Scottish Government

chapter 8 early years, children and young people: environment and unintentional injury

Introduction

From conception to adolescence, the interface between children and their environment is different from their parents and grandparents. Children are not simply small adults. They behave very differently as they explore their surroundings and are at greater risk from threats they may not recognise or to which they cannot readily respond. As they grow, children spend time in different settings from adults making the quality of these environments, such as schools and places where they play or socialise, critical to their health and safety. Also important is the fact that, relative to their body size, children breathe, eat and drink much more than adults (see Table 1).

Table 1 Comparison of infant and adult intakes relative to body weight

Source: Licari, L. et al. Children's health and the environment: developing action plans

Combined with children's immature metabolism and rapidly developing body systems, children are often at special risk from contaminants in air, food, water, soil and in their homes. For example when children are exposed to lead, mercury and solvents these can destroy brain cells and prevent the formation of vital connections in the brain. This can result in a loss of intelligence and behavioural problems. Environmental toxins can also damage the developing reproductive, endocrine and cardiovascular systems. This has made the reduction of hazardous chemicals in the environment a key objective of government.

Throughout life "windows of vulnerability" to specific environmental risks open and close.

In the embryo, growth is rapid as cells take on characteristics appropriate to their future function. Here, concern typically relates to maternal exposure to toxins with potential to harm the baby. Immediately following birth, body structures continue to evolve, forming vital connections.

In the first year, the developing nervous system is especially vulnerable to damage, e.g. from metals such as lead and mercury. The immature metabolism absorbs, distributes and excretes many substances differently from that of adults. This creates special challenges for regulators seeking to create child-safe environments.

Fundamentally, children have more years of life ahead of them giving extra time to succumb to the chronic effects of environmental exposures. Sometimes disease results from cumulative exposure to harmful agents whilst, in other cases, an early, and possibly time-limited exposure, increases risk to health in adulthood. Skin cancers, for example, can sometimes be linked to excessive exposure to Ultraviolet ( UV) light in childhood. A single episode of sunburn with blistering of the skin is considered to increase the future risk of melanoma for the rest of that child's life.

As a child becomes increasingly independent this brings different risks. For example, the pattern of child injuries changes as developing neurophysiological responses confront new environmental challenges. Infants are especially at risk of falls from the arms of carers or collisions with moving objects, with a relatively high risk of head injury. As these children become toddlers (from the second to the fifth year of life approximately) they become more active, exploring their surroundings, e.g. staircases or accessible household objects. Falls and ingestion of poisons and medicines become frequent. As they reach school age greater muscular control allows protection of the face and head making fractures and lacerations to hands and arms more common as they are increasingly used to break falls or deflect blows.

The rapidly maturing neurological, muscular, skeletal and intellectual status of growing children, however, offers limited protection from many environmental hazards. Injury risk in childhood is strongly socially patterned - a sure sign that environmental factors operate in the web of causality. Scottish data consistently demonstrate that children from our most deprived areas are three times as likely to die from unintentional injury as children in the most affluent places: http://www.isdscotland.org/isd/3067.html . This is even more marked for fire deaths. Notably, no environmental threat is greater than road traffic - the largest single cause of traumatic death in schoolchildren.

Today there is much to celebrate in relation to children's environmental heath in the developed world. At the same time, we in Scotland, following the experience of the particular threat to children of E.coli O157, recognise the potential threat of new infectious diseases. However, there is now a new pattern of disease in children in which environment plays are role but which is poorly understood. Diseases such as asthma have greatly increased in the past 30 years. Other disease in which environmental factors may be responsible include birth defects, leukaemia, childhood cancers and attention deficit/hyperactivity disorders in children.

Scotland overall enjoys a high quality, healthy environment, inherited, but also secured and protected through policies shaped by concern for safety and health. However, in less affluent areas, the picture is often quite different. Here, the problem is seldom toxic or infectious hazard, but rather, untidy, uncared for and damaged localities. Lacking in amenity, alienating and frequently threatening, these environments contribute to a cocktail of disadvantage inconsistent with health and well-being.

Unsatisfactory places sustain inequality and cannot nurture the behaviours, attitudes and resilience required for future health. A relevant environmental health agenda for the 21st century is as much about the creation of places which engender good physical and mental health, as it is about protection from hazards. Nested within this wider agenda, and reflecting their special vulnerability, is a distinct children's environmental health agenda.

Unsurprisingly, development of a health promoting environment demands attention to many factors that interact in complex ways. Policy makers must consider the unintended consequences of one policy on another. Anti-obesity measures, for example, encouraging children to walk or cycle to school or undertake more sporting activities mean greater injury risk as active children encounter environmental hazards such as road traffic, makeshift playgrounds and unsatisfactory sporting or leisure equipment. This does not mean that anti-obesity measures should not be taken as they are vital to reduce future risks of major diseases such as heart disease and diabetes, rather, that all impact and risks should be taken into account.

An International Dimension to Children's Health and Environment

Children's environmental health is now a focus for the World Health Organisation ⁸⁷. The Children's Environmental Health Action Plan for Europe ( CEHAPE) focuses on environmental risk factors considered to have most impact on the health of children across 53 European countries.

Amongst the key goals of the initiative are safe drinking water and adequate sanitation; protection from injuries; the opportunity for adequate physical activity; clean outdoor and indoor air and environments free from chemical hazards.

Since committing in 2004, as part of the UK, to participate in CEHAPE, Scotland has contributed to preparation of the UK's submission to an Intergovernmental Mid-term Review scheduled for June 2007. The meeting will take stock of progress and hear national proposals for further improvement. Examples such as changes to Scotland's building regulations in 1996 to prevent scalds by requiring thermostatic valves at bath hot-water outlets; the publication of a new bathing water strategy and, not least, the 2006 legislation on smoking in public places allow Scotland to demonstrate a UK lead in progress towards some CEHAPE Goals.

Complex problems demand fresh approaches

Scottish environmental health specialists recently analysed today's generic challenges in environmental health ⁸⁸. Amongst these were:

1. Identifying approaches to policy and action on environment that recognise health and well-being as not the product of simple cause and effect relationships but rather a complex mix of physical social and behavioural factors.

2. Understanding and delivering health promoting environments.

3. Accepting that how people feel about their physical surroundings, can impact on not just mental health and well-being, but also physical disease processes (of special relevance to health inequalities).

4. Reflecting in policy, that the health we inherit in later life is substantially programmed in childhood.

By implication, the right environments for children benefits their health for all of their lives. The challenge, like so many in public health, is about accepting the complexity of our environment, creating better systems and organising to deliver healthier environments for children.

Scotland's Strategic Framework for Environment and Health announced in 2005 continues to be built on these principles. 2007 will see further development of proposals culminating in discussion amongst interested parties on how the framework will be used to develop action on initial priorities. Given the importance of the environment for children's health today and in the future the Scottish Framework must address the very special issues of children's environmental health.

"how people feel about their physical surroundings, can impact on not just mental health and well-being, but also physical disease"