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Case Report International Journal of Pediatrics & Child Care Open Access

Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats Norma Helena Perlroth1, 2, Christina Wyss Castelo Branco2, 3 1University Hospital Gaffrée Guinle, Department of Pediatrics, Pediatric Emergency Care, Federal University of the State of Rio de Janeiro, RJ, Brazil. 2Doctoral Program in Nursing and Biosciences, Federal University of the State of Rio de Janeiro, RJ, Brazil. 3Department of Zoology, Institute of Biosciences, Federal University of the State of Rio de Janeiro, RJ, Brazil.

Received: March 15, 2017; Accepted: April 1, 2017; Published: July 17, 2017

*Corresponding author: Norma H. Perlroth, University Hospital Gaffrée Guinle, Department of General Medicine – Pediatrics, Federal University of the State of Rio de Janeiro, Rua Mariz e Barros, 775, CEP: 20270-002, Rio de Janeiro – RJ – Brazil. Phone: +55 21 22397352; E-mail: norma.perlroth@gmail. com

Abstract Introduction Background: This research has been carried out with Brazilian In the globalized world of the 21st century, most of the child children living in heterogeneous environments and vulnerable to population has been stimulated by many opportunities and challenges, but they have also found huge barriers in relation exposure to harmful agents. A review focused on the impacts of threats multiple factors that can interact and influence the likelihood of their to their health, development and well-being in the form of environmental threats [1]. According to international data, in from domestic1999 to 2013 indoor and to outdoorconducted environment exclusively on in this Brazil. children’s We grouped health was held. The assessment was based on scientific research produced an estimated rate of 16,000 deaths per day, mostly from diseases that2015, are approximately promptly preventable 5.9 million and children treatable died withunder tested, age five, cost- in the studies in three, the first one, considered as Home Life (HL) refers effective and quality-delivered interventions [2]. The number ingestionto the effects of chemical on children’s compounds health and of hazardoushome environmental components pollution. related Medications,to the household cleaning area, products related and to pesticides two subthemes: were the most unintentional common between 1990 and 2015, nearly 230 million children worldwide agents of poisoning and parental smoking and the use of wood of under-five deaths over the past two decades is astounding: stove for cooking were directly responsible for respiratory diseases.

factors focused on childhood diarrhea, geo-helminthiasis and urban died before their fifth birthday, more than today’s population of sanitationThe second conditions. group called Precarious Social (S)households, correlates lack socio-environmental of sewage system, InBrazil, 2015, the there world’s were fifth 19,000 most fewer populous deaths country of children [3]. But in the this good age improper waste management enhanced the importance of water- groupnews is than that in nowadays, 1990, the under-five reference mortalityyear for measuring rate has decreased. progress transmitted illness in children health. The third group, considered as [2]. biological agents as regional risk factors to child morbidity-mortality. The survival of every child is still an unpostponable priority AirRegional pollution (R), exposesdue to increased environmental levels chemicalof PM10, contaminations SO and O were and 2 3 and varies enormously depending on where a child was born associated with higher prevalence of respiratory diseases, which can and grows. Environmental risk factors, such as air, water and soil pollution, chemical exposures and climate change, contribute arsenic and in special lead were considered potential risk factors to be also influenced by the region seasonality. Agrochemicals, mercury, to more than 100 diseases and injuries [4]. In low and medium- and accidental contacts with biological agents of pathologies for income nations, the most commons environmental disorders, childrenchildren’s were health related throughout to regional the country.peculiarities. Infectious This reviewtropical highlights diseases constituting major public health problem, are the lack of potable that the occurrence of environmental exposed diseases in Brazilian water and sanitation access, resulting in waterborne diseases, children is extremely serious and not random, and it is possible to such as diarrhea [5] and lower respiratory tract infections. While in developed countries, the most prevalent diseases are allergy be considered by stakeholders and government to improve the quality ofestablish life of that causal age links bracket. and, thus, to define protection factors that must and asthma [6]. Researchers have been analyzing the way the environment can change the expression of the genes and how Key words: Child health; Environmental risks; Brazil; Developing that can cause diseases. Medications, pesticides, air pollutants, countries; chemicals, heavy metals, hormones, nutrition products and behaviors can change the genetic expression by way of a huge amount of gene regulatory mechanisms [7].

Symbiosis Group *Corresponding author email: [email protected]@gmail.com Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

Important information regarding accidental poisonings and intoxications is that children, by nature, are curious, and can open, eat and drink what adults know to be dangerous agents. ofmonths, body weightingest seventhan thetimes average more water,adult [22].and, atThe pre-school intake of age air (1of Parents and caretakers, by negligence or lack of information, restingto 5 years infants of age), is fromtwice three as high to four in average times more adults food [23]. by kilogramPeculiar keep medications and domestic products in inappropriate habits, such as constantly putting their hand in their mouth places, underestimating what children can do. The habit of self- [9] and playing and crawling in the ground also contribute to a medication can lead to a higher intake of medication, which makes higher exposure. Thus, agents present in the air, the water, the it easier for those agents to reach domiciles, where children can ground and in food have a higher probability to be absorbed by potentially get access and be poisoned by them [8]. children than by adults. Pollution in the indoor environment is a multifaceted mixture Facing these facts, the authors conducted a review on the of agents migrating indoors from the outdoor air in addition to relationship between exposure to environmental pollutions agents generated by indoor sources [9]. Tobacco smoke is a threat and diseases in Brazilian children. Brazil is a large country,

function [10, 11]. The smoke of tobacco is full of exogenous diversity in terms of biomes and socioeconomic development. mutagenicto children’s and health cancerous with agents adverse [12, effects 13]. on their pulmonary Severalbeing the unfavorable fifth in overall environmental surface area, andconditions has a wide and regional toxic substances present in several regions of Brazil, but independent of socioeconomic and cultural differences and occurring in rural Data from the WHO [14] shows secondary domestic pollution and industrialized areas, are a threat to the lives of children, and due to the burning of solid fuel (wood, coal, manure, crop residue) a prolonged exposure could compromise the survival of their generations and others to come. The scope of the review covers thoseon fires solid or traditional fuels releases stoves a dangerousas one of the mixture top ten of risks thousands to health of indoor and outdoor pollutants for the entire Brazil from 1999 substancesin the world, such affecting as particulate children matter, directly. carbon The inefficientmonoxide, burnnitrous of to 2013. The main knowledge and environmental issues acting oxide, sulfuric oxides, formaldehyde, hydrocarbons and polycyclic organic matter, which includes carcinogenic substances such as remaining gaps. benzopyrene [15]. The amount of smoke women and their young on children health were identified and discussed, as well the children inhale can be equal to that of two packs of cigarettes a Material and Methods An ample bibliographic revision was carried out using the up of gases, such as water vapor, molecular nitrogen, SO2, CO, day [16]. Through the air, the smoke from forest fires is made CO2 4, among others, and ash micro particles [17]. The total suspended particulate matter, inhalable particulate matter and following electronic databases: MedLine, PubMed, Scielo, Lilacs , CH articles in the Brazilian literature published from 1999 to 2013. Besidesand BDENF the (Nursinguse of the Database) aforementioned were used databases, to retrieve a research relevant take place, side effects through a combination of harm caused by nitrogen dioxide can cause, on children who live near where fires was also carried out on the websites of organizations such poisoning [17]. heat, pulmonary irritation, oxygen deprivation (asphyxia) and The contamination of the environment by chemical agents as the World Health Organization – WHO, the United Nations selectedChildren’s documents. Emergency Texts Fund published - UNICEF on the the Pan website American of Brazilian Health organizationsOrganization – of PAHO research in order in healthto update and information human geography found on such the untreated(aluminum, water; mercury, industrial pesticides, activities; petroleum mineral hydrocarbons, exploration silver, and agriculturevinyl chloride, can arsenic,be responsible cyanide, for benzopyrene) the increase resulting in congenital from used. The databases were searched separately and then combined malformations, asthma, cancer, disruption of the endocrine toas eliminateBrazilian Instituteduplication. of Geography and Statistic (IBGE) were also system, neurological and behavioral disorders in children The search strategy involved terms as referred to Brazilian [18, 19]. The physical agents that can also present hazards to includes, concomitantly, the Portuguese, the English and Spanish materials, and water offensive odors and incompatible color [20]. Virtual Health Library/Health Sciences Descriptors (DeCS) that children’s health are sediment resuspension, turbidity, corrosive This vulnerability children have to environmental hazards research carried out exclusively in Brazil, published in national occurs because the child population is a peculiar demographic languages. The criteria for inclusion were: articles with data from

during the early childhood that several biological systems, like and evaluated according to criteria of journal classification thegroup brain, that lungshows structure very specific and thephysiological immune system characteristics: develop andit is in the QUALIS system of CAPES (Brazilian Federal Agency for mature [9]. Toxic gases can compromise pulmonary function accessthe Improvement to the full text of of Higher articles Education) in the databases (https://sucupira. and whose and neurodevelopment or exacerbate preexisting conditions, methodologycapes.gov.br/) allowed as A1-A2-B; for the discovery international of evidence journals, regarding available the and children born prematurely can be more vulnerable to environmental hazards due to pulmonary immaturity at birth [21]. Children ingest more water and food and breathe more andenvironmental guidelines. influence The research in the strategyhealth of includedchildren. Thethe following types of papers were excluded: case study, dissertations, theses

air by body weight unit than adults. Infants, during the first 6 descriptors: “children health”, “environmental risks”, “health Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 2 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

vulnerability”, “accident prevention”, “poisoning”, “sanitizing products”, “pesticide exposure”, “environmental pollutants”, “air pollution”, “tobacco smoke pollution”, “diarrhea infantile”, “basic availablesanitation” by “parasitic databases. diseases”, “water pollution”, “environmental health”, as well as Boolean operators (AND, OR and NOT) made

We grouped the studies in three, as follow: The first group, andwhich its we surrounding will call HOME area LIFE might (HL), refershave, tosuch the possibleas unintentional effects on injurieschildren’s caused health by hazardous chemical compoundscomponents and related home to environmental the household

sanitation and socio-environmental factors, such as diarrheal pollution. The second group, called SOCIAL (S), correlates

regionaldiseases environmental and soil-transmitted physical, parasites chemical and and their biological influence agents on aschildren’s a risk factor health. to Thechild third morbidity group, and REGIONAL mortality. (R), The exposes references the Figure 1: Categorization of studies for analysis. area. It has an estimated population of 29,041,466 [24], and the ofResults the identified articles are shown in supplementary material. Over 448 studies were reviewed in this paper to identify SEone Region, with the which highest relates Human the richestDevelopment region Indexwith the – HDI number [25]. ofIt research.can be observed that 42% of the studies were carried out in the emerging patterns and gaps in the children’s environmental The SE Region, predominate in the majority of papers. In the health field. After exclusions, the search performed retrieved 127 category 49 articles were raised and in the R group, there were N Region, the majority of the articles deal with one subtheme of articles (Fig.1). In the HL group, there were 22 articles, in the S analyzed 56 studies. the R2 group, with relation to peculiar questions of the region, Geographic distribution which comprehends most of the Amazon Basin, with its local In order to have an overview of the geographic distribution

capital,particularities, has the fewest such as number mining, of forestpapers. fires, Although and malariaBrazil is cases,a fed- of the studies, we considered for the analysis the five geographic erativeamong union, others. few The studies CW Region, included despite two or holding more regions the country’s in their theregions absolute of Brazil: area Northof the (N),country, Northeast has an (NE), estimated Central-West population (CW), of researches showing low number of integrated research on chil- 17,186,877Southeast (SE) people and andSouth is the(S). regionThe N Region,with the takes lowest up population45.25% of

an estimated population of 56,241,859 inhabitants [24]. The CW Homedren’s environmentLife in the country. density [24]. The NE Region has 18.2% of the country’s area and- In this section, 22 articles related to two subthemes were

Region has 18.86% of the country’s area and an estimated popu inhabitants.lation of 15,251,494 This region inhabitants has the [24]. highest The GrossSE Region Domestic has 10.85% Prod- selected: “unintentional ingestion of chemical compounds” and of the country’s area and an estimated population of 85,241,641 “home environmental pollution”. In the first subtheme, 9 articles were used (Tab. I). uctTable - GDP I: HOME of Brazil LIFE [22]. The S Region has 6.77% of the country’s Unintentional ingestion of chemical compounds Reference Purpose Type of Study Health Efects Age Region Outcomes

to analyze the risk Tavares et al. factors associated acute newborn S longitudinal with poisoning in intoxication -14 y Associated factors: male gender and age (from children zero tothe four occurrence years), easier of intoxication. access to drugs at (2013)[26] home and the adult’s presence did not prevent

to analyze the intoxication by acute newborn NE pesticides in children, longitudinal Associated- as individual factors: accident male genderin children and andage with(from [27] intoxication -19 y zero to four years); trigger factor: raticides Lira et al. (2009) adolescents and youngsters among teenagers. intentional character (attempted suicide)

Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 3 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

to identify the main therapeutic classes N, NE, responsible for drug CO, longitudinal ethality < 1 y Associatedhypnotic and factors: antiparkinsonism male gender drugs,and infants with intoxications related SE,S (85%); trigger factor: antiepileptic, sedative- Lessa & Bochner to the hospitalization 1,21% l (2008) [28] of children 15.2% of hospitalizations in children under one month and 21.1% in infants. to describe the epidemiological newborn NE characteristics of all longitudinal Associated factor: male gender and age under -12 y five (64.5%), easier access to drugs at home Lourenço et al. exogenic poisoning 3,84% lethality (80%) and parents present in 57.7% of the (2008) [29] cases in children bronchodilators. incidents; trigger factor: anticonvulsants and

of the acute exogenous Siqueira et al. to describe the profile CO intoxications, among cross-sectional 0-12 y Associated factor: male gender and children 39.7% vomiting children (1-3 y), easier access to drugs at home; trigger / (2008) [30] factor: drug (34%), rat poison (14%) and 20.7% sleepiness to analyze the chemical products for domestic use (13%). characteristics of Martins et al. accidental poisoning S longitudinal 0-15 y Associated factor: female gender and among children and hospitalization children (1-3 y); trigger factor: drugs 17.2% adolescents (47.5%), pesticides (14.1%) and cleaning (2006) [31] hospitalization. products (11.3%), with 17.2% of children’s

Ramos et al. acute S of poisonings among cross-sectional 0-4 y Associated factor: male gender and children to establish the profile intoxication children (1 y), easier access to drugs at home and the (2005) [32] adult’s presence in 76.2% of the incidents; to study acute trigger factor: analgesics. Bucaretchi et al. exposure to months of median age. Easier access to drug imidazoline longitudinal 2 m- 13 y SE asymptomatic in theAssociated house. The factor: exposure female pathway gender and was 21 oral derivatives in 15% and nasal. (2003) [33] children

to describe drug intoxication among SE Associatedmedicinal use. factor: Analgesics, children decongestants,(2-3 y); trigger Matos et al. children longitudinal 0-4 y and S bronchodilators,factor: drugs administration antiepileptics errors and oraland contraceptives were the therapeutic classes (2002) [34] 0,11% lethality involved, and decongestants, antiepileptics, antihistamines and expectorants were associated to cause of death.

According to the authors, during early childhood, children on hospital units [30] and infant deaths were reported as a are very curious and have no idea how dangerous toxic agents complication of acute intoxication to toxic agents [28, 29, 34]. can be. The medication was the toxic agent most commonly

epileptic, sedative-hypnotic and antiparkinsonian drugs [28, 29], On the subtheme called “home environmental pollution”, 13 bronchodilatorsfound in the research [29], imidazolewith 77.7% derivatives of the studies. [33] and Included painkillers anti- stage,articles wereaffecting found negatively (Tab.II). Articles anthropometric demonstrated measurements the impact of [32, 34]. There is also the hypothesis of medication poisoning secondhand smoking on children’s health since the intrauterine through transplacental transmission and breast-feeding in Parental smoking was also responsible for wheezing babies [35], children less than one month of age [28]. ear(weight, infections length, and and eye head irritation circumference) [36] and ofhistory newborns of respiratory [37, 44]. diseases [42, 45, 47]. In the case control studies, children exposed study [26, 27, 29, 30, 31], and poisoning was generally accidental to smoking show higher risk to develop the abovementioned in childrenPesticides and were intentional the second in adolescents. toxic agent In (55.5%) both cases found the inhome the diseases than those who are not exposed [35, 36, 39, 40]. In was the locus of such occurrences. addition, children living in crowded environments and poor housing conditions play a fundamental role in the causal chain of Ease of access to those products was essential for self- respiratory diseases [38, 42, 46]. As well, the use of a wood stove for cooking was responsible for a higher occurrence of recurrent of intoxication [26, 29, 30, 32]. Vomiting and somnolence were wheezing [41]. consideredharm and the a common adult’s presence clinical manifestation did not prevent on the children occurrence seen

Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 4 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

Table II: HOME LIFE

Home environmental pollution

Reference Purpose Type of Study Health Efects Age Region Outcomes

to investigate parental Schvartsman smoking patterns and their SE y, exposure to cigarettes smoking in the cross-sectional wheezing 6 - 23 m association with wheezing in householdsAssociated of factors: cases indicated male gender, that the age risk < 2 of [35] et al. (2013) children wheezing was dose dependent. to investigate if there is a Coelho et al. relation between respiratory newborn SE cross-sectional diseases and passive tobacco coryza - 4 y Associated factor: children under two years; smoking among children otitis / wheeze / infections,trigger factor: wheezing, exposure coryza to secondhand and eye irritation. smoke (2012) [36] - 17.39% of the passive smoker group had ear to investigate the prevalence Maternal smoking throughout the entire of maternal smoking during reduced pregnancy had negative impact on Zhang et al. pregnancy and its impact on cross-sectional anthropometric CO anthropometric measurements of newborns newborn anthropometric measurements measurements with reduction in the weight, length and head (2011) [37] of newborns circumference. to determine the prevalence of Prietsch et al. acute lower respiratory illness cross-sectional < 5 y S with a clear dose-response effect and increased and to identify associated pneumonia riskHousehold of acute crowding lower respiratory and maternal tract smoking disease. factors among children wheezing / (2008) [38] to assess asthma prevalence Casagrande et SE and potential risk factors cross-sectional 6-7 y rhinoconjunctivitis Associated factor: male gender, smoking mother associated eczema / eczema and rhinoconjunctivitis. during children’s first year of life, presence of al. (2008) [39] to evaluate risk factors for Macedo et al. newborn S under six months of age, lack of or low maternal acute respiratory disease cross-sectional wheezing -11 m education,Associated previous factors: history male gender of wheezing, and babies early hospitalizations in children weaning and maternal smoking. (2007) [40] The use of wood stove was a 2.5 times higher to study the prevalence of and Prietsch et al. S risk for the occurrence of recurrent wheezing major factors associated with cross-sectional wheezing 0-12 y compared to those who did not use this type recurrent wheezing in children of stove. (2006) [41] to identify factors associated CO Children with lower socioeconomic status and Silva et al. with respiratory disease in cross-sectional < 5 y Gonçalves- bronchiolitis exposed to household smoking. children Asthma /

(2006) [42] to estimate the prevalence of exposure to smoking in smoking associated with low infant stature even Silva et al. households in children to cross-sectional short stature < 5 y CO afterAssociated adjusting factors: for smoking female duringgender, pregnancy parental Gonçalves- identify the main determinants and sociodemographic variables. of that exposure (2005) [43] to study the prevalence and risk factors for asthma in a Menezes cohort of children born in longitudinal 6-7 y S skin, asthma in the family, smoking during Chatkin & allergic rhinitis Associated factors: female gender, non-white 1993 and followed up to the 12.8% asthma / pregnancy and allergic rhinitis in children. age of six years (2005) [44] to study the prevalence of respiratory morbidity among smoking and respiratory diseases history. passive smoking children and NE cross-sectional < 5 y AssociatedRegarding thefactors: respiratory male gender, tract the parental most to determine the effects of Carvalho[45] & frequent complaints were wheeze, dyspnea, environmental tobacco smoke wheezing / asthma / Pereira (2002) asthma, bronchitis or pneumonia and rhinitis. in the respiratory system dyspnea / pneumonia to study the prevalence of acute disease of the lower Prietsch et al. S according to age and sex, passive smoking, airways and the role of the cross-sectional acute resp. disease < 5 y livingAssociated in crowded factors: environments similar distribution and poor domestic environment and housing conditions (2002) [46] maternal smoking

to determine the effects of Pereira et al. NE second-hand smoke in the cross-sectional < 5 y dyspnea Associated factors: male gender, environmental respiratory system in children 82% wheezing / tobacco smoke: fromproblems. 55.3% of passive smoking (2000) [47] children in the study, 82% had respiratory

Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 5 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

Social – Sanitation and Socio-environmental Factors In the second block, 49 articles related to two subthemes rate of children under 5 years of age due to water-transmitted water [60] are variables that influence the morbimortality

were selected: “waterborne diseases” and the “prevalence of illnesses, like diarrhea [57]. In this sence, cities with a low Human intestinal parasites”. Development Index (HDI) have the highest mortality coefficients agedue indexto diarrheal [55], leadingdisease these[49] with children 20% toof chronicthe children malnutrition in those Regarding the first subtheme, 22 articles were used (Tab.III). lack of a sewage system [65, 69], rudimentary lavatories, lack of [62].regions having a deficit of > 2 standard-deviations for the height/ aResearchers garbage collection identified [48, that 50, precarious53, 58, 62] andhouseholds the use of[63, no 65],potable the

Table III: SOCIAL - SANITATION AND SOCIO-ENVIRONMENTAL FACTORS Waterborne diseases Type of Reference Purpose Health Efects Age Region Outcomes Study to analyze the spatial distribution of morbidity due Torres et al. longitudinal to diarrhea among < 5 y SE the suburbs with the highest DHR- Diarrhea children and its 15.5% hospitalization with the highest population agglomerations. Hospitalization Ratio - were, in most cases, those (2013) [48] relation with lifestyle conditions to verify the temporal trends of the indicators of overall mortality due to diarrheal disease in Brazil Mendes et al. cross- mortality and hospital < 5 y N, NE, CO, showed a downwards trend. The Northeast Region sectional morbidity due to 80% lethality < 1 y SE, S 62,6% hospitalization (2013) [49] diarrheal disease in children accounted for 46% of hospitalization. to identify the association between diarrhea male gender; age 4-9 months; the risk of diarrheal Paz et al. in children cross- occurrence in children is almost 15 times greater malnutrition 0 -2 y and children sectional hospitalization/ SE than that of children living in good water and characteristics, access sanitation conditions. (2012) [50] to sanitation and housing conditions to discover the prevalence of cross- female gender; age 8 y; children playing in streams, Ciaccia et al. serological markers 7m- 18 y SE sectional jaundice residence without sewage collection, parents with for the hepatitis A low education, and low family income. virus among children (2012) [51] and teenagers to determine the seroprevalence of Markus et al. cross- male gender; use of community refectory, low- in children and to positive serology 1-14 y sectional S income per capita and indoor crowding. hepatitisidentify Afactors (HAV) (2011) [52] associated with a history of infection to determine the relationship between the variables for water conditions, Bellido et al. N, NE, CO, inadequate sanitation in the dwelling ;modest environmental longitudinal < 5 y 3.004 deaths SE, S economic conditions and low levels of parental sanitation, and education, major population concentration. (2010) [53] mortality in children associated with a group of waterborne diseases to analyze the trend male gender; age < 1 y; improved sanitation in mortality due < 5 y coverage, expanding coverage of health services, Waldman, to diarrhea among longitudinal SE improving prenatal care and childhood and Melli & children between1980 94,3% mortality < 1 y increasing schooling. and 2000 (2009) [54]

Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 6 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

less than one monthly minimum wage Cesar et al. to evaluate child cross- < 5 y 60% were from families with incomes health indicators in sectional N standard20% had deviations a height- two municipalities for-age deficit > 2 (approximately U$200), 41% had no type (2009) [55] mothers reported zero prenatal visits. of sewage treatment or disposal, 10% of to investigate the impact of a city- wide sanitation poor socioeconomic status; the prevalence of Genser et al. intervention in a < morbidity due to diarrhea decreased from 9.2 to 7.3 diarrhea longitudinal 0-2 y large urban center diarrhea NE days per year after the intervention; a in Northeast Brazil (2008) [56] on determinants of child diarrhea reduction of 21%.. to determine the incidence of diarrhea and male gender, age < 1y; early weaning; Melo et al. to assess some mother younger than 25 years; malnourished, longitudinal < 40 m NE relevant associated of diarrhea per year missed immunizations and previous factors to it in each child:11.1 days pneumonia. (2008) [57] children living in two slums to comparatively assess the prevalence of diarrhea and poor conditions of collective life in geographical Vasconcelos the implications cross- areas; diarrhea accounted for a quarter of all MJ; Batista F.. < 5 y NE of the disease sectional regarding outpatient 4.1% hospitalization admissions with a ratio of almost 33% in the urban (2008) [58] appointments and hospitalizations inland and 35.3% in the rural inland. to investigate the epidemiological effect diarrhea prevalence fell from 9·2 days per child- Barreto et al. of this city-wide longitudinal < 36 m NE year before the citywide sanitation intervention to sanitation programme diarrhea 7·3 days per child-year afterwards. on diarrhea morbidity 22% < morbdiity due to (2007) [59] in children to determine diarrhea prevalence and mine water consumption; sewage disposal on the to identify factors cross- streets or in the yard; inadequate garbage disposal associated to the 1 - 5 y SE sectional Teixeira[60] & condition in children Heller, (2005) 17.5% diarrhea month of life. living in subnormal and flies; child hospitalization during the first settlement areas

male=female gender; age< 10 y; absence of Zago-Gomes et cross- 6-14 y sectional SE amongto describe school specific children a past history of hepatitis. anti-HAV prevalence 38.6% seropositive domestic water filter, absence of sewage system and al. (2005) [61] to identify the environmental factors cross- Teixeira JC; intermittent water supply, poor quality child related in children sectional 1 - 5 y SE living in areas malnutrition [62] 11.23% chronic diapers with feces in the area around the house. Heller l. (2004) occupied by homeless hygiene before feeding, and dumping children’s or landless people to investigate the socioeconomic, demographic, age < six months; unfavorable socioeconomic Vanderlei et al. and biological longitudinal < 2 y conditions, greater multiparity, younger age of the determinants of NE child, and severity of the diarrhea. hospitalization due to 100 % hospitalization (2003) [63] children acute diarrhea (AD) in

Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 7 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

to study the determinants of the prevalence of diarrhea among children for hygiene behavior Strina et al. whom mainly unhygienic behavior and households and of its role in longitudinal < 5 y NE with inadequate excreta disposal was 1.9 times that the transmission 2.2% diarrheal disease (2003) [64] or prevention of diarrheal disease among children in the “mainly hygienic” group. to study the etiology Schnack et al. Cryptosporidium Entamoeba histolytica of childhood diarrhea longitudinal < 5 y S Giardia lamblia in a population sample (85.1%), 95.7% of diarrhea conditions. (2003) [65] in a metropolitan area (56.4%), (4.3%); environmental to estimated risk areas for hepatitis A Medronho et al. area with poor environmental and sanitary in four census tracts longitudinal 1-9 y SE conditions. in children living in a 33,3% seropositive (2003) [66] metropolitan area to assess the prevalence of antibodies to hepatitis Assis et al. cross- male=female gender; low socioeconomic status and A and E viruses in 2-9 y sectional N poor sanitary hygienic. children who were 86,4%seroprevalence anti-HAV/ 4,5% anti-HEV (2002) [67] students of nurseries and public schools to characterize and analyze trends of children with diarrhea cross- diarrhea and the hospitalizations due to the disease. Monteiro, < 5 y age: 6 to 23 m; reduction in both the prevalence of Benicio & using two household sectional morbidity SE surveys undertaken in 1.70% to 0.9% the third poorest families. A more significant reduction was observed among (2000) [68] mid-80s and mid-90s. to describe the effects of inadequate solid waste collection on the health in a cross- diarrheal, parasitic, and < 5 Y sample of children sectional dermatological diseases SE Catapreta[69] & Heller, (1999) living in low-income age: 6 to 23 m; absence of solid waste collection. neighborhoods and favelas

Even though diarrheal diseases represent the second most [74]; households with no proper waste management and no common cause for hospital admissions in children under 5 years solid residue collection [78]; the unhealthy condition to which of age [48], researches have seen a considerable decrease in this population is subjected [72, 87], with a direct relationship morbimortality caused by those illnesses. The factors that may with low maternal schooling [81, 95] and low income family have contributed to that decrease were the increase in purchasing [80, 85-91, 95]. The higher prevalence of Ascaris lumbricoides, power and consequently the betterment of living conditions [54] Giardia duodenalis, Trichuris trichiura and hookworm infections and the increase in the coverage of basic sanitation services [56, in children living in contaminated environments [75, 90, 92, 59]. 93] with inadequate daily caloric intake [94] may result in hospitalizations due to diarrheal disease [79], compromising to water-transmitted illnesses, is also present in area with poor their future anthropometric status [76, 94]. Author’s suggested that hepatitis A, another disease related environmental and sanitary conditions. The prevalence of positive On the other hand, studies suggested that a reduction of the prevalence of the parasites infections was possible by the low socioeconomic status [51, 66, 67], absence of both domestic increase of sewage systems [73, 88, 89, 91, 92], the use of a water anti-HAV among school children was significantly associated with

water filter and sewage system [61] and indoor crowding [52]. filterThe [70] prevalence and the household of parasitic being diseases in an urban in children area [96]. who go to daycare was another topic in this research. Daycares were found Still in the Social research block, in the “prevalence of suggest that geo-helminths represent a major public health to contain giardiasis [82, 83, 95] and several helminths [77, 84, problemintestinal and parasites”, are an important 27 articles indicator were used of the (Tab. sanitary IV). The conditions studies in which a certain population lives. The association between the endoparasitic diseases in children of public institutions that prevalence of intestinal parasitic diseases with socioeconomic ingested86]. The variablewater without ‘drinking in-home water’ treatment showed a great[81, 95]. influence Another on and environmental factors was reported in the most of researches variable, the relationship between the presence of helminth eggs in the water closet of kinder garden and the frequency like: children from slums [71] or residing in townships with a low HDI in the N and NE regions, especially in rural areas of these eggs in the feces of their users were 15,4% positive. Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 8 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

Table IV: SOCIAL - SANITATION AND SOCIO-ENVIRONMENTAL FACTORS

Prevalence of intestinal parasites Type of Reference Purpose Health Efects Age Region Outcomes Study The prevalence of infection was to analyze the prevalence and the factors associated with Belo et al. of lower and higher occurrence intestinal parasites infections 5-14 y SE cross- respectively.29%, ( 7 to 83%) The presencebetween schoolsof toilets in children and adolescents in sectional in the home was associated with a elementary schools 29% parasitosis (2012) [70] lower prevalence of helminths. to evaluate the association between the Intestinal parasitosis occurred in prevalence of intestinal Araujo Filho et cross- parasitosis with socioeconomic and body for age in 6-10 y SE sectional and environmental factors in infected> weight, children height schools.60.7% of children from the slum, al. (2011) [71] two different socioeconomic in 5.9% of children from private groups of children The prevalence of A. lumbricoides to analyze the prevalence and Silva et al. intensity of infection by Ascaris alarming results regarding the 1-12 y NE was 53.6%. Analysis revealed lumbricoides among children cross- 3.2% abdominal degree of unhealthy condition to sectional pain 1.3% diarrhea which the population is subjected, in (2011) [72] 0.8% vomiting addition to its poor hygiene habits. The prevalence of A. lumbricoides

to evaluate the impact T. trichuria of a citywide sanitation infection wasG. duodenalis reduced from 24.4% Barreto et al. intervention on the prevalence < parasitosis 1-4 y NE to 12.0%, from 18.0% to of Ascaris lumbricoides, cross- appeared5.0%, and to be explained from by the 14.1% to 5.3%. Most of this reduction (2010) [73] Trichuris trichuria, and Giardia sectional increased coverage in the sewage duodenalis infections in system constructed during the preschool children. intervention.

A. to estimate the prevalence lumbricoidesOf all children, 36.5% were infected and identify risk factors for with oneT. or trichiura more geohelminths ( geohelminth infections among prevalence of, 25.1%;geohelminth hookworm, infections Fonseca et al. children in municipalities 5-14 y N e NE 15.3%; , 12.2%). Overall with low human development 36.5% parasitosis was 45.7% in rural areas and 32.2% (2010) [74] cross- low maternal schooling, presence of sectional garbagein urban nearareas. the Low home family and income, number indices (HDI) of individuals in the household were associated with infection.

There were positive results from to study the variation in the prevalence of infestations were of A. lumbricoides 58% samples and the most prevalent Basso et al. intestinal parasites among T. trichiura Enterobius < parasitosis 6-14 y S schoolchildren over a 35-year vermicularis Giardia lamblia (47%), (36%), period cross- Entamoeba coli (2008) [75] sectional The overall prevalence (8%), diminished (24%) and (20%).

from 89% to 37%, indicating an averageG. duodenalis decrease was ofdiagnosed 1.4% per in year. to estimate the association between Giardia duodenalis breastfeeding duration and living Matos et al. infection and anthropometric cross- newborn-2 y NE 13.5% of the children. The children’s sectional < G. duodenalisindices / > anthropometric conditions (garbage collection and (2008) [76] weight-for-age and height- the effect of G. duodenalis infection for-agedeficits, as measured by onpaved anthropometric streets or sidewalks) status. modified

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were positive for helminthes larvae In the private day care centers, 61% to test for helminthes in Araújo et al. sandboxes public and private 4-6 y SE and 50% for eggs. In the public day in day care centers care centers, 64% were positive cross- 60% helminthiasis (2008) [77] sectional for larvae and 36% for eggs. No seen.influence of either season of the year or day care finance condition was There was a higher prevalence of A. lumbricoides, T. trichiura and to study the bagging and hookworm in children living in more than 5 Moraes et al. collection of household episodes of 5-14 y NE solid waste and the health cross- isolation and collection of household diarrhea per year implications for children living sectional solidhouseholds waste aswithout compared proper to thosebagging/ in (2007) [78] in human settlements areas with regular garbage collection and adequate isolation of solid waste.

to determine the prevalence and to identify risk factors Associated factors: age of children associated with Giardia Pereira et al. newborn in(24-48 the household, months); predisponding food hygiene, day- lamblia infection in diarrheic CO cross- hospitalization -10 y carefactors: centers number attendance, of children living and on cats a children hospitalized for sectional 9.9% rural farm within the past six months diarrhea (2007) [79] prior hospitalization and the number of household adults.

had enteroparasites. A smaller They found that 75.27% of children Buschini et al. highly infected by newborn to analyze the distribution and S harbored several parasites enteroparasites -15 y frequency of enteroparasite cross- fraction (26.73%) of children (2007) [80] occurrence in children from sectional G. duodenalis A. seven community schools lumbricoides(multiparasitism), especially (56%), and The enteroparasite(18%). prevalence

2003. Associated factors to a higher was 76.74% in 2002 and 34% in Mascarini newborn gender male and 72-83 month age SE to estimate the prevalence -6 y prevalence of enteroparasitosis: & Donalísio and incidence of intestinal 23.2% positive prevalence in enteroparasitosis group children (84.37%). Greater (2006a) [81] parasites among children at longitudinal acquisition in the children that municipal daycare centers ingested water without in-home treatment. G. duodenalis presented prevalence to estimate the prevalence Mascarini of intestinal parasites among followed by Cryptosporidium sp. G. duodenalis SE children at municipal daycare cross- of 23.7% (2002) and 21.4% (2003) & Donalísio centers sectional 22.5% 0-6 y and Blastocystis hominis with 15.5% (2002) and 3.7% (2003) (2006b) [82] with 13.1% (2002) and 5.5% (2003).G. duodenalis was more prevalent in children from to investigate possible 0Associated to 4 years factors: and E. vermicularis in associations between children between three and four occurrence of enteroparasites years old. The prevalence of intestinal Carvalho et al. and the socioeconomic and newborn SE sanitary conditions of children -6 y frequent parasite was G. duodenalis matriculated in day care cross- 53.4% positive parasitism was 53.40%, and the most (2006) [83] centers sectional family income, maternal education and(26.88%). factors beyond Predisposing sanitation factors:should be considered.

least 1 parasite. There was a higher to evaluate whether child prevalenceThe overall ofprevalence intestinal was parasites 51% of at Gurgel et al. daycare centers are an 1-5 y NE environment that protects care than those who did not attend 63% positive (63%) in children who attended day (2005) [84] against or exposes children to longitudinal intestinal parasite infestation. 1.5 times higher. (41.4%) and the risk of infestation is

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to characterize the morbidity by intestinal intestinal helminth infections. The helminth infections and associated21.38% of sampleand predisponding children presented factors with these parasitic diseases included factors associated with these cross- 1 - 5 y SE Teixeira[85] & diseases,the identification with emphasis of the on sectional complaints about the quality of the Heller (2004) environmental factors, in 21.3% positive waterthe children’s from the age,public family system income, and children residing in subnormal settlement areas deficiencies in sanitation. to determine the prevalence The overall prevalence of helminths Quadros et al. and intensity of infection by Associated factors: gender- A.female. 2-6 y S intestinal parasites among cross- lumbricoides G. lamblia and protozoa was 70.5% children attending early sectional 70% positive and T. trichiura (2004) [86] education centers parasites. (35%), (14%) (13%) among other to verify the occurrence of intestinal parasites and commensals occurred in the study Ferreira et al. commensal organisms among cross- 59.7 % of intestinalG. lamblia parasites and 5-14 y SE children attending a school sectional of fecal samples and Schistosoma population – in 30.5 % located in a settlement of 59.7% positive mansoni in only 1 case. (2003) [87]

‘landless farm workers’ The results showed the protective effects of availability of water in to develop an environmental the washbasin, better hygiene, health indicator for use Carneiro et al. sanitation and socioeconomic status; as a basis for developing A. lumbricoides 0-14 y SE cross- the interactive effect of crowding preventive measures against 12.2%infection positive sectional Ascaris lumbricoides infection (2002) [88] without water in the washbasin than in children inwas those five havingtimes larger water. in households

mesoregion was for T. trichiura to analyze the prevalence of The largest helminthesA. lumbricoides prevalence/ Carvalho et al. intestinal helminth infections 7-14 y SE in mesoregions considered cross- (24.2%) and Taenia (18.7%) sp. harmless for schistosomiasis 18% positive in the south/south-west region; (2002) [89] sectional studyhookworm area. (12.1%) and (0.7%) in the northwest region of the The most frequent intestinal to study the prevalence T. trichiura A. Prado et al. and intensity of infection by cross- lumbricoides hookworms 7-14 y NE intestinal parasites in a sample sectional parasites:Schistosoma manson (38.6%), (31.2%), of school children 66.1% positive G. lamblia Entamoeba (2001) [90] histolytica(8.4%), i (2.2%), (8.9%) and (5.5%). to characterize and analyse trends in infant and child Helminthes in general (from 22.3% Ferreira et al. intestinal parasitic diseases < parasitosis from prevalenceto 4.8%) and was giardiasis observed (from in all 14.5% social < 5 y SE using two household surveys cross- stratato 5.5%). and A the significant inverse associationdecline in undertaken in mid-80s and sectional between income and intestinal (2000) [91] mid-90s 30.9% to 10.7% parasites was kept unchanged in the period.

parasitic infection; G. lamblia, E. coli, to determine the prevalence A.20.1% lumbricoides of children and had hookworm at least onewere of intestinal parasitosis the most frequent parasites, with a in a school children and Rocha et al. 0-14 y SE breeding places described in cross- wereprevalence more offrequent 6.2%, 6.2%, among 4.8% students and thereevaluating county the snails’ 20.1% positive (2000) [92] sectional from1.4%, the respectively. rural area The; the hookworms prevalence

of E. coli was greater in the urban area.

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Overall prevalence of intestinal A. lumbricoides to describe the prevalence of T. trichiura anemia, parasitic infections, parasites was 42%; Tsuyuoka et al. and nutritional status of 4-15 y NE an(28.7%), association between(15.6%), parasitic and children attending public cross- infectionshookworm and (1.7%). poor Theresanitary was primary schools 26.7% anemia/ (1999) [93] sectional 42% parasitosis conditions, but there was no association between anemia and presence of intestinal parasites. to evaluate the role of cross- G. lamblia Endolimax nana Saldiva et al. intestinal parasites on sectional A. lumbricoides 1-12 y SE (44%), nutritional status in three 78% inadequate T. trichiura (43%), (41%) and rural areas of Brazil daily caloric intake/ (1999) [94] protein daily intake (40%) were the most 34% inadequate considered as showing stunting. prevalent; 11% of the children were The frequency of giardiasis in public institutions was shown to be to show different frequencies greater than in private institutions. of intestinal parasitosis Machado et al. cross- 2-15 y SE similar among day-care centers, but daycare centers Helminthiasi, frequencies were among children in day-care sectional > morbidity in greater for public schools among (giardiasis and helminthiasis) (1999) [95] centers and junior and high children from low-income families and those whose parents had low levels of education. schools (public and private) The contamination levels in

schoolthe children’s which showed feces was the 37.8% lowest contaminationand 16.1% in the by toilets. intestinal The Coelho et al. to establish a relationship 2-6 y SE between the presence of children helminth eggs in the water 15.4% of infected locatedhelminths in the(12% most in fecescentral and area 0% of in (1999) [96] closet elements and the cross- the toilets) was the one that was frequency of these eggs in the sectional relationship between the elements feces of their users the city. There was not significant contamination. of water closets and user’s feces The researchers found in 23 infected elements eggs of Ascaris attributed to CO, SO2, and PM10, when considered individually, lumbricoides, Enterobius vermicularis and larvs of nemathoids partially deformed [96]. wereAuthors around also15%, observed 13%, and a 7%, higher respectively. prevalence of Respiratory Regional – Regional environmental factors In this segment, 56 articles were chosen and divided in the highest number of hospital admissions happened in the peak ofDiseases the transition (RD) associated between with Summer seasonality. and Fall, In the in SE the region N and [102] CO regions the hospitalization of RD was seen both in the dry [109, three subthemes ranging from the “impacts of air pollution on 115] and in the wet season [110, 116, 120]. respiratory diseases”, “exposure to chemical micropollutants” and “exposure to other biological agents” on children’s health. Another point of focus for the study was a relation between

betweenFor the risk first of subtheme low birth “impacts weight ofand air pollutionexposure onto respiratory pollutants of RD in children. Andrade Filho et al. [97] noted that respiratory diseases”, 28 articles were used (Tab. V). A significant association diseasesexposure mayto fine be particulatemore associated matter to from meteorological fire and the conditions,prevalence was found, like PM10, CO [98, 112, 118], SO2 and O3 [107]. A

increasing risk of early neonatal death with higher exposure to the N region. Riguera et al. [101], while studying pollution from research [108] also revealed a gradient of approximately 50% of burningespecially sugarcane humidity, and than respiratory to exposure symptoms to aerosols in from school fires age in children in the SE region, noted a higher frequency of rhinitis in traffic-relatedSeveral authors air pollution, have explored compared the deleterious with those effect less exposed. of outdoor the harvesting period for sugarcane. air pollution on pediatric respiratory morbidity [117,119,124] with decrease in lung function [106], with increased risk for Another point of focus for the study was a relation between asthma [111] and pneumonia in children [99, 113] in urban areas like the cities of São Paulo [100, 114, 122, 123], Rio de Janeiro of RD in children. Andrade Filho et al. [97] noted that respiratory [105], Curitiba [119] and Sobral [104]. Considering the lack of diseasesexposure mayto fine be particulatemore associated matter to from meteorological fire and the conditions,prevalence

the N region. Riguera et al. [101], while studying pollution from respiratoryinformation mortalityon the air inpollution children effects and airon mortalitypollution, inin children’s a city of burningespecially sugarcane humidity, and than respiratory to exposure symptoms to aerosols in from school fires age in SEgroup, Region. a study The [121] estimated showed proportionsthe significant of associationrespiratory between deaths children in the SE region, noted a higher frequency of rhinitis in the harvesting period for sugarcane.

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Table V: REGIONAL- SPECIFIC ENVIRONMENTAL REGIONAL FACTORS Impacts of air pollution on respiratory diseases Type of Reference Purpose Health Efects Age Region Outcomes Study

to investigate the effects

matter emitted through male gender: age:< 1 y Andrade Filho et biomassof fine particulate burning on (46,6%); 1- 4 y ( 39,6%); longitudinal < 9 y N hospitalizations for relative5-9 y (20,6%); humidity weather than to respiratory diseases in exposureconditions: to aerosols dry season; emitted 45% pneumonia al.(2013) [97] children living Northern by biomass burning in the region Amazonian region.

to analyze the male gender; air pollution relationship between Romão et al. exposure to PM10 and outcomes ; This effect was longitudinal newborn SE low birth weight in a weight dose-dependentinfluences pregnancy and was city in the southeast 5,9% of low birth observed for all pregnancy (2013) [98] region exposure windows

to evaluate the role of highermale gender; levels of age:8,5 NO and y outdoor, indoor and 2 O(media); was associated exposure with to personal exposure to 3 Vieira et al. increased risk for asthma combustion-related longitudinal 6 -10 y SE and pneumonia in children. pollutants NO and O 2 3 The measurements taken on respiratory health of 67.2% wheezing (2012) [99] in indoor and personal children exposure were the most accurate.

to evaluate the effects of higher of PM air pollutants in relation 10 Jasinski et al. aged:higher < 5 of y ( O 85,6%); increased 9,6% to respiratory morbidity longitudinal hospital <19 y SE 3 adverse effects onand children 2,4% among children and >admissions respiratory and adolescents pulmonary adolescents (2011) [100] function.

to estimate the urbanmale zone gender; ; greater age: < PM 13 prevalence of 2,5 concentration;y; 94.5% lived rhinitis in the - from respiratory symptoms June to October, a period Riguera et al. and to analyze cross- 10 - 14 y SE that matches the sugarcane associated factors as sectional harvest season; pollution in well as peak expiratory 11% asthma the cane trash burn season (2011) [101] 33,2% rhinitis may contribute to the schoolchildren exacerbation of asthma and flow measurements in rhinitis episodes

male gender; age under of children and 5 y; there is an obvious to analyze the profile Natali et al. seasonality to admissions admissions due to longitudinal <19 y SE respiratoryadolescents’ diseases hospital in 51% pneumonia/ peaks occurring in early a city in the southeast (2011) [102] 18% asthma with theautumn. most significant region

to examine the association between male gender; age < 5 y; wheezing in children respiratory symptoms in and adolescents and Moraes et al. cross- children and adolescents living downwind of the <-14 y NE sectional were associated with dispersion plume of living downwind of a atmospheric pollutants 27,3% wheezing (2010) [103] petrochemical plant. emitted by the Guamaré Petrochemical Complex

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male=female gender; low- income population; highest to assess self-reported rates of respiratory diseases morbidity among cross- were seen in April, May 5-9 y NE children and to analyze sectional diseases and June - the rainy months Barreto & its conditioning factors 28,7% respiratory Grisi , (2010) [104] either of over reporting or environmental; finding is suggestive pollution.

to estimate the pollutants was associated association between age: < 2 y; exposure to air Moura et al. levels of air pollutants longitudinal PM10 1 m -12 y SE in emergency paediatric and respiratory 6,7% morbidity3 withvisits a due significant to symptoms increase of symptoms in children bronchial obstruction in (2009) [105] 3% morbidity O children..

to assess the association between daily exposure male=female gender; air Castro et al. cross- decrease in lung to air pollution and 6 -14 y SE pollution, especially PM sectional function 10 lung function in school and NO2. children (2009) [106]

to assess the association between prenatal the pollutants SO and O exposure to air 2 3 longitudinal newborn SE were associated with low pollutants and low birth weight Nascimento[107] & birth weight. weight in a medium- 3.95% low birth Moreira, (2009) sized city mothers exposed to the highest quartile of to examine the the distance-weighted Medeiros et al. association between longitudinal newborn SE and peri- natal mortality > neonatal death trafficincreased density, risk compared exhibited (2009) [108] traffic-related pollution withapproximately those less exposed 50% to analyze hospitalizations for during the dry season, respiratory diseases Rosa et al. cross- themale rate gender; of admissions age:< 1 y;for among children in an < 15 y N sectional respiratory diseases was area with high levels 63,7% of environmental hospitalization/ (2008a) [109] rainy season. pollution 90,7% pneumonia 10% higher than during the to analyze the male gender; age < 5 y; climatic seasonality of primary care visits for RD, Rosa et al. cross- primary care visits for < 15 y N especially those due to upper sectional disease airway diseases, are related 32.7% respiratory in children to the rainy season. (2008) [110] respiratory disease (RD) PM10, O3, and SO2 to compare the pattern concentrations exceeded of asthma spatial Castro et al. distribution among longitudinal < 6 y SE children treated at respectively;the WHO guidelines impact of someby outpatient services from local1.25%, pollution 1%, and sources, 7.25% 15% asthma (2007) [111] 2001 to 2003 poor social, environmental conditions.

pregnancy; especially in to evaluate the effect first and third trimesters of of air pollution on low cross- SO 2 newborn SE suggesting that there is an birth weight in full term sectional weight theassociation first months between of the year;air Junger & Ponce de newborns > low birth pollution and the incidence Leon, (2007) [112] of low birth weight. the effect of PM remained to estimate the 10 association between Nascimento et al. pollution changes would pneumonia admissions longitudinal <10 y SE statisticallyhave an effect significant; on the air and increased air pneumonia9,8% pollutants hostitalization/ (2006) [113] respiratory illnesses. occurrence of children’s

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NO2 was positively associated with all to assess the effect of air Farhat et al. cross- pollution on pediatric < 13 y SE and positive associations sectional respiratory15% respiratory morbidity betweenoutcomes; air pollution.significant and hospitalization/diseases respiratory morbidity in (2005) [114] children were found.

to study variation in dry season was correlated malewith gender; higher age: asthma 1-3 y; Saldanha et al. longitudinal < 5 y CO hospitalization rates with climateservices (dry use or for rainy the asthma10% treatmentperiods) ofand asthma health in hospitalization/ (2005) [115] children patients hospitalized:seasons. 52.3% versus 47.7% in the rainy maternal exposure to CO, to study the effect of PM , and NO during the cross- 10 2 air pollution on birth newborn SE sectional weight Medeiros[116] & weight 4.6% low birth Gouveia, (2005) withfirst trimesterdecreased of birthweight. pregnancy was significantly associated to estimate correlation between atmospheric positive correlation between pollutants and the the number of admissions Nascimento et al. number of children longitudinal < 7 y SE by respiratory disease and respiratory30% admissions by the concentrations of SO hospitalization/disease 2 respiratory disease in and PM . (2004) [117] 10 the year 2001 female gender; birth weight exhibited a seasonal to explore the pattern; negative effects of

association between exposure to PM10 and CO Gouveia et al. exposure to outdoor cross- newborn SE air pollution during sectional weight for a 1 ppm increase in mean pregnancy and birth 5% low birth exposureduring the to first CO duringtrimester; the (2004) [118] weight of 23 g in birth weight was first trimesterestimated. a reduction

to assess the effects of 10, O3 and air pollution levels on Bakonyi et al. respiratory morbidity longitudinal respiratory <14 y S allon pollutants respiratory (PM diseases

among children diseases.4,5% > amongsmoke) children; presented NO an2 did effect not from 1999 to 2000 exceed limit for air quality. (2004) [119] to study the association between some environmental the dry season and lower factors with the need relative humidity were cross- for hospitalization <5 y CO associated with increased [120] sectional hospitalization of children with a pediatric hospitalization rate Botelho et al. (2003) 7,6% diagnosis of acute due to ARI. respiratory infection

(ARI) between mortality and concentrationsSignificant associations of CO, SO , to evaluate the 2 and PM were detected. The association between 10 cross- estimated proportions of child mortality and air to respiratory < 5 y SE sectional respiratory deaths attributed pollution from 1994 to > deathdisease due Conceição et al. to CO, SO , and PM , when 1997 2 10 (2001) [121] considered individually,

were around 15%, 13%, and 7%, respectively. to investigate the PM , O , SO , CO and NO responses of children 10 3 2 2 concentrationsage: < 2 y and in 14-19 ambient y; Braga et al. of different ages to air cross- <19 y SE air; daily respiratory pollution exposure, sectional < 2y: 9,4% hospital admissions for daily records of hospital hospitalization/hospitalization children and adolescents (2001) [122] admissions >14y: 5,1% increased with air pollution.

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of children in hospital for to investigate the age:total < 1respiratory y; daily admissions disease Gouveia N.; short term effects of cross- and pneumonia showed air pollution on the < 5 y SE sectional [123] respiratory morbidity associated with O Fletcher T. (2000) > hospitalization 3 of children significant increases NO2 10 (5-8%), (9%), and with PM (9%). between the increase of to report the significantrespiratory associations emergency association between visits and air pollution air pollution and cross- were observed; the most <13 y SE pediatric respiratory sectional respiratory20% robust associations were Lin et al. hospitalization/ emergency visits in the emergency visits observed with PM10, and to (1999) [124] southeast region a lesser extent with O3; air pollution is a substantial pediatric health concern.

pesticides,In the mercury, subtheme arsenic “exposure and lead to chemicalwere considered micropollutants”, potential Leukemia (AML) and Acute Lymphocytic Leukemia (ALL) in 15 articles (Tab. VI) were identified. In the analyzed articles, young child were significantly associated with periconceptional prevalenceexposure toof pesticidesmorbimortality (esbiothrin, due to tetramethrin,cancer in adolescents d-allethrin in Researchers have suggested the relation between the use of risk factors to children’s health. citiesand d-phenothrin) of the CO region, [126]. where Curvo there [125] was analyzed an increase the in positive grain agrochemicals and adverse events in children and adolescents. carcinogenic. risk factor to premature birth and inadequate maturation harvesting and 48.91% of agrochemicals used were shown to be [128]The findings and to some showed types that of prenatalcancer in pesticidechildren. exposureAcute Myeloid is a

Table VI: REGIONAL- SPECIFIC ENVIRONMENTAL REGIONAL FACTORS

Exposure to chemicals micropollutants Reference Purpose Type of Study Health Effects Age Region Outcomes to analyze the association male gender; the average use of pesticides in between the agricultural Curvo et al. use of pesticides and longitudinal <19 y CO association for both morbidity as for mortality cancer morbidity and the counties showed a statistically significant mortality in children and > morbidity (2013) [125] > mortality adolescents for cancer children and adolescents, with 95% to investigate the confidence interval. male gender; associations with ever use of association between Ferreira et al. NE, CO, SE pesticide exposure during pregnancy may be pesticide exposure during longitudinal < 2 y e S involved in the etiology of acute leukemia in pregnancy and leukemia 48.4% of AML/ 47.6%, children. (2013) [126] in children of ALL

to study a longitudinal increase in blood mercury from 2004 to 2006 Dutra et al. assessment of mercury 1µg/g- longitudinal 8 -10 y N male gender; age: 8 y; there was a significant exposure in schoolchildren 8.22µg/g hair the main exposure to mercury was during in an urban area blood10µg/L- level at (p < 0.001), exposurepregnancy. through air pollution; (2012) [127] 60µg/Lbirth to investigate potential relations between prenatal pesticide exposure is a risk factor for Cremonese et al. birth per capita pesticide longitudinal newborn S adverse pregnancy events such as premature >low premature Apgar consumption and adverse birth and inadequate maturation. score (2012) [128] events in live born infants to estimate the prevalence of lead poisoning in Ferron et al. children and to identify cross- 0 -5 y S associated factors, as well sectional 16% blood activities.; soil, and air pollution. 10.0 μg male gender; age: 2,6 y; waste recylcing as possible local sources of lead levels ≥ (2012) [129] contamination /dL

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to assess children hight level exposure to arsenic from Sakuma et al. cross- of urinary anthropic contamination may explain the environmental sources in 7-14 y SE e S sectional arsenic in one higher urinary arsenic values. a region of lead mining group (2010) [130] area to analyze household risk factors associated with male gender; living in or close to a high dental Olympio et al. high lead levels in surface cross- contaminated area and member of the enamel lead 14-18 y SE e S dental enamel sectional household worked in the manufacturing of levels in adolescents living in paints, paint pigments, ceramics or batteries. (2010) [131] poor neighborhoods

to identify the contamination sources and male gender; the carcinogenic risk factor for Mattos et al. potential risk factors of the cross- ingestion was about 4 times; sociodemographic 0-16 y SE exposure in children from sectional 40% Pb-S > an economically deprived 6μg/dLμg contaminated soil. (2009) [132] community 5% Pb-S > 10 aspects: low income, sewer destiny, dust and /dL the values were well below the level set Farias et al. cross- -1 4-12 y SE to assess total Hg levels sectional 0.04mg.kg -1 coastal population low Hg levels in children’s hair from a by World Health Organization for an adult (2008) [133] to evaluate transplacental population unexposed to Hg (2.0mg.kg ). mercury transfer by Santos et al. cross- in newborn N maternal blood Hg showed a strong positive sectional samples of mothers and Hg:newborns 16.68µg/L correlationcorrelation with between age andmaternal a positive and cord(but bloodweak) measuring Hg in blood correlation with frequency of fish consumption; (2007) [134] newbornsto investigate (umbilical the general cord) the reducedHg levels) number was strongly of children positive. and the development and the important absence of data from a control group made areas in imbalance of cross- imbalances in 1 - 5 y SE Rodrigues &; children with levels of lead sectional Cognition and concerning general development following lead [135] it difficult to confirm the observed results Carnier, (2007) contamination in the blood contamination, though it is consistent with the research literature. Language blood lead levels in the control group were to evaluateabove the10μg/dl condition lower than those presented by the exposed of all children living cross- Padula et al. 0 - 12 y SE in close proximity to a sectional neurological36,8% ≥ 10µg/dL/> rates higher than those acceptable to the CDC battery factory risk group (p <0.05) 314 children with blood lead (2006) [136] to investigate the use of higher in the clinical(10μgPb examination, / dl blood. no signs and a battery of neurological Tavares et al. exposure to development tests in longitudinal 3 - 7 y N a clinical picture characteristic of mercury two groups of riverine symptoms were foundpoisoning; that could jointly reflect (2005) [137] children MeHg = 5.37 ± to determine the blood 3.35µg/g visible presence of scum surrounding the lead levels in children home, family history of lead poisoning, and Carvalho et al. living in an inactive lead cross- malnutrition; the environmental legacy of the 1 - 4 y NE foundry and to identify sectional lead foundry, represent a relevant risk factor factors associated with Pb : 17.1 ± 7. 3 for increased blood lead levels in children, (2003) [138] differences in these levels mg/dL especially those presenting pica. to carry out cross-sectional studies in four comparable the current mercury pollution seems Grandjean et al. cross- riverine communities 7 - 12 y N sectional that had exposure to 80% hair- brain development. mercury > 10 sufficiently severe to cause adverse effects on (1999) [139] methylmercury microg/g Another chemical contaminant related with Brazilian compared to other communities in the Brazilian Amazon [137], but in the clinical examination, no signs and symptoms were

children’s health living in several parts of the Amazon basin (N poisoning. methylmercuryRegion) has been [139]. mercury, Children used can in the be goldsubjected extraction to mercury process found that could jointly reflect a clinical picture characteristic of [133] and resulting in the contamination of freshwater fish with Concerning the prevalence of lead poisoning, studies found

exposure through: prenatal transfer across the placenta [134] recycling [129] and residing close proximity to a battery factory consumption; breastfeeding, by ingesting breast milk containing blood lead levels ≥ 10.0 μg/dl, in children, associated with waste with positive correlation with mother’s frequency of fish [136]. Another study showed a strong association between adolescents with high dental enamel lead levels living in or close on brain development [139]. Riverine children presented higher mercury; and a diet rich in fish [127] with possible adverse effects a contaminated area [131]. In those three studies, the high lead levels seemed not affect the child population health. Another exposure to methyl mercury (one organic form of mercury) as Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 17 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

study showed a strong association between adolescents with high dental enamel lead levels living in or close a contaminated area [131]. Sakuma et al. [130] reported that contamination from the Onimportance the third of early subtheme diagnosis “exposure of and correct to other treatment biological for lead in a former mining area may explain the higher urinary dengueagents”, fever we used and 13malaria articles in endemic (Tab. VII). regions. Authors The have prevalence studied arsenic values among the children living nearly, despite the of dengue in children living in areas in the N Region [141, 142], median arsenic values do not warrant immediate health concern. CO Region [145] and SE Region [147] have led to a disruption Conversely, researchers suggested relations among important of routine health services, demanding further efforts towards imbalances in cognition and language in early childhood with providing technical training to health professionals working on

[135], and also neurological risk factor of exposure to lead on for malaria, researches had investigated children and adolescents dustindices and of by contamination ingestion, in children for lead from up an 10.0μg/dl economically to 45.40μg/dl deprived the frontline of dengue treatment in children’s patient care. As community [132] especially in those presenting pica and malnutrition [138]. who live in the N region [151, 152]. The lethality was 1.6% and vomitingbesides the and common some degree symptoms of malnourishment of malaria triad [151],(fever, andchills there and washeadache) a prevalence they had of malaria among among others adolescents like pallor, anemia,[152]. myalgia,

Table VII: REGIONAL- SPECIFIC ENVIRONMENTAL REGIONAL FACTORS

Exposure to other biological agents Type of Reference Purpose Health Effects Age Region Outcomes Study

83 eyes were affected; the most common To describe an lesions were corneal opacities observed extremely cross- in 34 eyes and conjunctival nodules uncommon outbreak sectional N diagnosed in 12 eyes; the necessity of eye lesions in a (Cruz et al of caution when tourists interact with 57,8% eye 11.6±6.5 y unfamiliar ecosystems, especially in 2013) [140] Brazilian Amazonia specific area of the disturbed environments.

to identify dengue occurrence of other febrile illnesses that cross- virus serotypes, need to be determined; all zones and sectional 0 - 10 y N (Costa CA & in 2008 in infant eleven districts in the study had positive Façanha GP. population 17% positive cases. 2011) [141] to present the clinical although the hemorrhagic form was and epidemiological almost three times more frequent in 2007, cross- characteristics of 4 the mortality rate was lower; 2006 - the sectional 0 - 14 y N (Rocha LA. children affected by highest incidence was in children under 1 6,9% positive (2006) & Tauil PL. dengue, in 2006 and year; 2007 - there were a predominance 57,7% positive (2007) 2009) [142] 2007 in children 10-14 years.

to evaluate activities in the forest around the houses factors related to and the living situation near the primary longitudinal the occurrence 0 - 14 y N forest; cases in very young children, (Guerra et of cutaneous 11-14 y suggested transmission in and around [143] 34% positive/ al. 2007) leishmaniasis in the house, and in a few cases, children children entering the forest.

freshwater sponge spicules Drulia to carry out aiming to cross- uruguayensis and D. ctenosclera may be Ribeiro et detect sponge spicules sectional 8 - 13 y N new etiological agent of ocular pathology (Volkmer- in surgically removed sponge spicules injuries that occurred in a town at the [144] ocular lesions 100% freshwater al. 2006) right bank of Araguaia river.

the most common clinical manifestations to study the etiology of exanthema cases, cross- itching, prostration, myalgia and positive in children seen in the sectional dengue fever 0 - 13 y CO tourniquetamong the testdengue results; patients constant were: control fever, emergency room in a (Campagna[145] 77,5% positive for of epidemiological and serological region where dengue et al. 2006) surveillance of exanthematous diseases is is endemic necessary.

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no evidence of association between to identify risk the disease and other risk factors such factors for cutaneous longitudinal leishmaniasis house, domiciliary or peridomiciliary 0 - 5 y NE transmission in characteristics,as child’s habits or insidepresence or outsideof vectors the or (Ampuero[146] et al. 2005) children in an 33% positive probable reservoir animals; the hypothesis endemic area is that humans serve as both the reservoir and source of infection for this age group.

to identify clinical characteristics only exanthema was more often associated indicative of dengue cross- and to evaluate sectional for suspected cases was shown to be 1 - 12 y SE the applicability to withof little dengue; use, theparticularly Health Ministry with smaller criteria (Rodrigues[147] et al. 2005) 50,4% positive children and during periods of reduced Ministry criteria for incidence. childrensuspected of the case Health

to perform a children living in the city outskirts where seroepidemiological cross- the socioeconomic conditions were worse survey in order to sectional 2-8 y SE than in the central region of the city; detect anti-toxocara (Coelho[148] et antibodies among al. 2004) 38,3% positive cats without vermifuge treatment. schoolchildren enteroparasitism and pet dogs and/or occurred from November to April, to describe the clinical in rural areas, including around the and some laboratory longitudinal home; laboratory tests suggesting aspects of bites 1-14 y SE rhabdomyolysis included an increase in (Bucaretchi[149] caused by Crotalus total blood creatine kinase and lactate et al. 2002) durissus ssp snakes in 87% palpebral ptosis/ dehydrogenase levels and myoglobinuria; children 74,19% myalgia no deaths were recorded. most accidents occurred from October to to describe the clinical March, in rural areas, including around aspects and outcome longitudinal the home. The main clinical complications of bites caused by 94,5% edema/ 1-14 y SE (Bucaretchi ecchymosis [150] Bothrops spp. snakes 94,5% pain/ et al. 2001) in children 73,4% observed were local infection (15.1%), compartment syndrome (4.1%), gangrene to study the clinical (1.4%) and acute renal failure (1.4%). characteristics of cross- falciparum malaria sectional 0 - 14 y N 91.5% patients had uncomplicated malaria among children (Noronha[151] 98,4% fever/ andalthough the lethality there waswas urban1.6%; transmissionmost children et al. 2000) treated at a reference 80,3% headache/ (85.2%) have been infected in rural areas, center 68,9% chills/ to evaluate (13.1%), mainly in the suburbs. epidemiological, clinical and cross- laboratory features sectional the farm and mining to help support their 0 - 14 y N of Plasmodium vivax adolescents (37%) probably working on (Ventura[152] et 97% fever/91% chills/ al. 1999) malaria in children 85% pallor/ family ; primary infection in 80% of the and adolescents 89,2% anemia patients; 13,6% malarial triad.

Another cause of illnesses in children related to regional sponges species Drulia uruguayensis and Drulia ctenosclera, in socio-environmental factors are accidents that happen in area school age children who swam in some rivers near their homes, contiguous to the household. Authors detected anti-toxocara in the Brazilian Amazon. These works revealed that freshwater antibodies positive among schoolchildren living in a house with sponge spicules may be a dangerous etiological agent of ocular pathology to kids that swim on those rivers. a yard and/or unpaved street and there was also an association Discussion between a seronegative ELISA test and previous treatment of cutaneous leishmaniasis in children living in N and NE Region, Home Life suggestedpet dogs and/or transmission cats with in and vermifuge around [148]. the house, The occurrenceand in a few of cases, children were entering the forest [143] or presence of a We can summarize, in relation to infant exposure to risk family member with a history of these disease [146]. Especially in rural areas in the SE Region where there are deforestation and toxic substances, parental smoking and the burning of domiciliary factors in the domicile lives that there are three direct threats: residences near natural forest children can be stung by snakes and biomass and living conditions at home. show clinical complications [149, 150]. Clinical researches [140, According to our research, the exposure to toxic agents at 144] detected important ocular lesions caused by freshwater

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home, in children younger than 5 years of age, was mostly due to household air pollution [14]. Even with such relevant information, household cleaning substances, pesticides and the inappropriate use of medicine. This result is very close to the conclusion of the use of wood stove for cooking as a major factor associated for studies conducted by Mowry et al. [153], which suggests there is recurrentwe found onlywheezing one research in children done [41]. on Brazil about this risk effects: a need to create stronger national prevention campaigns focused on the inappropriate conditions in which products are purchased, Social – Sanitation and Socio-environmental Factors on explaining about packaging of those agents, on raising In this group, we worked with information about the awareness of the risks of the domestic environment and of the prevalence of diseases children suffered that are related to placement of the hazardous substances, which, in the research, sanitary conditions, like having no water supply waste. This data

of parasitosis and morbidity due to diarrhea are affected by The present review has clearly shown the harmful effect of were in the children’s reach. environmentalconfirm the available changes, scientific high populationevidence that concentration, the dissemination poor parent smoking on the respiratory health of the children and hygiene and when faeces are disposed of improperly which can then contaminate food or other humans - person-to-person of exposure to the adverse effect of second-hand smoking on has identified three critical and biologically relevant windows transmission [161]. Studies have shown that intestinal parasites like Ascaris children: i) in-utero, with a negative impact on the anthropometric lumbricoides and Trichuris trichiura are common in daycares, infectionmeasures ratesof the are newborn, much higherconfirmed and alsomaternal by Salihu smoking and Wilson has a preschoolers and elementary school-age children. The CDC [162] higher[154]; ii)effect in the because first two the years children of life, stay when a longer the respiratorytime at home tract in corroborates that data by declaring that the Ascaris infection is one of the most common intestinal worm infections. It is found in years, when respiratory diseases like bronchiolitis, asthma or association with poor personal hygiene, poor sanitation, and in pneumoniadirect contact are withmore the common, grownups elevating [155]; the iii) children after the morbidity. first two places where human feces are used as fertilizer. According to the CDC [162], heavy infestations can affect the nutritional balance and showed that, from over 40 studies, all but one have reported an to the anthropometric state [76] and malnutrition of children increasedConfirming risk among that data, children the research whose parents done by smoke, Gupta and et al. pooling [156] canharm be the secondary children’s to growth. parasitosis Our andstudy are confirmed intimately that associated alterations to the insalubrious environment [62] especially in household that to have a 1.7-fold higher risk of these illnesses than children of do not have a proper waste management and collection of solid nonsmokingthe studies’ results, mothers children while paternalwhose mothers smoking smoke alone are causes estimated a 1.3- residues [78]. So improving the living conditions of the deprived population, as well as giving them access to a better healthcare of indoor factors in dwellings on the development of childhood are essential measures to cause a positive change in the situation asthma,fold increase corroborates in risk. Heinrich the above [157], data, in suggesting an review that of the one influence of most shown above. to exposure to environmental tobacco smoke. We have seen the general mortality and hospital morbidity consistent findings for the cause of asthma in childhood is related But even worse than exposing children to tobacco smoke is rates due to diarrheic diseases in children under five years of age have been decreasing in Brazil. However, the Northern contaminating them with third-hand smoking – THS [158], which and cancer, as the nicotine residues provoke on lesions that break and Northeastern Regions, areas with the lower HDI in the according to Ramírez et al. [159] can cause changes to the DNA highest percentage of admittance of children under one year of the molecule bonds responsible for transmitting the genetic country, still show the highest coefficients of mortality and the hydric resources of the planet, it is a country where a vast so important theme. age [49]. Even though Brazil has almost 13% of all superficial code. In our research, we did not find any Brazilian study about number of people do not have bathroom inside the household, Another important point to discuss is the smoke resulting corresponding to 7.2 million people [163]. Thirty four million from burning the domiciliary biomass and its repercussions people have no access to canalized water; 103 million people

generated waste is treated [164]. The NE Region is where the lack on children’s respiratory system. In Brazil, a country of vast ofhave a sewerage no access system to a waste is most disposal dire, and system, approximately and only 38.7% 15.3 million of the socioeconomic contrasts, gas cylinders are expensive and/or people are affected by the lack of sanitation [165]. The regional hard to get, which makes the lower classes use firewood and coal in ovens. Data from the Tolmasquim & Guerreiro [160] shows that firewood is the second highest source of residential energy heterogeneity of the coefficients of mortality due to diarrhea consumption in the country, accounting for 33.9% of all energy andreflects to sanitation. that socioeconomic and cultural inequality, as well as the used in domestic supply. The WHO [14] reinforces that data by difficulty the lowest classes have in getting access to healthcare likeconfirming wood and that coal. worldwide, The most around serious 3 billion piece people of data cook is that and more heat Regional - Regional environmental factors their homes using open fires and simple stoves burning biomass The relationship between the air pollution and the climatic variables has been a growing concern also on a regional level in than 50% of premature deaths among children under 5 are due to pneumonia caused by particulate matter (soot) inhaled from Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 20 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al.

Brazil due to the potential effects on human health, as it is also to environmentally relevant concentrations of certain chemicals, responsible for the increase of the number of the cases and the among them endocrine disrupters, induces morphological,

of age. As a country with a tropical climate, throughout the year the reproductive organs, by interfering with hormone actions. In weathergravity of is acute mild respiratoryand, on occasion, infection very in hot, children with undermarked five periods years biochemical and/or physiological disorders in the brain and of rain and drought. The reduction of the relative humidity of the Brazilian children. our research, we did not find articles focusing this issue in the Conversely, exposure to environmental contaminants, airways, especially for a susceptible population [110]. air below 30% is considered dangerous to the integrity of the including heavy metals, is a generalized problem relatively well- Some viruses have a seasonal behavior, with a higher studied in Brazil. The CDC [175] informs that today there are frequency in the rain season and during sharp climatic changes, which also causes the precipitation of the particulate matter from the atmosphere in big cities, increasing the number of cases of recommendsapproximately public half ahealth million actions U.S. children be initiated. ages 1-5In our with review, blood pneumonia, asthma and bronchiolitis in vulnerable children. lead showed levels above morbidity 5 µg/dl, when the the referencelevels in the level blood at were which higher CDC

change represents a massive direct threat to respiratory health acquisition [135]. byD’Amato promoting et al. or [166] aggravating confirm thisrespiratory data and diseases report or that indirectly climate than 10µg/dl [136] and could cause alterations in language We have also seen in the Amazon the presence of another by increasing exposure to risk factors for respiratory diseases. toxic exposure agent, the mercury. When it transforms into concentrated in the Amazon region, accounting for a long-term More than 85% of all fires in Brazil during the dry season are neurological development of children that ingest contaminated source of emission of gases from the burning of biomasses during methylmercury (MeHg) – its most toxic form - it can affect the the dry season [167, 168]. Children and adolescents living in the Subequatorial Brazilian Amazon region exposed to high levels of fish during a prolonged period of time [137]. According to PM2.5 had toxicological risk quotients comparable to or higher Bose-O’Reilly et al. [176], even though epidemiologic studies than in children living in metropolitan regions where the PM 2.5 goodin many dietary countries source report of lean that protein fish intakeand omega-3 is the singlefatty acids, most air pollution is above the recommended limits to human health whichinfluential are important predictor for of bloodchildren or to hair develop mercury properly. levels, So, fish for isthe a [169]. In contrast to large cities in other countries where the main methylmercury exposure. sources of aerosol particles are emissions linked to fossil fuel authors, these beneficial effects may obscure adverse effects of According to literature, seroepidemiological surveys are an combustion [170], in Brazil, sugarcane burning contributed to

the aggravation of asthma and rhinitis episodes in susceptible important research tool, especially in Public Health, because they 60% of the fine-mode aerosol mass [171] and can contribute to pathology in a given population [148]. In that sense, the subtheme children [101]. allow the determination of the infection coefficient for a given of epidemiological studies present in endemic regions in Brazil, air pollution and respiratory morbidity in children who live in where“exposure the tosocioeconomic other biological conditions agents” showedare worse, us theor byimportance children urbanWe areas have withalso founda huge significant number of and automobiles. positive relations The effect between of the activities in the forest around the houses. Studies on pediatric air pollution was detected in terms of emergency services and malaria are scarce [177] despite the increasing number of cases admittances in large and small cities in Brazil. Parker et al. [172], in children and adolescents due to malaria urbanization in in a research conducted with North-American children, came various cities of the Amazon Region [152]. Concerning dengue fever, more than 2.5 billion people, in health effects for children living in areas with chronic exposure to over 100 countries, are estimated to live in risk areas for the higherto the samelevels conclusion: of O and PM the resultscompared provide with evidencechildren withof adverse lower 3 2.5 transmission of Aedes aegypty’s vector [178]. Our data survey exposures. Another threat to the health of children that called our attention exposed to the dengue virus [141, 142, 145, 147]. The researches was the environmental contamination due to agrochemicals. werehad only conducted 4 (30%) in studies the same dedicated Brazilian to the areas risk where factors today to children there In the last few years, Brazil has become the number one are more cases of the zika virus and chikungunya caused by Aedes consumer of agrochemicals in the world [173] and increasingly aegpty [179]. dependent of such products and chemical fertilizers. In that Besides being considered an international public health sense, that exposure to agrochemicals and pesticides increase the emergency with its epicenter in Brazil [180], the strong prevalence of morbimortality due to cancer in the infant-juvenile association, in time and place, between infections with the zika population, and is also a possible risk factor for adverse effects virus and a rise in detected cases of congenital malformations during pregnancy, such as acute leukemia, premature parturition and neurological complications in newborns [181, 182, 183] of and improper maturation [125, 126, 128]. Another perspective pregnant women who had contact with the vector highlights the on this type of exposure is the study conducted by Rasier et al. importance of A. aegypty control. In January 2016, the Brazilian [174] that reported exposure of the developing fetus or neonate

Ministry of Health [179] confirmed these data by disclosing Citation: Perlroth.N.H, Branco.C.W.C. (2017) Children’s Environment in Brazil: From Domestic (Indoor) to Regional Threats. Int J Page 21 of 28 pediatr Child Care. 2(2):1-28. Copyright: AChildren’s Study on Incidence Environment of Clinical in Brazil: Hypoxic From Ischemic Domestic Encephalopathy (Indoor) Injury to Regional in Newborns © 2017 Perlroth.N.H,etCopyright: al. withThreats Perinatal Asphyxia © 2016 Chauhan et al. evidence that the zika virus crossed the placental barrier, APR_2014_web_15Sept14.pdf. transmitting the disease to the developing fetus [179]. Nowadays, 7. Edwards T M, Myers J P. Environmental exposures and gene regulation the elimination of this vector is becoming a health emergency in countries around the world. in disease etiology. Environ Health Perspect. 2007;115(9):1264– An effective prevention policy for exposure to biological 8. 1270. doi: 10.1289/ehp.9951. agents to be successful should effectually involve academic community, public health sectors and the society as a whole. 75572005000700012.Bucaretchi F, Baracat EC. Acute toxic exposure in children: an overview. J Pediatr. 2005;81:S212-222. doi: 10.1590/S0021- Conclusions 9. The scenery for children life including adverse effects of Le Cann P, Bonvallot N, Glorennec P, Deguen S, Goeury C, et al. Indoor danger exposures in home life, lack of sanitation and other environment and children’s health: recent developments in chemical, socio-environmental factors with regional hazards can generate biological, physical and social aspects. Int J Hyg Environ Health. 10. 2011;215(1):1-18.DiFranza JR,Aligne doi: A, 10.1016/j.ijheh.2011.07.008. Weitzman M. Prenatal and Postnatal an unfavorable environment for their health in several parts of Brazil. 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