10,000 (9,500 to 11,000) additional visits annually
at 4°C of warming. Less severe outcomes, like visits
to healthcare facilities for seasonal allergies (allergic
rhinitis) and prescriptions for allergy medications
for children, may increase by 41,000 (34,000 to
57,000) visits and 121,000 (101,000 to 167,000)
prescriptions annually at 2°C of warming. On
average, the health impacts associated with pollen
exposure increase 17% and 30% at 2°C and 4°C,
respectively. Limited English-speaking, BIPOC, and
uninsured children are more likely to experience
these impacts stemming from oak pollen exposure,
specifically.
Changing seasonality also will alter the ways
children play or recreate outside. Overall, new
evidence suggests that lengthening warm seasons
are expected to result in more time spent on
outdoor recreation, especially boating and water
sports. On the other hand, the number of trips
associated with some recreation types, like skiing
and cold-water fishing, is projected to decrease
under climate change.
CHANGING SEASONS
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Climate Change and Children's Health and Well-Being in the United States
EXECUTIVE SUMMARY
Key Findings
If no additional adaptation actions are taken, approximately
185,000 (159,000 to 437,000) children are estimated to
experience complete home loss from coastal flooding at 50
cm of global sea level rise increasing to 1.13 million
(477,000 to 3 million) at 100 cm. More than 1 million
additional children living in coastal areas may be temporari-
ly displaced from their homes annually due to flooding at
both 50 cm and 100 cm. Well-timed adaptation measures,
including building sea walls, could delay or prevent many of
these impacts; however, they themselves are costly. Chil-
dren in each of the overburdened groups considered in this
report are disproportionally affected by temporary home
displacement at 50 cm and complete loss of home at 100 cm.
Inland flooding, also known as riverine flooding, could
increase in the future due to climate change. Existing
research suggests children will experience damage to their
homes from flooding in these areas.
In 21 Eastern states and the District of Columbia, an additional
2,600 (-7,500 to 20,200) new Lyme disease cases per year
are projected among children under 2°C of global warming.
At 4°C of global warming, the increase is much more
extreme: 23,400 (7,800 to 47,000) additional cases per year.
These additional cases represent a 31% to 272% increase
above baseline infection levels, respectively. States in the
northernmost areas of the Northeast and Midwest regions
are expected to see most of new cases among children.
Research demonstrates that Lyme disease may be under-
reported and undertreated among some overburdened
populations, increasing the likelihood of more severe
outcomes in these communities.
West Nile Virus (WNV) carried by rnosquitos is likely
to see a change in new cases as temperatures increase,
including among children. While existing evidence suggests
the estimated increase in new cases of West Nile Neuroinva-
sive Disease (WNND), a severe outcome associated with
WNV, is anticipated to be small in magnitude, growing
numbers of cases could be indicative of greater rates of
other types of mosquito-borne diseases.
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Climate Change and Children's Health and Well-Being in the United States
EXECUTIVE SUMMARY
Regional Highlights
Finally, this report documents where climate-induced impacts on children are projected to be most acute. Among
the impacts considered, this section identifies the states and regions that are likely to experience the greatest
impacts, including emerging areas of interest. The map below summarizes the findings for 2°C of global warning and
50 cm of global sea level rise. By synthesizing results across regions, the map demonstrates how children can
experience multiple climate stressors simultaneously. However, the map does not convey the geographic distribution
of all climate change impacts on children, or where baseline impacts are high.
NORTHEAST
ME, NH, and VT are among the states with
the highest projected learning losses per child
from high temperatures during the school
year, as well as low current A/C coverage.
These states may also experience the greatest
increase in Lyme disease rates. Children in
WV and VT are most likely to experience
health impacts associated with oak and birch
pollen exposures. MD and DC may have some
of the highest rates of climate-driven air
quality impacts per child, where 03 is the
primary exposure.
Dust in AZ, CO, NM, and UT is projected to
adversely impact respiratory health among
children. Wildfire smoke stemming from future
fire activity in CA is projected to lead to high
rates of poor health outcomes, such as asthma.
WNND incidence rates are projected to be
among the highest in AZ and CO. Inland
flooding effects are high in this region.
SOUTHERN GREAT PLAINS
Increases in exposures to grass pollens may
lead KS and OK to have some of the highest
rates of ED visits for asthma among children.
Children in central TX are expected to see
considerable per capita health impacts from
exposures to oak and grass pollen.
SOUTHEAST
Children in coastal areas of GA, LA, NC, SC, and
VA are the most likely to be affected by the
impacts of coastal flooding on their homes,
assuming no additional protective measures
are taken. Inland flooding effects also are high
in this region. Climate-driven changes to PM2.5
exposure may lead to significant air quality
health impacts in AL, GA, NC, and SC. KY
may experience among the greatest rates of
pollen-related and combined air quality-in-
duced impacts on children nationally.
NORTHWEST
ID and OR are projected to have high
concentrations of wildfire smoke, while
some of the highest rates of respiratory
health impacts among children nationally are
projected in WA due to degrading air quality
from the climate-induced sources in this
analysis. Additionally, increased grass pollen
is projected to result in high adverse health
effects per capita in OR. Inland flooding
effects are among the greatest in the country.
NORTHERN GREAT PLAINS
WY is among the states with the highest
projected learning losses per child nationally
given high warming and low current A/C
coverage. WNND incidence rates may be
greatest in ND, NE, and SD, compared to
national rates. MT and WY are projected to
experience some of the highest rates of
health effects to children from wildfire
smoke. Inland flooding effects are among the
greatest in the country.
MIDWEST
Increasing climate-driven concentrations of
03 in IL, IN, and OH may contribute to some
of the highest rates of air quality health
effects on children nationally. Ml is projected
to experience some of the most considerable
learning losses per student due to heat
exposure, while Ml and MN experience the
most extreme per capita increases in Lyme
disease cases. IN and OH are projected to see
the greatest impacts on children's health of
across all included pollen types.
A
If
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Climate Change and Children's Health and Well-Being in the United States
Glossary
This glossary provides a reference for important terms used throughout the report. For most terms, a
technical definition from an external source is provided. For other terms where a specific definition is
used in this report, that use case is provided instead of or in addition to a technical definition.
Adaptation - Actions taken to prepare for and/or adjust to climate change impacts.1 This is
complementary to, but separate from, mitigation.2
Aeroallergens - Airborne, natural substances such as plant or tree pollen, or mold or fungal spores,
that produce an allergic reaction, often presenting as allergic rhinitis (also known as "hay fever"),
allergic conjunctivitis, or other respiratory effects like asthma.3
Asthma (diagnosis) - A disease that causes inflammation and constriction (narrowing) of the airways
to the lungs, limiting or preventing air from entering or exiting the lungs. Asthma is more common in
children than adults and is more common in boys than girls.4
Asthma attack - A temporary worsening of asthma resulting in difficulty breathing, wheezing, severe
cough, or hospitalization, which may be trigged by environmental stressors such as such as
aeroallergens, wildfire smoke, or air pollution (triggers discussed in this report).5
Baseline - A quantity or scenario (such as of emissions of a pollutant) that is used as a default against
which a change is compared. In this report, "baseline" refers to conditions in 1986-2005.
Children - In this report, "children" refers to people younger than 18 years of age. See Chapter 1 for
a more detailed definition.
Climate change-related gentrification - The process that leads to the displacement of low-income
populations as wealthier residents seek safety from natural, climate change-related hazards to areas
that face fewer natural risks or implement hazard mitigation measures.6
Climate model - A set of mathematical equations that characterizes how energy and matter interact
in different parts of the ocean, atmosphere, and land.7 Some climate models are referred to as
general circulation models or GCMs.
Climate stressor - A condition, event, or trend related to climate that can exacerbate hazards.8 The
climate stressors covered in this report include heat, air quality, flooding, changing seasonality, and
infectious diseases.
Coastal flooding - Coastal flooding occurs when water inundates or covers normally dry coastal land
as a result of high or rising tides or storm surges.9 Coastal flooding results from a combination of
factors, including waves, tides, storm surges (intense waves of inrushing saltwater which arise during
storms), and changes in sea level over time. The most intense storm surges occur during hurricanes
and Nor'easters, when low barometric pressures (which temporarily force an increase in ocean
levels) and wind-driven water combine to push coastal water landward. The forces behind coastal
flooding exhibit natural vulnerability, but sea levels and the intensity and frequency of hurricanes and
other coastal storms can be worsened by climate change—as the climate warms, sea levels rise due
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Climate Change and Children's Health and Well-Being in the United States
to the combination of thermal expansion of water volume, melting of glaciers and other ice sheets,
and other factors.
Contiguous United States - The 48 adjoining U.S. states and the District of Columbia, which excludes
Alaska, Hawai'i, and U.S. territories.
Degree of global warming - A change in the global average surface temperature of one degree above
a specific baseline or time period. In this report, degrees of global warming are described relative to
averages observed in or modeled for the 1986-2005 period.
Environmental justice - the fair treatment and meaningful involvement of all people regardless of
race, color, national origin, or income, with respect to the development, implementation, and
enforcement of environmental laws, regulations, and policies.10
Flash flood - Flooding resulting from heavy rainfall, officially within 6 hours from the start of the
precipitation event. Flash floods can occur in rivers and streams, but also in the built environment,
such as paved streets.11
Greenhouse gas mitigation or emissions mitigation - The process of reducing greenhouse gas (GHG)
emissions or strengthening GFIG sinks that take GFIGs out of the atmosphere. This is complementary
to, but separate from, adaptation.12
Heat stress - A general term that refers to a variety of health outcomes that result from exposure to
heat over a sustained amount of time. The exact temperature and duration of exposure that can lead
to illness is dependent upon the person, the activity they are undertaking, their access to drinking
water, comorbidities they may have, and other factors. A few examples of severe illnesses that exist
under this umbrella term include the following:
• Heat stroke, which refers to the inability of a person's body to self-regulate or cool down.
This quickly can lead to death.
• Heat exhaustion, which presents as a number of symptoms, including headache, nausea,
fatigue, and others.
• Rhabdomyolysis, which is the breakdown of muscle tissue. This can cause organ failure and
death.13
Home loss - In this report, "home loss" refers to the loss of physical, home-based space by a person
due to some sort of environmental condition, including flooding or wildfire.
Infectious diseases - Illnesses that may be spread from bacteria or viruses.14
Lyme disease - Illness caused by the bacterium Borrelia burgdorferi, which is spread to humans by
tick bites. Most commonly, in the U.S., Lyme is spread by the deer tick, also known as the blacklegged
tick [Ixodes scapularis SayJ. It also is spread by the Western blacklegged tick, I. pacificus Cooleyand
Kohls.15
Managed retreat-The process by which coastal communities move away from areas endangered by
climate change-related hazards.
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Climate Change and Children's Health and Well-Being in the United States
Ozone (O3) - A greenhouse gas and air pollutant that occurs naturally (stratospheric ozone) or is
created through the release and reaction of volatile organic compounds and nitrogen oxides in the
presence of sunlight (ground-level, or tropospheric, ozone)16
Particulate matter (PIVh.sand PM10) - Airborne particles that are less than 2.5 (PM2.5) or 10 (PM10)
micrometers in diameter. This report primarily focuses on the health effects from exposure to
ambient PM2.5, which can contribute to the development of asthma, diabetes, COPD, heart attacks,
and other respiratory and cardiac conditions.17 PM10 refers to particles that are 10 micrometers or
smaller and may be visible to the naked eye. While these particles are larger, and therefore may not
be inhaled as deeply into the lungs, this type of particulate matter can still cause considerable injury
to the lungs and airways, leading to chronic effects such as asthma and COPD.18
Pathogen - An organism such as a bacteria, virus, fungus, or parasite that harms its host upon
exposure. Examples include Vibrio spp., Lyme disease via B. burgdorferi, and West Nile Virus. They
can be spread to humans via food, water, animal vectors, or other humans.19
Pluvial flooding - Flooding occurring from excessive precipitation that cannot be immediately
absorbed into soil or drained away.20
Riverine flooding - Flooding that occurs when a river or stream overflows its banks.21
Seasonality - Recurring events or processes that are correlated with seasons, such as rising
temperatures at the end of winter or the onset of allergies during ragweed season.
Social vulnerability (also, "socially vulnerable") - Referring to the measure or level of vulnerability of
a particular population in the face of different types of environmental stressors and natural
hazards.22 This report includes the following variables as measures of social vulnerability: age (which
is a prevailing factor throughout this report), race, ethnicity, poverty status, whether English is a
child's first or primary spoken language, and whether a child is covered by health insurance.
Storm surge - A rise in coastal water levels during a weather event (e.g., hurricane, tropical storm),
as a consequence of winds propelling ocean water towards the shore. Storm surge can be extremely
powerful and cause considerable flooding. It is generally the cause of the majority of injuries,
property damage, and deaths during tropical weather events.23
Vibriosis - Illness resulting from exposure to non-cholera-causing Vibrio species.24
West Nile Virus -The most common mosquito-borne illness in the U.S. West Nile does not frequently
cause severe illness in children, and typically presents as cold-like symptoms, although it may have
extreme health effects on children who are immunocompromised. Such effects may include
temporary or permanent paralysis or death.25
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Climate Change arid Children's Health and Well-Being in the United States
Chapter 1: Introduction
The goal of this report is to
describe and quantify some of
the future impacts of climate
change on children across the
U.S. using the best-available
literature and data.
The intended audience
includes parents, healthcare
providers, researchers, public
health practitioners, and
decision makers who design
and implement strategies and
policies to reduce these risks
through greenhouse gas
mitigation and adaptation.
Our climate is changing, and the health and well-being of
children will continue to be affected in many ways.26 Multiple
lines of evidence show risks to children through increasing
temperatures, rising sea levels, changing rainfall patterns,
more extreme wildfire seasons, and shifting patterns of
disease exposure.27 Children are uniquely vulnerable to
climate change in part because of the natural physiology of
developing and growing bodies.28 They physically,
psychologically, and socially experience health effects
differently from adults.29
For example, a baby may be born early and underweight if
the pregnant mother experiences a heatwave or is exposed
to poor air quality.30,31 Poor birth outcomes such as these can
lead to lifelong effects on behavior and learning.32 Likewise,
children of all ages can develop asthma or cardiac conditions,
or be exposed to heat or diseases that can have short- and
long-term health consequences.33,34,35 They also may
experience psychological or cognitive effects from exposure
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Climate Change arid Children's Health and Well-Being in the United States
to stress or trauma preceding, during, or following severe weather.36,37 Where possible, a qualitative
discussion of the mental health effects of climate change on children is provided throughout the
report and in greater depth in Appendix A.
Exposures can occur in a variety of ways, some of which are unique to children. Play - essential to
children's healthy physical and emotional development, as well as the very essence of childhood -
can change the pathways and extent to which children are exposed to different hazards.38-39 Outside
of play, children can be exposed to hazards by breathing in air pollutants, living in a home or
attending a school that is not air conditioned, living in a floodplain, or getting bitten by a tick or
mosquito.
40,41,42
Children also have less control over their physical environment than adults. For
instance, young children may be unable to open car doors when the inside conditions become
unpleasant or dangerous or cannot mask themselves when air quality is noticeably poor. Figure 1
shows some examples of ways in which children can be exposed to harmful conditions in a changing
climate via the climate stressors covered in this report.
Figure 1: Examples of Climate Stressors and Impacts on Children
Notes: This figure illustrates the five climate stressors covered in this report as well as some of the ways children are affected by
the chosen stressors. See Chapter 2 for details. The figure is not intended to provide a comprehensive accounting of all ways
through which children are affected by climate change.
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Climate Change and Children's Health and Well-Being in the United States
Many health outcomes from climate change can be prevented or minimized through well-timed and
appropriate action (see Chapter 8 for more information on ways to minimize health impacts to
children). For example, during extreme heat, it is important for children to hydrate often, to play
outside earlier or later in the day when temperatures are cooler, and to seek shade to rest and cool
off. Monitoring local air quality alerts, especially during wildfire smoke and ash warnings, and limiting
children's time outdoors when the air quality is poor, can help reduce exposure and potential health
effects. Successful strategies to minimize adverse health outcomes in children depend on a
combination of social factors, improved forecasting of weather and climate conditions, and better
understanding of how climate change impacts will vary in a changing climate.
This report provides national-scale, multi-sector analyses focused on quantification of projected
health risks to children in the contiguous U.S. from climate change. It investigates climate stressors
including changes to the frequency and intensity of extreme heat, climate-driven effects on air
quality, flooding, changes in seasonality (measured by recreation opportunities and pollen
exposures), and different types of infectious diseases. The analyses consider and quantify how
children may experience physical harm, and where possible, the extent to which effects
disproportionately fall on overburdened children. The report builds on a framework developed by
EPA in a 2021 report on climate change and social vulnerability.43
Each chapter includes the following components: a discussion of a climate stressor, a literature
review of the known attributable health effects, and projections of how risks may change in the U.S.
under different levels of future warming. The report concludes with a chapter on actions for
addressing and preparing for these risks, through applications of hazard mitigation and adaptation
measures, improved risk communication to support healthy choices for children and their parents
and caregivers, and recommendations for future research.
The analyses presented in this report are part of the EPA's Climate Change Impacts and Risk Analysis
(CIRA) project, a multi-model framework using consistent inputs to enable comparison of climate-
driven impacts across time and space.44 The purpose of CIRA is to quantify the physical effects and
economic damages of climate change in the U.S. Using detailed models of sectoral impacts (e.g.,
human health, infrastructure, and water resources), the project seeks to quantify and monetize how
risks, impacts, and damages may change in response to greenhouse gas mitigation and adaptation
actions. The data and methods follow this framework and are applied in the detailed analyses in this
report. Each underlying study has been peer-reviewed and published in the scientific literature; the
corresponding research papers are cited throughout this report and in the appendices.
This report is intended to provide insights about risks to children's health across multiple impacts and
future levels of global warming, with consideration for important sources of uncertainty involved
with projecting future risks. It is not designed to be a comprehensive assessment of climate change
impacts on children. Estimates should not be interpreted as definitive predictions of future impacts
at a particular time or place. Instead, the intention is to produce estimates using the best available
data and methods, identified by extensive literature reviews and prior analyses. The analyses can be
revisited and updated as science and modeling capabilities continue to advance. Finally, there are
many potential effects of climate change that are not explored in this report due to limitations of
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Climate Change arid Children's Health and Well-Being in the United States
available data and robust methodologies. Therefore, the results capture only a portion of the
potential risks to children's health.
The analyses presented in this report focus on how children experience the impacts of climate
change as children (see definition below). Another important dimension of how climate change will
affect children is through the increasing intensity of impacts they may experience as future adults.
For instance, a child born the year this report was published may live to see the effects of a changing
climate into the 22nd century, which are projected to be even more extreme than the impacts
experienced by adults today. Projections of the cumulative effects of climate change on current and
future generations of children is beyond the scope of this report.
How are children defined in this report?
U.S. EPA's Policy on Children's Health defines children's environmental health as the effect of environmental
exposure during early life: from conception, infancy, early childhood, and through adolescence until 21 years of
age. In this report, the term "children" encompasses individuals aged 0-17, or the period immediately postpartum
(newborn) through the age customarily acknowledged in the U.S. as the end of childhood. Specific analyses may
use narrower age ranges in which the underlying studies and methods indicate specific age groups. For instance,
several studies are specific to school-aged children (aged 5-17) or infants only (aged less than one year). When
possible, the report accounts for fetal effects, including preterm birth and low birth weight.
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Climate Change arid Children's Health and Well-Being in the United States
Chapter 2:Approach
This report takes an expansive
approach to documenting climate
risks to children, including both
qualitative descriptions of the
pathways by which climate
affects children's health and
quantified health impacts for key
endpoints. The quantified impacts
are summarized using an
"impacts by degree of global
warming" framework used in this
and other EPA reports on climate
change impacts.
This chapter describes the analytic approaches used
throughout this report to assess the impacts of climate
change on children's health and well-being in the
contiguous U.S. It first explains the selection of the five
specific climate stressors assessed in this report and then
describes the three types of analyses conducted for each:
a literature summary identifying impacts of climate
change in children, a detailed analysis of one key impact
pathway, and a discussion of emerging climate change
impacts.
Lastly, this chapter provides an overview of the standard
analytic approach used for the detailed analysis of each of
the five climate stressors, including details on the impacts
by degree approach, adaptation assumptions, how
uncertainty is conveyed, geographic considerations, and
how disproportionate risks to overburdened children are
assessed.
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Climate Change and Children's Health and Well-Being in the United States
CLIMATE STRESSORS
This report focuses on five climate stressors that are likely to impact children in
unique ways: extreme heat, air quality, changing seasons, flooding, and infectious
diseases. The selection of these specific climate stressors was guided by findings from
recent research synthesizing the current state of understanding about how climate change affects
children,45 along with the availability of methodologies to quantify future risks for each. Many other
types of climate stressors can and do interfere with the health and well-being of children in the U.S.
beyond what is covered in this report.
IMPACT ANALYSIS TYPES
Each of the following chapters explores three types of evidence pertaining to the risk
of impacts on child health for a particular climate stressor. Figure 2 summarizes the
specific analyses for the five climate stressors covered in the report.
• Literature reviews summarize evidence that establishes pathways between climate stressors and
various health outcomes among all children, with consideration for environmental justice
concerns.
• Detailed analyse: provide quantitative assessments of ways in which changing environmental
conditions could affect children via a well-established impact pathway also known to be of
substantial magnitude. Following the CIRA approach, results are summarized by degree of global
warming relative to baseline conditions in 1986-2005. Analyses convey changes in risks to
children, discuss geographies where impacts are concentrated, and when possible, determine
whether already overburdened populations are more likely to be disproportionately affected
than other groups.
• Emerging climate impact discussions highlight new literature quantifying other key climate-
impact pathways of harm to children's health. These discussions indicate where deeper analysis
is needed to further characterize future impacts.
Figure 2: Summary of Climate Stressors, Analyses, and Emerging Impacts Included in this Report
Climate Stressors
Detailed Analyses*
Emerging Climate Impacts
fl Extreme heat
6 / | Learning losses
fii
, H Emergency department
Pi | (ED) visits
|-i, Air quality
/rjgn\ PM2.5 and 03 and children's
0HJ) health
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Climate Change and Children's Health and Well-Being in the United States
ANALYTIC APPROACH IN DETAILED ANALYSES
Detailed analyses in each chapter follow a standard analytic approach, which is
summarized in this section and described in more detail in Appendix A. Individual
analyses rely on specific data sources, methods, and assumptions that are explained in
the relevant chapters and accompanying appendices.
STEPWISE ANALYTIC APPROACH
Figure 3: Overarching
Stepwise Analytic
Approach
Each detailed analysis follows a three-step approach to estimate future
impacts on children (see Figure 3). Step 1 identifies current risks among
children using literature and quantitative data to document or model
conditions in 1986-2005. This baseline represents the reference point for
understanding future changes. Step 2 draws on existing climate data
provided by six general circulation models (GCMs), or climate models, to
project future climate hazards, including temperatures, rainfall, and sea
level rise. To provide a simple and common climate change metric for all
analyses, the climate projections are indexed to changes in global
temperature per degree Celsius from the baseline. The detailed climate
scenarios are drawn from the fifth phase of the Coupled Model
Intercomparison Project (CMIP5) and represent a recent, well-established
understanding of how climatic conditions may change in the future.46 The
climate scenarios in Step 2 also enable projections of other environmental
conditions associated with climate change, such as changes in air quality
and pollen exposure. Finally, Step 3 uses the climate data generated in Step
2 as an input to a variety of models that estimate the impacts on children's health from changes in
climate variables and compares the outcomes to a future without climate change, while accounting
for changes in population. The analyses leverage existing statistical relationships from peer-reviewed
literature to make the connections between climate and impacts.
The detailed analyses in this report focus on the following endpoints:
5^~~\ Heat and learning: Learning losses per child relative to a normal year of learning and future
lost income associated with learning losses across each graduating student cohort.
Air quality and children's health: Cases of asthma, incidence of hay fever, lost school days,
ED visits for asthma, hospital admissions for respiratory illness, and infant deaths.
Pollen and children's health: Prescriptions filled for allergy medications, first doctor visit for
hay fever, and ED visits for asthma.
Coastal flooding and children's homes: Children at risk of temporary or total home loss
with consideration for different protective adaptation scenarios.
Lyme disease: Cases of Lyme disease in 21 states and the District of Columbia caused by
changes in extent and range of the blacklegged tick and Lyme-disease causing bacteria.
JQl
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Climate Change and Children's Health and Well-Being in the United States
IMPACTS BY DEGREE OF WARMING
Climate impacts are generally expected to become worse as the Earth continues to warm. To
synthesize results across impacts, each analysis presents results for incremental increases in global
warming relative to mean conditions in 1986-2005 (baseline). As described in Sarofim et al.,47 this
approach eliminates confusing scenario jargon and aids comparability across analyses. Impacts in this
report are presented for global average temperature increases of 2°C and 4°C (equivalent to 3.6°F
and 7.2°F; see accompanying appendices for results at other degrees of warming).
Figure 4 shows that under a "higher GFIG emissions" scenario, climate models on average project
that global temperature increases of 2°C and 4°C could be reached by the years 2056 and 2097,
respectively, but the uncertainty range around this central estimate spans several decades. For
"lower emissions" futures, which are considered more likely as of the writing of this report, the
arrival of these temperatures could be pushed back further into the future. The "even lower
emissions" scenario reflects emissions reduction action that is generally sooner and more aggressive
than is considered likely as of the writing of this report.48
Figure 4: Projected Timing for Global Average Temperature Changes
Emissions
Scenario 2020 2030 2040 2050 2060 2070 2080 2090 2100
Even Lower
(RCP2.6)
Lower 2039
(RCP4.5)
2033
Higher 2056
Global Warming Relative to 1986-2005 Estimated Arrival Times
rc 1.8"F 2"C 3.6"F 3"C 5.4"F 4"C 7.2°F Earliest 1MB Latest
Notes: This figure describes the range (lines) and mean (boxes) estimated arrival times for each degree of global
warming above mean levels observed in 1986-2005 across global climate models and emissions scenarios.
SEA LEVEL RISE PROJECTIONS
The coastal flooding analysis in Chapter 6 summarizes results associated with changes in global
average sea level rise in 25 cm increments relative to a baseline sea level period from the year 2000.
To compare the baseline with the impacts summarized by degree of warming, the analysis highlights
impacts at 50 cm (equivalent to 19.7 inches) and 100 cm (equivalent to 39.4 inches) of global sea
level rise, which are commonly used index values for this metric (see Appendix A for details).49 The
projected changes in global average sea level generally correspond to higher changes in sea level in
the U.S. For instance, U.S. sea level rise may be more than 50% greater than global sea level rise,
particularly along the Atlantic and Gulf coasts, where land levels are falling as sea levels rise.50
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Climate Change and Children's Health and Well-Being in the United States
What is 1°C of global warming?
The "degrees of warming" considered in this report are relative to temperature levels in 1986-2005, the baseline
considered in the CIRA project. Care should be taken when viewing these results in relation to other analyses that use
different baselines, like the targets under the Paris Agreement that consider degrees of warming relative to pre-
industrial times. After adjusting for the differences in baselines, 2°C of warming relative to 1986-2005 would translate
to 2.45°C of warming relative to pre-industrial times. For context, by 2020, global mean temperatures had risen
roughly 0.5°C above the 1986-2005 baseline mean temperature.51
Additionally, the "degrees of warming" referred to throughout this report relate to changes in global mean
temperatures. Warming across the planet is not uniform because the oceans, which comprise a majority of Earth's
surface, are slower to warm than the land. 1°C of global warming results in more than 1°C of warming in areas that
largely comprise land surfaces. At 2°C of global warming, large areas of the contiguous U.S. are projected to
experience average annual temperature increases between 3°C and 4°C (5.4°F and 7.2°F). At 4°C of global warming,
most of the contiguous U.S. is projected to experience temperature increases between 5°C and 6°C (10.8°F and
12.6°F). See Appendix A for details.
FUTURE POPULATIONS OF CHILDREN
The detailed analyses incorporate projections of the future population of children. The analyses rely
on U.S. Census data for 2010 as well as future projections published in EPA's Integrated Climate and
Land Use Scenarios version 2 (ICLUSv2) model through 2100.52 Populations for a given future year
are matched with the "arrival year" for each climate scenario, as described in Figure 4. Appendix A
provides more details on the methods and data sources used to model both baseline and future
populations of children expected to experience the impacts described in this report.
ADAPTATION ASSUMPTIONS
Populations may adapt to climate change in many ways, with some actions limiting the impact of
climatic exposure, and other actions potentially exacerbating impacts. The detailed analyses of this
report treat adaptation in two different ways. The coastal flooding analysis directly models a baseline
"no additional adaptation" scenario as well as a "with adaptation" scenario that incorporates specific
assumptions, using a simplified cost-benefit analysis, about future investments in coastal flood risk
management. All other analyses assume no additional adaptation beyond the extent to which
populations have already adapted to recent climatic changes or weather variations.
These treatments reflect the current state of the underlying impacts literature, where only a few
studies of children's health and well-being currently incorporate the efficacy of future adaptation
actions which might be undertaken to reduce children's health risks. For instance, the air quality,
pollen, and Lyme disease analyses do not account for potential technological advancements or
changes in behavior that may result in more- or less-severe health impacts on children in the future.
The "with adaptation" scenario in the coastal flood risk analysis is intended to be illustrative and does
not represent a specific policy at national or regional levels; no specific programs, authorities, or
policy mechanisms were considered or evaluated.
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Climate Change and Children's Health and Well-Being in the United States
UNCERTAINTY AND PRECISION CONSIDERATIONS
There are important sources of uncertainty involved with estimating the future impact of climate
change on children's health. The underlying peer-reviewed health studies used in the extreme heat,
air quality, changing seasons, and infectious disease chapters include statistical analyses which
incorporate confidence intervals to characterize estimation uncertainty-the flooding analyses,
however, rely on process-based simulation modeling approaches that do not include statistical
representations of the uncertainty in flood response to changes in climate. The technical appendices
that accompany this main report provide some insight into the uncertainty ranges associated with
the estimates employed for projection purposes, where applicable.
There is also uncertainty about how the climate will change in the future. This uncertainty is
reflected, in part, in the differences in outputs across available global climate models. The detailed
analyses presented in this report use the findings from up to six global climate models; the impacts
presented reflect averages across those models (with ranges reflecting the low and high estimates
from among the suite of global climate models employed in these analyses). For coastal impacts,
which are connected to specific index values for future sea-level rise (50 and 100 cm), uncertainty in
the estimates is characterized by uncertainty bounds reported in a recent NOAA report that provides
global mean projections as well as the 17th and 83rd percentiles.53 We use these bounds to estimate
the number of children impacted in contiguous U.S. for each increment from 25 cm to 100 cm. There
is also uncertainty regarding future population, as well as how people may adapt to climate change
in the future. Combining these various sources of uncertainty was not attempted in this report.
GEOGRAPHIC CONSIDERATIONS
In addition to describing total impacts across all children in the contiguous U.S., the report showcases
the spatial distribution of those impacts, building on the spatial granularity inherent in the underlying
climate models, as well as population projections incorporated into the analysis. To accomplish this,
total impacts on children's health are mapped at the census block group, census tract, or county
levels, consistent with the underlying input data. Further, each detailed analysis identifies the five
states where the impacts per child are projected to be highest. The accompanying technical
appendices provide additional detail on the concentration of total impacts, taking into account the
influence of population projections as well.
DISPROPORTIONATE RISKS TO OVERBURDENED POPULATIONS
Where possible, the detailed analyses examine the degree to which children within several
demographics living in the contiguous U.S. (Black, Indigenous, and people of color (BIPOC); low
income; limited English speaking; and children without health insurance) may be disproportionately
exposed to the most severe impacts of climate change, building on an approach in a 2021 EPA
report.54 The detailed analyses conclude by estimating the likelihood that these groups of concern
live in geographic areas with the highest projected climate change effects. This likelihood is based on
current demographic distributions and projected changes in climate conditions. The estimated risks
for each demographic group are presented relative to each group's reference population, defined as
all individuals other than those in the group analyzed. Due to data limitations, this report does not
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Climate Change arid Children's Health and Well-Being in the United States
consider all possible dimensions of social vulnerability that children may experience, although it
includes summaries of existing literature within each chapter that discuss potential impacts that may
affect these individuals.
While differential risks to children can be linked to specific physiological differences between
children and adults, the disproportionate risks to overburdened populations tend to be associated
with social, historical, healthcare, and institutional disparities between groups. Climate change will
continue to exacerbate existing inequities in children's health. Due to a deeply rooted system of
discrimination and oppression (i.e., structural racism), Black, Indigenous, and other communities in
the U.S. are often particularly vulnerable to environmental hazards, including the effects of climate
change. For example, historic practices of redlining have created lasting effects and are correlated
with low-income neighborhoods and communities of color in urban areas being disproportionately
exposed to heat islands (e.g., lower vegetative cover and greater blacktop coverage leading to higher
temperatures).ss
Which overburdened populations of children are considered?
Black, Indigenous, and people of color (or BIPOC): This report uses the term BIPOC to refer to individuals
identifying as Black or African American; American Indian or Alaska Native; Asian; Native Hawaiian or
Other Pacific Islander; and/or Hispanic or Latino. It is acknowledged that there is no "one size fits all"
language when it comes to talking about race and ethnicity, and that no one term is going to be embraced
by every member of a population or community. The use of BIPOC is intended to reinforce the fact that
not all people of color have the same experience and cultural identity. This report therefore includes,
where possible, results for individual racial and ethnic groups.
Low income: Children living in households
with income that is at or below twice the
Federal poverty threshold for their
household size.
Limited English speaking: Children living in
households where all members 14 years and
over older have at least some difficulty with
speaking English.
No health insurance: Children without
health insurance.
Notes: 1) These definitions rely on standard
variables in the U.S. Census Bureau's
American Community Survey.56 2) Due to
data limitations, this report does not analyze
the impacts of climate change in Hawai'i,
Alaska, or U.S. territories. However, the
analyses use demographic data from the
U.S. Census which includes individuals living
in the contiguous U.S. who identify as "American Indian or Alaska Native" and "Native Hawaiian or Other
Pacific Islander." For more information, please see Appendix A.
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Climate Change arid Children's Health and Well-Being in the United States
Chapter 3: Extreme Heat
Chapter highlights
This chapter describes examples of how heat affects children's health arid well-being, and
how those risks are expected to increase in a warming climate. Children's physical, cognitive,
and mental health may be affected by climate-induced temperature increases, extreme
heat, and increased frequency of heat waves.
i 1 One key way that heat negatively impacts children is through learning. This chapter first
\ quantifies how heat experienced during the school year reduces learning and then
llljULA monet'zes those losses in terms of lost future income. Holding constant current levels of
school and home A/C availability, temperature increases of 2°C and 4°C of global warming
are associated with 4% and 7% reductions in average academic achievement per child, respectively,
relative to average learning gains experienced each school year. The lost annual future income across
each cohort of graduating students may reach $6.9 billion ($1.9 to $12.7 billion) at 2°C of global
warming and $13.4 billion at 4°C ($8.9 to $18.3 billion). Installing A/C in schools is less costly,
although it only partially mitigates these effects, and will exacerbate climate impacts if the electricity
used is not from renewable sources. Black, Hispanic, and low-income students are likely to
experience these impacts disproportionately.
This chapter also documents the relationship between increased summer temperatures
and ED visits at children's hospitals in the U.S. For each 1°F (equivalent to 0.6°C) increase
between May and September, the number of ED visits at U.S. children's hospitals could
increase by 113 visits per day, or over 17,000 visits over the five-month period.
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Climate Change arid Children's Health and Well-Being in the United States
I
HOW CLIMATE CHANGE AFFECTS HEAT AND CHILDREN
Heat is one of the most apparent indicators of climate change. Increasing average
surface temperature will generally lead to both less cold weather and more hot
weather: the hottest temperatures in the future may be warmer than any experienced
in recent decades.57 In addition to overall warming, climate change is intensifying heat waves and
extreme heat events. In particular, the U.S. is seeing higher temperatures year-round, with hotter
summers and longer heatwaves.58 Heat can have a wide range of health impacts, regardless of
location.59'60,61 Many of these effects are especially pronounced on the young and old, pregnant
women, people who have certain preexisting health conditions, and outdoor workers.62,63,64
IMPACTS OF HEAT ON CHILDREN
Heat can affect children in many ways, in part
because children's bodies respond differently to
heat than adults; this also is true for pregnant
women and fetuses.65,66,67 Thermoregulation,
which refers to how the body maintains a normal
internal temperature despite changing external
temperatures,68 is at the core of the physiological
response to excess heat. If the body is unable to
properly cool itself, excess heat can lead to
dehydration and organ damage. This can manifest
as lightheadedness, fainting, muscle breakdown,
renal (i.e., kidney) failure, seizure, coma, or death
in extreme cases.69,70,71
Children are particularly susceptible to heat-
induced adverse health outcomes because their
bodies are not as efficient at thermoregulation as
adults. For example, children also do not sweat as
much as adults, limiting a key method the body
uses to cool itself. This is especially true for the
youngest children (including infants) and girls more
than boys.72,73 Research shows that children with
preexisting health conditions—including asthma,
other respiratory conditions, impaired kidney
function, and endocrine disruption (e.g.,
diabetes74,75,76)—are also more vulnerable to the
effects of heat.
Exposures to heat can take several forms.
Tragically, one of the best-known metrics is the
number of children who die each year after being
Heat effects on children
Excess heat in children can lead to
fainting, muscle breakdown, organ failure,
seizure, coma, or death in extreme cases.
Heat is linked to poor cognitive function
and reduced ability to concentrate or
learn.
Children are at greater risk of developing
anxiety or depression due to high heat.
Heat can affect children in utero.
"Heat islands" and lack of access to A/C
exacerbate these effects among
overburdened populations.
Increasing humidity may also impact
children's health, although it is not
explored in this report.
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Climate Change and Children's Health and Well-Being in the United States
left in hot cars.77'78 Another unfortunate example is children collapsing during sporting activities in
hot weather.79 A child playing in heavy sports equipment or participating in other types of exerting
activities in hot weather may find it very difficult to maintain sufficient fluid levels. Children may not
receive enough encouragement to drink water or may be susceptible to pressure not to take breaks
when they feel heat-related discomfort.80 While there are recommendations for how to adapt to
increased heat exposure—such as guidelines for sports practices and games,81,82 car-based alert
systems that remind parents about a child in the backseat,83 and communications messaging around
risk84—children remain vulnerable in these settings.
Other heat effects may occur in the home or at school, especially in spaces that lack A/C. Heat is
linked to poor cognitive function and the ability to concentrate or learn, reducing learning outcomes.
One reason for this effect is that cognitive function declines during excessive heat, leading to slower
reaction times on assessments.85 A second reason is that heat affects the ability to have a "good
night's sleep," which can lead to cognitive disruption and learning difficulties.86,87,88 Further, hot
classrooms may be distracting and unmotivating. Finally, on extremely hot days, students may miss
or intentionally avoid school, particularly if the school is not air-conditioned.89 Emerging evidence
also suggests that extreme heat experienced in utero can have long-term cognition impacts on
children and are linked to losses in income and earning potential.90
Play is a fundamental component of childhood, and research suggests that children's activity levels
may vary due to high heat during outside play, including recess. This is especially true in areas that
historically have had cooler average temperatures;91 thus, children in these areas may be less able to
adapt (acclimatize) to hotter temperatures.92 While seemingly less severe, this can have implications
for children's physical and mental health.93,94
Adverse mental health impacts are also associated with rising temperatures. Children are at greater
risk of developing anxiety or depression due to high heat.95 Adolescents especially may respond to
heat with irrational and aggressive behaviors. Extreme heat linked to climate change has been
connected to increases in violent behavior and crime,96,97,98 all of which may impact children
directly.99 Additionally, research shows that climate change is likely to increase suicide rates in adults
and children.100
Children from overburdened households are at particular risk of experiencing harm due to high
temperatures.101 Poverty can leave children at greater risk of harm from heat exposure; race and
other demographics are correlated with high exposure and risk of heat-related impacts.102 A 2016
scientific assessment found that children—especially non-White, economically disadvantaged
individuals (among other characteristics)—are more vulnerable to adverse health outcomes such as
death due to heat exposure.103 Poverty is linked with adverse health outcomes, stress, and poor
cognition, and heat compounds these effects for children.104 Fleatwaves also have been linked to
preterm labor,105 especially in non-White, less-affluent populations.106 This, consequently, can result
in low birth weight,107 as well as subsequent developmental effects.108
Urban heat islands often are found in lower-income, predominantly BIPOC communities, exposing
residents to greater concentrations of higher temperatures.109 Additionally, many vulnerable
households do not have A/C due to cost or because the home was built when A/C was not common
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Climate Change and Children's Health and Well-Being in the United States
or necessary.110 Research shows connections between poverty and race with exposure to both
higher temperatures in an area as well as A/C access.111 The combination of exposure to high heat
plus poor health outcomes has been linked to the socioeconomic demographics of a given area,
along with access to A/C.112
Finally, a changing climate will moderate average cold temperatures across most of the contiguous
U.S. While this chapter focuses on heat, changes in cold temperatures likely will benefit some
aspects of children's health. For instance, mortality associated with extreme cold is projected to
decrease as the climate warms.113 Children are particularly susceptible to mortality associated with
extreme cold as they are less able to regulate their body temperature than adults.114 Flowever,
several studies have shown that the adverse effects of heat outweigh any potential benefits from
reductions in cold-related effects and, therefore, this chapter focuses on quantifying the
former.115,116
HEAT AND LEARNING LOSSES
This section analyzes the connection between heat
experienced during the school year and learning losses
among children. As described in the previous section, heat is
linked with poor cognitive function and reduced ability to concentrate or
learn. This report leverages national-level findings from Park et al. to
model adverse education effects among high school students, the cohort
examined in the study.117 Park et al. investigated how heat inhibits
learning among students in the contiguous U.S. and how A/C in schools
and homes reduces those effects. The analysis presented in this report
uses that historical relationship to assess how students may suffer from
heat during future school years.
Figure 5: Heat and Learning
Analysis Steps
Step 1
Determine existing
learning, school A/C,
and home A/C levels
Step 2
Calculate future
average daily max
temperature during
school year
Step 3
Quantify future
learning losses and
monetize lost future
Figure 5 summarizes the three overarching steps of the analysis, with
more details about the methods and underlying data sources in Appendix
B. First, several data sources are assembled to determine existing
learning gains each academic year as well as current levels of A/C in
schools and homes. Then, because school calendars vary considerably
across the county, this analysis considers local start and end dates for the school year to determine
how future temperatures will rise during that time by census tract (for instance, states in the South
generally start in early to mid-August whereas states in the North and Midwest often begin in late
August or early September). Finally, the analysis quantifies learning losses in terms of percent
reduction in learning relative to average gains per school year, then values those losses in terms of
lost future income using findings from Chetty et al.118 By valuing learning losses, the analysis can
compare findings to the total projected cost of installing A/C in schools as an adaptation strategy,
using estimates presented in LeRoy et al.119
Figure 6 demonstrates why accounting for local A/C coverage is important to accurately project
learning losses associated with heat. The top map presents baseline average maximum daily
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Climate Change arid Children's Health and Well-Being in the United States
temperatures during the local school year (1986-2005), while the middle and bottom maps describe
the current distribution of A/C in schools and homes, respectively. As shown, the regions that
currently experience the warmest academic years (the South and Great Plains) already have the most
protection from existing A/C. On the other hand, regions historically characterized by milder
temperatures during the school year have less school and home A/C coverage, particularly in the
Northeast, Midwest, and across the Rocky Mountains. This analysis highlights where future
infrastructure investments are most needed as temperatures warm.
Figure 6: Baseline Average Maximum Daily Temperatures During School Years in °F (Top), A/C
Coverage in Schools (Bottom Left), and A/C Coverage in Homes (Bottom Right)
Average Maximum Daily Temperatures during the School Year in 1986-2005 (°F)
0 1 -55 56-63 64-70 71 - 77 ¦ 78 - 87
A/C in schools A/C in homes
0% - 20% 20% - 40% 40% - 60% ¦ 60% - 80% HI 80% - 100%
Notes: The top map shows average daily maximum temperatures (°F) at the county level during state-specific
school calendar years in the baseline considered across this analysis (1986-2005). The middle and bottom maps
show the current coverage of A/C at the county level, assembled from various sources described in Appendix B.
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Climate Change arid Children's Health and Well-Being in the United States
Figure 7: Projected Additional Impacts of Heat on Learning Among Children
Degrees of
Global
Warming
Lost Future
Income Per Year
Per Child
Total Lost Future Income
Per Year Across Graduating
High School Students
2°C
$1,300
$6.9 billion
($380 to $2,400)
($1.9 to $12.7 billion)
4°C
$2,300
$13.4 billion
($1,600 to $3,200)
($8.9 to $18.3 billion)
Notes: This graphic presents the results of the heat arid learning losses analysis at 2°C (equivalent to 3.6°F) and 4°C
(equivalent to 7.2°F) of global warming, expressed in 2021 dollars. The results describe additional impacts relative
to the baseline (1986-2005) and assume populations of children will increase over the 21st century (see Chapter 2,
Appendix A). The table displays the average and range across climate models. Average lost future income per child
is population-weighted (see Figure 9 for variation across the country). Total lost income per year considers learning
losses experienced by each cohort of graduating high school students. Figure 8 compares these results with
baseline levels. Appendix B provides results for additional degrees of global warming.
Across the contiguous U.S., the average maximum daily temperatures during the school year are
projected to reach 69.7°F by the time global temperatures have increased by 2°C arid 73.9°F by the
time of 4°C of global warming (see Appendix B for details). These temperature levels correspond to
temperature increases of 5.8°F arid 10°F relative to baseline school year temperatures at 2°C and 4°C
of global warming, respectively. While baseline high temperatures are concentrated in the South
(see Figure 6), increases in temperatures relative to baseline school-year temperatures are found
throughout the contiguous U.S., including in parts of the Midwest and Northeast (see Appendix B for
details). Importantly, Park et al. do not find evidence that cold weather affects learning, so all
increases in temperatures are anticipated to contribute to learning losses.
Holding current market penetration of school and home A/C constant (see Figure 6), these
temperature increases are associated with approximately 4% and 7% reductions in learning relative
to average learning gains experienced each academic year at 2°C and 4°C of global warming,
respectively. Applying a valuation approach used by Park et al. that relies on information from Chetty
et al., these learning losses are projected to translate into future lost annual income per student on
the order of $1,300 (ranging from $380 to $2,400 across climate models) and $2,300 ($1,600 to
$3,200) at the same temperature thresholds (2021 dollars). To put these numbers in context, the
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Climate Change and Children's Health and Well-Being in the United States
median weekly earnings reported by the U.S. Bureau of Labor Statistics for 25- to 35-year-old
workers translates to roughly $48,000 in annual income in 2021.120The average income losses
associated with heat experienced as a student are equivalent to between 3% and 5% of annual
earnings for the median worker in that age cohort.
Considering lost future income across all graduating high school students each year is a way to
demonstrate the magnitude of learning losses across the contiguous U.S. Applying this approach, the
total lost future income related to learning shortfalls could reach $6.9 billion per year at 2°C of global
warming ($1.9 to $12.7 billion) and $13.4 billion peryear at 4°C ($8.9 to $18.3 billion). Relative to
temperature-related achievement impacts experienced during the baseline period (1986-2005),
future total earnings gaps are projected to increase by 10% and 19% at 2°C and 4°C of global
warming, respectively (see Figure 8).
These estimates are large in magnitude and suggest that heat can have long-term negative impacts
on academic performance and income gains when experienced during childhood. Further, these
projected impacts only consider the effects of heat exposure on learning during high school, and
research is mounting that heat experienced by elementary and middle school students also
contributes to learning losses.121 This newer research suggests the potential for cumulative impacts
not accounted for in the projections presented in this report. In other words, the impacts presented
here are likely to underestimate the total impact of heat on accumulated learning throughout
childhood.
As shown in Figure 9, not all students experience these impacts uniformly. At 2°C of global warming,
the states with the highest projected learning losses per student are Maine, Michigan, New
Flampshire, Vermont, and Wyoming. Once temperatures reach 4°C of global warming, Montana is
another state with among the highest impacts per student, nationally. These and other states in the
Northeast, upper Midwest, and mountainous areas experience a confluence of relatively high
warming during future school years compared with baseline temperatures and relatively low current
A/C coverage. While the Southeast and Southwest regions are expected to warm considerably, and
to levels greater than in the cooler states, learning losses are partially mitigated by the existing
availability of A/C in these areas.
Figure 8: Estimated Percent Change in Heat and Learning Loss Impacts Relative to Baseline
2°C 4°C
Total lost future income per year across graduating high school
students (Baseline: $70 billion)
Average lost future income per year per child (Baseline: $16,000)
0% 5% 10% 15% 20% 25%
Note: This graphic describes how the student achievement impacts associated with heat increase relative to
baseline conditions (1986-2005), as listed in the figure and under assumptions described in Appendix B. The teal
circles show increases between baseline and 2°C of global warming; the orange circles convey increases at 4°C.
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Climate Change arid Children's Health and Well-Being in the United States
Figure 9: Estimated Distribution of Lost Future Income Per Student Per Year from Heat
2°C of Global Warming
4°C of Global Warming
$0 $1-$1,440 $1,441-$2,360 $2,361 - $3,260 $3,261 - $4,300 *$4,301 - $7,310
Notes: These maps present the distribution of lost future income per child attributable to learning losses from heat
exposure during school years. Areas with darker shading have higher rates of learning losses. The five states with
the highest learning losses per child are outlined in black. See Appendix Cfor more details on the distribution of
impacts.
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Climate Change arid Children's Health and Well-Being in the United States
These findings can be compared to the cost of installing A/C
in schools. LeRoy et al. estimate the cost of furnishing all
public schools in the contiguous U.S. with A/C to be $42.4
billion, including $40.5 billion in new installations, $414.8
million in upgrades to existing HVAC technology, and $1.5
billion in annual operating and maintenance costs.122
Assuming HVAC systems have a 20-year lifespan and applying
a 3% discount rate, this would equate to an annualized cost
of installing and maintaining HVAC systems in U.S. public
schools of approximately $4.2 billion. In other words, the
annualized cost of installing and maintaining A/C systems in
schools is less than the projected annual lost income
associated with learning losses from heat at both 2°C and 4°C
of global warming. Holding aside the fact that many school
systems would be challenged to find resources to pay for these investments, having A/C in school
does not mitigate the potential for learning losses entirely. Park et al, show that learning losses are
erased only with A/C in school and at home. This suggests that additional investments in home A/C
infrastructure are also necessary to eliminate these risks. Analogous estimates of the cost of
installing, upgrading, and maintaining A/C in all homes are not available for comparison. While Park
et al. focus on the role of A/C in mitigating the adverse heat-indued learning impacts, relying on A/C
to reduce these impacts also poses other climate-related challenges, including the increase in energy
use that could contribute to further GHG emissions that worsen climate change.123 Chapter 8 of this
report explores other ways of protecting children from these effects.
Appendix B explores how
average learning losses per
student decrease under
different school A/C coverage
scenarios. Even when
increasing A/C in schools by
10 percentage points across
the contiguous U.S., students
still experience learning losses
relative to baseline at 4°C of
global warming.
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Climate Change and Children's Health and Well-Being in the United States
Park et al. use student-level data to reveal that hot school days disproportionately impact learning
among BIPOC students and students living in low-income households. The authors found that the
negative impact of prioryear heat on Black and Hispanic students was three times larger than the
impact on white students. Similarly, the impact of prioryear heat on students in lower-income zip
codes was twice as large as those from higher-income zip codes.
The results from Park et al. reflect the fact that Black, Hispanic, and low-income students generally
experience differential ambient heat exposure and have less access to A/C in their schools and at
home. Even in places where all students are exposed to the same levels of heat, the learning losses
to wealthier students may be offset via supplementary enrichment and instruction. The analysis by
Park et al. relies on highly granular data that can explore important variations among students within
the same general location; however, the student-level data were not available for this report. The
text below describes the current understanding of how overburdened communities may experience
the most significant learning impacts associated with heat.
What do we know about the disproportionate impacts of heat on learning?
Disproportionate exposure to heat: Vulnerable communities, especially those living within urban areas, are
disproportionately exposed to extreme heat in part because of residential segregation caused by historical
housing policies.124 Hoffman et al. found that land surface temperatures in historically redlined areas were
warmer than in non-redlined areas in 108 urban areas across the U.S., increasing the burden of heat on BIPOC
and low-income residents, including children. Similarly, another study found that people of color were more
likely to live in census tracts with higher surface urban heat island intensity compared to White people in 97%
of the largest urbanized areas in the U.S., further emphasizing the disparities in exposure to heat among
subpopulations.125 Park et al. also described mean temperature by race and income, finding that Black and
Hispanic children were exposed to higher ambient temperatures (68.8°F on average) than White children
(64.2°F on average). Average temperatures in this study during the school year did not vary by income.
Disproportionate access to A/C in homes: Literature and data describing A/C availability in households by
demographic group is minimal. Park et al. noted that Black and Hispanic households were 7% and 6% less likely
to have access to A/C compared to White households, respectively. Across urban areas specifically, recent
research shows that intra-city variation in A/C coverage in homes is considerable, and that the prevalence is
much lower in areas with multiple indicators of social vulnerability.126 A survey administered in 2009 by the
California Energy Commission (CEC) shed light on potential disparities in access to A/C in homes by race and
income in one state. CEC found that 56% of American Indian households, 57% of Black households, 58% of
Hispanic households, and 62% of Asian households had air conditioning statewide.127 In comparison, 68% of
White households were air-conditioned. Additionally, 61% of California households with income below $30,000
had air conditioning, compared to 69% of households with income between $75,000 and $150,000.
Disproportionate access to A/C in schools: Access to A/C in schools varies by demographic group as well. Park
et al. found that Black and Hispanic students were 1.6% more likely to be in schools with inadequate A/C than
White students. Lower-income students were 6.2% more likely to be in schools with inadequate A/C than
higher-income students.
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Climate Change arid Children's Health and Well-Being in the United States
HEAT AND EMERGENCY DEPARTMENT VISITS
Another way to measure the magnitude of heat's effects on children's health and
well-being is the number of emergency department (ED) visits associated with high
temperature days, Bernstein et al. offer an assessment of the relationship between daily
maximum temperature and the incidence of ED visits among a sample of 47 children's hospitals
across the U.S.128 The authors find that location-specific high heat days in May through
September are associated with a 17% greater likelihood of an ED visit. Information presented in
the study suggests each degree above 62°F is associated with a 0.5% increase in daily incidence of
ED visits at the children's hospitals in the study sample.
Extrapolating these findings specifically to all 222 children's hospitals with EDs in the contiguous
U.S. indicates what the future may mean for serious health impacts on high-temperature days.
Children's hospitals are within 80 miles of 92% of children in the country,129 arid thus can provide
services to the most acute cases of heat-related illness. Data from the Healthcare Cost and
Utilization Project's Kids' Inpatient Database (HCUP-KID, 2016 and 2019) documents
approximately 22,000 ED visits per day between May and September at children's hospitals,
equivalent to 3.4 million per summer. Temperature increases of 1°F between May and September
would increase the number of ED visits at children's hospitals by 113 visits per day, or over 17,000
visits over the five-month period. A more detailed assessment of these future risks across all
hospitals with EDs would better inform planning among healthcare providers.
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Climate Change arid Children's Health and Well-Being in the United States
Chapter 4. Air Quality
Climate change is likely to worsen air quality and cause or exacerbate air quality-related
negative health outcomes among children. Existing evidence clearly links exposure to air
pollutants with various adverse health effects in children, including asthma and other
respiratory diseases. Exposure to poor air quality is also associated with limiting brain
development. Many of these impacts emerge in childhood and affect people throughout their lives.
This chapter includes a quantitative analysis of long- and short-term childhood exposures to
climate-driven changes in outdoor particulate matter (PM2.5) and ground-level ozone (03)
as well as related effects on respiratory diseases such as asthma. Results show that new
annual cases of asthma could increase by 4% to 11% at 2°C and 4°C of global warming,
respectively. ED visits and hospital admissions from respiratory conditions also are expected to
increase, as are school days lost as a result of these effects. Most impacts stem from climate-induced
changes in 03 and PM2.5, although wildfires and ground-level dust in the arid Southwest also play a
role. Low-income and BIPOC children are more likely than others to experience new asthma diagnoses
associated specifically with PM2.5 exposure.
O Fetal health effects can occur when pregnant women are exposed to poor air quality during
V \ pregnancy. Projected increases in wildfire activity are associated with heightened levels of
tt* PM2.5 and PM10 and could result in more adverse birth outcomes. An additional 7,700 and
13,600 premature births may be attributable to wildfire annually at 2°C and 4°C of warming,
respectively. At 4°C, this represents a 92% increase in premature births relative to the baseline level
of births affected by wildfire smoke.
Chapter highlights
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Climate Change arid Children's Health and Well-Being in the United States
HOW CLIMATE CHANGE DEGRADES AIR QUALITY AND
IMPACTS CHILDREN
Climate change is likely to worsen air quality at the national level primarily due to
changes in environmental conditions, such as changes in temperature, precipitation, and wind
patterns, that can lead to increases in ambient particulate matter and ground-level (or tropospheric)
q3 130,131,132,133 wildfire smoke, dry and dusty conditions due to drought, and changes in agricultural
activities can also lead to increases in ambient concentrations of O3, particulate matter, and other
harmful pollutants like carbon monoxide and nitrogen oxides, which can damage the health of
children.134'135'136'137'138'139,140 In addition, wildfires can also burn manmade structures such as homes
and vehicles that release toxic chemicals into the air when they combust.141,142 The resulting smoke
can travel far from the immediate area, impacting children and adults at considerable distances from
the original location for weeks or even months
after an event occurs.143 Exposures to fine and
coarse dust are also projected to increase as
climate change progresses, particularly in the
arid Southwest.
IMPACTS OF AIR QUALITY ON CHILDREN
Children are particularly vulnerable to the
effects of air pollution for a variety of
reasons.144,145'146 Infants and children have more
immature lungs compared to adults; as a result,
their lungs can be more susceptible than those
of adults to harm following exposures to toxins
and hazards.147 They also generally breathe
faster than adults and take in more air relative
to their size and body weight, thus increasing
their relative exposure to air pollution compared
to adults.148 As a result, short-term and long-
term (i.e., annual) exposures to air pollution
have been shown to have significant effects on
child lung function and development, as well as
impacts on brain development,149'150'151
Short-term exposure to air pollution can cause
or worsen asthma, one of the most common
childhood diseases, and among the most
common reasons for child ED and hospital visits
nationwide.152 Particulate matter from wildfire
smoke has been shown to trigger asthma
attacks in children more than other sources of
Poor air quality and children
Worsening air quality is linked with asthma
and other respiratory diseases, cancer, and
dermatitis in children.
Decreased lung function in childhood may
lead to chronic, severe respiratory conditions
in adulthood.
Preterm birth, low birth weight, and birth
defects are associated with in utero
exposures.
Poor air quality can affect brain development
and mental health.
Children in many overburdened populations
are more likely to live in areas with poor air
quality and therefore often suffer these
health effects more acutely.
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Climate Change and Children's Health and Well-Being in the United States
PM.153 In addition, children have the highest rate of coarse dust-related asthma visits to EDs relative
to all age groups, an important consideration forthose living in the dry and dusty conditions of the
Southwest.154 Air pollution is also linked with lung injury and inflammation, school loss days, rhinitis,
upper and lower respiratory symptoms, cancer, dermatitis, autism spectrum disorder, and even
infant death, among others.155,156,157,158,159,160
Long-term exposure of pregnant women to air pollution can also have serious implications for
fetuses, leading to lifelong health effects. Pollutants are transferred to the fetus from the mother's
bloodstream when she breathes them in and can reduce blood flow and oxygen to the fetus due to
inflammation. In turn, reduced blood flow and oxygen levels can lead to adverse birth outcomes
including preterm birth (i.e., earlier than 37 weeks) and low birth weight (i.e., <2500 grams, or
approximately 5.5 pounds), limited fetal growth, birth defects, 0r stillbirth.161'162'163'164'165'166'167,168
Exposure to poor air quality can also lead to smaller head circumference, which is associated with
memory, learning, and concentration challenges in childhood; and abnormal abdominal
(stomach/midsection) circumference, an indicator of a propensity for obesity and other types of
metabolic conditions.169,170 Exposure to particulate matter can also lead to a greater likelihood of
pregnancy complications, including blood clots, dangerously high maternal and fetal blood pressure,
preeclampsia, gestational diabetes, and childhood diabetes.171'172'173'174'175'176,177 Studies have shown
that increased exposure to any amount of air pollution during the first 14-16 weeks of pregnancy,
even at levels below national standards, are associated with abnormal fetal development.178,179,180
Changes in lung function in children—measured using a spirometer, often when individuals have
respiratory illness or are being tested for asthma—can have lifelong impacts, as this can be indicative
of the potential quality of respiratory health in adults.181 Poor childhood lung function has been
linked to chronic, severe respiratory conditions such as chronic obstructive pulmonary disease
(COPD) and other types of degenerative lung ailments later in life.182,183 Impaired lung function from
air pollution can continue into adulthood, even if an individual's exposure decreases;184 however, it is
unclear whether effects are reversible.185
Long-term exposure to air pollution can also affect brain development and mental health.186,187,188
Infants and children youngerthan five years old experience rapid growth, particularly of the brain.189
The brain is among the fastest developing organs in a child's body and can be greatly impacted by
inhaled toxins and particulate matter, leading to cognitive effects.190 Some evidence suggests that
poor air quality can contribute to the development of neurocognitive disorders such as autism and
attention deficit/hyperactivity disorder.191,192 School-aged children may experience poor academic
performance if they live in areas with higher air pollution.193 Poor air quality may affect sleep
patterns, which also has mental health implications.194
Certain social factors make children more vulnerable to the health effects of poor air quality,
including race, ethnicity, and income.195 Overall, research indicates that increased air pollution-
related health risks associated with race and ethnicity are linked to social, historical, healthcare, and
institutional disparities between groups. In general, infants born to racial and ethnic minorities are at
greatest risk of adverse health outcomes related to air pollution exposure.196 Black and Hispanic
mothers have been shown to be especially at risk for preterm birth and low birth weight related to
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Climate Change and Children's Health and Well-Being in the United States
air pollution.197,198 Children in lower-income households are more likely to live in areas with poor air
quality and are more likely to have worse health outcomes.199 For instance, BIPOC children are more
likely to live in areas closer to a factory or road with heavy traffic, exposing them to more
pollution,200 and are less likely to have an adequate air filtration system in their home.201 Wildfires
are known to increase particulate matter and toxic gas concentrations far above national
standards,202 and these elevated exposures have been shown to be disproportionately higher among
children in lower-income households.203,204 Race appears to play a significant role in making some
children more vulnerable to harm from poor air quality. Black children, especially, are more likely to
live in areas with expected increases in childhood asthma cases related to climate-driven changes in
air pollution.205'206,207 Similarly, Black individuals—including children—have been shown to face
greater health effects from air quality, which may result from a wide range of factors including
systemic social inequalities, a historical lack of social capital, and/or baseline health status and ability
to avoid and mitigate harmful climate-related air pollution exposures.208
respiratory conditions specifically, this detailed analysis uses existing evidence from
several epidemiological studies to project changes in health and health-related effects among
children associated with heightened levels of outdoor PM2.5 and O3. These include:
• New diagnoses of asthma (Tetreault et al.209)
• Incidence of hay fever (Parker et al.210)
• School days lost from respiratory issues (Gilliland et al.211)
• ED visits associated with asthma (Alhanti et al.212 and Mar and Koenig213)
• Hospital admissions for respiratory issues (Ostro et al.214)
• Infant mortality (Woodruff et al.215)
While ambient concentrations of PM2.5 and O3 have many sources, this analysis targets the changes
in annual ambient concentrations expected from climate-induced changes in environmental
conditions (Fann et al.216) (i.e., the climate penalty), ambient dust concentrations in the
Southwestern U.S. (Achakulwisut et al.217), and wildfire activity in the West (Neumann et al.218).
These studies address the impact of climate change on PIVh.sand O3 air quality, but other studies
have focused on how greenhouse gas emission reduction policies can reduce air pollutant emissions
and have a positive effect on air quality and, by extension, children's health.219
Figure 10 describes the steps of the analysis, with further details on the methodology available in
Appendix C. This analysis considers all areas of the contiguous U.S. except for changes in southwest
dust exposure, which is restricted to four states in the Southwestern U.S. where these impacts are
particularly substantial. Future impacts are quantified using U.S. EPA's Benefits Mapping and Analysis
Program (BenMAP),220 a tool that estimates the human health impacts of air quality changes using air
quality data, spatially resolved baseline incidence data, and concentration-response functions for
short-term and long-term exposure, derived from epidemiology studies. BenMAP applies the
The health outcomes associated with long- and short-term exposure to poor air
quality are numerous. To convey the magnitude of impacts associated with
AIR QUALITY AND CHILDREN'S HEALTH
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Climate Change and Children's Health and Well-Being in the United States
relationship between these components to the population experiencing Figure 10: Analytic Steps
the change in pollution exposure to calculate the resulting health
impacts. For presentation purposes, impacts are summed across
pollutants and pollutant sources.
Figure 11 summarizes the analysis findings. An additional 34,500
(ranging from 27,900 to 42,800 across climate models) asthma cases
peryear among children are projected across the contiguous U.S. at
2°C of global warming, increasing to 89,600 (74,100 to 108,000)
additional cases annually at 4°C. These impacts are fueled
predominantly by climate-driven changes in ambient PIVh.sand Ob. At
4°C of warming, 98% of new cases of asthma are attributable to
climate-driven changes in ambient PIVh.sand 03 concentrations, 82%
of which are from O3 alone. In contrast, 1.5% and 0.5% of total cases
are attributable to southwestern dust and western wildfires,
respectively.
Other respiratory impacts are projected to be substantial, as well. The
analysis estimates 6,240 (5,210 to 7,300) additional ED visits for
asthma peryear at 2°C of global warming, increasing to 15,800 (14,500 to 17,200) additional visits
annually at 4°C, representing a considerable reaction to air pollution in children with asthma.
Additional cases of hay fever peryear among children are estimated to increase by 228,000 (179,000
to 276,000) at 2°C of global warming and 554,000 (447,000 to 662,000) at 4°C. Among the more
severe effects, 332 (230 to 430) additional respiratory hospitalizations among children peryear are
estimated at 2°C, increasing to 785 (353 to 1,220) per year at 4°C. Finally, this analysis also projects
additional deaths among newborns. At 2°C of global warming, an estimated 7 (4 to 10) additional
newborn deaths annually attributable to climate change, increasing to 15 (6 to 25) additional deaths
at 4°C.
What about other air pollutants?
This analysis specifically considers the relationships between children's health and changes in PM2.5 and 03
associated with climate change. The association between human health impacts and long-term exposure to
these pollutants is widely studied and documented in epidemiological literature, and projected future pollutant
concentrations were available for use in the detailed analysis portion of this chapter. Beyond the pollutants
considered here, children will also be negatively affected by various other pollutants that degrade air quality,
including ambient dust with particle size larger than PM2.5 (called the PM coarse fraction), carbon monoxide,
nitrogen dioxide, sulfur dioxide, and the complex mixtures of particulates and organic compounds that make up
wildfire smoke.221,222 Children's exposure to these pollutants may change in the future, leading to changes in
the incidence of various health effects, including respiratory symptoms in children and long-term health
outcomes when the children become adults. In other words, the health outcomes projected in this section are
only a subset of all health impacts to children which could result from climate-induced changes in air quality.
in Air Quality Analysis
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Climate Change and Children's Health and Well-Being in the United States
Figure 11: Projected Additional Annual Impacts of Air Quality on Children's Health
Degrees of New Incidence ED Visits School Infant Hospital
Global Asthma of Hay Fever/ for Days Deaths Admissions for
Warming Cases Rhinitis Asthma Lost Respiratory
Illness
2°C
34,500
228,000
6,240
2,240,000
7
332
(27,900
(179,000 to
(5,210 to
(1,850,000 to
(4 to 10)
(230 to 430)
to 42,800)
276,000)
7,330)
2,630,000)
4°C
89,600
554,000
15,800
5,480,000
15
785
(74,100 to
(447,000 to
(14,500 to
(5,170,000 to
(6 to 25)
(353 to 1,220)
1 08,000)
662,000)
17,200)
5,790,000)
Notes: This graphic presents the results of the air quality analysis at 2°C (equivalent to 3.6°F) and 4°C (equivalent to
7.2°F) of global warming. The results describe additional impacts per year, conditions relative to baseline (1986-
2005), and assume populations of children will increase over the 21st century (see Chapter 2, Appendix A). The table
displays the average and range across climate models. Figure 12 provides baseline levels and age ranges for each
health outcome included. Appendix C provides results for additional degrees of global warming.
The direct medical costs and indirect productivity losses associated with these health impacts may be
substantial. For instance, research documents that the lifetime medical and productivity costs
associated with new asthma diagnoses are approximately $49,600 per case,223 while the one-year
medical costs stemming from hay fever incidence are about $670 per case,224 with the potential for
further costs over a lifetime if symptoms persist (2021 dollars). ED visits for asthma may result in
medical costs of approximately $550 per visit,225,226 while hospitalizations can cost approximately
$10,000 per inpatient visit.227
To demonstrate how children's schedules and learning may be interrupted by these health impacts,
the analysis projects how climate-driven changes in air pollution will affect school attendance
specifically. Across the school-age population (aged 5-17), an additional 2.24 million (1.85 to 2.63
million) school days lost peryear are projected at 2°C of warming, increasing to an additional 5.48
million (5.17 to 5.79 million) annually at 4°C. To put these numbers in context, the projected
absences at 4°C of warning translate to 0.1 lost days per child per school year. These absences are
likely to disproportionately affect children with preexisting conditions, such as asthma.228 If the
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Climate Change and Children's Health and Well-Being in the United States
population is restricted to children with asthma, each child is expected to miss an additional 1 day of
school each year due to climate-driven changes in air pollution levels at 4°C of global warming.
Currently, students with asthma miss an average of 4.5 days per school year, amounting to a total of
164 million lost school days nationally.229
Research is not available to project what lost school days may mean in terms of current and future
costs to children. For example, missing school and after school enrichment or play may affect a
child's quality of life, and frequent absences from school may contribute to reduced academic
performance and affect cognition and future income. However, available research does translate sick
days for children to lost productivity for their parents and caregivers. The health impact valuation
literature often assumes approximately $120 per day in lost productivity for adults for each day
spent tending to illness for themselves or their dependents.230
Finally, the pain and suffering associated with losing an infant is immeasurable. Current practice in
health valuation suggests applying a value of approximately $10 million per adult death to account
for how much people are willing to pay to reduce their risks of a fatality. Research is limited on how
much parents and caregivers value reducing fatal risks to their children, although evidence suggests
society may value the health and well-being of children more than adults.231
Figure 12 depicts how these various impact measures change relative to their baseline levels (1986-
2005) as climate change progresses. Over 4.2 million children across the nation currently have
asthma, and over 840,000 new cases are diagnosed annually.232,233 Relative to these levels, new
cases of asthma attributable to climate increase by 4% and 11% at 2°C and 4°C of global warming,
respectively—the largest percent increases across the impact measures assessed. The percent
change in incidence of hay fever, school days lost, and ED visits from asthma all increase between 1%
and 5%. Hospitalizations from respiratory illnesses and infant mortality linked to climate-induced
changes in air quality are projected to increase by up to 0.2% at 4°C of global warming.
Figure 12: Estimated Percent Change in Air Quality Impacts Relative to Baseline
2°C 4°C
New cases of asthma, aged 0-17 (Baseline: 841,000/yr) ^
Incidence of hay fever-rhinitis, aged 3-17 (Baseline 11.9 million/yr) ^
School days lost from all causes, aged 5-17 (Baseline: 183 million/yr)
ED visits for asthma, aged 0-18: (Baseline: 733,000/yr) ^
Hospital admissions for repiratory illness, aged 0-18 (Baseline: -
429,000/yr)
Infant mortality, aged 0-0 (Baseline: 8,960/yr)
0% 2% 4% 6% 8% 10% 12%
Note: This graphic describes how the health impacts associated with climate-driven changes in air quality increase
relative to baseline conditions (1986-2005), as listed in the figure and under assumptions described in Appendix C.
The teal circles describe increases between baseline and 2°C of global warming; the light blue circles convey
increases at 4°C.
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Climate Change arid Children's Health and Well-Being in the United States
Figure 13 shows the geographic distribution of children aged 0-17 (per 100,000) experiencing new
diagnoses of asthma due to climate-driven changes in air quality at 2°C and 4°C of global warming
combined across all air pollutant sources and by specific air pollutant type and source. These maps
clearly show that the spatial distribution of changes in air quality varies significantly by air pollutant
type and source. For instance, the climate-induced changes in PM2.5 are concentrated in the
Southeast, while related changes in O3 are highest in some parts of the Midwest and Northwest.
Changes to air quality from climate-induced wildfire activity are most acute in the Northwest. Finally,
as the name implies and given the spatial scope of the underlying analyses, the impacts associated
with ambient dust are confined to four states in the Southwest.
Combined, the greatest impacts are observed in the inner Midwest and Appalachian regions, where
O3 concentrations are expected to increase, arid on the West Coast where wildfire activity degrades
air quality. Rates are also high across several states in the Southeast where climate-induced increases
in PM2.5 levels are greatest. The maps identify the five states with the highest number of affected
children per 100,000 across air pollutant sources, including the District of Columbia, Kentucky,
Maryland, Ohio, and Washington State at 2°C of global warming; Illinois also is among the top states
nationally at 4°C. Wildfire PM2.5 drives new cases in Washington, while climate-induced increases in
O3 concentrations drive the majority of impacts in the other top states.
Other impacts quantified in this analysis follow similar spatial patterns (see Appendix C). For instance,
the increase in school days lost per 100,000 individuals at 2°C of global warming is highest across the
Midwest and Mid-Atlantic (the District of Columbia, Illinois, Indiana, Ohio, and Maryland) where O3
levels associated with changing temperature and precipitation patterns are expected to be most
pronounced. Following that, climate-driven changes in precipitation and temperature may also lead
to decreased air pollution in some locations. This analysis shows that children in some parts of the
contiguous U.S.—such as parts of Maine, New Hampshire, Vermont, Florida, and Texas—are
expected to experience decreases in respiratory impacts as conditions change in the future.
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Climate Change arid Children's Health and Well-Being in the United States
Figure 13: Estimated Distribution of Additional Asthma Diagnoses from Air Quality Changes
Combined Air Pollution Sources (2°C) Combined Air Pollution Sources (4°C)
V
Climate Penalty, 03(2°C)
Wildfire (2°C)
Climate Penalty, PM2.S(2°C)
Southwest Dust (2°C)
CALIFORNIA
16
<0 1 - 27 28 -47 48 - 68 ¦69- 107 ¦108-692
Notes: The maps present the distribution of new asthma diagnoses attributable to climate-driven changes in air
quality per 100,000 children per year. Areas with darker shading have higher rates of affected children. The five
states with the highest rates of affected children relative to the county populations are outlined in black. The top
two maps show the additional impacts combined across pollution sources for both 2°C and 4°C of global warming.
The remaining four maps show the contributions from specific pollutant sources at 2°C specifically. See Appendix C
for more details on the spatial distribution of assessed impacts.
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Climate Change and Children's Health and Well-Being in the United States
Finally, Figure 14 presents the results of the analysis describing the likelihood that certain groups of
overburdened children live in areas with the greatest projected number of new asthma diagnoses
annually per 100,000 children, following methods described in Chapter 2 and Appendix A. The
analysis considers PIVh.sand O3separately, as the pollutants' contributions to health effects vary
across space. Low-income children are 11% and 9% more likely to experience the highest incidence
of new asthma diagnoses attributable to climate-driven changes in short-term PM2.5 exposure at 2°C
and 4°C of global warming, respectively. Similarly, BIPOC children are 23% and 20%, respectively,
more likely to experience these effects at the same temperature thresholds. When exploring these
same measures by racial and ethnic group, the analysis finds that Asian, Black or African American,
Pacific Islander, and Hispanic or Latino children are all more likely than their reference populations to
experience the highest likelihood of new asthma cases linked with climate-driven changes in PM2.5
exposure.
The analysis does not identify that the socially vulnerable groups of children considered in this report
are more likely to be diagnosed with asthma attributable to climate-driven changes in short-term O3
exposure, specifically. Flowever, among BIPOC children, Asian and Black or African American children
are more likely to experience impacts than their reference population, and at levels similar to the
PM2.5 assessment. More details of the O3 results are available in Appendix C.
Figure 14: Likelihood of Disproportionate Asthma Impacts Attributable to PM2.5 Exposure on
Overburdened Children
2°C 4°C
Limited English Speaking
0%
-2%
Low Income
I 11%
I 9%
BIPOC
1 23%
No Health Insurance
-6%
-8%
American Indian or Alaska Native
Asian
Black or African American
Pacific Islander
Hispanic or Latino
White, non-Hispanic
Notes: These graphics present the results of the social vulnerability analysis of new asthma diagnoses among
children attributable to PM2.5 exposure linked with climate change, following the methods described in Chapter 2
and Appendix A. The estimated risks for each socially vulnerable group are presented relative to each group's
reference population, defined as all individuals other than those in the group analyzed. Populations represent those
living in the contiguous U.S. but identifying as a particular race/ethnicity. Analogous results related to 03 exposure
are included in Appendix C.
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Climate Change arid Children's Health and Well-Being in the United States
WILDFIRE SMOKE AND FETAL HEALTH
I Wildfire activity across the western U.S. is increasing due to hotter temperatures,
more lightning strikes, and more variable precipitation. Wildfire smoke is comprised
of numerous air pollutants, notably PMisand PMio, which pose a threat to human health,
including adverse birth outcomes. For instance, Amjad et al.234 assessed the impacts of wildfire
exposure during pregnancy, finding evidence of association between maternal smoke exposure
and low birth weight, particularly when smoke exposure occurred late during pregnancy. Similarly,
Heft Neal et al.235 evaluated the association between wildfire smoke exposure and risk of preterm
birth (<37 weeks) in California, finding that 3.7% of observed premature births were attributable
to wildfire during the study period.
This report extrapolates the findings from Heft Neal et al. to consider what these adverse health
impacts might look like nationwide, given future warming conditions and associated wildfire
activity. The percentage of premature deaths attributable to wildfire activity from Heft-Neal et al,,
baseline data on premature births from CDC,236 and average future PM2.5 concentrations
associated with wildfires from Neumann et al.237 are used to estimate additional premature births
attributable to wildfire at 2°C and 4°C of global warming (see Appendix C for further details).
Nationwide, this analysis suggests an additional 7,700 and 13,600 premature births per year at 2°C
and 4°C of global warming, respectively, attributable to wildfire annually relative to a 2010
baseline of 14,700 annual premature births. At 4°C, this represents a 92% increase in premature
births relative to the baseline number of births affected by wildfire smoke. Additional research by
Childs et al. found that population exposure to moderately high wildfire smoke levels in California
has increased four-fold in the last decade, suggesting that estimates of a doubling of wildfire
exposure and of wildfire-induced premature births may be conservative.238 Premature births are
associated with $38,600 per case in direct health care costs throughout the first five years of life
and $2,300 in costs in subsequent years (2021 dollars).239
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Climate Change arid Children's Health and Well-Being in the United States
Chapter 5. Changing Seasons
Chapter highlights
Climate change is altering seasonality in numerous ways, leading to longer warm seasons
and shorter cool seasons. While seasonality-related changes have a myriad of health and
well-being effects on children, this chapter focuses on the effect of seasonality changes
on pollen exposure as well as opportunities for participation in outdoor recreation.
C. This chapter provides a detailed assessment of how children's health may suffer from pollen
o\ exposure as seasons lengthen and temperatures warm. At 2°C of global warming, the
| analysis projects an additional 5,800 (4,800 to 8,000) asthma-related ED visits per year in
children from oak, birch, and grass pollen exposures, increasing to approximately 10,000
(9,500 to 10,700) additional asthma-related ED visits at 4°C of warming. Far larger impacts are
expected on outcomes like physicians' visits for allergic rhinitis and prescriptions filled for allergy
medications, which are projected to increase by 72,000 (68,000 to 77,000) and 211,000 (199,000 to
224,000) visits per year, respectively, at 4°C of warming. These impacts are associated with 17% and
30% increases above baseline at 2°C and 4°C. Some groups of overburdened children are more likely
to experience the most severe impacts associated with oak pollen exposure specifically.
The chapter concludes by highlighting several studies that estimate how the number of
outdoor recreation trips may change with climate. Overall, lengthening warm seasons are
expected to result in more time spent on outdoor recreation, especially boating and water
sports. On the other hand, the number of trips associated with some recreation types, like
winter recreation and cold-water fishing, will decrease under climate change.
»
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Climate Change arid Children's Health and Well-Being in the United States
HOW CLIMATE CHANGE AFFECTS SEASONALITY AND
IMPACTS CHILDREN'S HEALTH
Climate change is altering seasons in the U.S., leading to longer warm seasons,
decreases in natural snow cover, and shorter periods of prolonged cold weather.240'241"242*243
Increasing temperatures and changing rainfall patterns are extending the growing season, resulting
in longer and more intense pollen and allergy seasons.244,245,246 Warming ambient air temperatures
translate into warming water temperatures, which in turn may increase growth of bacteria and
harmful algae, leading to increased potential for exposure to waterborne toxins and pathogens.247,248
Additionally, longer warm seasons and decreased rainfall increase the potential for more frequent
and severe wildfires and droughts, particularly in the western U.S. Shorter cold seasons reduce
snowpack melt, thus affecting snow-based recreational activities as well as water supply.
IMPACTS OF CHANGING SEASONALITY ON
CHILDREN
This chapter explores health impacts from
lengthening and intensifying pollen seasons and
effects on opportunities for participation in
outdoor recreation and play stemming from
changes in various weather conditions
(temperatures, precipitation, and, subsequently,
snowpack).
There are many health effects that can occur from
exposure to plant-, fungi-, and tree-based
aeroallergens, all of which could be more abundant
in a warmer climate. These include conditions such
as allergic conjunctivitis, atopic dermatitis of the
skin (eczema), and allergic rhinitis (commonly
known as hay fever).249,250 Some research suggests
that there may be correlations between hay fever
or eczema and attention deficit/hyperactivity
disorder (ADHD) in children.251,252,253 Most
diagnosed cases of hay fever in the U.S. are in
children, with the highest rates in southern and
southeastern states.254'255 Studies show that
historically, states with higher pollen counts and
greater rates of pediatric hay fever have sustained
either higher temperatures, with drier conditions
and a greater number of sunny days, or wetter
weather.256 Pollen particles in the respiratory tract
also may weaken the ability of children's immune
Seasonal changes and children
" r;
¦ This chapter explores the effects of
changing seasons associated with airborne
allergens (like pollen) and on outdoor
recreation participation.
¦ Asthma and other respiratory conditions
associated with pollen exposures are likely
to become more common and severe as
seasons lengthen.
¦ Overburdened children are more
susceptible than other children to adverse
health outcomes associated with pollen
exposure.
¦ Recreation types that benefit from an
extended warm season will likely see an
increase in participation among children,
whereas winter recreation will see a
decrease in participation.
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Climate Change and Children's Health and Well-Being in the United States
systems to respond to common viruses, thus putting children at risk of developing more respiratory
infections during high pollen seasons.257 Finally, mold is another source of environmental
aeroallergens, releasing spores into the air. Studies have shown that areas with warmer
temperatures and higher precipitation rates have more outdoor mold aeroallergens, which can cause
allergic and respiratory diseases, particularly in children.258,259
Asthma is among the most common childhood respiratory diseases. It is triggered or exacerbated by
plant- and fungi-based aeroallergens.260,261 This can pose health risks to children who are sensitive to
these types of allergens and can lead to sickness, missed school days, or worsened performance in
school.262,263 Exposures to tree and other plant pollen also increase the risk of asthma-related ED
visits in children.264,265 Furthermore, research has shown increases in the volume of prescriptions
filled for allergies and ED visits for asthma attacks in young children during times of peak pollen
counts in the atmosphere in urban and rural environments.266,267,268,269 This has environmental
justice and equity implications as childhood asthma cases occur disproportionately in children
belonging to Tribes or children of color living in urban areas that often have worse air quality and
poorer health outcomes.270,271,272,273,274
Additionally, climate change increasingly will affect personal choices that children and their families
make about spending time outdoors, as well as the quality of outdoor recreational spaces.275,276
Outdoor recreation is important to maintaining general well-being, particularly for children's
behavioral, social, and mental health benefits.277,278,279 As children interact more with nature, they
are shown to have decreased stress and improved mental health, and are likelier to maintain a
healthier body weight.280,281
Recreational activities that benefit from longer warm seasons may see an increase in future
participation among children. This increased time spent outdoors is likely to be beneficial to children
given the positive physical and mental health associations. Flowever, not all children have equal
access to outdoor recreation, particularly children living in poverty and BIPOC children.282 These
children may miss out on the benefits of outdoor recreation opportunities. Children who live in
socioeconomically disadvantaged areas often have fewer opportunities to engage in outdoor
recreation for multiple reasons, including limited availability of transportation to wilderness areas,
financial limitations, or a general lack of access to green spaces and safe areas to play in their
neighborhoods.283,284,285,286,287
Winter recreation—including skiing and snowmobiling—is one example of where climate change
might decrease participation among children.288,289,290 In addition to the reduction in access to these
activities, children in communities that rely on the revenue brought in by winter activities may
experience decreased financial security when jobs disappear, which can have myriad downstream
effects such as food insecurity, mental health challenges, difficulty concentrating and learning, and
limited access to healthcare.291,292,293 While climate change may also contribute to an increase in cold
snaps, primarily through changes in circulation patterns, winter recreation impact research indicates
that cold periods will be reduced as the climate warms overall.
Extended warm seasons will increase exposure to waterborne hazards such as harmful algal blooms
(HABs) or pathogens like Cryptosporidium.294,295,296,297,298 HABs subsequently can limit recreational
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Climate Change and Children's Health and Well-Being in the United States
activities such as fishing, swimming, or playing on the beach;299,300 additionally, Tribal communities'
use of water bodies for subsistence fishing and as sacred resources may be disrupted by these
hazards.301,302 Waterborne hazards can also affect children indirectly when the hazards result in
fisheries closures, reductions in tourism dollars, or other effects to their parents' or caregivers'
livelihoods.303,304,305,306,307
POLLEN AND CHILDREN'S HEALTH
This analysis projects increases in adverse health
outcomes among children from more frequent and
greater exposure to pollen resulting from climate change. It
relies on findings from Neumann et al.,308 which studied the
relationship between increasing season length attributable to climate
change for various pollen sources (oak, birch, and grass) and the
projected number of future ED visits associated with asthma. Because
ED visits represent a relatively rare outcome resulting from pollen
exposure, the analysis also considers how the number of physicians'
visits associated with allergic rhinitis and prescription fills for allergies
may increase in the future. The analysis is guided by findings from Saha
et al.309 that link these health outcomes to intensity of exposure to a
broader selection of tree, grass, and weed pollen, including ragweed.
Figure 15: Pollen Analysis Steps
Step 1
Identify baseline
health impacts among
children
Step 2
Calculate future pollen
season length by
pollen source
Step 3
Estimate increase in
health impacts from
lengthened pollen
season
Figure 15 summarizes the analysis steps; more detail about data
sources and assumptions is provided in Appendix D. Like the air quality
analysis presented in Chapter 4, future health effects associated with
climate-driven changes in seasonal conditions are quantified using U.S.
EPA's BenMAP310 model (see Chapter 4 for details). To forecast health impacts, the analysis starts
with data from a study projecting future ED visits for asthma. Then, estimates of future physicians'
visits and prescription fills associated with a lengthening pollen season are scaled by the rate of
change in projected ED visits, for each degree of global warming.
What are the sources of pollen and aeroallergens that affect children?
Different types of plants and trees produce different types of pollen or other aeroallergens. Ragweed is a
common type of allergen-producing plant that grows across the U.S.,311 including in urban areas,312 and is
known to cause irritation and inflammation of the respiratory tracts of sensitive individuals.313 One ragweed
plant can release up to a billion pollen grains into the air over the course of a season.314 Oak tree pollen is
another allergen that has been implicated in increased numbers of ED visits related to asthma.315'316'317,318
Finally, while mold is not a plant, molds release spores, another type of environmental allergen. Studies have
shown that areas with warmer temperatures and higher precipitation rates can lead to increases in outdoor
mold aeroallergens that can cause allergic and respiratory diseases, particularly in children.319,320 The same
types of increases in outdoor mold spore production have been seen after extreme weather events.321
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Climate Change and Children's Health and Well-Being in the United States
Figure 16: Projected Additional Annual Impacts of Pollen on Children's Health
Degrees of
Prescriptions
First Doctor Visit
ED Visits for
Global
Filled for
for Allergic
Asthma
Warming
Allergies
Rhinitis
2°C
121,000
41,000
5,800
(101,000 to 167,000)
(34,000 to 57,000)
(4,800 to 8,000)
4°C
211,000
72,000
10,000
(198,000 to 224,000)
(68,000 to 77,000)
(9,500 to 11,000)
Notes: This graphic presents the results of the pollen exposure analysis at 2°C (equivalent to 3.6°F) and 4°C
(equivalent to 7.2°F) of global warming. The results describe additional impacts per year for children, conditions
relative to baseline (1986-2005), and assume populations of children will increase over the 21st century (see
Chapter 2, Appendix A). The table displays the average and range across climate models. Figure 17 provides
baseline levels for each included health impact. Appendix D provides results for additional degrees of global
warming.
At 2°C of global warning, the analysis projects an average of 5,800 (ranging from 4,800 to 8,000
across climate models) additional asthma-related ED visits peryear among children from pollen
exposure (Figure 16). Once global temperatures reach 4°C above baseline levels, there are projected
to be an additional 10,000 (9,500 to 11,000) ED visits peryear associated with asthma exacerbations
among children. First-time pediatric visits to physicians for allergic rhinitis are projected to increase
by 41,000 (34,000 to 57,000) and 72,000 (68,000 to 77,000) annually at 2°C and 4°C of warming,
respectively. Pollen exposure could also result in an estimated 121,000 (101,000 to 167,000) to
211,000 (198,000 to 224,000) additional prescriptions filled for allergies each year at the same
temperature thresholds.
Relative contributions of oak, birch, and grass pollen to these total health impacts are also explored.
At 2°C of warming, 45% of cases are associated with birch pollen, 31% with oak pollen, and 24% with
grass pollen. Likewise at 4°C of warming, the contributions are 41% from birch pollen, 35% from oak,
and 24% from grass. Taken together, birch pollen is expected to be the largest contributor to future
climate-induced ED visits for asthma among the three sources explored in this analysis.
Figure 17 provides additional information about how these health impacts are projected to increase
in the future relative to levels observed in the baseline. Neumann et al. estimated ED visits would
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Climate Change and Children's Health and Well-Being in the United States
increase by 17% at 2°C of global warming and by 30% at 4°C. The analysis presented in this chapter
directly relies on these percent changes to estimate the future total number of doctors' visits for
allergic rhinitis and prescription fills for allergies. Therefore, Figure 17 conveys that these two less
severe health impacts will increase by the same percent. Further research is needed to more
definitively predict if these health measures are likely to increase at the same future rate.
There are several key reasons these results might represent a lower bound of the potential
magnitude of allergen-induced suffering among children in the future. First, Neumann et al. consider
only the effects associated with lengthening pollen seasons, although intensifying pollen seasons also
are linked with climate change and may result in more illnesses among children. These links to
climate change include changes to seasonality but are also connected to changes in pollen
production and allergenicity associated with elevated carbon dioxide in the atmosphere because
plants use carbon dioxide as an input to photosynthesis.322 In addition, the health outcomes in the
Neumann et al. study stem only from oak, birch, and grass pollen exposures, although pollen from all
species of trees, grass, and weeds, especially ragweed, will affect children.323,324,325 Finally, beyond
pollen, childhood exposures to other allergen sources such as mold could increase under climate
change and result in additional adverse health effects on children.326,327
The health burdens associated with pollen exposure can impose costs on children, their caregivers,
and society more generally. ED visits are typically associated with direct medical costs of
approximately $550 per case (2021 dollars).328,329 The costs of prescriptions for allergic rhinitis are
approximately $130 peryear, where patients may need one or more prescriptions filled annually.330
Visits to physicians are often valued at approximately $150 per visit. Experiencing both mild and
serious symptoms from exacerbations of allergies and asthma may result in child absences from
school or other enjoyable activities, as well as lost productivity for their parents and caregivers. Even
when children attend school, the discomfort and distraction associated with experiencing pollen
allergy symptoms can significantly diminish school performance.331
Figure 17: Estimated Percent Change in Pollen Health Impacts Relative to Baseline
2°C 4°C
Prescription fills for allergies, aged 0-17 (Baseline: 715,000/yr)
First doctor visit for allergic rhinitis, aged 0-17 (Baseline:
245,000/yr) W
ED visits for asthma, aged 0-17 (Baseline: 34,000/yr)
0% 5% 10% 15% 20% 25% 30% 35%
Note: This graphic describes how the health impacts associated with pollen exposure linked to climate change
increase relative to baseline conditions (1986-2005), as listed in the figure and under assumptions described in
Appendix D. The teal circles describe increases between baseline and 2°C of global warming; the green circles
convey increases at 4°C.
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Climate Change arid Children's Health and Well-Being in the United States
Figure 18: Estimated Distribution of Additional Asthma-Related ED Visits Per 100,000 Children
2°C of Global Warming
4°C of Global Warming
Notes: These maps present the distribution of additional asthma-related ED visits attributable to exposure to oak,
birch, and grass pollens and climate change per 100,000 children at the county level. Areas with darker shading
have higher rates of affected children. The five states with the highest rates of affected children relative to the
county populations are outlined in black. See Appendix Dfor more details on the spatial distribution of assessed
impacts as well as impacts by pollen source (oak, birch, and grass).
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Climate Change arid Children's Health and Well-Being in the United States
Figure 18 highlights the regional distribution of these future pollen-induced health impacts. As
shown, the incidence of asthma-related ED visits per 100,000 children is highest in parts of the
Northeast, Midwest, and Mid-Atlantic regions. The five states with the highest impacts per 100,000
children at 2°C of global warning are Indiana, Kentucky, Ohio, Vermont, and West Virginia. At 4°C of
warming, Connecticut and Rhode Island experience among the highest per capita rates nationally.
Children are also impacted at a higher rate in central Texas. California and the Southwest region are
among the areas projected to experience the lowest pollen-related pediatric health impacts per
capita.
Appendix D provides more detail on the spatial distribution of future asthma-related ED visits linked
to each pollen source considered in Neumann et al. As shown, birch pollen is the main contributor to
these health impacts experienced throughout Indiana, Kentucky, Ohio, and West Virginia. ED visits
associated with oak pollen are more common throughout the Northeast region, whereas grass pollen
contributes to higher concentrations of cases in the Northwest region as well as Utah and Kansas.
Both oak and grass pollen contribute to the higher rates in central Texas.
Finally, Figure 19 presents the results of the analysis describing the likelihood that overburdened
populations of children live in areas with the greatest projected number of asthma-related ED visits
from pollen exposure per 100,000 children, following methods described in Chapter 2 and Appendix
A. The analysis does not identify that the overburdened populations of children are more likely to
experience the greatest impacts associated with combined effects of oak, birch, and grass pollen.
White, non-Hispanic children are most likely to experience pollen-related health impacts (see
Appendix D). It should be noted that vulnerability to pollen-related morbidity depends only in part on
pollen exposures. Equally important are underlying rates of allergies and asthma, which numerous
studies have shown are disproportionally high among BIPOC children.332-333
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Climate Change and Children's Health and Well-Being in the United States
However, when disaggregating the analysis by pollen type, the health impacts associated with oak
pollen are shown to be concentrated among some of the groups assessed. The underlying pollen
exposure data suggest that the higher exposures to birch and grass pollen tend to occur in suburban
and rural areas, while exposure to oak pollen is at least as prevalent and perhaps somewhat higher in
urban areas - and urban areas tend to be better correlated with the locations of overburdened
children.
For instance, children living in limited English-speaking households are 28% and 46% more likely to
experience the highest incidence of ED cases for asthma attributable to oak pollen exposure at 2°C
and 4°C of global warming, respectively. Further, children not covered by health insurance are 17%
and 21% more likely to experience these effects at the same temperature thresholds. Across groups,
BIPOC children also experience these effects disproportionately. When evaluating by racial and
ethnic group, the analysis finds Hispanic or Latino and Asian children are the groups driving these
measures at 2°C of global warming; Black or African American children are also among the groups
experiencing the highest likelihood of ED visits from oak pollen exposure at 4°C of global warming.
Figure 19: Likelihood of Disproportionate ED Visits for Asthma Impacts Attributable to Oak Pollen
Exposure on Overburdened Children
Limited English Speaking
Low income
BIPOC
No Health Insurance
2°C
4°C
28%
46%
American Indian or Alaska Native
Asian
-19%
I 6%
-52%
I 5%
Black or African American
-2%
| 5%
Pacific Islander
-52%
-63%
Hispanic or Latino
17%
| 33%
White, non-Hispanic
-8%
-18%
Notes: These graphics present the results of the social vulnerability analysis of asthma-related ED visits among
children attributable to oak pollen exposure linked with climate change, following the methods described in
Chapter 2 and Appendix A. The estimated risks for each group are presented relative to each group's reference
population, defined as all individuals other than those in the group analyzed. Populations represent those living in
the contiguous U.S. but identifying as a particular race/ethnicity. Analogous results related to birch and grass
pollen are included in Appendix D.
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Climate Change arid Children's Health and Well-Being in the United States
OUTDOOR RECREATION
Research demonstrates that climate change will alter recreational access,
opportunities, and preferences through changes in seasonality. This section
highlights several studies that project future recreation access under climate change. While none
of these studies are specific to children, they provide suggestive evidence for how recreational
opportunities will change for children in the future.
All Outdoor Recreation
Willwerth et al. predicted the future number of outdoor
recreation trips for Americans aged 15 and older resulting
from changes in temperature arid precipitation.334 The
authors find that participation in outdoor recreation
increases as weather warms, driven by time spent on water
sports and boating, and that individuals in the northern and
southern regions respond differently to the warmest days. If
individuals continue to respond to temperature as they have
between 2003 and 2019, the authors project a net increase
of 157 million outdoor recreation trips across all types
annually at 2°C of warming in the contiguous U.S. (not
global), arid up to 288 million trips at 4°C of warming.
Winter Recreation
Wobus et al. assessed how winter recreation, including skiing and snowmobiling, will decrease
without reliable snow in the future.335 The authors project that by 2050, the U.S. will see a net
decrease of 17.4 million winter recreation trips annually under a lower emissions scenario
(RCP4.5) and 21.5 million trips annually under a higher emissions scenario (RCP8.5). Children
currently represent the majority of skiers and snowboarders in the U.S.336
Freshwater Fishing
Jones et al. document how increases in ambient temperatures are likely to raise stream
temperatures and decrease the areas suitable for cold-water fishing (e.g., fly-fishing for trout).337
They estimate that annual cold-water fishing days will decline by 1.25 million days by 2030, to
6.42 million days by 2100. Instead, anglers will spend more time fishing in warm-water habitats.
This is notable as the largest share of fishing participants in the U.S. are between ages 6 and 12.338
Recreation at Reservoirs
Chapra et all, model how increasing temperatures and changing precipitation levels will affect the
frequency of HABs in large reservoirs, and how closures will impact recreation, including
swimming and boating.339 They estimate that the 279 reservoirs and lakes covered in the study
will experience a projected 1.2 million to 5.3 million visitor-days lost peryear by 2090.
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Climate Change arid Children's Health and Well-Being in the United States
Chapter 6. Flooding
Chapter highlights
This chapter describes how flooding affects children and how those impacts are expected
to increase as the climate changes. Evidence shows that children experience increased
safety risks—including drowning—during flooding events, as well as mental stress
associated with displacement from their homes and communities. Exposures to waterborne
pathogens and mold in flooded structures also pose health risks. Stress can affect birth outcomes.
This report quantifies the number of children who may experience adverse effects due to
flooding in coastal areas; specifically, children who may experience short-term
displacement from their home as well as those at risk of losing their homes completely, if
no additional adaptation measures are taken, approximately 185,000 (159,000 to 437,000) children
are projected to lose their homes from coastal flooding at 50 cm of global sea level rise, increasing to
1.13 million (477,000 to 3 million) at 100 cm. More than 1 million additional children may be
temporarily displaced from their homes due to coastal flooding at both 50 cm and 100 cm.
Adaptation, including building sea walls, could prevent these impacts for many children. The greatest
flooding impacts are concentrated along the Atlantic and Gulf coastlines. Children in overburdened
households are projected to experience these impacts disproportionately.
Inland (or riverine) flooding will increase in many areas due to climate change, although
fewer children are projected to experience these impacts relative to coastal flooding. For
instance, at 4°C, an estimated 560,000 children could be temporarily or permanently
displaced from their homes.
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Climate Change arid Children's Health and Well-Being in the United States
HOW CLIMATE CHANGE EXACERBATES FLOODING
AND IMPACTS CHILDREN
The frequency of flooding events due to sea level rise will continue to worsen as the
climate changes.340This includes inland flooding, which is the type seen following heavy rainfalls or
snowmelt, when flash-flooding occurs during a severe storm, or when rivers or other water bodies
overrun their banks,341 and coastal flooding, which refers to nuisance or high-tide flooding, storm
surge, high waves that occur during coastal storms, and inundation related to sea level rise.342 Storm
surge is a particular concern; it is the most common cause of physical injury and death during
hurricanes, and it also can flood large coastal
areas, causing property damage and persistent
health risks.343 The impacts of storm surge can be
compounded when surges coincide with high tides,
making the flooding that much more extreme and
destructive to life and property.344 Scientific
assessments and indicators developed over the
past decade have demonstrated a high likelihood
of climate change exacerbating or causing coastal
flooding, inundation, and inland flooding.345,346
IMPACTS OF FLOODING ON CHILDREN
Children face myriad threats from flooding. The
physical health impacts of flooding can include
cuts, bruises, sprains, and broken bones, which
may have short- or long-term health effects.347
However, tragically, drownings are among the
most common types of reported injuries.348
According to data from the National Oceanic and
Atmospheric Administration, between 2017 and
2021, 92 individuals who were 19 and younger
were reported to have died from flood-related
drownings, representing 16% of all flood-related
drownings.349 Child drownings often are associated
with falling into swimming pools or other similar
circumstances; however, flood-related injuries and
fatalities involving children often occur from slips
and falls into or near flooded waterbodies.350
Additionally, children may be injured or killed if a
car they are riding in becomes swept away or
overwhelmed by flash-flooding.351 Research shows
that as precipitation amounts have increased in
parts of the country, so too have flooding events,
STL
Flooding and children
Children are susceptible to increased
safety risks during floods, including
drownings.
Flooding increases children's exposure to
waterborne pathogens, as well as mold in
damaged structures.
Temporary or permanent displacement
from homes and communities can create
mental health challenges for children.
Stress experienced by pregnant women
during a flooding event can negatively
impact birth outcomes.
Overburdened populations often live in
flood-prone areas and are more likely to
experience flood impacts.
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Climate Change and Children's Health and Well-Being in the United States
including flash-flooding.352 This is especially significant as flash-flooding is responsible for the highest
number of flooding-related deaths.353,354
The risk of disease may increase during or after flooding events. For example, children may be
exposed to pathogens like the norovirus or bacteria of the genus Vibrio, either through open wounds
in their skin355 or ingesting drinking water. Depending upon the species, pathogens can cause a range
of health effects, including ear infections, flu-like symptoms, or death.356 Such health effects may
become a greater issue in the future as increased cases of vibriosis357 (any infection resulting from
exposure to non-cholera-causing Vibrio genus bacteria) and norovirus358 (the latter due largely to
effluent and increased sewage runoff)359 have been linked to climate change.360 While many children
may not suffer long-term effects from pathogens, immunocompromised children are at greater risk
of severe illness or death.361 Children can be exposed to different types of chemical and biological
pollutants or pathogens if they ingest contaminated water either accidentally, by water splashing
into their mouths, or from contaminated drinking water sources caused by infrastructure failures
during flood events.362
Homes that experience flooding are more likely to have dangerous levels of mold, which is linked to
increased incidence of asthma in children.363 Research also shows that mold-related asthma
diagnoses and incidences are likely to increase with climate change.364,365 There are demonstrated
correlations between childhood asthma, race, and socioeconomic status, meaning that exposure to
flooding could worsen health equity concerns.366,367
Pregnant women and fetuses are also at increased risk of experiencing harm associated with
flooding. Psychological stress experienced by mothers can be imparted to fetuses during pregnancy,
which in turn can lead to adverse pregnancy and birth outcomes, such as preterm birth, low birth
weight, and stillbirths, among other effects.368,369 Limited studies point to ways in which prenatal
stress incurred during flooding conditions can lead to cognitive effects in offspring or a failure to
thrive.370,371 Additional ways in which pregnant women may experience harm during flooding include
gastrointestinal issues linked to exposures to pathogens or dehydration due to lack of clean water,372
which can impact the health of the fetus.
Flooding can also impact children's mental health. For example, children may experience post-
traumatic stress disorder (PTSD) upon exposure to climate change-related trauma from extreme
weather events, such as destructive flooding, or after physical injury or loss of their home.373,374 PTSD
may be short-term or chronic and can manifest in a variety of ways in children, including regressions
in toilet-training and communications skills, panic attacks, and a propensity for aggressive
behavior.375,376,377 Stress in childhood, and especially in adolescence, that is related to climate change
or exposure to extreme events can contribute to lifelong mental illness, including depression or
attachment disorders. It also may contribute to the development of substance misuse
disorders.378,379
Flooding can disproportionately affect low-income and BIPOC populations. Many flood-prone areas
in the U.S. are predominantly disadvantaged, non-White communities.380 Furthermore, residents
within these same demographics are at risk of experiencing "worse" or exacerbated short- or long-
term impacts (e.g., displacement or chronic health conditions) of severe tropical weather-related
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Climate Change and Children's Health and Well-Being in the United States
flooding, such as hurricanes, compared to White and/or wealthier communities.381 As an example,
Hurricane Harvey and its documented impacts on the residents of the Greater Houston area have
fallen disproportionately on a broad range of disadvantaged, non-White communities.382'383'384'385,386
Managed retreat, as well as climate change-related gentrification (see "Glossary" for definitions), are
felt most acutely by low-income and BIPOC populations that are more likely to have limited
resources or fewer options to move.387,388 Additionally, leaving a particular area of land or body of
water that has cultural or historic significance to communities, including BIPOC individuals, can cause
psychological and emotional trauma.389 As sea level rise increases due to climate change, coastal
housing in many parts of the country is losing its value, while inland areas are becoming more and
more expensive. This minimizes the flexibility of many coastal inhabitants to relocate.390 Additionally,
groups with strong personal and cultural ties to an area may experience heightened levels of trauma
if moving becomes a necessity.391 Experiencing or exposure to gentrification, loss of housing or
housing uncertainty, or observing stress among trusted parents or caregivers may affect children's
mental health.392
COASTAL FLOODING AND CHILDREN'S HOMES
This section describes an analysis of coastal flooding risks to children through impacts
on their homes. The analysis leverages the National Coastal Property Model (NCPM),
including recent evidence from Neumann et al.,393 to model the number of children
likely to be temporarily displaced from or lose their home because of coastal flooding. The following
two measures of risk are proxies for a larger set of risks to children associated with coastal flooding:
1. Number of children likely to be temporarily displaced: This scenario is associated with a high
likelihood of temporary home displacement, such as relocation while minor flooding subsides
and structures are repaired. This scenario results in various risks to children, including
financial and mental stress or loss of schooling opportunities. When children return to their
homes following the flooding event, the structures may contain levels of mold that pose
health risks to children. Temporary displacement is triggered by damages to residences
associated with storm surge, a coastal hazard amplified by sea level rise.
2. Number of children likely to lose their home:Jh\s scenario considers the high likelihood of
permanent home loss through repeated flooding episodes causing damage or permanent
inundation and serves as an indicator of the most severe impacts of coastal flooding. For
instance, children forced to abandon their homes may experience the financial stress that is
placed on families that require new housing. This may be worsened by the mental stress
associated with displacement from a community and sites of personal and cultural
importance, as well as the threat of housing uncertainty. Concurrent or subsequent disrupted
school attendance may also lead to lower educational attainment. Home loss can be
triggered by intense and repeated damage from storm surge or by permanent inundation
from sea level rise.
Figure 20 summarizes the steps in the coastal flooding analysis, with more details in Appendix E.
First, children living in structures experiencing flooding damage under current conditions are
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Climate Change arid Children's Health and Well-Being in the United States
identified for the entire contiguous U.S. coastline. Next, the analysis
forecasts future coastal flooding from sea level rise and storm surge
resulting from climate change. The NCPM then identifies the annual
expected damages to residential structures within a 150 m grid. The
temporary home displacement scenario evaluates homes with minor
damage (2% annual expected damages). The home loss scenario
considers properties once annual expected damages reach 10%. Finally,
to approximate the number of children who may experience these
flooding risks, the analysis maps the 150 m grids to census block groups
to calculate the number of children living in those areas. Across all 302
coastal counties, the 2010 U.S. Census identifies over 17.2 million
children, equivalent to 23% of all children in the contiguous U.S. By the
end of the century, this is expected to grow to 24.5 million children across
coastal counties. To show how flooding impacts may progress over the
21st century, results showcase both 50 cm and 100 cm of global mean
sea level rise (see Chapter 2).
Figure 21 provides an example of the flooding risk severity and global sea
level rise scenarios included in this analysis. As shown in the lefthand graphic, the 50 cm scenario
generally projects more homes with some amount of flooding that likely results in temporary
displacement of families, with fewer homes completely lost. Then, at 100 cm, many more homes are
permanently lost, including homes that experienced temporary damage at 50 cm. In other words,
homes change from the temporary damage category to the more severe home loss category as sea
level rise progresses.
Figure 21: Flooding Scenarios in One Coastal Area
Figure 20: Coastal
Flooding Analysis Steps
Step i
Determine number of
children experiencing
coastal floods in the
baseline
Step 2
Forecast future coastal
flooding from sea level
rise and storm surge
Step 3
Estimate the number
of children in homes at
risk of complete loss
ortemporary flooding
100 cm (39.4 inches)
Notes: These maps present an illustrative example of how coastal flooding progresses between 50 cm and 100 cm.
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Climate Change and Children's Health and Well-Being in the United States
Figure 22: Projected Additional Coastal Flooding Impacts on Children Assuming No Additional
Adaptation
Total Home
Loss
Temporary
Home
Displacement
Global Mean Sea
Level Rise
Number of additional children living in
these homes in coastal areas
50 cm
185,000
1.01 million
(159,000 to 437,000)
100 cm
1.13 million
1.08 million
(477,000 to 3.0 million)
Notes: This graphic presents the results of the coastal flooding analysis at 50 cm (equivalent to 19.7 inches) and 100
cm (equivalent to 39.4 inches) of global sea level rise. The impacts assume populations of children will increase over
the 21st century (see Chapter 2, Appendix A) and convey the impacts to children under the "no additional
adaptation" scenario. The results describe additional coastal flooding impacts on children relative to baseline
conditions (see Figure 23). Temporary home displacement refers to the number of children affected each year,
whereas the number of children affected by home loss is cumulative (i.e., all children affected by home loss at or
before the sea level rise threshold). The table displays the average and a statistically derived range of uncertainty
for sea level rise for the 50 and 100 cm projections. Chapter 2 and Appendix E provide additional detail on the
specific basis for estimating uncertainty in sea level risk and the Appendix provides results for additional global sea
level rise thresholds and assuming "with adaptation."
In addition to the severity scenarios and global mean sea level rise projections, the NCPM models
two different assumptions about how communities adapt to the threat of coastal flooding by building
levees or sea walls, investing in beach nourishment, and elevating properties. The "no additional
adaptation" scenario assumes properties maintain the current level of protection, even in cases
where some building codes may require it in the future, while the "with adaptation" scenario
assumes properties are protected when the benefits of protection outweigh the financial costs of
implementing the protection measures.
Figure 22 summarizes the findings of the coastal flooding risk analysis assuming "no additional
adaptation" conditions. As indicated in the figure caption, the count of children experiencing home
loss considers all homes lost up to and including the time when sea level reaches the indicated sea
level rise threshold. The analysis finds that temporary home displacement would affect an additional
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Climate Change arid Children's Health and Well-Being in the United States
1.01 million children per year at 50 cm and 1.08 million children per year at 100 cm. Complete home
loss is projected to affect 185,000 (ranging from 159,000 to 437,000 across climate models) children
cumulatively as sea levels rise to 50 cm above current levels. The number of children cumulatively
affected by home loss increases to 1.13 million (477,000 to 2.96 million) at 100 cm of sea level rise.
The "with adaptation" scenario projects that the number of children affected by coastal flooding is
less widespread, but the effects of adaptation are site- and context-specific. Home loss is projected
to affect an estimated 170,000 (149,000 to 216,000) additional children and 300,000 (223,000 to
603,000) additional children at 50 cm and 100 cm of global mean sea level rise, respectively. Relative
to the "no additional adaptation" scenario, adaptation prevents home loss for an estimated 16,000
children at 50 cm on average across models. By the time global mean sea level rise reaches 100 cm,
adaptation could prevent home loss for 830,000 children on average, suggesting that well-timed
adaptation is especially effective at reducing risks under more significant global sea level rise levels.
The maps of impacts by state in Appendix E show that this substantial benefit of cost-effective
adaptation, where adopted, is uneven across states. For example, for 100 cm, adaptation reduced
the number of children experiencing total home loss in Florida by more than a factor of 10, and in
California by a factor of 2, but in North Carolina by less than 15 percent.
Adaptation prevents temporary home displacement for an estimated 380,000 children per year at 50
cm on average but only 124,000 children per year at 100 cm, since protection in response to coastal
flooding risks tends to prioritize areas that are at the highest risk of significant damage. While the risk
reduction benefits of coastal adaptation are apparent, the financial and time investments necessary
to implement such protection will be large (on the order of at least several billions of dollars
annually, and hundreds of billions through the end of the century) and are an important
consideration for the interpretation of these results.
The relatively high number of children still likely to be affected by coastal flooding under the "with
adaptation" scenario implies that there are limits to adaptation. Adaptation is a complex process and
is difficult to forecast. Many adaptation response decisions in coastal zones are not made with strict
cost-benefit decision rules, particularly at the local level. Other factors may include local zoning
bylaws, future land use plans, the presence of development-supporting infrastructure, or proximity
to sites of high cultural value. The analytical framework of the NCPM provides a simple, benefit-cost
decision framework that can be consistently applied for regional and national-scale analysis, but the
exact areas where adaptation is implemented may be more or less extensive than reported here.
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Climate Change and Children's Health and Well-Being in the United States
Figure 23: Estimated Percent Change in Coastal Flooding Impacts Relative to Baseline Conditions
Temporary Home Displacement
50 cm 100 cm
Children at risk of temporary home flooding, no additional adaptation
(Baseline: 660,000/yr)
Children at risk of temporary home flooding, with adaptation (Baseline:
660,000/yr)
-10% 0% 10% 20% 30% 40% 50% 60% 70%
Home Loss
Children at risk of total home loss, no additional adaptation
(Baseline: 49,000)
Children at risk of total home loss, with adaptation (Baseline:
49,000)
50 cm
100 cm
•
•
500%
1000%
1500%
2000%
2500%
Notes: This graphic describes how the number of children affected by coastal flooding damage to their homes will
increase relative to baseline (1986-2005) under assumptions described in Appendix E. The teal (darker) circles
describe increases between baseline and 50 cm of global sea level rise; the light blue circles convey increases at 100
cm. "Comets" highlight leftward movement and therefore decreases relative to baseline. The graphic includes
temporary displacement and home loss (with different axes) under the "no additional adaptation" and "with
adaptation" scenarios.
Figure 23 compares these various future flooding impacts to current conditions, further
demonstrating how conditions will change over time. While children currently experience the effects
of coastal flooding in many areas, families in homes that have sustained significant damage are likely
to have already moved elsewhere, meaning the number of children observed in damaged structures
currently is very low. Using various techniques and assumptions to approximate the number of
children in previously flooded structures, this analysis identifies around 49,000 children in homes lost
to flooding and 660,000 in temporarily damaged homes.
This means that the number of children temporarily displaced by flooding will increase between 47%
and 67% under the analysis's "with adaptation" and "no additional adaptation" scenarios at 100 cm.
Children experiencing complete home loss increases far more dramatically, in part because the
measure captures cumulative home loss. Even at 50 cm, the additional children who may sustain
home loss increases 3.5 times "with adaptation" and 3.8 times assuming "no additional adaptation."
At 100 cm, up to 23 times the number of children could experience total home loss if there is "no
additional adaptation" —even with adaptation, the estimated number of children who may lose their
home is 6.2 times the current number of children at risk from this type of loss.
Figure 24 describes the geographic distribution of children affected by home loss at 50 cm and 100
cm of global mean sea level rise assuming "no additional adaptation." Regionally, the affected
children are concentrated along the Mid-Atlantic and the Gulf coastlines. At 50 cm, the five states
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Climate Change arid Children's Health and Well-Being in the United States
with the highest number of affected children living in coastal counties per 100,000 are Georgia,
Louisiana, North Carolina, South Carolina, and Virginia, Florida also is among the states with the
highest impacts nationally at 100 cm of sea level rise. As shown, children on the Pacific and the
upper-Atlantic coasts of the U.S., including the Northern New Jersey and Long Island geographies
that were severely affected by Superstorm Sandy, may be spared the worst of future coastal flooding
impacts. These results reflect, in part, the coastal protection infrastructure deployed given the
known coastal floodplain risks in these areas. Future adaptation to these threats also may alter the
geographies with the highest concentrations of children affected.
Figure 24: Estimated Distribution of Additional Children's Home Loss from Coastal Flooding
50 cm of Global Sea Level Rise
/»
*
a-)r
VIRGINIA ¦
2,000 |
fl
NORTH
CAROLINA
13,000
SOUTH CAROLINA
f GEORGIA
| 1,000
LOUISIANA
4,000
100 cm of Global Sea Level Rise
*
...
f
'
w
No impact
1,000-3,000
3,000 - 8,000
8,000 - 20,000
120,000- 100,000
Notes: These maps present the distributions of children at risk of home loss from coastal flooding impacts per
100,000 children living in coastal counties. Areas with darker shading have higher rates of affected children. The
five states with the highest rates of affected children relative to the coastal county populations are outlined in
black. The risks assume "no additional adaptation" (see Appendix E for the "with adaptation" scenario).
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Climate Change and Children's Health and Well-Being in the United States
Finally, Figure 25 explores the social vulnerability dimensions of the impacts predicted in the "no
additional adaptation" scenario, implementing the methods described in Chapter 2 and Appendix A.
Overall, children in the demographic groups assessed are more likely to be disproportionately
impacted by temporary home displacement at 50 cm and complete loss of home at 100 cm. These
results may be reflective of the fact that the same child's home may be temporarily damaged at 50
cm but completely lost at 100 cm.
For instance, children in limited English-speaking households are 32% more likely to be affected by
temporary home displacement at 50 cm of global sea level rise, decreasing to 14% at 100 cm
respectively because a different group of homes and set of children are affected under the two
scenarios. At 100 cm, children in limited English-speaking households are 64% more likely to
experience home loss, representing a significant increase in disproportionate impacts relative to 50
cm. BIPOC children are 21% more likely to experience effects at 50 cm; these households generally
are Hispanic or Latino. At 100 cm, BIPOC children are 57% more likely to suffer home loss, although
these effects are concentrated among Asian and Pacific Islander children. Low-income children and
children not covered by health insurance also experience disproportionate impacts from temporary
flooding at 50 cm and complete home loss at 100 cm, although to a lesser extent than the other
groups.
Figure 25: Likelihood of Disproportionate Coastal Flooding Impacts on Overburdened Children
50 cm
100 cm
Limited English Speaking
Low Income
BIPOC
No Health Insurance
Temporary Home Displacement
32%
-3%
0%
-11%
14%
57%
Home Loss
Limited English Speaking -28% I I 64%
Low Income 11%
BIPOC
No Health Insurance
Notes: These graphics present the results of the social vulnerability analysis of coastal flooding impacts on children,
following the methods described in Chapter 2 and Appendix A. The differences in risk are measured for the "no
additional adaptation" scenario specifically (see Appendix E for other analysis details). The estimated risks for each
socially vulnerable group are presented relative to each group's reference population, defined as all individuals
other than those in the group analyzed. Populations represent those living in the contiguous U.S. but identifying as
a particular race/ethnicity.
-28%
-7%
-9%
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Climate Change arid Children's Health and Well-Being in the United States
INLAND FLOODING AND CHILDREN'S HOMES
Inland flooding, including riverine flooding ("fluvial flooding") and flash floods
associated with extraordinary precipitation events ("pluvial flooding"), will impact
children through damages to their homes and the potential for displacement. Riverine flooding
occurs when excessive rainfall over an extended period collects across a watershed and causes a
river to exceed its capacity. Because a warmer atmosphere can hold more moisture than a cooler
atmosphere, climate change is expected to change the frequency and magnitude of precipitation
and flooding across the country.394 Flood risk from high excessive riverine flow is widespread in
the contiguous U.S. and growing because of climate change, as well as changes in housing and
population density.395,396 Flood risks associated with high rainfall events are widespread nationally
and appear to be increasing in frequency, particularly as a result of hurricane-induced rainfall, but
are only beginning to be understood comprehensively as a serious flood risk and a source of
inequitable flood risk exposure.397
A recent study that connects the frequency and severity of inland flooding events to climate
change also provides insights on how children may be affected.398 The analysis considers annual
expected property damages from flooding, the same metric as the coastal flooding analysis
presented earlier in this chapter. With 2°C and 4°C of global warming, the greatest impacts are
projected to occur in the Northern Great Plains and Northwest regions, with a significant and
large burden of damage also seen in the Southwest and Southeast. At 2°C of global warming,
nearly 200,000 additional children may live in areas where flood damage could cause a temporary
evacuation. At 4°C, the estimate of children affected grows to more than 550,000 individuals.
Using a metric of more severe flood damage, including permanent home loss, nearly 17,000
children might be affected at 2°C of warming, and more than 55,000 at 4°C. These results are
informative about the number of children that may be affected by climate-induced riverine floods
and offer a useful comparison to the coastal flooding results presented earlier in the chapter,
where far more children will be impacted. Note that flood-proofing or other adaptation was not
considered in this study. Appendix E provides more details on the methods used for this analysis.
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Climate Change arid Children's Health and Well-Being in the United States
Chapter 7: Infectious Diseases
Chapter highlights
This chapter describes how varying temperature and precipitation patterns linked with
climate change are likely to alter the habitat, range, and density of pathogens, vectors, and
hosts that result in disease among children. Similarly, as people spend more time outdoors
as temperatures warm, especially in the "shoulder seasons" of spring and fall, children are more
exposed to ticks and mosquitos that carry vector-borne diseases.
Lyme disease, carried by blacklegged ticks, is one such disease that will be influenced by
changing temperatures and rainfall patterns. Across the 21 states and the District of
Columbia in which Lyme disease is currently prevalent, the detailed analysis presented in
this chapter projects an additional 2,600 (-7,500 to 20,200) new cases of Lyme per year among
children at 2°C of global warming (31% increase relative to baseline). At 4°C of global warming, the
increase relative to baseline is much more extreme: 23,400 (7,800 to 47,000) additional cases per year
among children (272% increase). States in the northernmost areas of the Northeast and Midwest
regions are expected to see the majority of new cases among children.
West Nile Virus (WNV), carried by mosquitos, is also likely to see a change in new cases as
temperatures increase. Existing research estimates an additional 59 cases per year of West
Nile Neuroinvasive Disease (WNND), a severe outcome associated with WNV, among
children at 2°C of global warming, rising to 133 cases at 4°C, The regions with the largest
increases in cases include the Southern Great Plains and the Southeast. While small in magnitude,
these results may indicate an increase in other mosquito-borne diseases as well.
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Climate Change arid Children's Health and Well-Being in the United States
HOW CLIMATE CHANGE ALTERS INFECTIOUS DISEASE
AND IMPACTS CHILDREN
Temperature and precipitation levels affect the habitat, range, and density of
pathogens, vectors, and hosts. Therefore, as the climate changes, the geographic extent and
concentrations of the organisms that spread disease will change, including mosquitos and
ticks.399'400>40:L'402'403'404'40S'406 Diseases may no longer be common or endemic in some areas due to
increased temperatures or changes in precipitation levels, but the diseases may become endemic in
new parts of the country or may be present for longer periods of the year in others. Finally, human
behavior is an important element in the spread of vector-borne diseases. As the climate warms, and
it becomes possible or necessary for some individuals to spend more time outside, the opportunity
increases for exposures to ticks, mosquitos, and other vectors to occur.407
IMPACTS OF INFECTIOUS DISEASES ON
CHILDREN
Mosquitos and ticks are key causes of
childhood vector-borne diseases linked to
climate change. Lyme disease is one of the
best-known and most common vector-borne
diseases in the U.S.408 People develop Lyme
disease after being bitten by the blacklegged
tick (also known as the deer tick, Ixodes
scapularis Say) or the western blacklegged tick
(/. pacificus Cooley and Kohls) infected with
the bacteria Borrelia burgdorferi sensu
stricto.409 In 2019, the U.S. Centers for Disease
Control and Prevention (CDC) reported 35,000
confirmed and probable cases in the U.S. Of
those, children between the ages of 0 and 19
experienced 6,560 confirmed and probable
cases—approximately 32% of total cases.410
Children aged 5-9 have the highest historical
incidence rate of Lyme disease of any age
group.411 Symptoms include a range of short-
term effects, including a classic rash (erythema
migrans; commonly known as the "bullseye"
or "target" rash). In some instances, children
can also experience lifelong or life-threatening
effects, including lethargy; neurological
impacts, such as facial paralysis commonly
known as Bell's Palsy; meningitis; juvenile
arthritis; and carditis, also known as
Infectious diseases and children
r /*¦
1# ¦
Climate change will influence the geographic
extent and concentration of organisms that
spread disease, including mosquitos and ticks.
Lyme disease, transmitted via ticks, can result
in a short-lived rash or lifelong neurological or
heart conditions.
West Nile Virus, transmitted via mosquitos, is
generally mild in children, except for those who
are immunocompromised. Other diseases
associated with mosquitos include Zika,
chikungunya, dengue, and malaria, and are
currently rare in the U.S.
Food- and water-borne diarrheal diseases could
also become more prevalent in the U.S. under
climate change.
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Climate Change and Children's Health and Well-Being in the United States
inflammatory heart disease.412,413,414,415 Juvenile arthritis generally is the most common, severe long-
term effect.416 Research suggests that longer periods between exposure and treatment are linked to
more serious and persistent health outcomes in children.417 Lyme disease can also result in a rare
syndrome with non-specific, generally subjective symptoms that has become known as "chronic
Lyme" or "post-treatment Lyme disease syndrome," in which symptoms persist for more than six
months post-treatment.418 At this time, few studies exist for pediatric cohorts that detail how
children's health may be affected over the long term.419,420
Other tickborne diseases that are endemic in the U.S. include anaplasmosis, babesiosis, and Rocky
Mountain spotted fever.421,422,423,424 Each is transmitted by the bite of different tick species across
the country, and some may occur as concurrent infections with Lyme disease.425 Rocky Mountain
spotted fever also is known as rickettsiosis, the general name for diseases caused by the bacteria
Rickettsia spp.426 Rickettsiosis mostly commonly is found in children and can cause extremely serious
health effects and lead to death.427,428
WNV is the most common domestic mosquito-borne disease in the U.S.429 In the U.S., it is spread
primarily by the species Culexpipiens, C. tarsalis, and C. quinquefasciatus.430 In children, the primary
means of exposure are via mosquito bites,431 although WNV can be transmitted from mother to child
in utero and through breast milk.432,433 Fortunately, WNV does not typically present symptomatically
or seriously as frequently in children as in adults (1-5% of WNV cases present in children); however, it
can cause severe health effects in young patients, especially those who are immunocompromised.434
Symptoms and health outcomes span from mild (including rash, gastrointestinal upset, and flulike
symptoms435) to severe (including encephalitis, symptoms similar to polio myelitis and meningitis,
paralysis, and other effects, including death436,437). Further, WNV can cause less-specific damages to
the central nervous system and associated chronic health effects.438,439 The long-term ramifications
of these more severe health outcomes are considerable, as they can lead to permanent damage or
death, especially in immunocompromised children.440,441
Mosquitos are successful vectors for numerous other diseases that can have deleterious health
impacts in children. Since 2015, the Zika virus has spread primarily via Aedes spp. mosquitos442 in
tropical and subtropical environments.443 The virus can be transmitted during pregnancy to a fetus
and can lead to extremely serious birth defects, including brain damage (such as microcephaly).444
Children also can be exposed to and develop complications from the Zika virus, which generally has
milder health effects445 but still may impact cognition in severe cases.446 These effects can have
lifelong consequences for children and parents, which researchers project could cost millions to
billions of dollars in healthcare costs.447 Other global mosquito-borne diseases associated with
considerable child health concerns include chikungunya, dengue, eastern equine encephalitis, and
malaria.448,449,450 Each can have severe health implications for children, including the potential to
cause neurological damage and moderately high mortality rates.451,452,453 Fortunately, current
incidence rates in the U.S. are low for each of these types of diseases and commonly are associated
with international travel. Flowever, incidence rates have been increasing over the past few decades,
and the diseases have the potential to become endemic in the U.S.454,455,456,457,458
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Other types of infectious diseases, such as those that are food- or water-borne diarrheal diseases,
could become more prevalent in the U.S. under climate change. For example, Cryptosporidium,,459
Salmonella,460 Escheria coli (E.coliJ,461 and Shigella462all have links to climate change and cause
gastrointestinal illness. The pathogens are likely to become more prevalent with increases in extreme
rainfall, changes in temperature that promote bacterial growth, insufficient or damaged
infrastructure, considerable storm runoff, poor wastewater management, or some combination of
these elements.463,464-465 The subsequent illnesses can lead to childhood deaths if left untreated,
owing to resultant malnutrition and dehydration.466,467 This is especially true in younger and
immunocompromised children.468
Infectious disease presents many potential issues related to disparities across demographic groups.
Research suggests correlations between underdiagnosis or misdiagnosis of Lyme disease, in part
because the rash may be difficult to detect on darker skin.469,470'471 Additionally, Black children may
be less likely to receive antibiotics either as a precautionary measure or as treatment.472,473 Research
shows that Black individuals experience greater rates of Lyme carditis, which is linked to delayed
treatment.474 Limited research also demonstrates that proportionately there is a greater cost of
Lyme disease and other types of tick-borne illnesses and treatment that is borne by low-income
individuals who either cannot afford treatment, or who seek or receive delayed healthcare, relative
to those who are not low income or have health insurance.475'476 Similarly, other types of infectious
diseases in the U.S. have had disproportionately adverse effects on different populations of children.
For instance, the Zika virus was found to have the greatest impacts on Hispanic or Latino children,
including newborns, infants, and older individuals.477 Areas of higher incidence of mosquito-borne
illnesses, such as Zika or WNV, frequently are in low-income areas.478'479
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LYME DISEASE
This section quantifies the potential increase of Lyme
disease cases among children linked with future
temperature and precipitation associated with climate
change. It leverages the analysis by Yang et al. (in review),480 which
associates national historical precipitation and temperature patterns
(e.g., changes in national temperatures, rather than global temperatures)
with new cases of Lyme disease among children in the eastern U.S.,
where the disease currently is prevalent.* Based on the historical
relationship, the authors project the future number of Lyme disease
diagnoses associated with infections from the blacklegged tick and the
bacteria that causes Lyme disease as linked with climate change.
Figure 26: Lyme Disease
Analysis Steps
Step 1
Identify baseline number
of new Lyme diagnoses
each year
Step 2
Calculate changes in tick
and bacteria presence
related to future rainfall
and temperature
Step 3
Estimate change in new
Lyme disease cases
among children
Figure 26 describes the analysis steps taken for this report, with more
details about the methods, data sources, and assumptions provided in
Appendix F. First, baseline Lyme disease diagnoses among children are
derived from data maintained by the U.S. Centers for Disease Control
and Prevention. Next, changes in tick and Lyme disease-causing bacteria
presence related to future rainfall and temperature are modeled. Finally, presence is used to
estimate Lyme disease cases among children.
Yang et al.'s analysis confirms that ticks and the Lyme disease-causing bacteria are highly sensitive to
temperature and precipitation conditions, and that their range and prevalence are expected to
increase as climate continues to change. In general, this means that areas of the U.S. with suitable
climatic conditions and habitat to support tick populations generally shift northward. Flowever,
differences in rainfall trajectories, and potential impacts on tick and host movements or behaviors,
make for a more nuanced geographic picture of future tick habitat.
How are Lyme disease and climate change connected?
Lyme disease is closely connected with climatic conditions. Disease transmission occurs most often between nymphal
ticks and humans, other mammals, rodents, and birds.481 Longer periods of warmer temperatures and increased
humidity earlier in the year allow ticks to emerge sooner and stay active for longer.482,483 That said, the ticks and their
hosts will not extend to or remain in areas that are too hot or cold,484 have heavy rainfall, or are overly wet or dry.485
As land use changes and host animals expand their ranges, so do ticks; and, as a consequence, Lyme disease is found
in new locations.486,487 Another important factor is that certain hosts such as lizards do not process or carry the
bacteria; therefore, disease transmittal is not as common where these host species are the primary food sources for
the ticks.488 Additionally, with moderate warming, humans may spend more time outside (i.e., in typically cooler
northern regions), which may increase opportunity for exposure to ticks and thus to Lyme.489 All of these changes are
reflected in how Lyme disease cases over the past 30 years have spread into new areas and increased.490
* The study scope includes 21 states (Connecticut, Delaware, Illinois, Indiana, Iowa, Maine, Maryland, Massachusetts, Michigan,
Minnesota, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, West
Virginia, and Wisconsin) as well as the District of Columbia.
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Figure 27: Projected Additional Cases of Lyme Disease Among Children Per Year Attributable to
Climate Change
Notes: This graphic presents the results of the Lyme disease analysis at 2°C (equivalent to 3.6°F) and 4°C (equivalent
to 7.2°F) of global warming. The results describe additional impacts per year for children living in the study region
(see Figure 28 for details) and conditions relative to baseline (1986-2005), and assume populations of children will
increase over the 21st century (see Chapter 2, Appendix A). The table displays the average and range across climate
models. Figure 29 provides baseline levels. Appendix F provides results for additional degrees of global warming.
Figure 27 summarizes the estimated number of additional cases of Lyme disease among children
linked with these changing climatic conditions. Across the 21 states arid the District of Columbia
included in Yang et al.'s sample, the analysis estimates an additional 2,600 (ranging from 7,500 to
20,200 across climate models) cases per year among children at 2°C of warming, and 23,400 (7,800
to 4-7,000) additional cases per year at 4°C of warming. In order words, these projections suggest a
dramatic increase in cases at more extreme warming levels. Even so, it is well -documented that Lyme
disease is underreported,491,492,493 with CDC estimates that as few as one in ten actual cases are
captured in its data. Because the estimates in this analysis are calibrated based on historical
reporting, the actual number of future cases similarly may be different.
Recent research is limited regarding the cost of Lyme disease in children. Yang et al. identify an
average healthcare cost of approximately $4,200 per case of Lyme disease, adjusted from Adrion et
al.,494 which considers children in the sample, although the study also includes all adults under age 65
(2021 dollars). Beyond healthcare costs, there may be indirect costs associated with lost productivity,
including lost workdays among parents caring for sick children, as well as quality of life losses among
affected children and their caretakers.
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Figure 28: Estimated Distribution of Additional Lyme Cases Per Year Among Children
2°C of Global Warming
4°C of Global Warming
IOWA
267
-3,000 --1,000 -1,000 --100 -100 - 0 0 - 1,000 1,000 -3,000 ¦3,000 -6,300
Notes: These maps present the distribution of new Lyme cases attributable to climate change per 100,000 children
per year relative to baseline levels at 2°C and 4°C of global warming. Areas with darker purple shading have higher
rates of affected children; areas with darker yellow shading see the largest reduction relative to baseline infections.
The five states with the highest rates of affected children relative to the county populations are outlined in black.
See Appendix F for more details on the spatial distribution of assessed impacts.
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Figure 28 conveys the spatial patterns of these new cases of Lyme disease per 100,000 children at
2°C and 4°C of warming relative to the baseline, where purple shading highlights increases in new
cases and yellow shading emphasizes decreases in new cases. As shown, not all areas are expected to
experience additional cases of Lyme disease among children at either temperature threshold. In fact,
most of the 21 states and the District of Columbia show pockets of both increasing and decreasing
case rates. Overall, the states with the most additional cases are in the northernmost parts of the
Northeast and Midwest. Michigan is one state where the spatial extent of new cases dramatically
changes between the two temperature levels; increasing case rates are experienced only in the
Upper Peninsula at 2°C of global warming while other areas of the state demonstrate increasing
rates starting at 4°C of global warming.
These regional patterns are further illustrated in Figure 29, which depicts changes in new cases
relative to their baseline levels (1986-2005) as climate change progresses among the 21 states and
the District of Columbia included in the analysis. Across this geography, the number of cases
increases 31% and 272% at 2°C and 4°C of warming, respectively. At the regional level, increases
relative to baseline are less in the Northeast than in the Midwest, although baseline rates are
currently significantly higher in the Northeast.
Finally, following the analytical methods for assessing social vulnerability as described in Chapter 2
and Appendix A, this analysis does not determine that overburdened populations of children are
more likely to live in areas with the greatest climate-driven increases in Lyme disease cases. The
social vulnerability analysis finds that White, non-Flispanic children are 73% to 93% more likely to live
in areas with the highest potential for Lyme disease at 2°C and 4°C of warming (see Appendix F). This
does not mean that there are no inequities associated with Lyme disease (see earlier discussion in
this chapter); rather, they may not be captured through this analysis. As evidenced by existing
research and discussed elsewhere in this chapter, early-stage Lyme disease may be underreported
and undertreated among some overburdened populations, which increases the probability of more
severe outcomes in these communities.
Figure 29: Estimated Percent Change in New Cases of Lyme Disease Per Year Among Children
Relative to Baseline by NCA Region and Overall
Northeast, aged 0-17 (Baseline: 6,100/yr)
Midwest, aged 0-17 (Baseline: 1,700/yr)
All 22 states in the sample, aged 0-17 (Baseline: 8,600/yr)
0% 100% 200% 300% 400% 500% 600% 700% 800%
Note: This graphic shows the number of new annual Lyme disease cases associated with climate change relative to
baseline conditions (1986-2005) by NCA region and overall under assumptions described in Appendix F. The teal
circles present increases at 2°C while the purple circles convey increases at 4°C.
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WEST NILE VIRUS
Climate change is projected to alter
the geographic distribution of West
Nile Virus (WNV) and its vectors, causing additional
disease outbreaks stemming from infected
mosquitos. Approximately 1% to 5% of all WNV
cases present symptomatically in children, and
these cases are usually milder than in adults.495
However, the lack of severity may result in under-
reporting or misclassification among younger
individuals.496 Cases of West Nile neuroinvasive
disease (WNND) occur in less than 1% of people
infected with WNV, and frequently result in
hospitalization for severe symptoms that are
harder to misclassify or ignore.497
Belova et al. estimated the future number of
WNND cases associated with increasing
temperatures in the U.S. among people of all
ages.498 The authors rely on data that show approximately half of all U.S. counties reported at
least one WNND case between 2004 and 2012, meaning the suitable habitat for mosquitos
carrying WNV is much broader geographically than the suitable habitat for ticks that cause Lyme
disease. At the baseline, the Southern Great Plains region of the U.S. has the highest incidence
rates for WNV infections.
The study findings translate to 1,490 and 3,330 additional cases of WNND at 2°C and 4°C of global
warming, respectively, compared to a baseline of 971 annual cases. According to the U.S. CDC,
children accounted for approximately 4% of all WNND cases reported from 1999 to 2007.499
Applying that proportion to the Belova et al. results, the analysis estimates an additional 59 cases
of WNND among children at 2°C of global warming, rising to 133 cases at 4°C. Children living in
North Dakota, South Dakota, Nebraska, Colorado, and Arizona are more likely to be impacted at
the highest rates per capita as climate changes. The regions with the highest projected total cases
include the Southern Great Plains as well as the Southeast. The direct medical costs stemming
from WNND across all ages are approximately $46,000 per case (2021 dollars).
These results demonstrate that the number of WNND cases resulting from climate change among
children is not expected to be significant, particularly relative to the increases in Lyme disease
cases at 1°C of global warming. However, WNND is just one outcome of an WNV infection, and
WNV is just one of many mosquito-transmitted diseases that affect children. Therefore, the
results from Belova et al. may indicate that other diseases that involve mosquitos as vector
species could increase in the future as the climate continues to change.
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Chapter 8: What You Can Do
Many health outcomes from
climate change can be
prevented or minimized
through well-timed and
appropriate action. Successful
strategies to minimize
adverse health outcomes
depend on a combination of
social factors, improved
forecasting of weather and
climate conditions, and
further research to better
understand the relationship
between climate change and
how children may be
impacted.
This report showcases some of the ways in which children are
vulnerable to a variety of health effects from climate change
due to biological and developmental factors. It also
demonstrates how climate change can have unequal effects
on overburdened populations due to differences in exposure,
sensitivity, and adaptive capacity, which are influenced by
historic inequities deeply rooted in our laws, policies, and
institutions.
There is an urgency to act to reduce emissions of greenhouse
gases that cause climate change, while also taking actions to
reduce health risks to children. Importantly, there are steps all
of us can take to reduce these risks to current and future
generations of children. This final chapter is designed to
facilitate a call to action by proposing steps people can take to
reduce the impacts of climate change on children's health.
The chapter concludes with recommendations on how
researchers can work to fill critical gaps in our understanding
of these risks.
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Talk about the risks of living in a changing
climate with children, their friends, schools,
physicians, sports teams and coaches, and
other parents. If you have questions about
how climate risks may impact the health of a
child, consult with medical professionals for
their recommendations.
Educate children and community members
(parents, schools, recreation programs, etc.)
about how to recreate safely while limiting
their exposures to environmental hazards,
including vector-borne diseases and elevated
temperatures. This includes encouraging
children to wear insect repellant to avoid tick and mosquito bites, being aware of where ticks live,
and preventing mosquito bites. Urge children to hydrate often, exercise earlier in the day when
temperatures are cooler, find shade and indoor places to cool off, and wear safe sunscreen when
outdoors. Empowering children and helping them understand their individual risks at all stages will
contribute to their individual resilience against climate change impacts.
How is the EPA helping to minimize the health
impacts of climate change on children?
EPA's mission is to protect and improve human health
and the environment. Helping vulnerable populations
such as children adapt to and protect themselves
against climate impacts is fundamental to that ethos.
EPA endeavors to protect children's health in a variety
of ways, including by providing information on how to
keep children safe during and after different types of
natural disasters, as well as researching climate change
effects on children. The agency also researches how
climate change can exacerbate childhood exposures to
chemical contaminants.
MINIMIZE HEALTH IMPACTS TO CHILDREN
This section summarizes some of the actions people can take to minimize the impacts
of climate change on children. These suggestions draw from abundant resources EPA
and other Agencies have assembled (external sources underlined).
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Keep track of local air quality using the Air Quality Index and pollen counts on your local weather
reports. Also, pay attention to wildfire, smoke, and ash warnings. When the air quality is poor,
consider limiting children's time outdoors, and have children avoid playing near high-traffic areas.
Keep kids safe during and after an extreme weather event. Work with clinicians to develop
community guidelines and develop action thresholds for specific local conditions and areas. Make
sure your family has an evacuation or safety plan if you live in an area prone to severe weather. After
a flood, watch for signs of mold and be sure to clean and dry affected areas. Focus on providing
children access to clean potable water and avoid having them wade in floodwaters or be exposed to
debris from disasters. If children are exposed to storms or floods, watch for gastrointestinal illness.
Know your community and community members, and if you see neighbors who may need a hand,
help out! Learn what climate stressors could impact you based on where you live. Use EPA's
EJSCREEN tool to identify areas that may have higher environmental burdens and vulnerable
populations. Become aware of adaptation resources and solutions available in your community and
support the development of those that are needed, including evacuation strategies and disaster
response strategies.
Discover ways you can work with your neighbors and your community to integrate smart growth and
environmental justice to prepare for and lessen the impacts of climate change, address disparities,
and build healthy neighborhoods. Work with communities to improve home efficiency and
insulation, and to develop community heat and cold action plans to protect against illness.
Learn the locations of large, industrial U.S. greenhouse-gas emitting facilities and how much they
emit using the Facility-Level Information on GHGsTool (FLIGHT).
Learn about adaptation mechanisms that can be used to protect you and your family from climate
hazards, including subsidies to help cover the costs of residential A/C and heat use and flood
resilience measures. Develop heat action and response plans to help your community prepare for
and prevent heat-related illness.
Plant trees and other vegetative coverto help offset heat while encouraging a sense of community.
Overburdened communities are especially vulnerable to the impacts of urban heat islands,
particularly in the summer. Encourage investments in green and cool roofs, permeable pavements,
and smart growth development practices.
Help increase climate change data and understanding with students by participating in citizen
science projects, which encourage public participation in scientific research.
Learn more about climate change science so that you can speak knowledgeably about the
greenhouse effect and the causes of climate change, and even be able to answer some commonly
asked questions about climate change.
Get involved in decision making. Local governments have voluntary advisory boards and
neighborhood councils where you can help to shape policies and funding decisions. They need
diverse participants, including people from the neighborhoods most affected by climate change and
health and environmental hazards.
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CONTRIBUTE TO SLOWING CLIMATE CHANGE
Individuals can take actions to reduce greenhouse gas emissions that cause climate
change. Reducing greenhouse gas emissions has immediate and long-term benefits in
reducing climate change and its impacts. The long-term benefits are particularly
important in children's lifetimes.
Promote environmental stewardship by encouraging your community schools, homeowners, and
local businesses to reduce their greenhouse gas emissions by managing their energy use and waste
generation. Reducing emissions is at the essence of limiting climate change, thus preventing the
most severe health effects reviewed in this report.
Heat and cool your home smartly by properly sealing and insula I in; your home; upgrading to
ENERGY STAR certified windows, doors, and heating and cooling systems, including certified smart
thermostats; and maintaining your heating and cooling equipment. Fora whole-house systems
approach, use the ENERGY STAR Home Advisor tool or Home Performance with ENERGY STAR. Also,
consider other improvements such as rooftop gardens, cool roofs, sustainable landscaping, and
switching to green power generated from renewable energy sources like rooftop solar. Take
advantage of state and Federal tax credits for residential renewable energy installation projects, such
as those for solar panels and for energy-efficient appliances and vehicles.
Take advantage of no-to-low-cost energy-saving tips, such as adjusting thermostats and turning off
lights when space is unoccupied, unplugging electronics when not in use, using ENERGY STAR LED
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lightbulbs, adjusting window shades to reduce heating and cooling requirements, and installing
programmable thermostats. Use EPA's Best Value Finder to find the lowest-priced ENERGY STAR
certified products.
Use greener transportation as much as possible. Biking, walking, carpooling, and public
transportation can significantly reduce greenhouse gas emissions. Choose an energy-efficient vehicle
or switch to an electric vehicle.
relationship between climate change and how children may be impacted physically, psychologically,
socially, and inequitably. This section highlights some of these concepts for consideration in efforts
to improve research on climate and children's health. Note that references to "demographics"
pertain to race, ethnicity, gender, sex, and socioeconomic status.
• Due to data limitations, the analyses in this report consider impacts in the contiguous U.S.
specifically. This is due in part to the lack of research focused on climate change effects on
children outside of this geographic area. Future efforts should include climate stressors and
health outcomes in Alaska, Hawai'i, and the U.S. territories. For further information on data
limitations, please see the Technical Appendices accompanying this report.
• Future analyses should incorporate a broader set of child demographics that could be used
for 1) better understanding population-specific effects and 2) understanding how different
socioeconomic factors could amplify or worsen effects, or result in different health outcomes
than those measured in this report. For example, additional investigation is needed on the
effects of heat on learning, specifically from an equity lens, factoring in how aggregated
characteristics may modify outcomes.
• There are limited data on how climate change causes or exacerbates developmental and
mental health effects in children. Therefore, research into how children are being affected,
both conceptually and in ways that can be quantitatively measured, is needed. For example,
extreme events affecting housing, such as floods and wildfires, can have short- and long-term
impacts on children who may experience stress and anxiety from the fear of losing their
home, or may experience post-traumatic stress disorder.
• It is difficult to conduct epidemiological and qualitative studies to understand the effects of
climate change events on birth and health outcomes during the periods of pre-conception
through early childhood. Flowever, the more data of these types that are available, the better
future assessments can be of how children are impacted by climate stressors.
• Future analyses should be expanded with the availability and application of data from
electronic health records, including doctor's office and ED visits, hospital admissions, and
prescription records. These data would provide a nuanced level of detail regarding specific
health issues that could be connected to climate data. Additionally, epidemiological studies
FILL KEY RESEARCH GAPS
I* III!
This report is intended to provide a snapshot of some of the ways in which children's
health and well-being may be affected by different climate change-related stressors.
Flowever, it is not comprehensive, and it shows how much we still do not know about the
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focusing on compounded effects at a national scale and adjusting for different demographics
could help to address limitations to data availability.
• Pursue analyses of climate change-induced effects at fine spatial resolutions, and with
consideration for effects on individual and combined demographics. Research at finer spatial
scales would capture a more precise picture of how effects are impacting specific areas and
subpopulations of children and their short- and long-term health outcomes.
• As described in this report, well-timed adaptation has the potential to reduce substantially
some of the adverse effects of climate change on children (e.g., protection of coastal
properties, or installation of air conditioning to reduce learning losses from extreme heat).
However, it is currently difficult to project where and to what extent these adaptation
measures might be implemented, and the timing of their adoption nationwide. Research
advancements are necessary to improve society's ability to forecast the likely
implementation of adaptation measures, costs and benefits, and their long-term
effectiveness.
• Further development of metrics/indicators is needed to help quantify how well society is
doing to address children's health risks as they relate to climate change mitigation and
adaptation responses.
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References
1 U.S. Environmental Protection Agency. "Climate Adaptation and EPA's Role." Available at:
https://www.epa.gov/climate-adaptation/climate-adaptation-and-epas-role. Accessed: December 7, 2022. Last
updated: September 19, 2022.
2 Pachauri, R.K. and Meyer, LA. eds., 2014. Annex II: Glossary [Mach, KJ, S. Planton and C. von Stechow (eds.)].
Climate Change 2014: Synthesis Report. Contribution of Working Groups I, II and III to the Fifth Assessment
Report of the Intergovernmental Panel on Climate Change, pp.117-130.
3 U.S. Centers for Disease Control & Prevention. "Allergens and Pollen." Available at:
https://www.cdc.gov/climateandhealth/effects/allergen.htm. Accessed: November 16, 2022. Last updated:
August 21, 2020.
4 National Library of Medicine, MedlinePlus. "Asthma." Available at: https://medlineplus.gov/asthma.html.
Accessed: November 16, 2022.
5 National Library of Medicine, MedlinePlus. "Asthma." Available at: https://medlineplus.gov/asthma.html.
Accessed: November 16, 2022.
6 Keenan, J.M., Hill, T. and Gumber, A., 2018. Climate gentrification: from theory to empiricism in Miami-Dade
County, Florida. Environmental Research Letters, 13(5), p.054001.
7 National Oceanic & Atmospheric Administration. "Climate Models." Available at: https://www.climate.gov/maps-
data/climate-data-primer/predicting-climate/climate-models. Accessed: November 16, 2022.
8 "U.S. Climate Resilience Toolkit," Available at: https://toolkit.climate.gov/. Accessed: November 16, 2022.
Updated: March 2, 2021.
9 Federal Emergency Management Agency natural hazards definitions, Available at:
https://hazards.fema.gov/nri/coastal-flooding. Accessed April 11, 2023.
10 U.S. Environmental Protection Agency. "Environmental Justice." Available at
https://www.epa.gov/environmentaljustice. Accessed: April 19, 2023. Updated: March 29, 2023.
11 "U.S. Climate Resilience Toolkit," Available at: https://toolkit.climate.gov/. Accessed: November 16, 2022.
Updated: March 2, 2021.
12 Intergovernmental Panel on Climate Change. 2014. "Climate Change 2014: Mitigation of Climate Change."
Contribution of Working Group III to the Fifth Assessment Report of the Intergovernmental Panel on Climate
Change [Edenhofer, O., R. Pichs-Madruga, Y. Sokona, E. Farahani, S. Kadner, K. Seyboth, A. Adler, I. Baum, S.
Brunner, P. Eickemeier, B. Kriemann, J. Savolainen, S. Schlomer, C. von Stechow, T. Zwickel and J.C. Minx (eds.)].
Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA
13 U.S. Centers for Disease Control & Prevention. "Heat Stress - Heat-Related Illness." Available at:
https://www.cdc.gOv/niosh/topics/heatstress/heatrelillness.html#exhaustion. Accessed: November 17, 2022.
Last updated: May 13, 2022
14 U.S. Centers for Disease Control & Prevention. "National Center for Emerging and Zoonotic Infectious Diseases."
Available at: https://www.cdc.gov/ncezid/who-we-
are/index.html#:~:text=lnfectious%20diseases%20are%20illnesses%20caused,from%20one%20person%20to%2
Oanother. Accessed: November 22, 2022. Last updated: November 14, 2022.
15 U.S. Centers for Disease Control & Prevention. "Lyme Disease." Available at:
https://www.cdc.gov/lyme/index.html. Accessed: November 22, 2022. Last updated: January 19, 2022.
16 U.S. Environmental Protection Agency. "What is Ozone?" Available at: https://www.epa.gov/ozone-pollution-
and-your-patients-health/what-ozone. Accessed: November 22, 2022. Last updated: July 25, 2022.
17 U.S. Environmental Protection Agency. "Particulate Matter Basics." Available at: https://www.epa.gov/pm-
pollution/particulate-matter-pm-basics. Accessed: November 22, 2022. Last updated: July 18, 2022.
18 U.S. Environmental Protection Agency. "Particulate Matter Basics." Available at: https://www.epa.gov/pm-
pollution/particulate-matter-pm-basics. Accessed: November 22, 2022. Last updated: July 18, 2022.
April 2023
82
-------
Climate Change and Children's Health and Well-Being in the United States
19 U.S. Food and Drug Administration. "Studying How Pathogens Cause Disease." Available at:
https://www.fda.gov/drugs/news-events-human-drugs/studying-how-pathogens-cause-disease. Accessed:
November 22, 2022. Last updated: December 2, 2016.
20 Rosenzweig, B.R., McPhillips, L, Chang, H., Cheng, C., Welty, C., Matsler, M., Iwaniec, D. and Davidson, C.I., 2018.
Pluvial flood risk and opportunities for resilience. Wiley Interdisciplinary Reviews: Water, 5(6), p.el302.
21 Federal Emergency Management Agency. "National Risk Index: Riverine Flooding." Retrieved from:
https://hazards.fema.gov/nri/riverine-flooding. Accessed: November 22, 2022.
22 Centers for Disease Control & Prevention, Agency for Toxic Substances and Disease Registry. "CDC/ATSDR Social
Vulnerability Index." Available at: https://www.atsdr.cdc.gov/placeandhealth/svi/index.html. Accessed:
November 22, 2022. Last updated: November 16, 2022.
23 National Oceanic & Atmospheric Administration, National Hurricane Center. "Storm Surge Overview." Available
at: https://www.nhc.noaa.gov/surge/. Accessed: November 22, 2022.
24 U.S. Centers for Disease Control & Prevention. "Cholera and Other Vibrio Illness Surveillance." Retrieved from:
https://www.cdc.gov/vibrio/index.html. Accessed: November 22, 2022. Last updated: March 5, 2019
25 U.S. Centers for Disease Control & Prevention. "West Nile Virus." Available at:
https://www.cdc.gov/westnile/index.html. Last updated: June 2, 2022. Accessed: November 17, 2022.
26 United Nations Children's Fund. 2021. 'The Climate Crisis is a Child Rights Crisis: Introducing the Children's
Climate Risk Index." Available at: https://www.unicef.org/reports/climate-crisis-child-rights-crisis
27 U.S. Global Change Research Program. 2016. The Impacts of Climate Change on Human Health in the United
States: A Scientific Assessment. Crimmins, A., J. Balbus, J.L Gamble, C.B. Beard, J.E. Bell, D. Dodgen, R.J. Eisen,
N. Fann, M.D. Hawkins, S.C. Herring, L. Jantarasami, D.M. Mills, S. Saha, M.C. Sarofim, J. Trtanj, and L. Ziska, Eds.
U.S. Global Change Research Program, Washington, DC, 312 pp.
28 U.S. Global Change Research Program. 2016. The Impacts of Climate Change on Human Health in the United
States: A Scientific Assessment. Crimmins, A., J. Balbus, J.L. Gamble, C.B. Beard, J.E. Bell, D. Dodgen, R.J. Eisen,
N. Fann, M.D. Hawkins, S.C. Herring, L. Jantarasami, D.M. Mills, S. Saha, M.C. Sarofim, J. Trtanj, and L. Ziska, Eds.
U.S. Global Change Research Program, Washington, DC, 312 pp.
29 Selevan, S.G., Kimmel, C.A. and Mendola, P. 2000. Identifying critical windows of exposure for children's health.
Environmental health perspectives, 108(suppl 3), pp.451-455.
30 Huang, M., Strickland, M.J., Richards, M., Holmes, H.A., Newman, A.J., Garn, J.V., Liu, Y., Warren, J.L., Chang, H.H.
and Darrow, LA. 2021. Acute associations between heatwaves and preterm and early-term birth in 50 US
metropolitan areas: a matched case-control study. Environmental Health, 20(1), pp. 1-14.
31 Bekkar, B., Pacheco, S., Basu, R. and DeNicola, N. 2020. Association of air pollution and heat exposure with
preterm birth, low birth weight, and stillbirth in the US: a systematic review. JAMA Network Open, 3(6),
pp.e208243-e208243.
32 Aarnoudse-Moens, C.S.H., Weisglas-Kuperus, N., van Goudoever, J.B. and Oosterlaan, J. 2009. Meta-analysis of
neurobehavioral outcomes in very preterm and/or very low birth weight children. Pediatrics, 124(2), pp.717-
728.
33 McGeachie, M.J., Yates, K.P., Zhou, X., Guo, F., Sternberg, A.L, Van Natta, M.L., Wise, R.A., Szefler, S.J., Sharma,
S., Kho, A.T. and Cho, M.H. 2016. Patterns of growth and decline in lung function in persistent childhood
asthma. New England Journal of Medicine, 374(19), pp.1842-1852.
34 Beard, C.B., R.J. Eisen, C.M. Barker, J.F. Garofalo, M. Hahn, M. Hayden, A.J. Monaghan, N.H. Ogden, and P.J.
Schramm. 2016. Ch. 5: Vectorborne Diseases. The Impacts of Climate Change on Human Health in the United
States: A Scientific Assessment. U.S. Global Change Research Program, Washington, DC, 129-156.
35 U.S. Environmental Protection Agency. "Climate Change Indicators: Lyme Disease." Available at:
https://www.epa.gov/climate-indicators/climate-change-indicators-lyme-disease. Last updated: April 2021.
Accessed: August 29, 2022.
36 Burke, S.E., Sanson, A.V. and Van Hoorn, J. 2018. The psychological effects of climate change on children. Current
psychiatry reports, 20(5), pp. 1-8.
37 U.S. Global Change Research Program. 2016. The Impacts of Climate Change on Human Health in the United
States: A Scientific Assessment. Crimmins, A., J. Balbus, J.L. Gamble, C.B. Beard, J.E. Bell, D. Dodgen, R.J. Eisen,
April 2023
83
-------
Climate Change and Children's Health and Well-Being in the United States
N. Fann, M.D. Hawkins, S.C. Herring, L. Jantarasami, D.M. Mills, S. Saha, M.C. Sarofim, J. Trtanj, and L. Ziska, Eds.
U.S. Global Change Research Program, Washington, DC, 312 pp.
38 Lai, A., Fearnley, E. and Wilford, E. 2019. Local weather, flooding history and childhood diarrhoea caused by the
parasite Cryptosporidium spp.: A systematic review and meta-analysis. Science of The Total Environment, 674,
pp.300-306.
39 Bateson, T.F. and Schwartz, J. 2007. Children's response to air pollutants. Journal of Toxicology and
Environmental Health, Part A, 71(3), pp.238-243..
40 Cedeno Laurent, J.G., Williams, A., Oulhote, Y., Zanobetti, A., Allen, J.G., and Spengler, J.D. 2018. Reduced
cognitive function during a heat wave among residents of non-air-conditioned buildings: An observational study
of young adults in the summer of 2016. PLoS Medicine, 15(7).
41 National Oceanic and Atmospheric Administration. "Severe Weather 101 - Flood Types." Available at:
https://www.nssl.noaa.gov/education/svrwxl01/floods/types/. Accessed: March 16, 2022.
42 U.S. Centers for Disease Control & Prevention. "Lyme Disease Charts and Figures: Most Recent Year." Available
at: https://www.cdc.gov/lyme/datasurveillance/index.html/charts-figures-recent. Last updated: April 29, 2021.
Accessed: June 29, 2022.
43 U.S. Environmental Protection Agency. 2021. "Climate Change and Social Vulnerability in the United States: A
Focus on Six Impacts. U.S. Environmental Protection Agency." EPA430-R-21-003. Available at:
https://www.epa.gov/cira/social-vulnerability-report
44 Martinich, J. and Crimmins, A., 2019. Climate damages and adaptation potential across diverse sectors of the
United States. Nature Climate Change, 9(5), pp.397-404.
45 Hellden, D., Andersson, C., Nilsson, M., Ebi, K.L., Friberg, P. and Alfven, T., 2021. Climate change and child health:
a scoping review and an expanded conceptual framework. The Lancet Planetary Health, 5(3), pp.el64-el75.
46 Taylor, K.E., Stouffer, R.J. and Meehl, G.A., 2012. An overview of CMIP5 and the experiment design. Bulletin of
the American Meteorological Society, 93(4), pp.485-498.
47 Sarofim, M.C., Martinich, J., Neumann, J.E., Willwerth, J., Kerrich, Z., Kolian, M., Fant, C. and Hartin, C., 2021. A
temperature binning approach for multi-sector climate impact analysis. Climatic Change, 165(1), pp. 1-18.
48 United Nations Intergovernmental Panel on Climate Change Sixth Assessment Synthesis Report 2023, available
at: https://www.ipcc.ch/report/ar6/syr/
49 Sarofim, M.C., Martinich, J., Neumann, J.E., Willwerth, J., Kerrich, Z., Kolian, M., Fant, C. and Hartin, C., 2021. A
temperature binning approach for multi-sector climate impact analysis. Climatic Change, 165(1), pp. 1-18.
50 Lorie, M., Neumann, J.E., Sarofim, M.C., Jones, R., Horton, R.M., Kopp, R.E., Fant, C., Wobus, C., Martinich, J.,
O'Grady, M. and Gentile, L.E., 2020. Modeling coastal flood risk and adaptation response under future climate
conditions. Climate Risk Management, 29, p.100233.
51 Using a 10-year moving average and global temperature values from NOAA (National Oceanic and Atmospheric
Administration). 2022. Climate at a glance. Accessed March 2023. www.ncdc.noaa.gov/cag.
52ICLUS v2 population estimates available at: https://www.epa.gov/gcx/iclus-fourth-national-climate-assessment
53 Sweet, W.V., Horton, R., Kopp, R.E., and Romanou, A. 2017. Sea level rise. In: Climate Science Special Report: A
Sustained Assessment Activity of the U.S. Global Change Research Program [Wuebbles, D.J., D.W. Fahey, K.A.
Hibbard, D.J. Dokken, B.C. Stewart, and T.K. Maycock (eds.)]. U.S. Global Change Research Program,
Washington, DC, USA. pp. 333-363.
54 U.S. Environmental Protection Agency. 2021. "Climate Change and Social Vulnerability in the United States: A
Focus on Six Impacts. U.S. Environmental Protection Agency." EPA430-R-21-003. Available at:
https://www.epa.gov/cira/social-vulnerability-report
55 Wilson, B., 2020. Urban heat management and the legacy of redlining. Journal of the American Planning
Association, 86(A), pp.443-457.
56 U.S. Census Bureau. "American Community Survey (ACS): Technical Documentation." Available at:
https://www.census.gov/programs-surveys/acs/technical-documentation.html
57 Reidmiller, D.R., Avery, C.W., Easterling, D.R., Kunkel, K.E., Lewis, K.L., Maycock, T.K. and Stewart, B.C., 2017.
Impacts, risks, and adaptation in the United States: Fourth National Climate Assessment, Volume II.
April 2023
84
-------
Climate Change and Children's Health and Well-Being in the United States
58 Wobus, C., Zarakas, C., Malek, P., Sanderson, B., Crimmins, A., Kolian, M., Sarofim, M. and Weaver, C.P., 2018.
Reframing future risks of extreme heat in the United States. Earth's Future, 6(9), pp.1323-1335.
59 Ebi, K.L, J.M. Balbus, G. Luber, A. Bole, A. Crimmins, G. Glass, S. Saha, M.M. Shimamoto, J. Trtanj, and J.L White-
Newsome, 2018. Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth National Climate
Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock,
and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 539-571.
60 Gubernot, D.M., Anderson, G.B. and Hunting, K.L, 2014. The epidemiology of occupational heat exposure in the
United States: a review of the literature and assessment of research needs in a changing climate. International
Journal of Biometeorology, 58(8), pp.1779-1788.
61 Limaye, V.S., Vargo, J., Harkey, M., Holloway, T. and Patz, J.A., 2018. Climate change and heat-related excess
mortality in the Eastern USA. EcoHealth, 15(3), pp.485-496.
62 Gubernot, D.M., Anderson, G.B. and Hunting, K.L, 2014. The epidemiology of occupational heat exposure in the
United States: a review of the literature and assessment of research needs in a changing climate. International
Journal of Biometeorology, 58(8), pp.1779-1788.
63 Sarofim MC, Saha S, Hawkins MD, Mills DM, Hess J, Horton R, Kinney P, Schwartz J, St. Juliana A. Ch. 2:
Temperature-Related Death and Illness. 2016. In: The Impacts of Climate Change on Human Health in the
United States: A Scientific Assessment. U.S. Global Change Research Program, Washington, DC, 43-68.
64 Limaye, V.S., Vargo, J., Harkey, M., Holloway, T. and Patz, J.A., 2018. Climate change and heat-related excess
mortality in the Eastern USA. EcoHealth, 15(3), pp.485-496.
65 Ebi, K.L, J.M. Balbus, G. Luber, A. Bole, A. Crimmins, G. Glass, S. Saha, M.M. Shimamoto, J. Trtanj, and J.L. White-
Newsome, 2018. Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth National Climate
Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock,
and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 539-571.
66 USGCRP, 2016. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment.
Crimmins, A., J. Balbus, J.L. Gamble, C.B. Beard, J.E. Bell, D. Dodgen, R.J. Eisen, N. Fann, M.D. Hawkins, S.C.
Herring, L. Jantarasami, D.M. Mills, S. Saha, M.C. Sarofim, J. Trtanj, and L. Ziska, Eds. U.S. Global Change
Research Program, Washington, DC, 312 pp.
67 Xu, Z., Sheffield, P.E., Su, H., Wang, X., Bi, Y. and Tong, S., 2014. The impact of heat waves on children's health: a
systematic review. International Journal of Biometeorology, 58(2), pp.239-247.
68 Tansey, E.A. and Johnson, C.D., 2015. Recent advances in thermoregulation. Advances in Physiology Education.
69 Bouchama, A. and Knochel, J. P., 2002. Heat stroke. New England Journal of Medicine, 346(25), pp.1978-1988.
70 USGCRP, 2016. The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment.
Crimmins, A., J. Balbus, J.L. Gamble, C.B. Beard, J.E. Bell, D. Dodgen, R.J. Eisen, N. Fann, M.D. Hawkins, S.C.
Herring, L. Jantarasami, D.M. Mills, S. Saha, M.C. Sarofim, J. Trtanj, and L. Ziska, Eds. U.S. Global Change
Research Program, Washington, DC, 312 pp.
71 Laitano, O., Oki, K. and Leon, L.R., 2021. The role of skeletal muscles in exertional heat stroke pathophysiology.
International Journal of Sports Medicine, 42(08), pp.673-681.
72 Xu, Z., Etzel, R.A., Su, H., Huang, C., Guo, Y. and Tong, S., 2012. Impact of ambient temperature on children's
health: a systematic review. Environmental Research, 117, pp.120-131.
73 Arlegui, L., Smallcombe, J.W., Fournet, D., Tolfrey, K. and Havenith, G., 2021. Body mapping of sweating patterns
of pre-pubertal children during intermittent exercise in a warm environment. European Journal of Applied
Physiology, 121(12), pp.3561-3576.
74 Xu, Z., Etzel, R.A., Su, H., Huang, C., Guo, Y. and Tong, S., 2012. Impact of ambient temperature on children's
health: a systematic review. Environmental Research, 117, pp.120-131.
75 Xu, Z., Hu, W., Su, H., Turner, L.R., Ye, X., Wang, J. and Tong, S., 2014. Extreme temperatures and paediatric
emergency department admissions. J Epidemiol Community Health, 68(4), pp.304-311.
76 Xu, Z., Sheffield, P.E., Su, H., Wang, X., Bi, Y. and Tong, S., 2014. The impact of heat waves on children's health: a
systematic review. International Journal of Biometeorology, 58(2), pp.239-247.
77 Dowd, M.D., 2018. Vehicular hyperthermia—a highly preventable and potentially fatal problem. Pediatric
Annals, 47(3), pp.e88-e90.
April 2023
85
-------
Climate Change and Children's Health and Well-Being in the United States
78 Vanos, J.K., Middel, A., Poletti, M.N. and Selover, N.J., 2018. Evaluating the impact of solar radiation on pediatric
heat balance within enclosed, hot vehicles. Temperature, 5(3), pp.276-292.
79 Grundstein, A.J., Hosokawa, Y. and Casa, D.J., 2018. Fatal exertional heat stroke and American football players:
the need for regional heat-safety guidelines. Journal of athletic training, 53(1), pp.43-50.
80 Yeargin, S., Torres-McGehee, T.M., Emerson, D., Koller, J. and Dickinson, J., 2021. Hydration, Eating Attitudes and
Behaviors in Age and Weight-Restricted Youth American Football Players. Nutrients, 13(8), p.2565.
81 Kerr, Z.Y., Register-Mihalik, J.K., Pryor, R.R., Pierpoint, L.A., Scarneo, S.E., Adams, W.M., Kucera, K.L., Casa, D.J.
and Marshall, S.W., 2019. The association between mandated preseason heat acclimatization guidelines and
exertional heat illness during preseason high school American football practices. Environmental Health
Perspectives, 127(A), p.047003.
82 Scarneo-Miller, S.E., DiStefano, L.J., Singe, S.M., Register-Mihalik, J.K., Stearns, R.L and Casa, D.J., 2020.
Emergency action plans in secondary schools: barriers, facilitators, and social determinants affecting
implementation. Journal of Athletic Training, 55(1), pp.80-87.
83 Williams, C.A. and Grundstein, A.J., 2018. Children forgotten in hot cars: a mental models approach for
improving public health messaging. Injury Prevention, 24(A), pp.279-287.
84 Vaidyanathan, A., Malilay, J., Schramm, P. and Saha, S., 2020. Heat-Related Deaths—United States, 2004-2018.
Morbidity and Mortality Weekly Report, 69(24), p.729.
85 Laurent, J.G.C., Williams, A., Oulhote, Y., Zanobetti, A., Allen, J.G. and Spengler, J.D., 2018. Reduced cognitive
function during a heat wave among residents of non-air-conditioned buildings: An observational study of young
adults in the summer of 2016. PLoS Medicine, 15(7), p.el002605.
86 Killgore, W.D., 2010. Effects of sleep deprivation on cognition. Progress in Brain Research, 185, pp.105-129.
87 Jan, J.E., Reiter, R.J., Bax, M.C., Ribary, U., Freeman, R.D. and Wasdell, M.B., 2010. Long-term sleep disturbances
in children: a cause of neuronal loss. European Journal of Paediatric Neurology, 14(5), pp.380-390.
88 Dodgen, D., Donato, D., Kelly, N., La Greca, A., Morganstein, J., Reser, J., Ruzek, S. Schweitzer, M.M. Shimamoto,
K. Thigpen Tart, and R. Ursano, 2016: Ch. 8: Mental Health and Weil-Being. The Impacts of Climate Change on
Human Health in the United States: A Scientific Assessment. U.S. Global Change Research Program,
Washington, DC, 217-246.
89 Xu, Z., Sheffield, P.E., Su, H., Wang, X., Bi, Y. and Tong, S., 2014. The impact of heat waves on children's health: a
systematic review. International Journal of Biometeorology, 58(2), pp.239-247.
90 Bhalotra, S., Clots-Figueras I., Gomes, J.F., and Mitra, A. 2022. Fetal temperature exposure on long term
cognitive and economic individual outcomes. Working paper available at:
https://conference.iza.org/conference_files/ClimateChange_2022/mitra_a32827.pdf
91 Basu, R., Pearson, D., Malig, B., Broadwin, R., and Green, R., 2012. The effect of high ambient temperature on
emergency room visits. Epidemiology 23(6): pp. 813-820.
92 Cisse, G., McLeman, R., Adams, H., Aldunce, P., Bowen, K., Campbell-Lendrum, D., Clayton, S., Ebi, K.L, Hess, J.,
Huang, C., Liu, Q., McGregor, G., Semenza, J., and Tirado, M.C., 2022. Health, wellbeing, and the changing
structure of communities. In: Climate Change 2022: Impacts, Adaptation and Vulnerability. Contribution of
Working Group II to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change [H.-O.
Portner, D.C. Roberts, M. Tignor, E.S. Poloczanska, K. Mintenbeck, A. Alegria, M. Craig, S. Langsdorf, S. Loschke,
V. Moller, A. Okem, B. Rama (eds.)]. Cambridge University Press, Cambridge, UK and New York, NY, USA, pp.
1041-1170,
93 Ridgers, N.D., Fairclough, S.J., and Stratton, G., 2010. Variables associated with children's physical activity levels
during recess: The A-CLASS project. International Journal of Behavioral Nutrition and Physical Activity, 7(1):74.
94 Lanza, K., Alcazar, M., Durand, C.P., Salvo. D., Villa, U., and Kohl, H.W., (2022). Heat-resilient schoolyards:
relations between temperature, shade, and physical activity of children during recess. Journal of American
Physical Activity and Health, 20(2):134-141.
95 Dodgen, D., Donato, D., Kelly, N., La Greca, A., Morganstein, J., Reser, J., Ruzek, J., Schweitzer, S., Shimamoto,
M.M., Thigpen Tart, K., and Ursano, R., 2016. Ch. 8: Mental health and well-being. In: The Impacts of Climate
April 2023
86
-------
Climate Change and Children's Health and Well-Being in the United States
Change on Human Health in the United States: A Scientific Assessment. U.S. Global Change Research Program,
Washington, DC, 217-246.
96 Ranson, M., 2014. Crime, weather, and climate change. Journal of Environmental Economics and Management,
67(3), pp.274-302.
97 Xu, R., Xiong, X., Abramson, M.J., Li, S. and Guo, Y., 2020. Ambient temperature and intentional homicide: A
multi-city case-crossover study in the US. Environment international, 143, p.105992.
98 Sandifer, P.A. and Walker, A.H., 2018. Enhancing disaster resilience by reducing stress-associated health impacts.
Frontiers in Public Health, 6, p.373.
99 Sheu, J.C., Torres, M.I., Gordon, M.R., Nguyen, P.T. and Coverdale, J.H., 2021. Potential impact of climate change
on human trafficking: A narrative review. The Journal of Nervous and Mental Disease, 209(5), pp.324-329.
100 Belova, A., Gould, C.A., Munson, K., Howell, M., Trevisan, C., Obradovich, N. and Martinich, J., 2022. Projecting
the suicide burden of climate change in the United States. GeoHealth, p.e2021GH000580.
101 Sarofim, M.C., Saha, S., Hawkins, M.D., Mills, D.M., Hess, J., Horton, R., Kinney, P., Schwartz, J. and St Juliana, A.,
2016. Temperature-related death and illness (No. GSFC-E-DAA-TN31167). US Global Change Research Program.
102 Sarofim, M.C., Saha, S., Hawkins, M.D., Mills, D.M., Hess, J., Horton, R., Kinney, P., Schwartz, J. and St Juliana, A.,
2016. Temperature-related death and illness (No. GSFC-E-DAA-TN31167). US Global Change Research Program.
103 Sarofim, M.C., S. Saha, M.D. Hawkins, D.M. Mills, J. Hess, R. Horton, P. Kinney, J. Schwartz, and A. St. Juliana,
2016: Ch. 2: Temperature-Related Death and Illness. The Impacts of Climate Change on Human Health in the
United States: A Scientific Assessment. U.S. Global Change Research Program, Washington, DC, 43-68.
104 Mani, A., Mullainathan, S., Shafir, E. and Zhao, J., 2013. Poverty impedes cognitive function, science, 341(6149),
pp.976-980.
105 llango, S.D., Weaver, M., Sheridan, P., Schwarz, L., Clemesha, R.E., Bruckner, T., Basu, R., Gershunov, A. and
Benmarhnia, T., 2020. Extreme heat episodes and risk of preterm birth in California, 2005-2013. Environment
international, 137, p. 105541.
106 Huang, M., Strickland, M.J., Richards, M., Holmes, H.A., Newman, A.J., Garn, J.V., Liu, Y., Warren, J.L., Chang,
H.H. and Darrow, L.A., 2021. Acute associations between heatwaves and preterm and early-term birth in 50 US
metropolitan areas: a matched case-control study. Environmental Health, 20(1), pp.1-14.
107 Chersich, M.F., Pham, M.D., Areal, A., Haghighi, M.M., Manyuchi, A., Swift, C.P., Wernecke, B., Robinson, M.,
Hetem, R., Boeckmann, M. and Hajat, S., 2020. Associations between high temperatures in pregnancy and risk
of preterm birth, low birth weight, and stillbirths: systematic review and meta-analysis. BMJ, 371.
108 Guo, T., Wang, Y., Zhang, H., Zhang, Y., Zhao, J., Wang, Y., Xie, X., Wang, L, Zhang, Q., Liu, D. and He, Y., 2018.
The association between ambient temperature and the risk of preterm birth in China. Science of the Total
Environment, 613, pp.439-446.
109 Ebi, K.L, J.M. Balbus, G. Luber, A. Bole, A. Crimmins, G. Glass, S. Saha, M.M. Shimamoto, J. Trtanj, and J.L.
White-Newsome. 2018. Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth
NationalClimate Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis,
T.K. Maycock, and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 572-
603.
110 O'Neill, M.S., Zanobetti, A. and Schwartz, J., 2005. Disparities by race in heat-related mortality in four US cities:
the role of air conditioning prevalence. Journal of Urban Health, 82(2), pp.191-197.
111 Voelkel, J., Hellman, D., Sakuma, R. and Shandas, V., 2018. Assessing vulnerability to urban heat: A study of
disproportionate heat exposure and access to refuge by socio-demographic status in Portland, Oregon.
International Journal of Environmental Research and Public Health, 15(4), p.640.
112 Guirguis, K., Basu, R., Al-Delaimy, W.K., Benmarhnia, T., Clemesha, R.E., Corcos, I., Guzman-Morales, J., Hailey,
B., Small, I., Tardy, A. and Vashishtha, D., 2018. Heat, disparities, and health outcomes in San Diego County's
diverse climate zones. GeoHealth, 2(7), pp.212-223.
113 Mills, D., J. Schwartz, M. Lee, M. Sarofim, R. Jones, M. Lawson, M. Duckworth, and L. Deck, 2014. Climate
Change Impacts on Extreme Temperature Mortaltiy in Select Metropolitan Areas in the United States. Climatic
Change.
April 2023
87
-------
Climate Change and Children's Health and Well-Being in the United States
114 Xu, Z., R.A. Etzel, H. Su, C. Huang, Y. Guo, and S. Tong, 2012. Impact of ambient temperature on children's
health: a systematic review. Environ Res, 117:120-31.
115 Sarofim, M.C., S. Saha, M.D. Hawkins, D.M. Mills, J. Hess, R. Horton, P. Kinney, J. Schwartz, and A. St. Juliana,
2016. Ch. 2: Temperature-Related Death and Illness. The Impacts of Climate Change on Human Health in the
United States: A Scientific Assessment. U.S. Global Change Research Program, Washington, DC, 43-68.
116 Ebi, K.L, J.M. Balbus, G. Luber, A. Bole, A. Crimmins, G. Glass, S. Saha, M.M. Shimamoto, J. Trtanj, and J.L.
White-Newsome, 2018: Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth National
Climate Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K.
Maycock, and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 539-571.
117 Park, R.J., Goodman, J., Hurwitz, M. and Smith, J., 2020. Heat and learning. American Economic Journal:
Economic Policy, 12(2), pp.306-39.
118 Chetty, R., Friedman, J.N., Hilger, N., Saez, E., Schanzenbach, D.W. and Yagan, D., 2011. How does your
kindergarten classroom affect your earnings? Evidence from Project STAR. The Quarterly Journal of Economics,
126(A), pp.1593-1660.
119 LeRoy, S., Matthews, M., Wiles R., 2021. Hotter Days, Higher Costs: The Cooling Crisis in America's Classrooms.
The Center for Climate Integrity. Available at: https://coolingcrisis.org/uploads/media/HotterDaysHigherCosts-
CCI-September2021.pdf
120 U.S. Bureau of Labor Statistics. 2021. "Median weekly earnings by age and sex, second quarter 2021." Accessed
online at: https://www.bls.gov/opub/ted/2021/median-weekly-earnings-by-age-and-sex-second-quarter-
2021.htm
121 Roach, T. and Whitney, J., 2022. Heat and learning in elementary and middle school. Education Economics,
30(1), pp.29-46.
122 LeRoy, S., Matthews, M., Wiles R., 2021. Hotter Days, Higher Costs: The Cooling Crisis in America's Classrooms.
The Center for Climate Integrity. Available at: https://coolingcrisis.org/uploads/media/HotterDaysHigherCosts-
CCI-September2021.pdf
123 Davis, L.W. and Gertler, P.J., 2015. Contribution of air conditioning adoption to future energy use under global
warming. Proceedings of the National Academy of Sciences, 112(19), pp.5962-5967.
124 Hoffman, J.S., Shandas, V. and Pendleton, N., 2020. The effects of historical housing policies on resident
exposure to intra-urban heat: a study of 108 US urban areas. Climate, 8(1), p. 12.
125 Hsu, A., Sheriff, G., Chakraborty, T. and Manya, D., 2021. Disproportionate exposure to urban heat island
intensity across major US cities. Nature Communications, 12(1), p.2721.
126 Romitti, Y., Sue Wing, I., Spangler, K.R. and Wellenius, G.A., 2022. Inequality in the availability of residential air
conditioning across 115 US metropolitan areas. PNAS Nexus, 1(4), p.pgac210.
127 California Energy Commission. 2009. 2009 Residential Appliance Saturation Study (RASS).
128 Bernstein, A.S., Sun, S., Weinberger, K.R., Spangler, K.R., Sheffield, P.E. and Wellenius, G.A., 2022. Warm Season
and Emergency Department Visits to US Children's Hospitals. Environmental Health Perspectives, 130(1),
p.017001.
129 Turner, A., Ricketts, T. and Leslie, L.K., 2020. Comparison of number and geographic distribution of pediatric
subspecialists and patient proximity to specialized care in the US between 2003 and 2019. JAMA Pediatrics,
174(9), pp.852-860.
130 U.S. Environmental Protection Agency. "Particulate Matter (PM) Basics: What is PM, and How Does it Get into
the Air?" Available at: https://www.epa.gOv/pm-pollution/particulate-matter-pm-basics#PM/. Accessed:
September 22, 2022. Last updated: July 18, 2022.
131 Nolte, C.G., Dolwick, P.D., Fann, N., Horowitz, L.W., Vaik, V., Pinder, R.W., Spero, T.L., Winner, D.A., and Ziska,
L.L. 2018. Air Quality. In Impacts, Risks, and Adaptation in the United States: Fourth National Climate
Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock,
and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC. pp. 512-538.
132 Fann, N.L., Nolte, C.G., Sarofim, M.C., Martinich, J. and Nassikas, N.J., 2021. Associations between simulated
future changes in climate, air quality, and human health. JAMA Network Open, 4(1), pp.e2032064-e2032064.
April 2023
88
-------
Climate Change and Children's Health and Well-Being in the United States
133 Perera, F. and Nadeau, K., 2022. Climate change, fossil-fuel pollution, and children's health. N Engl J Med, 386,
p. 2303-2314.
134 Fann, N., Brennan, T., Dolwick, P., Gamble, J.L, llacque, V., Kolb, L, Nolte, C.G., Spero, T.L and Ziska, L. 2016.
Ch. 3: Air Quality Impacts In The impacts of climate change on human health in the United States: A scientific
assessment (pp. 69-98). Washington, DC: US Global Change Research Program, 10(7930), p.J0GQ6VP6.
135 Liu, J.C., Mickley, L.J., Sulprizio, M.P., Dominici, F., Yue, X., Ebisu, K., Anderson, G.B., Khan, R.F., Bravo, M.A. and
Bell, M.L., 2016. Particulate air pollution from wildfires in the Western US under climate change. Climatic
Change, 138(3), pp.655-666.
136 Fiore, A.M., Naik, V. and Leibensperger, E.M., 2015. Air quality and climate connections. Journal of the Air &
Waste Management Association, 65(6), pp.645-685.
137 Koneswaran, G. and Nierenberg, D., 2008. Global farm animal production and global warming: impacting and
mitigating climate change. Environmental Health Perspectives, 116(5), pp.578-582.
138 Yoo, E.H., Brown, P. and Eum, Y., 2018. Ambient air quality and spatio-temporal patterns of cardiovascular
emergency department visits. International Journal of Health Geographies, 17(1), pp.1-16.
139 Yang, C.E., Fu, J.S., Liu, Y., Dong, X. and Liu, Y., 2022. Projections of future wildfires impacts on air pollutants and
air toxics in a changing climate over the western United States. Environmental Pollution, 304, p.119213.
140 Burke, M., Driscoll, A., Heft-Neal, S., Xue, J., Burney, J. and Wara, M., 2021. The changing risk and burden of
wildfire in the United States. Proceedings of the National Academy of Sciences, 118(2), p.e2011048118.
141 Odigie, K.O. and Flegal, A.R., 2014. Trace metal inventories and lead isotopic composition chronicle a forest
fire's remobilization of industrial contaminants deposited in the Angeles National Forest. PloS one, 9(9),
p.el07835.
142 Wan, X., Li, C. and Parikh, S.J., 2021. Chemical composition of soil-associated ash from the southern California
Thomas Fire and its potential inhalation risks to farmworkers. Journal of Environmental Management, 278,
p.111570.
143 Nolte, C.G., Dolwick, P.D., Fann, N., Horowitz, L.W., Vaik, V., Pinder, R.W., Spero, T.L., Winner, D.A., and Ziska,
L.L. 2018. Air Quality. In Impacts, Risks, and Adaptation in the United States: Fourth National Climate
Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock,
and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC. pp. 512-538.
144 Su, J.G., Jerrett, M., McConnell, R., Berhane, K., Dunton, G., Shankardass, K., Reynolds, K., Chang, R. and Wolch,
J., 2013. Factors influencing whether children walk to school. Health & Place, 22, pp.153-161.
145 Vishnevetsky, J., Tang, D., Chang, H.W., Roen, E.L, Wang, Y., Rauh, V., Wang, S., Miller, R.L, Herbstman, J. and
Perera, F.P., 2015. Combined effects of prenatal polycyclic aromatic hydrocarbons and material hardship on
child IQ. Neurotoxicology and Teratology, 49, pp.74-80.
146 Mathiarasan, S. and Hiils, A., 2021. Impact of environmental injustice on children's health—interaction between
air pollution and socioeconomic status. International Journal of Environmental Research and Public Health,
18(2), p.795.
147 Bell, J.E., Herring, S.C., Jantarasami, L, Adrianopoli, C., Benedict, K., Conlon, K., Escobar, V., Hess, J., Luvall, J.,
Garcia-Pando, C.P. and Quattrochi, D., 2016. Ch. 4: Impacts of extreme events on human health (pp. 99-128). US
Global Change Research Program, Washington, DC.
148 Bateson, T.F. and Schwartz, J., 2007. Children's response to air pollutants. Journal of Toxicology and
Environmental Health, Part A, 71(3), pp.238-243.
149 Perera, F.P., Rauh, V., Whyatt, R.M., Tsai, W.Y., Tang, D., Diaz, D., Hoepner, L., Barr, D., Tu, Y.H., Camann, D. and
Kinney, P., 2006. Effect of prenatal exposure to airborne polycyclic aromatic hydrocarbons on
neurodevelopment in the first 3 years of life among inner-city children. Environmental Health Perspectives,
114(8), pp.1287-1292.
150 Forns, J., Dadvand, P., Esnaola, M., Alvarez-Pedrerol, M., Lopez-Vicente, M., Garcia-Esteban, R., Cirach, M.,
Basagana, X., Guxens, M. and Sunyer, J., 2017. Longitudinal association between air pollution exposure at
school and cognitive development in school children over a period of 3.5 years. Environmental Research, 159,
pp.416-421.
April 2023
89
-------
Climate Change and Children's Health and Well-Being in the United States
151 Garcia, E., Rice, M.B. and Gold, D.R., 2021. Air pollution and lung function in children. Journal of Allergy and
Clinical Immunology, 148(1), pp. 1-14.
152 McGeachie, M.J., Yates, K.P., Zhou, X., Guo, F., Sternberg, A.L., Van Natta, M.L, Wise, R.A., Szefler, S.J., Sharma,
S., Kho, A.T. and Cho, M.H., 2016. Patterns of growth and decline in lung function in persistent childhood
asthma. New England Journal of Medicine, 374(19), pp.1842-1852.
153 Henry, S., Ospina, M.B., Dennett, L and Hicks, A., 2021. Assessing the Risk of Respiratory-Related Healthcare
Visits Associated with Wildfire Smoke Exposure in Children 0-18 Years Old: A Systematic Review. International
Journal of Environmental Research and Public Health, 18(16), p.8799.
154 Achakulwisut, P., Anenberg, S.C., Neumann, J.E., Penn, S.L, Weiss, N., Crimmins, A., Fann, N., Martinich, J.,
Roman, H. and Mickley, L.J., 2019. Effects of increasing aridity on ambient dust and public health in the US
Southwest under climate change. GeoHealth, 3(5), pp. 127-144.
155 Mathiarasan, S. and Hiils, A., 2021. Impact of environmental injustice on children's health—interaction between
air pollution and socioeconomic status. International Journal of Environmental Research and Public Health,
18(2), p.795.
156 U.S. Environmental Protection Agency. 2022. "Inventory of U.S. Greenhouse Gas Emissions and Sinks: 1990-
2020." EPA 430-R-22-003. https://www.epa.gov/ghgemissions/draft-inventory-us-greenhouse-gas-
emissionsand-sinks-1990-2020.
157 Khaniabadi, Y.O., Goudarzi, G., Daryanoosh, S.M., Borgini, A., Tittarelli, A. and De Marco, A., 2017. Exposure to
PM10, N02, and 03 and impacts on human health. Environmental Science and Pollution Research, 24(3),
pp.2781-2789.
158 Wright, R.J., Hsu, H.H.L., Chiu, Y.H.M., Coull, B.A., Simon, M.C., Hudda, N., Schwartz, J., Kloog, I. and Durant, J.L,
2021. Prenatal ambient ultrafine particle exposure and childhood asthma in the northeastern United States.
American Journal of Respiratory and Critical Care Medicine, 204(7), pp.788-796.
159 Fadadu, R.P., Grimes, B., Jewell, N.P., Vargo, J., Young, A.T., Abuabara, K., Balmes, J.R. and Wei, M.L, 2021.
Association of wildfire air pollution and health care use for atopic dermatitis and itch. JAMA Dermatology,
157(6), pp.658-666.
160 Lam, J., Sutton, P., Kalkbrenner, A., Windham, G., Halladay, A., Koustas, E., Lawler, C., Davidson, L, Daniels, N.,
Newschaffer, C. and Woodruff, T., 2016. A systematic review and meta-analysis of multiple airborne pollutants
and autism spectrum disorder. PloS One, 11(9), p.e0161851.
161 Ebisu, K., Malig, B., Hasheminassab, S., Sioutas, C. and Basu, R., 2018. Cause-specific stillbirth and exposure to
chemical constituents and sources of fine particulate matter. Environmental Research, 160, pp.358-364.
162 lodice, S., Hoxha, M., Ferrari, L, Carbone, I.F., Anceschi, C., Miragoli, M., Pesatori, A.C., Persico, N. and Bollati,
V., 2018. Particulate air pollution, blood mitochondrial DNA copy number, and telomere length in mothers in
the first trimester of pregnancy: effects on fetal growth. Oxidative Medicine and Cellular Longevity, 2018.
163 Mendola, P., Nobles, C., Williams, A., Sherman, S., Kanner, J., Seeni, I. and Grantz, K., 2019. Air pollution and
preterm birth: do air pollution changes over time influence risk in consecutive pregnancies among low-risk
women?. International Journal of Environmental Research and Public Health, 16(18), p.3365.
164 Sarovar, V., Malig, B.J. and Basu, R., 2020. A case-crossover study of short-term air pollution exposure and the
risk of stillbirth in California, 1999-2009. Environmental Research, 191, p.110103.
165 Rappazzo, K.M., Nichols, J.L., Rice, R.B. and Luben, T.J., 2021. Ozone exposure during early pregnancy and
preterm birth: A systematic review and meta-analysis. Environmental Research, 198, p.111317.
166 Laurent, O., Hu, J., Li, L., Kleeman, M.J., Bartell, S.M., Cockburn, M., Escobedo, L. and Wu, J., 2016. Low birth
weight and air pollution in California: Which sources and components drive the risk?. Environment
international, 92, pp.471-477.
167 Bekkar, B., Pacheco, S., Basu, R. and DeNicola, N., 2020. Association of air pollution and heat exposure with
preterm birth, low birth weight, and stillbirth in the US: a systematic review. JAMA Network Open, 3(6),
pp.e208243-e208243.
168 Palma, A., Petrunyk, I. and Vuri, D., 2022. Prenatal air pollution exposure and neonatal health. Health
Economics, 31(5), pp.729-759.
April 2023
90
-------
Climate Change and Children's Health and Well-Being in the United States
169 Clemens, T., Turner, S. and Dibben, C., 2017. Maternal exposure to ambient air pollution and fetal growth in
North-East Scotland: A population-based study using routine ultrasound scans. Environment international, 107,
pp.216-226.
170 Bar, J., Weiner, E., Levy, M. and Gilboa, Y., 2021. The thrifty phenotype hypothesis: the association between
ultrasound and Doppler studies in fetal growth restriction and the development of adult disease. American
Journal of Obstetrics & Gynecology MFM, 3(6), p.100473.
171 Yoo, E.H., Brown, P. and Eum, Y., 2018. Ambient air quality and spatio-temporal patterns of cardiovascular
emergency department visits. International Journal of Health Geographies, 17(1), pp.1-16.
172 Perera, F.P., Rauh, V., Whyatt, R.M., Tsai, W.Y., Tang, D., Diaz, D., Hoepner, L., Barr, D., Tu, Y.H., Camann, D. and
Kinney, P., 2006. Effect of prenatal exposure to airborne polycyclic aromatic hydrocarbons on
neurodevelopment in the first 3 years of life among inner-city children. Environmental Health Perspectives,
114(8), pp.1287-1292.
173 Ha, S., Sundaram, R., Louis, G.M.B., Nobles, C., Seeni, I., Sherman, S. and Mendola, P., 2018. Ambient air
pollution and the risk of pregnancy loss: a prospective cohort study. Fertility and Sterility, 109(1), pp. 148-153.
174 Pedersen, M., Stayner, L., Slama, R., S0rensen, M., Figueras, F., Nieuwenhuijsen, M.J., Raaschou-Nielsen, O. and
Dadvand, P., 2014. Ambient air pollution and pregnancy-induced hypertensive disorders: a systematic review
and meta-analysis. Hypertension, 64(3), pp.494-500.
175 Choe, S.A., Kauderer, S., Eliot, M.N., Glazer, K.B., Kingsley, S.L., Carlson, L, Awad, Y.A., Schwartz, J.D., Savitz, D.A.
and Wellenius, G.A., 2018. Air pollution, land use, and complications of pregnancy. Science of The Total
Environment, 645, pp. 1057-1064.
176 Falkner, B., 2020. Maternal and gestational influences on childhood blood pressure. Pediatric Nephrology, 35(8),
pp. 1409-1418.
177 Cao, L., Wang, L., Wu, L, Wang, T., Cui, X., Yu, L., Diao, R. and Mao, H., 2021. Particulate matter and
hypertensive disorders in pregnancy: systematic review and meta-analysis. Public Health, 200, pp.22-32.
178 Bekkar, B., Pacheco, S., Basu, R., DeNicola, N., 2020. Association of air pollution and heat exposure with preterm
birth, low birth weight, and stillbirth in the U.S.: A systematic review. JAMA Network Open 3(6).
179 Leung, M., Weisskopf, M.G., Laden, F., Coull, B.A., Modest, A.M., Hacker, M.R., Wylie, B.J., Wei, Y., Schwartz, J.
and Papatheodorou, S., 2022. Exposure to PM 2.5 during Pregnancy and Fetal Growth in Eastern
Massachusetts, USA. Environmental Health Perspectives, 130(1), p.017004.
180 Peterson, A.K., Habre, R., Niu, Z., Amin, M., Yang., T, Eckel, S.P., Farzan, S.F., Lurmann, F., Pavlovic, N., Grubbs,
B.H., Walker, D., Al-Marayati, L.A., Grant, E., Lerner, D., Bastain, T.M., and Breton, C.V., 2022. Identifying pre-
conception and pre-natal periods in which ambient air pollution exposure affects fetal growth in the
predominantly Hispanic MADRES cohort. Environmental Health Perspectives, 21(10).
181 Garcia, E., Rice, M.B. and Gold, D.R., 2021. Air pollution and lung function in children. Journal of Allergy and
Clinical Immunology, 148(1), pp. 1-14.
182 Peralta, A.A., Schwartz, J., Gold, D.R., Vonk, J.M., Vermeulen, R. and Gehring, U., 2022. Quantile regression to
examine the association of air pollution with subclinical atherosclerosis in an adolescent population.
Environment international, 164, p.107285.
183 Schinasi, L.H., Kenyon, C.C., Hubbard, R.A., Zhao, Y., Maltenfort, M., Melly, S.J., Moore, K., Forrest, C.B., Roux,
A.V.D. and de Roos, A.J., 2022. Associations between high ambient temperatures and asthma exacerbation
among children in Philadelphia, PA: a time series analysis. Occupational and Environmental Medicine, 79(5),
pp.326-332.
184 Mathiarasan, S. and Hiils, A., 2021. Impact of environmental injustice on children's health—interaction between
air pollution and socioeconomic status. International Journal of Environmental Research and Public Health,
18(2), p.795.
185 Garcia, E., Rice, M.B. and Gold, D.R., 2021. Air pollution and lung function in children. Journal of Allergy and
Clinical Immunology, 148(1), pp. 1-14.
April 2023
91
-------
Climate Change and Children's Health and Well-Being in the United States
186 Gilliland, F.D., Berhane, K., Rappaport, E.B., Thomas, D.C., Avol, E., Gauderman, W.J., London, S.J., Margolis,
H.G., McConnell, R., Islam, K.T. and Peters, J.M., 2001. The effects of ambient air pollution on school
absenteeism due to respiratory illnesses. Epidemiology, pp.43-54.
187 Miller, J.G., Gillette, J.S., Manczak, E.M., Kircanski, K. and Gotlib, I.H., 2019. Fine particle air pollution and
physiological reactivity to social stress in adolescence: The moderating role of anxiety and depression.
Psychosomatic Medicine, 81(7), p.641.
188 Reuben, A., Arseneault, L., Beddows, A., Beevers, S.D., Moffitt, T.E., Ambler, A., Latham, R.M., Newbury, J.B.,
Odgers, C.L, Schaefer, J.D. and Fisher, H.L, 2021. Association of air pollution exposure in childhood and
adolescence with psychopathology at the transition to adulthood. JAMA Network Open, 4(4), pp.e217508-
e217508..
189 Perera, F.P., Rauh, V., Whyatt, R.M., Tsai, W.Y., Tang, D., Diaz, D., Hoepner, L., Barr, D., Tu, Y.H., Camann, D. and
Kinney, P., 2006. Effect of prenatal exposure to airborne polycyclic aromatic hydrocarbons on
neurodevelopment in the first 3 years of life among inner-city children. Environmental Health Perspectives,
114(8), pp.1287-1292.
190 Yi, C., Wang, Q., Qu, Y., Niu, J., Oliver, B.G. and Chen, H., 2022. In-utero exposure to air pollution and early-life
neural development and cognition. Ecotoxicology and Environmental Safety, 238, p. 113589.
191 Park, J., Sohn, J.H., Cho, S.J., Seo, H.Y., Hwang, I.U., Hong, Y.C. and Kim, K.N., 2020. Association between short-
term air pollution exposure and attention-deficit/hyperactivity disorder-related hospital admissions among
adolescents: A nationwide time-series study. Environmental Pollution, 266, p.115369.
192 McGuinn, LA., Wiggins, L.D., Volk, H.E., Di, Q., Moody, E.J., Kasten, E., Schwartz, J., Wright, R.O., Schieve, L.A.,
Windham, G.C. and Daniels, J.L., 2022. Pre-and Postnatal Fine Particulate Matter Exposure and Childhood
Cognitive and Adaptive Function. International Journal of Environmental Research and Public Health, 19(7),
p.3748..
193 Rahman, F., Coull, B.A., Carroll, K.N., Wilson, A., Just, A.C., Kloog, I., Zhang, X., Wright, R.J. and Chiu, Y.H.M.,
2022. Prenatal PM2. 5 exposure and infant temperament at age 6 months: Sensitive windows and sex-specific
associations. Environmental Research, 206, p. 112583.
194 Sanchez, T., Gozal, D., Smith, D.L, Foncea, C., Betancur, C. and Brockmann, P.E., 2019. Association between air
pollution and sleep disordered breathing in children. Pediatric Pulmonology, 54(5), pp.544-550.
195 Perera, F. and Nadeau, K., 2022. Climate change, fossil-fuel pollution, and children's health. New England
Journal of Medicine, 386(24), pp. 2303-2314.
196 Mathiarasan, S. and Hiils, A., 2021. Impact of environmental injustice on children's health—interaction between
air pollution and socioeconomic status. International Journal of Environmental Research and Public Health,
18(2), p.795.
197 Bekkar, B., Pacheco, S., Basu, R. and DeNicola, N. 2020. Association of air pollution and heat exposure with
preterm birth, low birth weight, and stillbirth in the US: a systematic review. JAMA Network Open, 3(6),
pp.e208243-e208243.
198 DeNicola, N.G., Bekkar, B., Pacheco, S. and Basu, R., 2019. A scoping review of climate-change related exposures
on obstetrics outcomes [18G], Obstetrics & Gynecology, 133, p.78S.
199 Jabin, N., Salam, M.T., Rahman, M.M., Sharna, T.I., Franklin, M., Ahmed, A., Quaiyum, M.A. and Islam, T., 2022.
Social inequality influences the impact of household air pollution on birth outcomes. Science of The Total
Environment, 822, p. 153405.
200 Jones, K.K., Anderko, L. and Davies-Cole, J., 2020. Neighborhood environment and asthma exacerbation in
Washington, DC. Annual Review of Nursing Research, 38(1), pp.53-72.
201 Mathiarasan, S. and Hiils, A., 2021. Impact of environmental injustice on children's health—interaction between
air pollution and socioeconomic status. International Journal of Environmental Research and Public Health,
18(2), p.795.
202 Yang, C.E., Fu, J.S., Liu, Y., Dong, X. and Liu, Y., 2022. Projections of future wildfires impacts on air pollutants and
air toxics in a changing climate over the western United States. Environmental Pollution, 304, p.119213.
203 Davies, I.P., Haugo, R.D., Robertson, J.C. and Levin, P.S., 2018. The unequal vulnerability of communities of color
to wildfire. PloS One, 13(11), p.e0205825.
April 2023
92
-------
Climate Change and Children's Health and Well-Being in the United States
204 Aguilera, R., Corringham, T., Gershunov, A., Leibel, S. and Benmarhnia, T., 2021. Fine particles in wildfire smoke
and pediatric respiratory health in California. Pediatrics, 147(A).
205 Molina, M.F., Okoniewski, W., Puranik, S., Aujla, S., Celedon, J.C., Larkin, A. and Forno, E., 2022. Severe asthma
in children: description of a large multidisciplinary clinical cohort. Pediatric Pulmonology.
206 U.S. Environmental Protection Agency. 2021. "Climate Change and Social Vulnerability in the United States: A
Focus on Six Impacts. U.S. Environmental Protection Agency." EPA430-R-21-003. Available at:
https://www.epa.gov/cira/social-vulnerability-report
207 Fann, N., Brennan, T., Dolwick, P., Gamble, J.L, llacque, V., Kolb, L, Nolte, C.G., Spero, T.L and Ziska, L., 2016.
Ch. 3: Air Quality Impacts In The impacts of climate change on human health in the United States: A scientific
assessment (pp. 69-98). Washington, DC: US Global Change Research Program, 10(7930), p.J0GQ6VP6.
208 U.S. Environmental Protection Agency. 2021. "Climate Change and Social Vulnerability in the United States: A
Focus on Six Impacts. U.S. Environmental Protection Agency." EPA430-R-21-003. Available at:
https://www.epa.gov/cira/social-vulnerability-report
209 Tetreault, L.F., Doucet, M., Gamache, P., Fournier, M., Brand, A., Kosatsky, T. and Smargiassi, A., 2016.
Childhood exposure to ambient air pollutants and the onset of asthma: an administrative cohort study in
Quebec. Environmental Health Perspectives, 124(8), pp. 1276-1282.
210 Parker, J.D., Akinbami, LJ. and Woodruff, T.J., 2009. Air pollution and childhood respiratory allergies in the
United States. Environmental Health Perspectives, 117(1), pp.140-147.
211 Gilliland, F.D., Berhane, K., Rappaport, E.B., Thomas, D.C., Avol, E., Gauderman, W.J., London, S.J., Margolis,
H.G., McConnell, R., Islam, K.T. and Peters, J.M., 2001. The effects of ambient air pollution on school
absenteeism due to respiratory illnesses. Epidemiology, pp.43-54.
212 Alhanti, B.A., Chang, H.H., Winquist, A., Mulholland, J.A., Darrow, LA. and Sarnat, S.E., 2016. Ambient air
pollution and emergency department visits for asthma: a multi-city assessment of effect modification by age.
Journal of Exposure Science & Environmental Epidemiology, 26(2), pp.180-188.
213 Mar, T.F. and Koenig, J.Q., 2009. Relationship between visits to emergency departments for asthma and ozone
exposure in greater Seattle, Washington. Annals of Allergy, Asthma & Immunology, 103(6), pp.474-479.
214 Ostro, B., Roth, L., Malig, B. and Marty, M., 2009. The effects of fine particle components on respiratory hospital
admissions in children. Environmental Health Perspectives, 117(3), pp.475-480.
215 Woodruff, T.J., Darrow, L.A. and Parker, J.D., 2008. Air pollution and postneonatal infant mortality in the United
States, 1999-2002. Environmental Health Perspectives, 116(1), pp. 110-115.
216 Fann, N.L., Nolte, C.G., Sarofim, M.C., Martinich, J. and Nassikas, N.J., 2021. Associations between simulated
future changes in climate, air quality, and human health. JAMA Network Open, 4(1), pp.e2032064-e2032064.
217 Achakulwisut, P., Anenberg, S.C., Neumann, J.E., Penn, S.L, Weiss, N., Crimmins, A., Fann, N., Martinich, J.,
Roman, H. and Mickley, L.J., 2019. Effects of increasing aridity on ambient dust and public health in the US
Southwest under climate change. GeoHealth, 3(5), pp. 127-144.
218 Neumann, J.E., Amend, M., Anenberg, S., Kinney, P.L, Sarofim, M., Martinich, J., Lukens, J., Xu, J.W. and Roman,
H., 2021. Estimating PM2. 5-related premature mortality and morbidity associated with future wildfire
emissions in the western US. Environmental Research Letters, 16(3), p.035019. https://doi.org/10.1088/1748-
9326/abe82b
219 Perera, F., Cooley, D., Berberian, A., Mills, D. and Kinney, P., 2020. Co-benefits to children's health of the US
Regional Greenhouse Gas Initiative. Environmental Health Perspectives, 128(7), p.077006.
220 U.S. Environmental Protection Agency. "Environmental Benefits Mapping and Analysis Program - Community
Edition (BenMAP-CE). Available at: https://www.epa.gov/benmap.
221 U.S. Environmental Protection Agency. "Criteria Air Pollutants." Available at: https://www.epa.gov/criteria-air-
pollutants.
222 Liu, J.C., Mickley, L.J., Sulprizio, M.P., Yue, X., Peng, R.D., Dominici, F. and Bell, M.L., 2016. Future respiratory
hospital admissions from wildfire smoke under climate change in the Western US. Environmental Research
Letters, 11(12), p. 124018.
223 Belova, A., Fann, N., Haskell, J., Hubbell, B. and Narayan, T., 2020. Estimating lifetime cost of illness. An
application to asthma. Annals of the American Thoracic Society, 17(12), pp.1558-1569.
April 2023
93
-------
Climate Change and Children's Health and Well-Being in the United States
224 Soni, A., 2008. Allergic Rhinitis: Trends in use and expenditures, 2000 and 2005. Medical Expenditure Panel
Survey, Agency for Healthcare Research and Quality. Medical Expenditure Panel Survey Statistical Brief #204.
225 Smith, D.H., Malone, D.C., Lawson, K.A., Okamoto, L.J., Battista, C. and Saunders, W.B., 1997. A national
estimate of the economic costs of asthma. American Journal of Respiratory and Critical Care Medicine, 156(3),
pp.787-793.
226 Stanford, R., Mclaughlin, T. and Okamoto, L.J., 1999. The cost of asthma in the emergency department and
hospital. American Journal of Respiratory and Critical Care Medicine, 160(1), pp.211-215.
227 Stanford, R., Mclaughlin, T. and Okamoto, L.J., 1999. The cost of asthma in the emergency department and
hospital. American Journal of Respiratory and Critical Care Medicine, 160(1), pp.211-215.
228 Hsu, J., Qin, X., Beavers, S.F. and Mirabelli, M.C., 2016. Asthma-related school absenteeism, morbidity, and
modifiable factors. American Journal of Preventive Medicine, 51(1), pp.23-32.
229 Azor-Martinez, E., Gonzalez-Jimenez, Y., Seijas-Vazquez, M.L., Cobos-Carrascosa, E., Santisteban-Martinez, J.,
Martinez-Lopez, J.M., Jimenez-Noguera, E., del Mar Galan-Requena, M., Garrido-Fernandez, P., Strizzi, J.M. and
Gimenez-Sanchez, F., 2014. The impact of common infections on school absenteeism during an academic year.
American Journal of Infection Control, 42(6), pp.632-637.
230 U.S. Bureau of Labor Statistics, 2015. Current Population Survey. 2015 Annual Social and Economic Supplement.
Available at: https://www.bls.gov/opub/reports/womens-databook/2016/home.htm.
231 Robinson, LA., Raich, W.J., Hammitt, J.K. and O'Keeffe, L, 2019. Valuing children's fatality risk reductions.
Journal of Benefit-Cost Analysis, 10(2), pp.156-177.
232 U.S. Centers for Disease Control and Prevention. "Most Recent National Asthma Data." Available at:
https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm
233 U.S. Environmental Protection Agency. "Environmental Benefits Mapping and Analysis Program - Community
Edition (BenMAP-CE). Available at: https://www.epa.gov/benmap.
234 Amjad, S., Chojecki, D., Osornio-Vargas, A. and Ospina, M.B., 2021. Wildfire exposure during pregnancy and the
risk of adverse birth outcomes: A systematic review. Environment International, 156, p.106644.
235 Heft-Neal, S., Driscoll, A., Yang, W., Shaw, G. and Burke, M., 2022. Associations between wildfire smoke
exposure during pregnancy and risk of preterm birth in California. Environmental Research, 203, p.111872.
236 U.S. Centers for Disease and Control. 2012. Births: Final Data for 2010. National Vital Statistics Reports (NVSS),
61(1). Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_01.pdf
237 Neumann, J.E., Amend, M., Anenberg, S., Kinney, P.L, Sarofim, M., Martinich, J., Lukens, J., Xu, J.W. and Roman,
H., 2021. Estimating PM2. 5-related premature mortality and morbidity associated with future wildfire
emissions in the western US. Environmental Research Letters, 16(3), p.035019.
238 Childs, M.L., Li, J., Wen, J., Heft-Neal, S., Driscoll, A., Wang, S., Gould, C.F., Qiu, M., Burney, J. and Burke, M.,
2022. Daily Local-Level Estimates of Ambient Wildfire Smoke PM2. 5 for the Contiguous US. Environmental
Science & Technology, 56(19), pp.13607-13621.
239 Trasande, L., Malecha, P. and Attina, T.M., 2016. Particulate matter exposure and preterm birth: estimates of
US attributable burden and economic costs. Environmental Health Perspectives, 124(12), pp. 1913-1918.
240 U.S. Environmental Protection Agency. 2021. "Seasonality and Climate Change: A Review of Observed Evidence
in the United States." Available at: https://www.epa.gov/climate-indicators/seasonality-and-climate-change
241 Diffenbaugh, N.S., Scherer, M. and Ashfaq, M., 2013. Response of snow-dependent hydrologic extremes to
continued global warming. Nature Climate Change, 3(4), pp.379-384.
242 Lipton, D., Rubenstein, M.A., Weiskopf, S.R., Carter, S.L., Peterson, J., Crozier, L, Fogarty, M., Gaichas, S., Hyde,
K.J., Morelli, T.L. and Morisette, J., 2018. Ecosystems, Ecosystem Services, and Biodiversity (pp. 268-321). US
Global Change Research Program.
243 U.S. Environmental Protection Agency. "Climate Change Indicators: Snowpack." Available at:
https://www.epa.gov/climate-indicators/climate-change-indicators-snowpack. Last updated: July 21, 2021.
Accessed: July 1, 2022
244 Ziska, L.H. and Beggs, P.J., 2012. Anthropogenic climate change and allergen exposure: the role of plant biology.
Journal of Allergy and Clinical Immunology, 129(1), pp.27-32.
April 2023
94
-------
Climate Change and Children's Health and Well-Being in the United States
245 Ebi, K.L, J.M. Balbus, G. Luber, A. Bole, A. Crimmins, G. Glass, S. Saha, M.M. Shimamoto, J. Trtanj, and J.L.White-
Newsome. 2018. Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth NationalClimate
Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock,
and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 572-603.
246 Anderegg, W.R., Abatzoglou, J.T., Anderegg, L.D., Bielory, L, Kinney, P.L. and Ziska, L, 2021. Anthropogenic
climate change is worsening North American pollen seasons. Proceedings of the National Academy of Sciences,
118(1), p.e2013284118.
247 Moore, S.K., Trainer, V.L, Mantua, N.J., Parker, M.S., Laws, E.A., Backer, L.C. and Fleming, L.E., 2008, November.
Impacts of climate variability and future climate change on harmful algal blooms and human health. In
Environmental Health (Vol. 7, No. 2, pp. 1-12). BioMed Central.
248 Gobler, C.J., 2020. Climate change and harmful algal blooms: insights and perspective. Harmful Algae, 91,
p.101731.
249 Reid, C.E. and Gamble, J.L., 2009. Aeroallergens, allergic disease, and climate change: impacts and adaptation.
EcoHealth, 6, pp.458-470.
250 Sheffield, P.E., Weinberger, K.R. and Kinney, P.L, 2011. Climate change, aeroallergens, and pediatric allergic
disease. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(1), pp.78-84.
251 Romanos, M., Gerlach, M., Warnke, A. and Schmitt, J., 2010. Association of attention-deficit/hyperactivity
disorder and atopic eczema modified by sleep disturbance in a large population-based sample. Journal of
Epidemiology & Community Health, 64(3), pp.269-273.
252 van der Schans, J., Cicek, R., de Vries, T.W., Hak, E. and Hoekstra, P.J., 2017. Association of atopic diseases and
attention-deficit/hyperactivity disorder: A systematic review and meta-analyses. Neuroscience & Biobehavioral
Reviews, 74, pp. 139-148.
253 Strom, M.A., Fishbein, A.B., Paller, A.S. and Silverberg, J.I., 2016. Association between atopic dermatitis and
attention deficit hyperactivity disorder in US children and adults. British Journal of Dermatology, 175(5),
pp.920-929.
254 Hoppin, J.A., Jaramillo, R., Salo, P., Sandler, D.P., London, S.J. and Zeldin, D.C., 2011. Questionnaire predictors of
atopy in a US population sample: findings from the National Health and Nutrition Examination Survey, 2005-
2006. American Journal of Epidemiology, 173(5), pp. 544-552.
255 Silverberg, J.I., Braunstein, M. and Lee-Wong, M., 2015. Association between climate factors, pollen counts, and
childhood hay fever prevalence in the United States. Journal of Allergy and Clinical Immunology, 135(2), pp.463-
469.
256 Silverberg, J.I., Braunstein, M. and Lee-Wong, M., 2015. Association between climate factors, pollen counts, and
childhood hay fever prevalence in the United States. Journal of Allergy and Clinical Immunology, 135(2), pp.463-
469.
257 Gilles, S., Blume, C., Wimmer, M., Damialis, A., Meulenbroek, L., Gokkaya, M., Bergougnan, C., Eisenbart, S.,
Sundell, N., Lindh, M. and Andersson, L.M., 2020. Pollen exposure weakens innate defense against respiratory
viruses. Allergy, 75(3), pp.576-587.
258 Cecchi, L., d'Amato, G., Ayres, J.G., Galan, C., Forastiere, F., Forsberg, B., Gerritsen, J., Nunes, C., Behrendt, H.,
Akdis, C. and Dahl, R., 2010. Projections of the effects of climate change on allergic asthma: the contribution of
aerobiology. Allergy, 65(9), pp. 1073-1081.
259 Sheffield, P.E., Weinberger, K.R. and Kinney, P.L, 2011. Climate change, aeroallergens, and pediatric allergic
disease. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(1), pp.78-84.
260 Sheffield, P.E., Weinberger, K.R. and Kinney, P.L, 2011. Climate change, aeroallergens, and pediatric allergic
disease. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(1), pp.78-84.
261 DellaValle, C.T., Triche, E.W., Leaderer, B.P. and Bell, M.L., 2012. Effects of ambient pollen concentrations on
frequency and severity of asthma symptoms among asthmatic children. Epidemiology (Cambridge, Mass.),
23(1), p.55.
262 Marcotte, D.E., 2015. Allergy test: Seasonal allergens and performance in school. Journal of Health Economics,
40, pp. 132-140.
April 2023
95
-------
Climate Change and Children's Health and Well-Being in the United States
263 Papapostolou, G., Kiotseridis, H., Romberg, K., Dahl, A., Bjermer, L, Lindgren, M., Aronsson, D., Tunsater, A. and
Tufvesson, E., 2021. Cognitive dysfunction and quality of life during pollen season in children with seasonal
allergic rhinitis. Pediatric Allergy and Immunology, 32(1), pp.67-76.
264 Jariwala, S.P., Kurada, S., Moday, H., Thanjan, A., Bastone, L, Khananashvili, M., Fodeman, J., Hudes, G. and
Rosenstreich, D., 2011. Association between tree pollen counts and asthma ED visits in a high-density urban
center. Journal of Asthma, 48(5), pp.442-448.
265 Erbas, B., Jazayeri, M., Lambert, K.A., Katelaris, C.H., Prendergast, L.A., Tham, R., Parrodi, M.J., Davies, J.,
Newbigin, E., Abramson, M.J. and Dharmage, S.C., 2018. Outdoor pollen is a trigger of child and adolescent
asthma emergency department presentations: A systematic review and meta-analysis. Allergy, 73(8), pp. 1632-
1641.
266 Ito, K., Weinberger, K.R., Robinson, G.S., Sheffield, P.E., Lall, R., Mathes, R., Ross, Z., Kinney, P.L. and Matte, T.D.,
2015. The associations between daily spring pollen counts, over-the-counter allergy medication sales, and
asthma syndrome emergency department visits in New York City, 2002-2012. Environmental Health, 14(1),
pp.1-12.
267 Ziska, L.H., 2020. An overview of rising C02 and climatic change on aeroallergens and allergic diseases. Allergy,
Asthma & Immunology Research, 12(5), p.771.
268 Bozigar, M., Lawson, A.B., Pearce, J.L., Svendsen, E.R. and Vena, J.E., 2021. Using Bayesian time-stratified case-
crossover models to examine associations between air pollution and "asthma seasons" in a low air pollution
environment. PLOS One, 16(12), p.e0260264.
269 Saha, S., Vaidyanathan, A., Lo, F., Brown, C. and Hess, J.J., 2021. Short term physician visits and medication
prescriptions for allergic disease associated with seasonal tree, grass, and weed pollen exposure across the
United States. Environmental Health, 20(1), pp.1-12.
270 Saha, S., Vaidyanathan, A., Lo, F., Brown, C. and Hess, J.J., 2021. Short term physician visits and medication
prescriptions for allergic disease associated with seasonal tree, grass, and weed pollen exposure across the
United States. Environmental Health, 20(1), pp.1-12.
271 Tuong, L.A.C., Trivedi, R., Greenberg, P. and Narisety, S.D., 2020. The relationship of race and aeroallergen
sensitization in a pediatric urban allergy clinic. Annals of Allergy, Asthma & Immunology, 125(6), pp.709-711.
272 Wohlford, E.M., Huang, P.F., Elhawary, J.R., Millette, LA., Contreras, M.G., Witonsky, J., Holweg, C.T., Oh, S.S.,
Lee, C., Merenda, C. and Rabin, R.L., 2021. Racial/ethnic differences in eligibility for asthma biologies among
pediatric populations. Journal of Allergy and Clinical Immunology, 148(5), pp.1324-1331.
273 Beck, A.F., Huang, B., Simmons, J.M., Moncrief, T., Sauers, H.S., Chen, C., Ryan, P.H., Newman, N.C. and Kahn,
R.S., 2014. Role of financial and social hardships in asthma racial disparities. Pediatrics, 133(3), pp.431-439.
274 Beck, A.F., Huang, B., Auger, K.A., Ryan, P.H., Chen, C. and Kahn, R.S., 2016. Explaining racial disparities in child
asthma readmission using a causal inference approach. JAMA Pediatrics, 170(7), pp.695-703.
275 Brice, B., Fullerton, C., Hawkes, K.L., Mills-Novoa, M., O'Neill, B.F. and Pawlowski, W.M., 2017. The impacts of
climate change on natural areas recreation: a multi-region snapshot and agency comparison. Natural Areas
Journal, 37(1), pp.86-97.
276 Miller, A.B., Winter, P.L, Sanchez, J.J., Peterson, D.L and Smith, J.W., 2022. Climate change and recreation in
the western United States: Effects and opportunities for adaptation. Journal of Forestry, 120(4), pp.453-472.
277 White, M.P., Alcock, I., Grellier, J., Wheeler, B.W., Hartig, T., Warber, S.L, Bone, A., Depledge, M.H. and Fleming,
L.E., 2019. Spending at least 120 minutes a week in nature is associated with good health and wellbeing.
Scientific Reports, 9(1), pp.1-11.
278 Fyfe-Johnson, A.L, Hazlehurst, M.F., Perrins, S.P., Bratman, G.N., Thomas, R., Garrett, K.A., Hafferty, K.R., Cullaz,
T.M., Marcuse, E.K. and Tandon, P.S., 2021. Nature and children's health: a systematic review. Pediatrics,
148(A).
279 Tremblay, M.S., Gray, C., Babcock, S., Barnes, J., Costas Bradstreet, C., Carr, D., Chabot, G., Choquette, L.,
Chorney, D., Collyer, C. and Herrington, S., 2015. Position statement on active outdoor play. International
Journal of Environmental Research and Public Health, 12(6), pp.6475-6505.
April 2023
96
-------
Climate Change and Children's Health and Well-Being in the United States
280 White, M.P., Alcock, I., Grellier, J., Wheeler, B.W., Hartig, T., Warber, S.L., Bone, A., Depledge, M.H. and Fleming,
L.E., 2019. Spending at least 120 minutes a week in nature is associated with good health and wellbeing.
Scientific Reports, 9(1), pp.1-11.
281 Gladwell, V.F., Brown, D.K., Wood, C., Sandercock, G.R. and Barton, J.L., 2013. The great outdoors: how a green
exercise environment can benefit all. Extreme Physiology & Medicine, 2(1), pp. 1-7.
282 Fyfe-Johnson, A.L, Hazlehurst, M.F., Perrins, S.P., Bratman, G.N., Thomas, R., Garrett, K.A., Hafferty, K.R., Cullaz,
T.M., Marcuse, E.K. and Tandon, P.S., 2021. Nature and children's health: a systematic review. Pediatrics,
148(A).
283 Casey, J.A., James, P., Cushing, L, Jesdale, B.M. and Morello-Frosch, R., 2017. Race, ethnicity, income
concentration and 10-year change in urban greenness in the United States. International Journal of
Environmental Research and Public Health, 14(12), p. 1546.
284 Wolch, J.R., Byrne, J. and Newell, J.P., 2014. Urban green space, public health, and environmental justice: The
challenge of making cities 'just green enough'. Landscape and Urban Planning, 125, pp.234-244.
285 Cousins, J.J., 2021. Justice in nature-based solutions: Research and pathways. Ecological Economics, 180,
p. 106874.
286 Mitchell, R. and Popham, F., 2008. Effect of exposure to natural environment on health inequalities: an
observational population study. The Lancet, 372(9650), pp.1655-1660.
287 Fyfe-Johnson, A.L, Hazlehurst, M.F., Perrins, S.P., Bratman, G.N., Thomas, R., Garrett, K.A., Hafferty, K.R., Cullaz,
T.M., Marcuse, E.K. and Tandon, P.S., 2021. Nature and children's health: a systematic review. Pediatrics,
148(A).
288 Wobus, C., Small, E.E., Hosterman, H., Mills, D., Stein, J., Rissing, M., Jones, R., Duckworth, M., Hall, R., Kolian,
M. and Creason, J., 2017. Projected climate change impacts on skiing and snowmobiling: A case study of the
United States. Global Environmental Change, 45, pp.1-14.
289 Zeng, X., Broxton, P. and Dawson, N., 2018. Snowpack change from 1982 to 2016 over conterminous United
States. Geophysical Research Letters, 45(23), pp. 12-940.
290 Parthum, B. and Christensen, P., 2022. A market for snow: Modeling winter recreation patterns under current
and future climate. Journal of Environmental Economics and Management, 113, p.102637.
291 Parthum, B. and Christensen, P., 2022. A market for snow: Modeling winter recreation patterns under current
and future climate. Journal of Environmental Economics and Management, 113, p.102637.
292 Lim VK, Sng QS. Does parental job insecurity matter? Money anxiety, money motives, and work motivation. J
Appl Psychol. 2006 Sep;91(5):1078-87.
293 Jackson, D.B. and Vaughn, M.G., 2017. Parental history of disruptive life events and household food insecurity.
Journal of Nutrition Education and Behavior, 49(7), pp.554-560.
294 Curriero, F.C., Patz, J.A., Rose, J.B. and Lele, S., 2001. The association between extreme precipitation and
waterborne disease outbreaks in the United States, 1948-1994. American Journal of Public Health, 91(8),
pp.1194-1199.
295 Weirich, C.A. and Miller, T.R., 2014. Freshwater harmful algal blooms: toxins and children's health. Current
Problems in Pediatric and Adolescent Health Care, 44(1), pp.2-24.
296 Chapra, S.C., Boehlert, B., Fant, C., Bierman Jr, V.J., Henderson, J., Mills, D., Mas, D.M., Rennels, L, Jantarasami,
L., Martinich, J. and Strzepek, K.M., 2017. Climate change impacts on harmful algal blooms in US freshwaters: a
screening-level assessment. Environmental Science & Technology, 51(16), pp.8933-8943.
297 Pershing, A.J., R.B. Griffis, E.B. Jewett, C.T. Armstrong, J.F. Bruno, D.S. Busch, A.C. Haynie, S.A. Siedlecki, and D.
Tommasi, 2018: Oceans and Marine Resources. In Impacts, Risks, and Adaptation in the United States: Fourth
National Climate Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis,
T.K. Maycock, and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA,
pp. 344-381.
298 Centers for Disease Control and Prevention. "Cyanobacterial Blooms: Information for Healthcare Providers."
Available at: https://www.cdc.gov/habs/specific-groups/healthcare_providers.html. Last updated: May 2, 2022.
Accessed: July 25, 2022.
April 2023
97
-------
Climate Change and Children's Health and Well-Being in the United States
299 Schaefer, A.M., Yrastorza, L., Stockley, N., Harvey, K., Harris, N., Grady, R., Sullivan, J., McFarland, M. and Reif,
J.S., 2020. Exposure to microcystin among coastal residents during a cyanobacteria bloom in Florida. Harmful
Algae, 92, p. 101769.
300 Wolf, D., Georgic, W. and Klaiber, H.A., 2017. Reeling in the damages: Harmful algal blooms' impact on Lake
Erie's recreational fishing industry. Journal of Environmental Management, 199, pp.148-157.
301 Harley, J. R., Lanphier, K., Kennedy, E. G., Leighfield, T. A., Bidlack, A., Gribble, M. O., & Whitehead, C., 2020. The
Southeast Alaska Tribal Ocean Research (SEATOR) Partnership: Addressing data gaps in harmful algal bloom
monitoring and shellfish safety in southeast Alaska. Toxins, 12(6), 407.
302 Kourantidou, M., Jin, D., and Schumaker, E.J., 2022. Socioeconomic disruptions of harmful algal blooms in
indigenous communities: The case of Quinault Indian nation. Harmful Algae, 118.
303 Hoagland, P., Jin, D., Polansky, L.Y., Kirkpatrick, B., Kirkpatrick, G., Fleming, L.E., Reich, A., Watkins, S.M.,
Ullmann, S.G. and Backer, L.C., 2009. The costs of respiratory illnesses arising from Florida Gulf Coast Karenia
brevis blooms. Environmental Health Perspectives, 117(8), pp.1239-1243.
304 Chapman, E.J., Byron, C.J., Lasley-Rasher, R., Lipsky, C., Stevens, J.R. and Peters, R., 2020. Effects of climate
change on coastal ecosystem food webs: Implications for aquaculture. Marine Environmental Research, 162,
p. 105103.
305 Smith, K.E., Burrows, M.T., Hobday, A.J., Sen Gupta, A., Moore, P.J., Thomsen, M., Wernberg, T. and Smale, D.A.,
2021. Socioeconomic impacts of marine heatwaves: Global issues and opportunities. Science, 374(6566),
p.eabj3593.
306 Kirkpatrick, B., Fleming, L.E., Backer, L.C., Bean, J.A., Tamer, R., Kirkpatrick, G., Kane, T., Wanner, A., Dalpra, D.,
Reich, A. and Baden, D.G., 2006. Environmental exposures to Florida red tides: effects on emergency room
respiratory diagnoses admissions. Harmful Algae, 5(5), pp.526-533.
307 Weirich, C.A. and Miller, T.R., 2014. Freshwater harmful algal blooms: toxins and children's health. Current
Problems in Pediatric and Adolescent Health Care, 44(1), pp.2-24.
308 Neumann, J.E., Anenberg, S.C., Weinberger, K.R., Amend, M., Gulati, S., Crimmins, A., Roman, H., Fann, N. and
Kinney, P.L., 2019. Estimates of present and future asthma emergency department visits associated with
exposure to oak, birch, and grass pollen in the United States. GeoHealth, 3(1), pp.11-27.
309 Saha, S., Vaidyanathan, A., Lo, F., Brown, C. and Hess, J.J., 2021. Short term physician visits and medication
prescriptions for allergic disease associated with seasonal tree, grass, and weed pollen exposure across the
United States. Environmental Health, 20(1), pp.1-12.
310 U.S. Environmental Protection Agency. "Environmental Benefits Mapping and Analysis Program - Community
Edition (BenMAP-CE). Available at: https://www.epa.gov/benmap.
311 Esch, R.E., Hartsell, C.J., Crenshaw, R. and Jacobson, R.S., 2001. Common allergenic pollens, fungi, animals, and
arthropods. Clinical Reviews in Allergy & Immunology, 21(2), pp.261-292.
312 Thompson, J.L and Thompson, J.E., 2003. The urban jungle and allergy. Immunology and Allergy Clinics, 23(3),
pp.371-387.
313 Jacquet, A., 2011. Interactions of airway epithelium with protease allergens in the allergic response. Clinical &
Experimental Allergy, 41(3), pp.305-311.
314 Oswalt, M.L. and Marshall, G.D., 2008. Ragweed as an example of worldwide allergen expansion. Allergy,
Asthma & Clinical Immunology, 4(3), pp. 1-6.
315 Darrow, L.A., Hess, J., Rogers, C.A., Tolbert, P.E., Klein, M. and Sarnat, S.E., 2012. Ambient pollen concentrations
and emergency department visits for asthma and wheeze. Journal of Allergy and Clinical Immunology, 130(3),
pp.630-638.
316 Ito, K., Weinberger, K.R., Robinson, G.S., Sheffield, P.E., Lall, R., Mathes, R., Ross, Z., Kinney, P.L. and Matte, T.D.,
2015. The associations between daily spring pollen counts, over-the-counter allergy medication sales, and
asthma syndrome emergency department visits in New York City, 2002-2012. Environmental Health, 14(1),
pp.1-12.
317 Anenberg, S.C., Weinberger, K.R., Roman, H., Neumann, J.E., Crimmins, A., Fann, N., Martinich, J. and Kinney,
P.L., 2017. Impacts of oak pollen on allergic asthma in the United States and potential influence of future
climate change. GeoHealth, 1(3), pp.80-92.
April 2023
98
-------
Climate Change and Children's Health and Well-Being in the United States
318 U.S. Environmental Protection Agency. 2017. Multi-Model Framework for Quantitative Sectoral Impacts
Analysis: A Technical Report for the Fourth National Climate Assessment. U.S. Environmental Protection
Agency, EPA 430-R-17-001.
319 Cecchi, L., d'Amato, G., Ayres, J.G., Galan, C., Forastiere, F., Forsberg, B., Gerritsen, J., Nunes, C., Behrendt, H.,
Akdis, C. and Dahl, R., 2010. Projections of the effects of climate change on allergic asthma: the contribution of
aerobiology. Allergy, 65(9), pp. 1073-1081.
320 Sheffield, P.E., Weinberger, K.R. and Kinney, P.L, 2011. Climate change, aeroallergens, and pediatric allergic
disease. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(1), pp.78-84.
321 Sheffield, P.E., Weinberger, K.R. and Kinney, P.L, 2011. Climate change, aeroallergens, and pediatric allergic
disease. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(1), pp.78-84.
322 Ziska, LH. 2021. Climate, Carbon Dioxide, and Plant-Based Aero-Allergens: A Deeper Botanical Perspective.
Front. Allergy 2:714724.
323 Reid, C.E. and Gamble, J.L., 2009. Aeroallergens, allergic disease, and climate change: impacts and adaptation.
EcoHealth, 6, pp.458-470.
324 Sheffield, P.E., Weinberger, K.R. and Kinney, P.L, 2011. Climate change, aeroallergens, and pediatric allergic
disease. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(1), pp.78-84.
325 Saha, S., Vaidyanathan, A., Lo, F., Brown, C. and Hess, J.J., 2021. Short term physician visits and medication
prescriptions for allergic disease associated with seasonal tree, grass, and weed pollen exposure across the
United States. Environmental Health, 20(1), pp.1-12.
326 Cecchi, L., d'Amato, G., Ayres, J.G., Galan, C., Forastiere, F., Forsberg, B., Gerritsen, J., Nunes, C., Behrendt, H.,
Akdis, C. and Dahl, R., 2010. Projections of the effects of climate change on allergic asthma: the contribution of
aerobiology. Allergy, 65(9), pp. 1073-1081.
327 Sheffield, P.E., Weinberger, K.R. and Kinney, P.L, 2011. Climate change, aeroallergens, and pediatric allergic
disease. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 78(1), pp.78-84.
328 Smith, D.H., Malone, D.C., Lawson, K.A., Okamoto, L.J., Battista, C. and Saunders, W.B., 1997. A national
estimate of the economic costs of asthma. American Journal of Respiratory and Critical Care Medicine, 156(3),
pp.787-793.
329 Stanford, R., Mclaughlin, T. and Okamoto, L.J., 1999. The cost of asthma in the emergency department and
hospital. American journal of respiratory and critical care medicine, 160(1), pp.211-215.
330 Law, A.W., Reed, S.D., Sundy, J.S. and Schulman, K.A., 2003. Direct costs of allergic rhinitis in the United States:
estimates from the 1996 Medical Expenditure Panel Survey. Journal of Allergy and Clinical Immunology, 111(2),
pp.296-300.
331 Meltzer, E.O., Blaiss, M.S., Derebery, M.J., Mahr, T.A., Gordon, B.R., Sheth, K.K., Simmons, A.L, Wingertzahn,
M.A. and Boyle, J.M., 2009. Burden of allergic rhinitis: results from the Pediatric Allergies in America survey.
Journal of Allergy and Clinical Immunology, 124(3), pp.S43-S70.
332 Wegienka, G., Johnson, C.C., Zoratti, E. and Havstad, S., 2013. Racial differences in allergic sensitization: recent
findings and future directions. Current Allergy and Asthma Reports, 13(3), pp.255-261.
333 U.S. Centers for Disease Control and Prevention. "Percentage of children with current asthma by race and
state/territory." Last updated June 11, 2018. Accessed January 12, 2023. Available at:
https://www.cdc.gov/asthma/asthmadata/Child_Prevalence_Race.html
334 Willwerth, J., M. Sheahan, N. Chan, C. Fant, J. Martinich, and M. Kolian. 2023. 'The effects of climate change on
outdoor recreation participation in the United States: Projections for the 21st century." Weather, Climate, and
Society.
335 Wobus, C., Small, E.E., Hosterman, H., Mills, D., Stein, J., Rissing, M., Jones, R., Duckworth, M., Hall, R., Kolian,
M. and Creason, J., 2017. Projected climate change impacts on skiing and snowmobiling: A case study of the
United States. Global Environmental Change, 45, pp.1-14.
336 National Ski Areas Association. 2022. "U.S. Downhill Snowsports Participant Demographics 2021/22." Available
online at: https://nsaa.org/webdocs/Media_Public/lndustryStats/Skier_Demographics_2022.pdf. Accessed
November 2022.
April 2023
99
-------
Climate Change and Children's Health and Well-Being in the United States
337 Jones, R., Travers, C., Rodgers, C., Lazar, B., English, E., Lipton, J., Vogel, J., Strzepek, K. and Martinich, J., 2013.
Climate change impacts on freshwater recreational fishing in the United States. Mitigation and Adaptation
Strategies for Global Change, 18(6), pp.731-758.
338 Statista. "Distribution of recreational fishing participants in the United States in 2021, by age group." Available
here: https://www.statista.com/statistics/315844/age-distribution-of-fishing-participants-us/. Accessed
November 2022.
339 Chapra, S.C., Boehlert, B., Fant, C., Bierman Jr, V.J., Henderson, J., Mills, D., Mas, D.M., Rennels, L, Jantarasami,
L., Martinich, J. and Strzepek, K.M., 2017. Climate change impacts on harmful algal blooms in US freshwaters: a
screening-level assessment. Environmental Science & Technology, 51(16), pp.8933-8943.
340 Fleming, E., J. Payne, W. Sweet, M. Craghan, J. Haines, J.F. Hart, H. Stiller, and A. Sutton-Grier, 2018: Coastal
Effects. In Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II
[Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.LM. Lewis, T.K. Maycock, and B.C. Stewart (eds.)].
U.S. Global Change Research Program, Washington, DC, USA, pp. 322-352.
341 U.S. Climate Resilience Toolkit, "Inland Flooding." Retrieved from: https://toolkit.climate.gov/topics/coastal-
flood-risk/inland-flooding. Accessed: April 1, 2022.
342 National Oceanic and Atmospheric Administration. "Severe Weather 101 - Flood Types". Retrieved from:
https://www.nssl.noaa.gov/education/svrwxl01/floods/types/. Accessed: March 16, 2022.
343 National Oceanic & Atmospheric Administration. "Storm Surge Overview." https://www.nhc.noaa.gov/surge/.
Last accessed: November 1, 2022.
344 National Oceanic & Atmospheric Administration. "Storm Surge Overview." https://www.nhc.noaa.gov/surge/.
Last accessed: November 1, 2022.
345 Wong, P.P., I.J. Losada, J.-P. Gattuso, J. Hinkel, A. Khattabi, K.L. Mclnnes, Y. Saito, and A. Sallenger, 2014: Coastal
systems and low-lying areas. In: Climate Change 2014: Impacts, Adaptation, and Vulnerability. Part A: Global
and Sectoral Aspects. Contribution of Working Group II to the Fifth Assessment Report of the
Intergovernmental Panel on Climate Change [Field, C.B., V.R. Barros, D.J. Dokken, K.J. Mach, M.D. Mastrandrea,
T.E. Bilir, M. Chatterjee, K.L. Ebi, Y.O. Estrada, R.C. Genova, B. Girma, E.S. Kissel, A.N. Levy, S. MacCracken, P.R.
Mastrandrea, and L.L White (eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York,
NY, USA, pp. 361-409.
346 U.S. Environmental Protection Agency. "Climate Change Indicators: Coastal Flooding". Retrieved from:
https://www.epa.gov/climate-indicators/climate-change-indicators-coastal-flooding. Accessed: March 16,
2022.
347 Ohl, C.A. and Tapsell, S., 2000. Flooding and human health: the dangers posed are not always obvious. BMJ,
321(7270), pp.1167-1168.
348 National Oceanic and Atmospheric Administration. "National Weather Service (NWS) Preliminary US Flood
Fatality Statistics." Retrieved from: https://www.weather.gov/arx/usflood. Last accessed: April 7, 2022.
349 National Oceanic and Atmospheric Administration. 2021. National Oceanic and Atmospheric Administration.
"National Weather Service (NWS) Preliminary US Flood Fatality Statistics." Retrieved from:
https://www.weather.gov/arx/usflood. Last accessed: April 7, 2022.
350 Terti, G., Ruin, I., Anquetin, S. and Gourley, J.J., 2017. A situation-based analysis of flash flood fatalities in the
United States. Bulletin of the American Meteorological Society, 98(2), pp.333-345.
351 Sharif, H.O., Hossain, M.M., Jackson, T. and Bin-Shafique, S., 2012. Person-place-time analysis of vehicle
fatalities caused by flash floods in Texas. Geomatics, Natural Hazards and Risk, 3(4), pp.311-323.
352 Davenport, F.V., Burke, M. and Diffenbaugh, N.S., 2021. Contribution of historical precipitation change to US
flood damages. Proceedings of the National Academy of Sciences, 118(4), p.e2017524118.
353 Han, Z. and Sharif, H.O., 2021. Analysis of flood fatalities in the United States, 1959-2019. Water, 13(13),
p.1871.
354 Terti, G., Ruin, I., Anquetin, S. and Gourley, J.J., 2017. A situation-based analysis of flash flood fatalities in the
United States. Bulletin of the American Meteorological Society, 98(2), pp.333-345.
April 2023
100
-------
Climate Change and Children's Health and Well-Being in the United States
355 Tomenchok, L.E., Gidley, M.L, Mena, K.D., Ferguson, A.C. and Solo-Gabriele, H.M., 2020. Children's abrasions in
recreational beach areas and a review of possible wound infections. International Journal of Environmental
Research and Public Health, 17(11), p.4060.
356 Virginia Department of Public Health. 2018. "Vibriosis (Non-Cholera) Fact Sheet." Available at:
https://www. vdh. Virginia.gov/epidemiology/epidemiology-fact-sheets/vibriosis-non-cholera/?pdf=1134.
357 Sheahan, M., Gould, C.A., Neumann, J.E., Kinney, P.L., Hoffmann, S., Fant, C., Wang, X. and Kolian, M., 2022.
Examining the relationship between climate change and vibriosis in the United States: projected health and
economic impacts for the 21st century. Environmental Health Perspectives, 130(8), p.087007.
358 Pouillot, R., Smith, M., Van Doren, J.M., Catford, A., Holtzman, J., Calci, K.R., Edwards, R., Goblick, G., Roberts,
C., Stobo, J. and White, J., 2022. Risk assessment of norovirus illness from consumption of raw oysters in the
United States and in Canada. Risk Analysis, 42(2), pp.344-369.
359 Demeter, K., Derx, J., Komma, J., Parajka, J., Schijven, J., Sommer, R., Cervero-Arago, S., Lindner, G., Zoufal-
Hruza, C.M., Linke, R. and Savio, D., 2021. Modelling the interplay of future changes and wastewater
management measures on the microbiological river water quality considering safe drinking water production.
Science of the Total Environment, 768, p. 144278.
360 Froelich, B.A. and Daines, D.A., 2020. In hot water: effects of climate change on Vibrio-human interactions.
Environmental Microbiology, 22(10), pp.4101-4111.
361 Shah, M.P. and Hall, A.J., 2018. Norovirus illnesses in children and adolescents. Infectious Disease Clinics, 32(1),
pp. 103-118.
362 Olds, H.T., Corsi, S.R., Dila, D.K., Halmo, K.M., Bootsma, M.J. and McLellan, S.L., 2018. High levels of sewage
contamination released from urban areas after storm events: A quantitative survey with sewage specific
bacterial indicators. PLoS Medicine, 15(7), p.el002614.
363 Ramesh, B., Jagger, M.A., Zaitchik, B.F., Kolivras, K.N., Swarup, S., Yang, B., Corpuz, B.G. and Gohlke, J.M., 2022.
Estimating changes in emergency department visits associated with floods caused by Tropical Storm Imelda
using satellite observations and syndromic surveillance. Health & Place, 74, p.102757.
364 D'Amato, G., Chong-Neto, H.J., Monge Ortega, O.P., Vitale, C., Ansotegui, I., Rosario, N., Haahtela, T., Galan, C.,
Pawankar, R., Murrieta-Aguttes, M. and Cecchi, L, 2020. The effects of climate change on respiratory allergy
and asthma induced by pollen and mold allergens. Allergy, 75(9), pp.2219-2228.
365 Rao, C.Y., Riggs, M.A., Chew, G.L, Muilenberg, M.L, Thorne, P.S., Van Sickle, D., Dunn, K.H. and Brown, C., 2007.
Characterization of airborne molds, endotoxins, and glucans in homes in New Orleans after Hurricanes Katrina
and Rita. Applied and Environmental Microbiology, 73(5), pp.1630-1634.
366 Bell, J.E., Herring, S.C., Jantarasami, L, Adrianopoli, C., Benedict, K., Conlon, K., Escobar, V., Hess, J., Luvall, J.,
Garcia-Pando, C.P. and Quattrochi, D., 2016. Ch. 4: Impacts of Extreme Events on Human Health (pp. 99-128).
US Global Change Research Program, Washington, DC.
367 Assari, S. and Moghani Lankarani, M., 2018, June. Poverty status and childhood asthma in white and black
families: National Survey of Children's Health. In Healthcare (Vol. 6, No. 2, p. 62). MDPI.
368 Yu, X., Feric, Z., Cordero, J.F., Meeker, J.D. and Alshawabkeh, A., 2018. Potential influence of temperature and
precipitation on preterm birth rate in Puerto Rico. Scientific Reports, 8(1), pp.1-9.
369 Traylor, C.S., Johnson, J.D., Kimmel, M.C. and Manuck, T.A., 2020. Effects of psychological stress on adverse
pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review. American Journal of
Obstetrics & Gynecology MFM, 2(4), p. 100229.
370 Laplante, D.P., Hart, K.J., O'Hara, M.W., Brunet, A. and King, S., 2018. Prenatal maternal stress is associated with
toddler cognitive functioning: The Iowa Flood Study. Early Hum Dev, 116, pp.84-92.
371 Kroska, E.B., O'Hara, M.W., Elgbeili, G., Hart, K.J., Laplante, D.P., Dancause, K.N. and King, S., 2018. The impact
of maternal flood-related stress and social support on offspring weight in early childhood. Archives of Women's
Mental Health, 21(2), pp.225-233.
372 Ramesh, B., Jagger, M.A., Zaitchik, B., Kolivras, K.N., Swarup, S., Deanes, L. and Gohlke, J.M., 2021. Emergency
department visits associated with satellite observed flooding during and following Hurricane Harvey. Journal of
Exposure Science & Environmental Epidemiology, 31(5), pp.832-841.
April 2023
101
-------
Climate Change and Children's Health and Well-Being in the United States
373 Ebi, K.L, J.M. Balbus, G. Luber, A. Bole, A. Crimmins, G. Glass, S. Saha, M.M. Shimamoto, J. Trtanj, and J.L.
White-Newsome. 2018. Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth
NationalClimate Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.LM. Lewis,
T.K. Maycock, and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 572-
603.
374 Burke, S.E., Sanson, A.V. and Van Hoorn, J., 2018. The psychological effects of climate change on children.
Current Psychiatry Reports, 20, pp. 1-8.
375 Dodgen, D., Donato, D., Kelly, N., La Greca, A., Morganstein, J., Reser, J., Ruzek, J., Schweitzer, S., Shimamoto,
M.M., Thigpen Tart, K., and Ursano, R., 2016. Ch. 8: Mental health and well-being. In: The Impacts of Climate
Change on Human Health in the United States: A Scientific Assessment. U.S. Global Change Research Program,
Washington, DC, 217-246.
376 National Institutes of Health, National Institute of Mental Health. "Post-traumatic stress disorder." Available at:
https://www.nimh.nih.gov/health/topics/post-traumatic-stress-disorder-ptsd. Accessed May 6, 2022. Last
updated: May 2019
377 Crandon, T.J., Dey, C., Scott, J.G., Thomas, H.J., AN, S. and Charlson, F.J., 2022. The clinical implications of
climate change for mental health. Nature Human Behaviour, pp. 1-8.
378 Sheth, C., McGlade, E. and Yurgelun-Todd, D., 2017. Chronic stress in adolescents and its neurobiological and
psychopathological consequences: an RDoC perspective. Chronic Stress, 1, p.2470547017715645.
379 Burke, S.E., Sanson, A.V. and Van Hoorn, J., 2018. The psychological effects of climate change on children.
Current Psychiatry Reports, 20, pp. 1-8.
380 Lu, Y., 2017. Hurricane flooding and environmental inequality: do disadvantaged neighborhoods have lower
elevations?. Socius, 3, p.2378023117740700.
381 Lichtveld, M., Covert, H., El-Dahr, J., Grimsley, L.F., Cohn, R., Watson, C.H., Thornton, E. and Kennedy, S., 2020. A
community-based participatory research approach to hurricane Katrina: when disasters, environmental health
threats, and disparities collide. American Journal of Public Health, 110(10), pp.1485-1489.
382 Collins, T.W., Grineski, S.E., Chakraborty, J. and Flores, A.B., 2019. Environmental injustice and Hurricane
Harvey: A household-level study of socially disparate flood exposures in Greater Houston, Texas, USA.
Environmental Research, 179, p.108772.
383 Chakraborty, J., Grineski, S.E. and Collins, T.W., 2019. Hurricane Harvey and people with disabilities:
Disproportionate exposure to flooding in Houston, Texas. Social Science & Medicine, 226, pp.176-181.
384 Chakraborty, J., Collins, T.W. and Grineski, S.E., 2019. Exploring the environmental justice implications of
Hurricane Harvey flooding in Greater Houston, Texas. American journal of public health, 109(2), pp.244-250.
385 Flores, A.B., Collins, T.W., Grineski, S.E. and Chakraborty, J., 2020. Disparities in health effects and access to
health care among Houston area residents after Hurricane Harvey. Public Health Reports, 135(4), pp.511-523.
386 Flores, A.B., Collins, T.W., Grineski, S.E. and Chakraborty, J., 2020. Social vulnerability to Hurricane Harvey:
Unmet needs and adverse event experiences in Greater Houston, Texas. International journal of disaster risk
reduction, 46, p.101521.
387 Tate, E., Rahman, M.A., Emrich, C.T. and Sampson, C.C., 2021. Flood exposure and social vulnerability in the
United States. Natural Hazards, 106(1), pp.435-457.
388 Neal, W.J., Bush, D.M. and Pilkey, O.H., 2005. Managed retreat. Encyclopedia of Coastal Science, pp.602-606.
389 Jantarasami, L., Novak, R., Delgado, R., Marino, E., McNeeley, S., Narducci, C., Raymond-Yakoubian, J.,
Singletary, L., Powys-White, K., 2018. Tribes and Indigenous peoples. In In Impacts, Risks, and Adaptation in the
United States: Fourth National Climate Assessment, Volume II [Reidmiller, D.R., Avery, C.W., Easterling, D.R.,
Kunkel, K.E., Lewis, K.L.M., Maycock, T.K., and Stewart, B.C. (eds.)]. U.S. Global Change Research Program,
Washington, DC, USA, pp. 572-603.
390 McAlpine, S.A. and Porter, J.R., 2018. Estimating recent local impacts of sea-level rise on current real-estate
losses: a housing market case study in Miami-Dade, Florida. Population Research and Policy Review, 37(6),
pp.871-895.
April 2023
102
-------
Climate Change and Children's Health and Well-Being in the United States
391 Eakin, H., Bojorquez-Tapia, L.A., Janssen, M.A., Georgescu, M., Manuel-Navarrete, D., Vivoni, E.R., Escalante,
A.E., Baeza-Castro, A., Mazari-Hiriart, M. and Lerner, A.M., 2017. Urban resilience efforts must consider social
and political forces. Proceedings of the National Academy of Sciences, 114(2), pp.186-189.
392 Ebi, K.L, J.M. Balbus, G. Luber, A. Bole, A. Crimmins, G. Glass, S. Saha, M.M. Shimamoto, J. Trtanj, and J.L.White-
Newsome. 2018. Human Health. In Impacts, Risks, and Adaptation in the United States: Fourth NationalClimate
Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock,
and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, pp. 572-603.
393 Neumann, J.E., Chinowsky, P., Helman, J., Black, M., Fant, C., Strzepek, K. and Martinich, J., 2021. Climate effects
on US infrastructure: the economics of adaptation for rail, roads, and coastal development. Climatic Change,
167(3), pp.1-23.
394 Dottori, F., Szewczyk, W., Ciscar, J.C., Zhao, F., Alfieri, L, Hirabayashi, Y., Bianchi, A., Mongelli, I., Frieler, K.,
Betts, R.A. and Feyen, L., 2018. Increased human and economic losses from river flooding with anthropogenic
warming. Nature Climate Change, 8(9), pp.781-786.
395 Wing, O.E., Bates, P.D., Smith, A.M., Sampson, C.C., Johnson, K.A., Fargione, J. and Morefield, P., 2018.
Estimates of present and future flood risk in the conterminous United States. Environmental Research Letters,
13(3), p.034023.
396 Wing, O.E., Lehman, W., Bates, P.D., Sampson, C.C., Quinn, N., Smith, A.M., Neal, J.C., Porter, J.R. and Kousky,
C., 2022. Inequitable patterns of US flood risk in the Anthropocene. Nature Climate Change, 12(2), pp.156-162.
397 Flores, A.B., Collins, T.W., Grineski, S.E., Amodeo, M., Porter, J.R., Sampson, C.C. and Wing, O., 2022. Federally
Overlooked Flood Risk Inequities in Houston, Texas: Novel Insights Based on Dasymetric Mapping and State-of-
the-Art Flood Modeling. Annals of the American Association of Geographers, pp.1-21.
398 Wobus, C., Porter, J., Lorie, M., Martinich, J. and Bash, R., 2021. Climate change, riverine flood risk and
adaptation for the conterminous United States. Environmental Research Letters, 16(9), p.094034.
399 Beard, C.B., Eisen, R.J., Barker, C.M., Garofalo, J.F., Hahn, M., Hayden, M., Monaghan, A.J., Ogden, N.H. and
Schramm, P.J., 2016. Ch. 5: Vectorborne Diseases (pp. 129-156). US Global Change Research Program,
Washington, DC.
400 U.S. Environmental Protection Agency. "Climate Change Indicators: Lyme Disease." Accessed from:
https://www.epa.gov/climate-indicators/climate-change-indicators-lyme-disease. Last updated: April 2021.
Last accessed: August 29, 2022.
401 Eisen, R.J., Eisen, L., Ogden, N.H. and Beard, C.B., 2016. Linkages of weather and climate with Ixodes scapularis
and Ixodes pacificus (Acari: Ixodidae), enzootic transmission of Borrelia burgdorferi, and Lyme disease in North
America. Journal of Medical Entomology, 53(2), pp.250-261.
402 Paull, S.H., Horton, D.E., Ashfaq, M., Rastogi, D., Kramer, L.D., Diffenbaugh, N.S. and Kilpatrick, A.M., 2017.
Drought and immunity determine the intensity of West Nile virus epidemics and climate change impacts.
Proceedings of the Royal Society B: Biological Sciences, 284(1848), p.20162078.
403 Liu-Helmersson, J., Brannstrom, A., Sewe, M.O., Semenza, J.C. and Rocklov, J., 2019. Estimating past, present,
and future trends in the global distribution and abundance of the arbovirus vector Aedes aegypti under climate
change scenarios. Frontiers in Public Health, 7, p.148.
404 Moore, S.M., Eisen, R.J., Monaghan, A. and Mead, P., 2014. Meteorological influences on the seasonality of
Lyme disease in the United States. The American Journal of Tropical Medicine and Hygiene, 90(3), p.486.
405 Ogden, N.H., Radojevic, M., Wu, X., Duwuri, V.R., Leighton, P.A. and Wu, J., 2014. Estimated effects of projected
climate change on the basic reproductive number of the Lyme disease vector Ixodes scapularis. Environmental
Health Perspectives, 122(6), pp.631-638.
406 Ginsberg, H.S., Hickling, G.J., Burke, R.L., Ogden, N.H., Beati, L, LeBrun, R.A., Arsnoe, I.M., Gerhold, R., Han, S.,
Jackson, K. and Maestas, L, 2021. Why Lyme disease is common in the northern US, but rare in the south: The
roles of host choice, host-seeking behavior, and tick density. PLoS Biology, 19(1), p.e3001066.
407 Beard, C.B., Eisen, R.J., Barker, C.M., Garofalo, J.F., Hahn, M., Hayden, M., Monaghan, A.J., Ogden, N.H. and
Schramm, P.J., 2016. Ch. 5: Vectorborne Diseases (pp. 129-156). US Global Change Research Program,
Washington, DC.
April 2023
103
-------
Climate Change and Children's Health and Well-Being in the United States
408 Radolf, J.D., Strle, K., Lemieux, J.E. and Strle, F., 2021. Lyme disease in humans. Current Issues in Molecular
Biology, 42(1), pp.333-384.
409 Seinost, G., Dykhuizen, D.E., Dattwyler, R.J., Golde, W.T., Dunn, J.J., Wang, I.N., Wormser, G.P., Schriefer, M.E.
and Luft, B.J., 1999. Four clones of Borrelia burgdorferi sensu stricto cause invasive infection in humans.
Infection and Immunity, 67(7), pp.3518-3524.
410 Dutta, A., Hunter, J.V. and Vallejo, J.G., 2021. Bannwarth syndrome: a rare manifestation of pediatric Lyme
neuroborreliosis. The Pediatric Infectious Disease Journal, 40(11), pp.e442-e444.
411 Kugeler, K.J., Mead, P.S., Schwartz, A.M. and Hinckley, A.F., 2021. Changing Trends in Age and Sex Distributions
of Lyme Disease—United States, 1992-2016. Public Health Reports, p.00333549211026777.
412 Steere, A.C., Strle, F., Wormser, G.P., Hu, L.T., Branda, J.A., Hovius, J.W., Li, X. and Mead, P.S., 2016. Lyme
borreliosis. Nature Reviews Disease Primers, 2(1), pp. 1-19.
413 Chason, M.E., Monaghan, M., Wang, J., Cheng, Y. and DeBiasi, R.L., 2019. Symptom resolution in pediatric
patients with Lyme disease. Journal of the Pediatric Infectious Diseases Society, 8(2), pp.170-173.
414 Beach, C.M., Hart, S.A., Nowalk, A., Feingold, B., Kurland, K. and Arora, G., 2020. Increasing burden of Lyme
carditis in United States children's hospitals. Pediatric Cardiology, 41(2), pp.258-264.
415 Wong, K., Sequeira, S. and Bechtel, K., 2020. Pediatric bilateral facial paralysis: an unusual presentation of Lyme
disease. Pediatric Emergency Care, 36(11), pp.e651-e653.
416 Sundheim, K.M., Levas, M.N., Balamuth, F., Thompson, A.D., Neville, D.N., Garro, A.C., Kharbanda, A.B.,
Monuteaux, M.C. and Nigrovic, L.E., 2021. Seasonality of acute Lyme disease in children. Tropical Medicine and
Infectious Disease, 6(4), p. 196.
417 Chason, M.E., Monaghan, M., Wang, J., Cheng, Y. and DeBiasi, R.L., 2019. Symptom resolution in pediatric
patients with Lyme disease. Journal of the Pediatric Infectious Diseases Society, 8(2), pp.170-173.
418 Mac, S., Bahia, S., Simbulan, F., Pullenayegum, E.M., Evans, G.A., Patel, S.N. and Sander, B., 2020. Long-term
sequelae and health-related quality of life associated with Lyme disease: a systematic review. Clinical Infectious
Diseases, 71(2), pp.440-452.
419 Beach, C.M., Hart, S.A., Nowalk, A., Feingold, B., Kurland, K. and Arora, G., 2020. Increasing burden of Lyme
carditis in United States children's hospitals. Pediatric Cardiology, 41(2), pp.258-264.
420 Mac, S., Bahia, S., Simbulan, F., Pullenayegum, E.M., Evans, G.A., Patel, S.N. and Sander, B., 2020. Long-term
sequelae and health-related quality of life associated with Lyme disease: a systematic review. Clinical Infectious
Diseases, 71(2), pp.440-452.
421 Krause, P.J., Telford III, S.R., Pollack, R.J., Ryan, R., Brassard, P., Zemel, L. and Spielman, A., 1992. Babesiosis: an
underdiagnosed disease of children. Pediatrics, 89(6), pp. 1045-1048.
422 Diuk-Wasser, M.A., Vannier, E. and Krause, P.J., 2016. Coinfection by Ixodes tick-borne pathogens: ecological,
epidemiological, and clinical consequences. Trends in Parasitology, 32(1), pp.30-42.
423 Saetre, K., Godhwani, N., Maria, M., Patel, D., Wang, G., Li, K.I., Wormser, G.P. and Nolan, S.M., 2018.
Congenital babesiosis after maternal infection with Borrelia burgdorferi and Babesia microti. Journal of the
Pediatric Infectious Diseases Society, 7(1), pp.el-e5
424 Schotthoefer, A.M., Hall, M.C., Vittala, S., Bajwa, R. and Frost, H.M., 2018. Clinical presentation and outcomes of
children with human granulocytic anaplasmosis. Journal of the Pediatric Infectious Diseases Society, 7(2), pp.e9-
el5.
425 Diuk-Wasser, M.A., Vannier, E. and Krause, P.J., 2016. Coinfection by Ixodes tick-borne pathogens: ecological,
epidemiological, and clinical consequences. Trends in Parasitology, 32(1), pp.30-42.
426 Gottlieb, M., Long, B. and Koyfman, A., 2018. The evaluation and management of Rocky Mountain spotted fever
in the emergency department: a review of the literature. The Journal of Emergency Medicine, 55(1), pp.42-50.
427 Cale, D.F. and McCarthy, M.W., 1997. Treatment of Rocky Mountain spotted fever in children. Annals of
Pharmacotherapy, 31(4), pp.492-494.
428 U.S. Centers for Disease Control & Prevention. Rocky Mountain Spotted Fever: Epidemiology and statistics.
Retrieved from: https://www.cdc.gov/rmsf/stats/index.html. Last updated: August 15, 2022.
April 2023
104
-------
Climate Change and Children's Health and Well-Being in the United States
429 Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
(NCEZID), Division of Vector-Borne Diseases (DVBD). "West Nile Virus". Last accessed: February 4, 2022.
Available at: https://www.cdc.gov/westnile/index.html.
430 Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases
(NCEZID), Division of Vector-Borne Diseases (DVBD). "West Nile Virus". Last accessed: February 4, 2022.
Available at: https://www.cdc.gov/westnile/index.html.
431 Brault, A.C., 2009. Changing patterns of West Nile virus transmission: altered vector competence and host
susceptibility. Veterinary Research, 40(2), pp.1-19.
432 Pridjian, G., Sirois, P.A., McRae, S., Hinckley, A.F., Rasmussen, S.A., Kissinger, P., Buekens, P., Hayes, E.B.,
O'Leary, D., Kuhn, S. and Swan, K.F., 2016. Prospective study of pregnancy and newborn outcomes in mothers
with West nile illness during pregnancy. Birth Defects Research Part A: Clinical and Molecular Teratology,
106(8), pp.716-723.
433 Dahm, T., Rudolph, H., Schwerk, C., Schroten, H. and Tenenbaum, T., 2016. Neuroinvasion and inflammation in
viral central nervous system infections. Mediators of Inflammation, 2016.
434 Barzon, L., Pacenti, M., Sinigaglia, A., Berto, A., Trevisan, M. and Palu, G., 2015. West Nile virus infection in
children. Expert Review of Anti-infective Therapy, 13(11), pp.1373-1386.
435 Hayes, E.B. and O'Leary, D.R., 2004. West Nile virus infection: a pediatric perspective. Pediatrics, 113(5),
pp.1375-1381..
436 Civen, R., Villacorte, F., Robles, D.T., Dassey, D.E., Croker, C., Borenstein, L, Harvey, S.M. and Mascola, L, 2006.
West Nile virus infection in the pediatric population. The Pediatric Infectious Disease Journal, 25(1), pp.75-78.
437 Barzon, L., Pacenti, M., Sinigaglia, A., Berto, A., Trevisan, M. and Palu, G., 2015. West Nile virus infection in
children. Expert Review of Anti-infective Therapy, 13(11), pp.1373-1386.
438 Autore, G., Bernardi, L., Perrone, S. and Esposito, S., 2021. Update on Viral Infections Involving the Central
Nervous System in Pediatric Patients. Children, 8(9), p.782.
439 Herring, R., Desai, N., Parnes, M. and Jarjour, I., 2019. Pediatric West Nile virus-associated neuroinvasive
disease: a review of the literature. Pediatric Neurology, 92, pp.16-25.
440 Collins-Sawaragi, Y.C., Koletsi, P., Donlevy, E.E. and Drysdale, S.B., 2022. Initial Seronegative West Nile Virus
Encephalitis in an Immunocompromised Child. The Pediatric Infectious Disease Journal, 41(1), pp.60-61.
441 Farnaes, L., Schiff, D., McElroy, A.K., Coufal, N.G., Crawford, J.R. and Cannavino, C., 2018. Encephalitis and
thalamic injury from neuroinvasive West Nile virus in children on treatment for acute lymphoblastic leukemia.
Pediatric Neurology, 80, pp.84-87.
442 Baker, R.E., Mahmud, A.S., Miller, I.F., Rajeev, M., Rasambainarivo, F., Rice, B.L, Takahashi, S., Tatem, A.J.,
Wagner, C.E., Wang, LF. and Wesolowski, A., 2022. Infectious disease in an era of global change. Nature
Reviews Microbiology, 20(4), pp. 193-205.
443 Hennessey, M., Fischer, M. and Staples, J.E., 2016. Zika virus spreads to new areas—region of the Americas,
May 2015-January 2016. American Journal of Transplantation, 16(3), pp.1031-1034.
444 van der Linden, H., Pessoa, A., van der Linden, A., Florencio, R.N., Carvalho, M.D.C. and van der Linden, V., 2022.
Epilepsy and EEG Abnormalities in Congenital Zika Syndrome. Journal of Clinical Neurophysiology, 39(4), pp.248-
252.
445 Lindsey, N. P., Porse, C. C., Potts, E., Hyun, J., Sandhu, K., Schiffman, E., Cervantes, K. B., White, J. L, Mason, K.,
Owens, K., Holsinger, C., Fischer, M., Staples, J. E., & Zika Virus Disease Enhanced Surveillance Working Group
(2020). Postnatally Acquired Zika Virus Disease Among Children, United States, 2016-2017. Clinical infectious
diseases : an official publication of the Infectious Diseases Society of America, 70(2), 227-231.
446 Ramond, A., Lobkowicz, L., Clemente, N. S., Vaughan, A., Turchi, M. D., Wilder-Smith, A., & Brickley, E. B. (2020).
Postnatal symptomatic Zika virus infections in children and adolescents: A systematic review. PLoS Neglected
Tropical Diseases, 14(10), e0008612.
447 Lee, B.Y., Alfaro-Murillo, J.A., Parpia, A.S., Asti, L, Wedlock, P.T., Hotez, P.J. and Galvani, A.P., 2017. The
potential economic burden of Zika in the continental United States. PLoS Neglected Tropical Diseases, 11(4),
p.e0005531.
April 2023
105
-------
Climate Change and Children's Health and Well-Being in the United States
448 Beard, C.B., Eisen, R.J., Barker, C.M., Garofalo, J.F., Hahn, M., Hayden, M., Monaghan, A.J., Ogden, N.H. and
Schramm, P.J., 2016. Ch. 5: Vectorborne Diseases (pp. 129-156). US Global Change Research Program,
Washington, DC.
449 Keener, V., Helweg, D., Asam, S., Balwani, S., Burkett, M., Fletcher, C., Giambelluca, T., Grecni, Z., Nobrega-
Olivera, M., Polovina, J. and Tribble, G., 2018. Hawai 7 and US-affiliated Pacific Islands (pp. 1242-1308). US
Global Change Research Program
450 U.S. Centers for Disease Control and Prevention. Eastern equine encephalitis virus. Retrieved from:
https://www.cdc.gov/easternequineencephalitis/index.html. Last updated: June 2, 2022. Last accessed:
December 28, 2022.
451 Crawley, J., Chu, C., Mtove, G. and Nosten, F., 2010. Malaria in children. The Lancet, 375(9724), pp.1468-1481.
452 Ward, C.E. and Chapman, J.I., 2018. Chikungunya in children: a clinical review. Pediatric Emergency Care, 34(7),
pp.510-515.
453 Adams, L.E., Martin, S.W., Lindsey, N.P., Lehman, J.A., Rivera, A., Kolsin, J., Landry, K., Staples, J.E., Sharp, T.M.,
Paz-Bailey, G. and Fischer, M., 2019. Epidemiology of dengue, chikungunya, and Zika virus disease in US States
and Territories, 2017. The American Journal of Tropical Medicine and Hygiene, 101(4), p.884.
454 Campbell, LP., Luther, C., Moo-Llanes, D., Ramsey, J.M., Danis-Lozano, R. and Peterson, A.T., 2015. Climate
change influences on global distributions of dengue and chikungunya virus vectors. Philosophical Transactions
of the Royal Society B: Biological Sciences, 370(1665), p. 20140135.
455 Little, E., Bajwa, W. and Shaman, J., 2017. Local environmental and meteorological conditions influencing the
invasive mosquito Ae. albopictus and arbovirus transmission risk in New York City. PLoS Neglected Tropical
Diseases, 11(8), p.e0005828.
456 Reidmiller, D.R., Avery, C.W., Easterling, D.R., Kunkel, K.E., Lewis, K.L, Maycock, T.K. and Stewart, B.C., 2017.
Impacts, risks, and adaptation in the United States: Fourth national climate assessment, volume II.
457 Ward, C.E. and Chapman, J.I., 2018. Chikungunya in children: a clinical review. Pediatric Emergency Care, 34(7),
pp.510-515.
458 Erraguntla, M., Dave, D., Zapletal, J., Myles, K., Adelman, Z.N., Pohlenz, T.D. and Lawley, M., 2021. Predictive
model for microclimatic temperature and its use in mosquito population modeling. Scientific Reports, 11(1),
pp.1-11.
459 Lai, A., Fearnley, E. and Wilford, E., 2019. Local weather, flooding history and childhood diarrhoea caused by the
parasite Cryptosporidium spp.: A systematic review and meta-analysis. Science of The Total Environment, 674,
pp.300-306.
460 Trtanj, J., Jantarasami, L., Brunkard, J., Collier, T., Jacobs, J., Lipp, E., McLellan, S., Moore, S., Paerl, H.,
Ravenscroft, J. and Sengco, M., 2016. Ch. 6: Climate impacts on water-related illness. The Impacts of Climate
Change on Human Health in the United States: A Scientific Assessment, pp.157-188.
461 Philipsborn, R., Ahmed, S.M., Brosi, B.J. and Levy, K., 2016. Climatic drivers of diarrheagenic Escherichia coli
incidence: a systematic review and meta-analysis. The Journal of Infectious Diseases, 214(1), pp.6-15.
462 Wu, X., Liu, J., Li, C. and Yin, J., 2020. Impact of climate change on dysentery: Scientific evidences, uncertainty,
modeling and projections. Science of The Total Environment, 714, p. 136702.
463 Lai, A., Fearnley, E. and Wilford, E., 2019. Local weather, flooding history and childhood diarrhoea caused by the
parasite Cryptosporidium spp.: A systematic review and meta-analysis. Science of The Total Environment, 674,
pp.300-306.
464 Wu, X., Liu, J., Li, C. and Yin, J., 2020. Impact of climate change on dysentery: Scientific evidences, uncertainty,
modeling and projections. Science of The Total Environment, 714, p. 136702.
465 Li, C., Wu, X., Ji, D., Liu, J., Yin, J. and Guo, Z., 2019. Climate change impacts the epidemic of dysentery:
determining climate risk window, modeling and projection. Environmental Research Letters, 14(10), p.104019.
466 Bula-Rudas, F.J., Rathore, M.H. and Maraqa, N.F., 2015. Salmonella infections in childhood. Advances in
Pediatrics, 62(1), pp.29-58.
467 Shoultz, D.A., de Hostos, E.L and Choy, R.K., 2016. Addressing Cryptosporidium infection among young children
in low-income settings: the crucial role of new and existing drugs for reducing morbidity and mortality. PLoS
Neglected Tropical Diseases, 10(1), p.e0004242.
April 2023
106
-------
Climate Change and Children's Health and Well-Being in the United States
468 Huang D.B., Chappell C., Okhuysen P.C., 2004. Cryptosporidiosis in children. Semin Pediatr Infect Dis. (4):253-9.
469 Lindsey, N.P., Hayes, E.B., Staples, J.E. and Fischer, M., 2009. West Nile virus disease in children, United States,
1999-2007. Pediatrics, 123(6), pp.el084-el089.
470Springer, Y. P., & Johnson, P. T. J. (2018). Large-scale health disparities associated with Lyme disease and human
monocytic ehrlichiosis in the United States, 2007-2013. PloS One, 13(9), e0204609.
471 Hunt, K.M., Michelson, K.A., Balamuth, F., Thompson, A.D., Levas, M.N., Neville, D.N., Kharbanda, A.B.,
Chapman, L, Nigrovic, LE. and Pedi Lyme Net, 2023. Racial differences in the diagnosis of Lyme disease in
children. Clinical Infectious Diseases, 76(6), pp.1129-1131.
472 Fix, A.D., Pena, C.A. and Strickland, G.T., 2000. Racial differences in reported Lyme disease incidence. American
Journal of Epidemiology, 152(8), pp.756-759.
473 Garro, A. C., Thompson, A. D., Neville, D. N., Balamuth, F., Levas, M. N., Kharbanda, A. B., Bennett, J. E., Grant,
D. S., Aresco, R. K., Nigrovic, L. E., & Pedi Lyme Net Network (2022). Empiric antibiotics for children with
suspected Lyme disease. Ticks and Tick-Borne Diseases, 13(5), 101989.
474 Schwartz, A.M., Hinckley, A.F., Mead, P.S., Hook, S.A. and Kugeler, K.J., 2017. Surveillance for lyme disease-
United States, 2008-2015. MMWR Surveillance Summaries, 66(22), p.l.
475 Springer, Y.P. and Johnson, P.T., 2018. Large-scale health disparities associated with Lyme disease and human
monocytic ehrlichiosis in the United States, 2007-2013. PLoS One, 13(9), p.e0204609.
476 Hook, S.A., Jeon, S., Niesobecki, S.A., Hansen, A.P., Meek, J.I., Bjork, J.K., Dorr, F.M., Rutz, H.J., Feldman, K.A.,
White, J.L. and Backenson, P.B., 2022. Economic Burden of Reported Lyme Disease in High-Incidence Areas,
United States, 2014-2016. Emerging Infectious Diseases, 28(6), p.1170.
477 Griffin, I., Zhang, G., Fernandez, D., Cordero, C., Logue, T., White, S.L., Llau, A., Thomas, L, Moore, E., Noya-
Chaveco, P. and Etienne, M., 2017. Epidemiology of pediatric Zika virus infections. Pediatrics, 140(6).
478 Monaghan, A.J., Morin, C.W., Steinhoff, D.F., Wilhelmi, O., Hayden, M., Quattrochi, D.A., Reiskind, M., Lloyd,
A.L., Smith, K., Schmidt, C.A. and Scalf, P.E., 2016. On the seasonal occurrence and abundance of the Zika virus
vector mosquito Aedes aegypti in the contiguous United States. PLoS Currents, 8.
479 Bisanzio, D., Martello, E., Izenour, K., Stevens, K., Kaur, R., McKenzie, B.A., Kraemer, M., Reithinger, R. and
Zohdy, S., 2021. Arboviral diseases and poverty in Alabama, 2007-2017. PLOS Neglected Tropical Diseases,
15(1), p.e0009535.
480 Yang, H., Gould, C.A., Jones, R., St. Juliana, A., Sarofim, M., Rissing, M., and Hahn, M. (in review) "Modeling the
by-degree human health and economic impacts of Lyme disease in the eastern United States under climate
change."
481 Steere, A. C., Strle, F., Wormser, G. P., Hu, L. T., Branda, J. A., Hovius, J. W., Li, X., & Mead, P. S., 2016. Lyme
borreliosis. Nature Reviews, Disease Primers, 2.
482 Beard, C.B., Eisen, R.J., Barker, C.M., Garofalo, J.F., Hahn, M., Hayden, M., Monaghan, A.J., Ogden, N.H. and
Schramm, P.J., 2016. Ch. 5: Vectorborne Diseases (pp. 129-156). US Global Change Research Program,
Washington, DC.
483 Ogden, N.H., Radojevic, M., Wu, X., Duwuri, V.R., Leighton, P.A. and Wu, J., 2014. Estimated effects of projected
climate change on the basic reproductive number of the Lyme disease vector Ixodes scapularis. Environmental
Health Perspectives, 122(6), pp.631-638.
484 Ginsberg, H.S., Hickling, G.J., Burke, R.L., Ogden, N.H., Beati, L, LeBrun, R.A., Arsnoe, I.M., Gerhold, R., Han, S.,
Jackson, K. and Maestas, L, 2021. Why Lyme disease is common in the northern US, but rare in the south: The
roles of host choice, host-seeking behavior, and tick density. PLoS Biology, 19(1), p.e3001066.
485 Moore, S.M., Eisen, R.J., Monaghan, A. and Mead, P., 2014. Meteorological influences on the seasonality of
Lyme disease in the United States. The American Journal of Tropical Medicine and Hygiene, 90(3), p.486.
486 Eisen, R.J., Eisen, L., Ogden, N.H. and Beard, C.B., 2016. Linkages of weather and climate with Ixodes scapularis
and Ixodes pacificus (Acari: Ixodidae), enzootic transmission of Borrelia burgdorferi, and Lyme disease in North
America. Journal of Medical Entomology, 53(2), pp.250-261.
487 Beard, C.B., Eisen, R.J., Barker, C.M., Garofalo, J.F., Hahn, M., Hayden, M., Monaghan, A.J., Ogden, N.H. and
Schramm, P.J., 2016. Ch. 5: Vectorborne Diseases (pp. 129-156). US Global Change Research Program,
Washington, DC.
April 2023
107
-------
Climate Change and Children's Health and Well-Being in the United States
488 Ginsberg, H.S., Hickling, G.J., Burke, R.L., Ogden, N.H., Beati, L, LeBrun, R.A., Arsnoe, I.M., Gerhold, R., Han, S.,
Jackson, K. and Maestas, L, 2021. Why Lyme disease is common in the northern US, but rare in the south: The
roles of host choice, host-seeking behavior, and tick density. PLoS Biology, 19(1), p.e3001066.
489 Beard, C.B., Eisen, R.J., Barker, C.M., Garofalo, J.F., Hahn, M., Hayden, M., Monaghan, A.J., Ogden, N.H. and
Schramm, P.J., 2016. Ch. 5: vectorborne diseases (pp. 129-156). US Global Change Research Program,
Washington, DC.
490 U.S. Environmental Protection Agency. "Climate Change Indicators: Lyme Disease." Accessed from:
https://www.epa.gov/climate-indicators/climate-change-indicators-lyme-disease. Last updated: April 2021.
Last accessed: August 29, 2022.
491 Nelson, C.A., Saha, S., Kugeler, K.J., Delorey, M.J., Shankar, M.B., Hinckley, A.F. and Mead, P.S., 2015. Incidence
of clinician-diagnosed Lyme disease, United States, 2005-2010. Emerging Infectious Diseases, 21(9), p.1625.
492 Cartter, M.L, Lynfield, R., Feldman, K.A., Hook, S.A. and Hinckley, A.F., 2018. Lyme disease surveillance in the
United States: looking for ways to cut the Gordian knot. Zoonoses and Public Health, 65(2), pp.227-229.
493 Kugeler, K.J., Mead, P.S., Schwartz, A.M. and Hinckley, A.F., 2021. Changing Trends in Age and Sex Distributions
of Lyme Disease—United States, 1992-2016. Public Health Reports, p.00333549211026777.
494 Adrion, E.R., Aucott, J., Lemke, K.W. and Weiner, J.P., 2015. Health care costs, utilization and patterns of care
following Lyme disease. PloS One, 10(2), p.e0116767.
495 Barzon, L., Pacenti, M., Sinigaglia, A., Berto, A., Trevisan, M. and Palu, G., 2015. West Nile virus infection in
children. Expert Review of Anti-infective Therapy, 13(11), pp.1373-1386.
496 Barzon, L., Pacenti, M., Sinigaglia, A., Berto, A., Trevisan, M. and Palu, G., 2015. West Nile virus infection in
children. Expert Review of Anti-infective Therapy, 13(11), pp.1373-1386.
497 Belova, A., Mills, D., Hall, R., Juliana, A.S., Crimmins, A., Barker, C. and Jones, R., 2017. Impacts of increasing
temperature on the future incidence of West Nile neuroinvasive disease in the United States. American Journal
of Climate Change, 6(01), p. 166.
498 Belova, A., Mills, D., Hall, R., Juliana, A.S., Crimmins, A., Barker, C. and Jones, R., 2017. Impacts of increasing
temperature on the future incidence of West Nile neuroinvasive disease in the United States. American Journal
of Climate Change, 6(01), p. 166.
April 2023
108
------- |