Children's Environmental Health
Background

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It may often be confusing to understand what different organizations mean when they use the term "environmental health." Years ago, environmental health focused on sanitation, infectious disease, and food safety. After many successful interventions to improve sanitation and food and water safety, the risks from infectious disease decreased. Meanwhile, as chemicals became ubiquitous in the environment, environmental health broadened to include chemical pollutants. Ensuring that humans are not exposed to unsafe levels of pollutants became a priority. Today environmental health is viewed even more broadly, and includes the environment that we create for ourselves and children, both individually and collectively. A healthy environment depends on activity level, food and drink choices, smoking status, social connections, family violence, and other factors. Environmental health has even broadened to include health considerations associated with the design of homes, buildings, roadways, and communities.

There is no single definition of "children's environmental health." In contrast to the broad use of "environmental health," "children's environmental health" (as commonly used) focuses on chemical contaminants and the health effects resulting from exposure during childhood.

The focus of the content on these children's environmental health web pages is on chemical pollutants and the hazards they pose as a result of exposure during childhood, a period which spans conception through adolescence. This use of "children's environmental health" is consistent with the U.S. Environmental Protection Agency and the National Institute of Environmental Health Sciences.

The Minnesota Department of Health (MDH) has programs that focus on different aspects of the broadest definition of environmental health. Infectious disease, injury prevention, and safety, for example, are important concerns for children and adults and are addressed by different divisions of the department. The Environmental Health Division of the MDH also has developed children's environmental health initiatives that focus on protecting children from chemical pollutants.

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MDH initiatives

Children's environmental heath is an important concern to the MDH. The MDH has incorporated consideration of children's special vulnerabilities and exposures into existing programs and has developed special initiatives to safeguard children's health from hazards in the environment. The MDH has a long history of working to protect children's health. Many successful years of implementing health protection programs and collaborating with partners to protect children's health have provided the foundation on which new children's environmental health initiatives are built. The MDH has programs to address well-established environmental health hazards, and also actively investigates emerging hazards that are poorly understood and lack scientific data or proven interventions. The MDH regularly collaborates with other state and local agencies, non-profit organizations, academic institutions, and professional groups. Working with partners is a key feature of many successful MDH initiatives.

The MDH Environmental Health Division houses many programs with a special emphasis on children. For more information on these programs and other MDH programs focusing on children's environmental health, visit MDH Initiatives.

There are also many programs in the MDH (outside the Division of Environmental Health) that work to protect children's health. MDH programs focus on a variety of child health issues, such as immunizations, obesity, violence and safety, asthma, physical activity, infectious disease, nutrition, school health, and tobacco use. MDH staff are working to reduce infant mortality, improve the quality of life for children with special health care needs, and improve child and adolescent health and safety. For more information on these initiatives, see Life Stages and Populations.

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Special concerns for children

Most people have heard the phrase "children are not little adults." There are several reasons why environmental contaminants may have a different effect on children compared to adults. One reason is that exposures may be different; the other reason is that an environmental chemical may affect children differently than adults. In recent years there has been much research to learn more about the differences between adults and children that lead to differences in vulnerability to toxic substances.

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Children may be more exposed

Children may be more exposed to environmental contaminants. Children eat, drink, and breathe more per pound of body weight than adults. That means that in proportion to body weight, children are more exposed than adults to contaminants in air, food, water, and soil. Very young children also have unique behaviors, such as mouthing objects and crawling on floors. These behaviors will increase the contact that young children have with contaminants in soil and dust. The diets of infants and children are also different than adult diets. During infancy children drink breast milk or formula, and once weaned, children do not have a varied diet but are slowly introduced to new foods. Adverse health effects can result from parental exposures before conception, the time period near conception, and during pregnancy, as well as during childhood through adolescence. (1)

    Air Intake
    Pound for pound of body weight, children breathe more air than do adults. It is estimated that the average air intake of a resting infant is twice that of a resting adult on a body weight basis. (2, 3) That means, for example, that a 6-month old child will inhale twice the dose of radon as an adult. In addition, the breathing zones of children are closer to the floor than those of adults, where heavier airborne contaminants such as radon tend to accumulate. (4, 5)

    Food and Drink Consumption
    In its 1993 landmark report Pesticides in the Diets of Infants and Children, the National Research Council (NRC) concluded that on a body weight basis, children eat more calories and drink more water than adults. (6) Children must not only maintain homeostasis, but also consume the energy needed for growth. The Agency for Toxic Substances and Disease Registry reported that "children in the first six months of life drink seven times as much water per pound as average American adults. Children one through five years of age eat three to four (or more) times as much food per pound body weight as average American adults." (2)

    The NRC also concluded that diversity in types of food consumed increases with age. (6) Certain foods (such as human breast milk, fruit juice, fruit, and cow's milk) are consumed much more frequently by children. (6) Breast milk and formula are foods consumed only by very young children. For infants at certain ages, breast milk or formula is the only source of nourishment. There is a special concern about contaminants in breast milk and formula because they make up either all or a large proportion of a child's diet. For some toxicants, the most significant exposure during infant development is through breast milk. At this time, health scientists believe the benefits of breastfeeding outweigh the risks. Because children's diets are less varied and they consume more food than adults in proportion to their body weight, they may be more exposed to contaminants in food.

    Dermal Exposure
    Children have higher skin surface area to body weight ratios and greater contact with their surroundings. (7) Therefore, children may absorb through their skin a larger dose of a pollutant on a body weight basis than would an adult. Newborns, especially those that are pre-term, have increased absorption of some compounds through the skin. (8)

    Transplacental Exposure
    Fetuses can also be exposed to toxicants and are very susceptible to harmful effects. Available data on fetal exposures to diethylstilbestrol (DES), thalidomide, alcohol, and tobacco smoke show significant adverse health effects. (9) Depending on the timing of the exposure, there may be different health effects. Some chemicals that get into a pregnant woman's body will cross the placenta and may even concentrate in fetal tissue. (10)

    Children have unique behaviors
    girl with dogAs children pass rapidly through developmental phases, their activity patterns and behaviors change. Newborns spend prolonged periods of time in a single environment and are unable to voluntarily decrease exposure to some environmental hazards because they are unable to recognize a hazard and incapable of crawling or walking away. (4) Toddlers are more mobile and spend more time on floors, carpets, and grass. Behaviors such as pica, crawling, and oral exploratory activity increase ingestion of contaminants on surfaces. For example, children can experience greater exposure to pesticide residues from grass, lead dusts from floors, volatile organic chemicals from carpets, and chromated copper arsenate (CCA) from wood playground equipment. (4)

    Children spend time in unique environments such as day care facilities, school buildings, gymnasiums, and playgrounds. Hazards in these environments are of special concern. Harmful exposures are also possible at the workplaces of teenagers.

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Children are still developing and may be more sensitive than adults

Children also may be uniquely sensitive to environmental contaminants. It takes time for infants to develop the cellular proteins and functions that often protect an adult from toxic exposures. During infancy, organs like the kidney do not have adult capabilities for removing toxins from the body. A child's cells are dividing, changing, and growing from conception through adolescence in ways that are different than the cells of adults. Some contaminants have toxic effects during childhood that an adult will not experience. The reverse is also true - sometimes adults are more susceptible to a contaminant.

Physiological and biochemical differences between children and adults can have a large effect on how environmental contaminants act on the body. From birth through childhood, children differ from adults in their ability to absorb, metabolize, and excrete contaminants. (11) Factors that affect absorption of compounds include gastric pH level, intestinal emptying time, amount of natural intestinal flora, and presence of metabolic enzymes. (12) Detoxifying enzyme systems develop throughout childhood, so the ability to detoxify chemicals or activate xenobiotics to reactive intermediates is age-dependent. (11) By one year of age, metabolic capacity appears to be similar to that of an adult. (12) Children may be less able to eliminate some compounds because, for example, they are less efficient at excreting contaminants via the kidneys or bile. (11) Children also differ from adults in the composition (water, fat, protein, and mineral content) of their bodies and their immune response. (6, 13) As organ systems develop, they may be more or less sensitive to damage than the mature systems of adults.

There is ample evidence to show that the unique developmental stages experienced in childhood make children more vulnerable to harmful effects from exposures to certain hazards in the environment than adults. For example, there are several contaminants that affect the developing brain. As it passes through different stages of development, the brain is uniquely sensitive to some contaminants. Adverse effects from lead differentially affect children because their brain is developing and because they are more exposed. Lead is known to cause learning problems and reduce intelligence. (14) Lead exposure can also contribute to attention-deficit/hyperactivity disorder and distractibility and increases the risk for antisocial and delinquent behavior. (14)

The developing brain is also sensitive to exposure to organic mercury (methylmercury). In utero exposure to methylmercury can affect the developing brain by "disrupt[ing] normal patterns or neuronal migration and nerve cell histology." (15) Evidence for the toxicity of methylmercury resulted from poisoning incidents in Iraq and Minamata Bay. Exposed mothers who had no or mild adverse effects gave birth to severely affected children. (15)

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Children have more future years

Another reason that environmental contaminants may pose a greater risk to children than adults is that children have more future years to develop diseases with long latency periods. (16) For example, if a 70 year old adult and a 5 year old child are first exposed to a carcinogen that shows its effects after 40 years, the result is that the child's life is much more affected. Diseases requiring chronic exposure are likely to have more serious impacts when children are exposed throughout their lifetime beginning at an early age. (17) Furthermore, cancer risk is believed to be "front-loaded." Some scientists have found (using animal studies) that a large portion of a lifetime risk of cancer from some environmental carcinogens is actually due to exposures early in life rather than the total exposure throughout life.

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A broader look at children's environmental health

Balancing Risks and Benefits

When safer alternatives are not available, the use of some chemicals requires a balancing of risk and benefit. Public health professionals frequently have to weigh the risks and benefits associated with an activity, even when considerable uncertainty exists about the fate of the chemical in the environment, human exposures, and health effects.

A common example of an activity that requires a balancing of risk and benefit is the application of pesticides. The targeted use of pesticides can be beneficial to children's health because food is more plentiful and nutritional status is enhanced, and because children's burden of diseases transmitted by vectors such as mosquitoes is reduced. These benefits need to be weighed against the risks of neurodevelopmental effects in children resulting from chronic, low-level exposures or acute poisoning incidents resulting from inappropriate use, storage, and disposal. In this case, the weight given to various risks and benefits will differ depending on geographical region and other factors. There are health protective actions that have been undertaken, including the promotion of integrated pest management to reduce reliance on chemical pesticides, the elimination of pesticides that have the potential to pose the greatest risks to children, the provision of information on safe application and disposal to professionals and families, research on health effects and safer alternatives, and the involvement of communities.

Environmental contaminants are ubiquitous. All humans have some level (albeit usually a low level) of environmental pollutants in their bodies. According to the World Health Organization (WHO), "Over 40 percent of the environmental disease burden falls on children under 5 years of age, yet [they] constitute only 10 percent of the world population." (18) Around the world, the hazards that children face vary greatly and are largely dependent on geographic, economic, and social determinants. Poverty, especially, can exacerbate environmental risk factors. (19)

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Risks around the world

The WHO has categorized environmental health risks to children as "basic," "modern," and "emerging." (19) Basic risks are unhealthy housing, unsafe water supply, lack of sanitation, indoor air pollution, and leaded gasoline. Risks that are considered modern are chronic respiratory illness and asthma, injuries from transport accidents, toxic chemicals, and neurodevelopmental and behavioral effects. Emerging risks are, for example, endocrine disruptors, environmental allergens, and UV radiation. Basic risks are more significant for children in poverty-stricken countries and modern risks face children in industrialized countries. As populations transition from low to high income, basic risks decrease and modern risks increase. Emerging risks tend to affect all children. The pattern of leading environmental health problems in children shifts as more countries develop. (19)

Hazards that children face are determined, in part, by the geographic location where the child is raised (developed or developing country, urban or rural area), income and educational level of the family and community, and cultural factors. For example, lead poisoning remains a problem for children all over the world, but priorities for interventions are different depending on location. Children in some developing countries are exposed to lead in gasoline. In the U.S., lead was banned as a gasoline additive in the 1970s but remains a problem particularly for children who live in pre-1950s housing with deteriorated paint. Some cultures in both developing and developed countries use lead in home remedies. Because living conditions and environmental health risks vary so greatly from country to country, in regions within different countries, and among population segments in a community, interventions and priorities for action need to be carefully tailored to be most effective.

Although children all over the world are exposed to environmental health risks, the type and magnitude of risks facing children in the United States are often unique. Children who grow up in the U.S. are, in general, healthier than those in many parts of the world. The last century of public health and technological progress has afforded significant improvements in children's health. However, environmental hazards still affect children's health. Children have been exposed to environmental health hazards for hundreds of years and they continue to be exposed. Some exposures were recognized as being harmful centuries ago, while it has taken longer for the toxicity of others to be discovered. Among the fairly new chemicals emitted into the environment, some have been identified as toxic and others will likely be identified as harmful in the future as more research is conducted. Many resources are devoted to understanding which exposures are hazardous for children. Decreasing children's exposures to both familiar and emerging environmental contaminants is a public health priority.

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Environmental health hazards

There are various interpretations of what hazards are considered environmental in origin. Environmental factors may include contaminants that are naturally present, manufactured or used by humans for a specific purpose, or by-products of an activity. (20) The built environment, consumer products, and social factors may also affect health.

Naturally-present hazards include, for example, radioactive materials such as rock and soil that emit radon, metals such as arsenic that contaminate drinking water, particulate matter that results from forest fires, wind, and erosion, infectious pathogens that contaminate food, and dust mites that could cause allergic responses in sensitized children. The spatial and temporal distribution of naturally present contaminants tends not to be uniform throughout the U.S.

Some contaminants are manufactured or spread through the environment for human purposes. These contaminants may be presently being dispersed through human use or may have previously been used for certain purposes. Examples include pesticides used on food crops, lead used in paint or automobile gasoline, Bisphenol A used in plastic bottles, and phthalates used in children's toys. Information on how to reduce or avoid children's exposure to these chemicals, visit Chemicals of Special Concern to Children's Health.

By-products of activities and production processes include, for example, chloroform in drinking water resulting from chlorination of water supplies, nitrogen oxides from combustion, or many hazardous compounds in cigarette smoke. By-products of activities can also include substances that contaminate other substances; for example, radioactive materials and their decay products often are present in phosphate fertilizer products. (21)

Consumer products that are designed for children may cause choking or injury hazards or have unacceptable levels of known toxicants. Art and craft products intended for children can contain substances known to be hazardous. (15) Products designed for adult use may also be hazardous to children. Examples include cleaning products, firearms, and automobiles.

child on playgroundThe built environment can also affect health. (22) Poorly designed playground equipment or stairways may contribute to unintentional injuries. Urban planning that does not take into account public health may make cross walks and intersections unsafe, thereby discouraging walking and bicycling and encouraging transportation in vehicles. Greater automobile use, in turn, can result in higher levels of pollution from exhaust, greater incidence of injuries from collisions, and lower levels of physical activity. (23)

There are also many social factors that affect children's health and may act in combination with environmental hazards to exacerbate adverse health effects. For example, exposure to environmental contaminants likely varies based on the socio-economic status of the child. (24) Factors that may be affected by a child's socio-economic status include the distance he or she lives from the source of pollution, whether the home is in an urban, suburban, or rural area, the condition and age of the home, and the quality of the drinking water supply. (24) Psychosocial stresses may impact a child's health. For example, lack of supportive relationships and community resources, violence, and financial worries are risk factors for greater asthma problems for some children in inner-city environments. (25) In some cases, environmental health effects are moderated by factors such as nutritional status and level of parental stimulation during development. (26) Social factors are extremely important to a child's health and development.

Protecting children's health from hazards in the environment requires the involvement of many parties. Professionals whose work may include some aspect of children's environmental health are trained in a number of different disciplines, including public health, environmental sciences, health sciences, health care, urban planning, psychology, education, social sciences, and others. Parents, guardians, and childcare providers certainly play a very important role in keeping kids safe and healthy as well.

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Children's health risks have changed over the last century

In the last century, there have been many significant advances in public health that have increased the life expectancy of Americans. In 1900, top causes of death included infectious diseases such as pneumonia/influenza, tuberculosis, diarrheal diseases, and diphtheria. (27) Overcrowding, poor housing conditions, and inadequate water treatment and waste disposal systems in the early 1900s resulted in outbreaks of cholera, dysentery, TB, typhoid fever, influenza, yellow fever, and malaria. (28) Advancements in sanitation, nutrition, and vector control, and deliberate public health interventions such as vaccination and treatment of infectious diseases have changed the landscape of public health. (29) Improvements in drinking water treatment, sewage disposal, food safety, organized solid waste disposal, and public education about hygienic practices and waste disposal have decreased the number of children suffering from infectious diseases such as measles, smallpox, polio-myelitis, and cholera. (30, 16) Technological advances in the detection and treatment of disease expanded our ability to effectively manage many infectious diseases. (28) Development of insecticides and herbicides for use on food crops has greatly improved the accessibility and affordability of food. (30)

As a result of these advances, people in the U.S. experienced great improvement in their health. Gains in life expectancy during the 20th century were greater than at any other time in history. (31) In the 20th century, life expectancy in the U.S. increased by 27 years. (32) In fact, it is estimated that mortality reductions in children up to age 20 have contributed approximately 58 percent of the 27 year gain. In 1900, 30.4 percent of all deaths occurred among children under 5 years of age; in 1997, that figure had dropped to 1.4 percent. (28) The infant mortality rate decreased by 93 percent between 1915 and 1998. (32)

The leading causes of death for children have changed significantly over the last century. Infectious diseases no longer account for the most deaths among children. Between 1900 and 1998, "the percentage of child deaths attributable to infectious diseases declined from 61.6 to 2" percent. (32)

In 2000, more children died from accidents and injuries than any other cause. (33) For children under 9 years of age, birth defects as well as cancer were also leading causes of death. (33) In addition to unintentional injury, cancer, suicide, and homicide claimed the most lives of 10 to 19 year olds in 2000. (33)

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Reducing exposures to contaminants

There are simple steps you can take to reduce your child's exposure to environmental contaminants. For detailed information on reducing exposures to pesticides, volatile organic chemicals, polycyclic aromatic hydrocarbons, and metals, visit Reducing Exposures to Contaminants.

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The future of children's environmental health

With an ever-expanding population that will place more demands on natural resources and land use, we will continue to face difficult environmental dilemmas and challenges to protecting children's health. Both familiar and emerging issues will cause controversy, constructive debates, new research, and innovation. We will continue to struggle with balancing environmental and health protection with development, technological advancements, and economic growth.

Amidst the challenges we face, it is important to remember that the health of the population of U.S. children is better today than it ever has been. Significant public health and medical advances have increased our ability to prevent, detect, and treat disease. Today, we lead healthier lives and survive into old age. In general, instead of dying in the early or middle part of our lives due to infectious diseases, the diseases that do threaten our health require long periods of time to progress and manifest. In fact, some of the exposures that children experience may result in disease that shows up in old age.

Today we have more resources to undertake quality research on exposures and health effects, more awareness of the role the environment plays in human health, and more technological capabilities to conduct ground-breaking research. Political representatives, government agencies, health organizations, public interest groups, and the general public have recognized and embraced children's environmental health as an important issue worthy of resource commitments and policy ingenuity. Awareness of environmental impacts on children's health by parents, teachers, and childcare providers has increased and led to individual actions to reduce children's exposures. Innovative research methods have expanded the ability to study environmental and health issues in fields such as toxicology, epidemiology, exposure assessment, genetics, and engineering. Greater attention is also being paid to legal, political, and ethical issues surrounding children's environmental health.

There are still many opportunities to protect children from environmental health risks. Although many environmental problems are global in nature, protecting children from environmental health risks starts at home. Families can seek out educational materials to learn about how to better protect their children from risks in the environment. Individuals can take actions to make the environments where children play, learn, and live safer, become involved in political and community organizations, and support other cooperative efforts to improve children's health. Partnerships among multiple organizations will yield the most effective and protective actions to improve children's health. The MDH regularly works with other agencies and organizations on children's environmental health issues, and has found that the most progress can be made collectively.

Included in upcoming work at the MDH will be a continued focus on improving children's health. The MDH will carefully address the changes in Minnesota statute that mandates that safe drinking water and air quality standards include a reasonable margin of safety to adequately protect the health of infants and children. In the Health Risk Limits (HRL) for Groundwater rule revision, ensuring children are adequately protected is of special emphasis. In preparing for the revision, MDH staff has examined the existing HRL algorithm and its foundations in science and policy with an eye to whether and how children are accounted for within the rule. During this special examination of the rule, staff has sought out recent and ongoing research on children's exposures and risks. Staff has also communicated with other environmental and public health workers on a national level to learn about directions in environmental health policy.

MDH staff will continue to develop expertise in assessing risks to children's health by seeking out educational opportunities on children's health and risk assessment and researching emerging science and policy issues (e.g. less than lifetime exposure, children's exposure assessment, acceptable level of risk for children). MDH scientists will continue to provide consultation on the local, state, and national levels on a variety of risk assessment topics. MDH staff will do outreach to many stakeholders, research emerging issues, and include children's concerns in all risk assessment activities.

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How to find out more

For more information on children's environmental health initiatives, visit the Initiatives page.

For links to information sources, please visit the Links page.

For specific questions, please Contact Us.

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References

(1) Altshuler, K, M Berg, LM Frazier, J Laurenson, J Longstreth, W Mendez, and CA Molgaard. Critical Periods in Development: OCHP Paper Series on Children's Health and the Environment. Paper 2003-2, U.S. Environmental Protection Agency, February 2003.

(2) Agency for Toxic Substances and Disease Registry, U.S. Department of Health and Human Services. "Healthy Children - Toxic Environments: Acting on the Vulnerability of Children Who Dwell Near Hazardous Waste Sites," Report of the Child Health Workgroup Presented April 28, 1997 to the Board of Scientific Counselors.

(3) U.S. Environmental Protection Agency. Child-Specific Exposure Factors Handbook. EPA-600-P-00-002B, September 2002.

(4) Bearer, CF. Environmental health hazards: how children are different from adults. The Future of Children: Critical Issues for Children and Youths 5(2):11-26, Summer/Fall 1995.

(5) Goldman, LR. Case studies of environmental risks to children. The Future of Children: Critical Issues for Children and Youths 5(2):27-33, Summer/Fall 1995.

(6) National Research Council. Pesticides in the Diets of Infants and Children. Washington, D.C.: National Academy Press, 1993.

(7) Faustman, EM, SM Sibernagel, RA Fenske, TM Burbacher, and RA Ponce. Mechanisms underlying children's susceptibility to environmental toxicants. Environmental Health Perspectives 108(Suppl.1):13-21, March 2000.

(8) U.S. Environmental Protection Agency. Dermal Exposure Assessment: Principles and Applications. EPA 600/8-91/011B, January 1992.

(9) Selevan, S, CA Kimmel, and P Mendola. Identifying Critical Windows of Exposure for Children's Health. Environmental Health Perspectives 108(Suppl. 3):451-455, June 2000.

(10) Timbrell, J. Principles of Biochemical Toxicology, Third Edition. Philadelphia: Taylor and Francis, 2000.

(11) Miller, MD, MA Marty, A Arcus, J Brown, D Morry, and M Sandy. Differences Between Children and Adults: Implications for Risk Assessment at California EPA. International Journal of Toxicology, 21:403-418, 2002.

(12) Scheuplein, R, G Charnley, and M Dourson. Differential Sensitivity of Children and Adults to Chemical Toxicity. Regulatory Toxicology and Pharmacology 35:429-447, 2002.

(13) Schneider, D and N Freeman. Children's Environmental Health: Reducing Risk in a Dangerous World. Washington, D.C.: American Public Health Association, 2000.

(14) U.S. Environmental Protection Agency. America's Children and the Environment: Measures of Contaminants, Body Burdens, and Illnesses, 2nd Edition. EPA 240-R-03-001, February 2003.

(15) American Academy of Pediatrics, Committee on Environmental Health; RA Etzel, ed.; and SJ Balk, ed. Handbook of Pediatric Environmental Health. American Academy of Pediatrics, 1999.

(16) Landrigan, PJ, JE Carlson, CF Bearer, JS Cranmer, RD Bullard, RA Etzel, J Groopman, JA McLachlan, FP Perera, JR Reigard, L Robison, L Schell, WA Suk. Children's health and the environment: A new agenda for prevention research. Environmental Health Perspectives 106(3):787-794, June 1998.

(17) Goldman, L, Environmental Protection Agency. Presentation entitled "Children's Environmental Health," at the EPA Workshop on Information Needs to Address Children's Cancer Risk. Summary of the Workshop on Information Needs to Address Children's Cancer Risk, EPA/600/R-00/105, December 2000.

(18) The Bangkok Statement, "International Conference on Environmental Threats to the Health of Children: Hazards and Vulnerability," Bangkok, March 3-7, 2002, accessed 2/6/04.

(19) Healthy Environments for Children: Initiating an Alliance for Action. World Health Organization, 2002.

(20) Carpenter, DO, KF Arcaro, B Bush, WD Niemi, S Pang, and DD Vakharia. Human health and chemical mixtures: An overview. Environmental Health Perspectives 106(Suppl. 6):1263-1270, December 1998.

(21) Moeller, D. Environmental Health, 2nd ed. Cambridge: Harvard University Press, 1997.

(22) Dooley, EE. "Building Awareness of the Built Environment." Environmental Health Perspectives 110(11), November 2002.

(23) Cummins, SK, and RJ Jackson. The Built Environment and Children's Health. Pediatric Clinics of North America 48(5):1241-1252, October 2001.

(24) Hubal, EAC, LS Sheldon, JM Burke, TR McCurdy, MR Berry, ML Rigas, VG Zartarian, and NCG Freeman. Children's exposure assessment: a review of factors influencing children's exposure, and the data available to characterize and assess that exposure. Environmental Health Perspectives 108(6):475-486, June 2000.

(25) Clark, NM, RW Brown, E Parker, TG Robins, DG Remick Jr., MA Philbert, GJ Keeler, and BA Israel. Childhood asthma. Environmental Health Perspectives 107(Suppl. 3):421-429, June 1999.

(26) Jacobson, JL, and SW Jacobson. Breast-feeding and gender as moderators of teratogenic effects of cognitive development. Neurotoxicology and Teratology 24:1-10, 2002.

(27) U.S. Department of Health and Human Services. Prevention '84/'85. Washington D.C.: Public Health Service Office, 1985.

(28) Centers For Disease Control And Prevention: Morbidity And Mortality Weekly Report. Control of Infectious Diseases: 1900-1999. Journal of the American Medical Association 282(11):1029-1032, September 1999.

(29) McMichael, AJ and R Beaglehole. The changing global context of public health. The Lancet 356(9228):495-499, August 2000.

(30) Centers For Disease Control And Prevention: Morbidity And Mortality Weekly Report. Safe and Healthier Foods: 1900-1999. Journal of the American Medical Association 282(20):1909-1912, November 1999.

(31) Michaud, C, C Murray, and B Bloom. Burden of disease - Implications for future research. Journal of the American Medical Association 285(5):535-539, February 2001.

(32) Guyer, B, MA Freedman, DM Strobino, and EJ Sondik. Annual Summary of Vital Statistics: Trends in the Health of Americans During the 20th Century. Pediatrics 106(6):1307-1317, December 2000.

(33) National Vital Statistics Report, Vol. 50, No. 16, September 16, 2002.

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Updated Thursday, 15-Sep-2011 09:20:40 CDT