Clean, safe and secure environments to support early childhood development

Why is the environment important for What is nurturing care? early childhood development? To reach their full potential, children need the five inter-related and indivisible components of nurturing Clean, safe and secure environments contribute to enabling care: good health, adequate environments for nurturing care. Clean air, safe and secure nutrition, safety and security, surroundings, and outlets for physical activity are essential responsive caregiving and conditions for children to survive and thrive. An infant or young opportunities for early learning. child who is exposed to environmental pollutants from sources This begins in pregnancy and such as unsafe drinking water, air pollution or chemicals, as well continues throughout the life course. as a child who lacks access to spaces for outdoor physical activity and exploration is at higher risk of both We have made great strides in noncommunicable diseases (NCDs) as well as infectious improving child survival, but we also diseases (such as pneumonia and diarrhoea) and developmental need to create the conditions to help delays that can reduce their lifelong cognitive, socio-emotional children thrive as they grow and and physical potential. develop. Nurturing care protects children from the worst effects of This brief summarizes some of the most important adversity and produces lifelong and environmental health risks faced by children today and it intergenerational benefits for health, explains why infants and young children are particularly productivity and social cohesion. vulnerable. It elaborates on the components of Nurturing Care, especially good health and security and safety. It aims to alert Nurturing care happens when we policymakers and practitioners, whether involved with childcare maximize every interaction with a or environmental issues, about the importance of considering child. Every moment, small or big, early childhood needs in policies and practices, to create structured or unstructured, is an environments in which young children can thrive. Examples of opportunity to ensure children are practical actions are provided for key settings that affect healthy, receive nutritious food, children’s early development - healthcare, home, and childcare are safe, and learning about settings; and the broader urban and community settings that themselves, others and their create both risks and opportunities for children’s development. world. What we do matters but how we do it matters more. Environmental health and early childhood – the linkages

WHO estimates that about one Air pollution, for example. Infants Harmful exposures to environmental quarter of deaths of children under 5 and young children breathe more air pollutants start as early as in utero, could be prevented through healthier than adults. A typical adult takes as a pregnant mother exposes her environments that reduce key risks between 12 and 18 breaths a minute, developing foetus to the toxicants to including: air pollution, unsafe while a 3-year old child takes 20 to which she, herself is exposed, via the drinking water, sanitation, and 30 breaths a minute and a newborn air, water, foods or her own skin inadequate hygiene as well as baby takes 30 to 40 breaths. contact with harmful chemicals. exposures to certain toxic chemicals, such as lead and mercury. On busy streets, infants in strollers Clean and safe indoor and outdoor and young children are most directly environments optimize a child’s Infants and young children are exposed to vehicle tailpipes. Air early development opportunities, particularly vulnerable to pollution reduces lung function, by reducing the exposure to environmental pollution since their increases risk of common respiratory contaminants and by enabling bodies and respiratory airways are infections and asthma, and can social interaction and physical much smaller, and their organs and cause childhood cancers and even activity, whether it is in play and immune systems are still developing. obesity, due to adverse metabolic exploration, or simply accompanying And they have a higher proportion of changes. It is an important cause of a caregiver on foot to the local grocery. skin to volume ratio. Relative to their preventable child mortality and there Such activity is key to reducing obesity size, young children also ingest more is evidence that both prenatal and risks for infants as well as young food and drink more water. postnatal exposure to air pollution children, as well as developing motor, Behaviours typical of infants and can negatively influence neuro socio-emotional and cognitive skills.3 young children – such as putting development.1-2 Finally, air pollution hands and objects into their mouths contributes to climate change, which Advancing healthier environments to explore their environments – as is expected to increase food thus represent a major opportunity well as the need to explore and play insecurity, undernutrition, water- and for improving children’s health, outdoors – also put young children at vector-borne diseases, affecting development and wellbeing – and is particularly high risk of exposure to children in particular. essential for achieving Sustainable hazards in unsafe or poorly adapted Development Goal 3, Good Health community environments. and Wellbeing. It is also part of commitments made under other SDG goals and targets such as Clean Water and Sanitation (SDG 6), Sustainable Energy (SDG 7), Sustainable Cities and Communities (SDG 11), Responsible Consumption and Production [including sound chemicals and waste management] (SDG 12) and Climate Action (SDG 13).

What are the nurturing care Good health Adequate nutrition components? Refers to the health and well-being of Refers to maternal and child nutrition. the children and their caregivers. Why Why both? We know that the nutritional both? We know that the physical and status of the mother during pregnancy mental health of caregivers can affect affects her health and well-being and their ability to care for the child. that of her unborn child. After birth, the mother’s nutritional status affects her ability to breastfeed and provide adequate care. Remember Key SDG indicators relevant to environmental health* •• Mortality rate [0-5] attributable to household and ambient air pollution Clean, safe and secure environments (SDG 3.9.1) create the conditions for children to develop to their full potential. •• Mortality rate [0-5]-attributed to unsafe water, unsafe sanitation and lack of hygiene (3.9.2) Air pollution is estimated to cause 543 000 child deaths annually due to •• Mortality rate [0-5] attributable to unintentional poisoning acute lower respiratory infections (SDG 3.9.3); before the age of 5.1 This includes emissions from polluting household •• % of [0-5] population exposed to annual mean levels of PM 2.5 stoves and fuels at home to above 10 µg/m3 (SDG 11.6.2) emissions from traffic, dust, waste •• % of urban population living in slums, informal settlements or burning, power generation and other inadequate housing (SDG 11.1.1) outdoor (ambient) sources. Similarly, exposures to chemicals, heavy •• % of population that has convenient access to public metals and other toxicants through transport [with special attention to women/children**]. air, water, food or skin contact are (SDG 11.2.1) particularly harmful for infants and young children and can lead to •• Proportion of urban solid waste regularly collected lifelong disorders as well as reducing and with adequate final discharge out of total urban their potential to develop mentally solid waste generated [11.6.1] and physically. Individual •• Average share of the built-up area of cities that contaminants often have multiple is open space for public use [accessible to impacts on health. women and children**] (SDG 11.7.1) Lead exposures, for example can reduce children’s IQ, as well as cause learning disability, antisocial * For SDG indicators with age behaviour and increased risk of stratification, [0-5] is noted for cardiovascular disease in adulthood. Persistent organic pollutants purposes of this brief as the One important source of exposure (POPs) are another cause of relevant age group. is through ingesting or inhaling neuro-developmental delays ** Target refers to particles of paint.4 Methylmercury and exposure occurs “women/children” exposures, often through dietary through direct contact with sources, adversely affect neonatal pesticides, or indirectly, brain and nervous system through air pollution or even development, including cognition, ingested through pathways memory, attention, language, fine such as mother’s breast motor and visual spatial skills, and milk contaminated with can occur in-utero as well. pesticide residues.5-6

Safety and security Opportunities for early learning Responsive caregiving Refers to safe and secure environments Refers to any opportunity for the infant or Refers to the ability of the caregiver to for children and their families. Includes child to interact with a person, place, or notice, understand, and respond to their physical dangers, emotional stress, object in their environment. Recognizes child’s signals in a timely and appropriate environmental risks (e.g., pollution), and that every interaction (positive or manner. Considered the foundational access to food and water. negative, or absence of an interaction) is component because responsive contributing to the child’s brain caregivers are better able to support the development and laying the foundation other four components. for later learning. Strengthen

Many countries are already working to protect, promote, and support healthier environments through national standards, policies and regulatory actions, in line with WHO guidelines, international conventions and the WHO Global Strategy on Health, Environment and Climate Change.7 Greater awareness of the risks of environmental hazards to children’s cognitive and physical development can support more assertive action. Here are a few examples of how we can strengthen our actions.

Government leadership and Fig. 1 Proportions of children under 5 years living in areas in which the WHO policies at national level: air quality guidelines (PM2.5) are exceeded, by country, 2016. •• Adopt WHO Air Quality Guidelines. Worldwide 9 out of 10 children under the age of 5 breathe unsafe air, exceeding WHO recommended limits for the most harmful Particle 8 Matter pollutants (PM2.5), and millions of infants and young children are growing up in areas where average pollution levels exceed WHO guidelines several times over. National policies that include clean household energy solutions, reduce

diesel fuel sulphur content, shift to Population above Air Quality Guidelines (PM2.5) renewable energy and electric Above 98% 75–98% 50–75% 10–50% Under 10% Data not available Not applicable vehicles, and enforce strict limits on tailpipe and smokestack emissions Source: Air pollution and child health: prescribing clean air. Summary. Geneva: World Health Organization; 2018. from vehicles, factories, waste and agricultural burning, will help achieve WHO Air Quality •• Ban lead in paint and adopt and cosmetics, jewellery, batteries, Guidelines. The same measures enforce safe management of electronic waste and traditional reduce emissions of CO and short- 2 chemicals, based on international medicines. Common mercury lived climate pollutants like black chemicals conventions and SDG exposure pathways for pregnant carbon, methane and ozone, 12.9-10-11 Lead exposure reduces IQ, women and children include slowing the pace of climate change. accounting for 63.8% of the global discarded waste, artisanal mining, •• Integrate WHO Housing and burden of developmental or consumption of fish and shellfish Health guidelines into national intellectual disability that is not containing mercury residues building codes, including WHO attributable to biological factors. emitted by sources such as coal guidelines for Household Fuel Lead is still present in paint, toys, power plants. Combustion and reinforce national standards for safe Water, Sanitation and Hygiene (WASH). Household Fig. 2 WHO member states with legally-binding controls on lead paint, as of air pollution exposures from the 30 September 2018. burning of wood, coal, kerosene and charcoal, dung and crop waste in inefficient stoves is responsible for a significant proportion of child deaths from pneumonia in low- and middle-income countries. Kerosene is a major risk factor for burns and accidental poisonings. In addition, household air pollution exposures during pregnancy increases risk of stunting and may affect brain development. Lack of household access to save water, sanitation Yes - 36,36% (70 countries) No - 38,22% (73 countries) No data - 25,13% (48 countries) and hygiene remains a significant factor in under-5 deaths from Data source: World Health Organization/ United Nations Environment Programme. diarrhoeal disease. Add

•• Enact or enforce robust legislation The health sector, urban leaders, and local communities can work together to for solid waste management, a) assess risks using health-based tools b) prescribe solution using health- restricting e-waste imports and based guidance and c) implement policies that promote clean, safe, and prohibiting child labour in waste secure environmentsfor children, in the context of healthy, sustainable cities, management and mining. communities and health services. The same strategies reduce climate Electronic and electrical waste, is emissions, making communities and health care services more resilient to the fastest growing solid waste climate change. Below are indicative examples of areas where health, urban stream in the world. When and community leaders can take action. improperly recycled, often through home-based enterprises, it Primary health care providers Currently one in 4 healthcare exposes children to toxicants facilities lack basic water and one which can lead to permanent lung Health care providers can build their in five lack basic sanitation services damage and cancer, as well as own awareness about environmental worldwide. Local health services can reduced intelligence and attention health risks and solutions; so as to raise awareness about needs and deficits. In terms of mining, the ILO integrate environmental health gaps to local government leaders estimates that nearly one million themes directly into primary and district health authorities. children between 5-7 years of age healthcare services, and particularly are engaged in small-scale mining delivery of maternal and child health •• Maternal, newborn and child and quarrying activities, putting programmes, visits, and outreach. health services. Since children are them at risk of direct exposures to among the most vulnerable groups toxic chemicals, including mercury Below are just a few indicative to environmental risks, incorporating (in the case of gold). examples of actions and issues that environmental health themes in can be prioritized at primary health maternal, newborn and child health •• Incorporate criteria for child- and care level: (MCH) services can expand the parent-friendly designs in national awareness of pregnant women, •• Clinical training for health care land-use plans and investments mothers, partners and families providers. Doctors, nurses and with reference to the WHO Global about key risks and solutions. Action Plan on Physical Activity. health-workers need to be trained Planning walkable cities and to act more effectively. WHO’s •• Household-based environmental neighbourhoods, with services and Children’s Environmental Health risk assessment. In the course of schools accessible on foot or by training package for health care routine maternal, newborn and public transport, and safe public providers covers some two dozen child health programmes, health and green spaces for movement, core areas of environment health workers can support assessment of play and exploration, needs to start risk, exposure pathways, household health and safety risks with national policies and assessment methods and solutions. and promote awareness about the investments in urban land use, Another tool, the paediatric importance of safe and clean home housing and transport. Greener environmental health history record, environments and solutions, such and more walkable cities also keep can help clinicians assess a patient’s as clean cookstoves and cities cooler during heat waves, and risks and solutions in clinical visits. elimination of lead paint. reduce urban air pollution as well Health systems may also consider •• Childcare and other early as the carbon footprint, creating the creation of Children’s childhood institutions. Ensure that multiple synergies between health Environmental Health Units. environmental risks are addressed and climate resilience.12-13 •• Safe water, sanitation, hygiene in health and safety codes for and healthcare waste childcare and other early childhood management (WASH) in health settings (e.g., nurseries, preschools), facilities to ensure quality and including for: radon, asbestos, lead safety of health care services. in paint and soils, formaldehyde in building materials, as well as for WASH facilities, safe green/open space provision, responsible waste management and recycling. Local government

Rapid urbanization calls for urban leaders to use their mandate to develop more child-friendly cities – which are greener, more sustainable and more vibrant places for people of all ages to live, work and visit. Selected examples of strategies and tools, include:

•• Urban health impact assessment. Assess air pollution impacts from access to safe drinking water/ traffic, household energy and other sanitation and structures free of sources, and recommend health- mould, wet, damp as well as toxic optimized emission-reduction materials such as asbestos and lead. strategies for traffic, waste management and household •• Safe routes for children’s active energy, as well as green space transport to school and other expansion, using WHO Health activities. Develop suitable Impact Assessment methods and pedestrian and bike routes that •• Safe, healthy community tools such as WHO AirQ+, CHEST , children can use. This includes environments. Initiate and lead Sustainable Transport and Health continuous sidewalks and bike programmes on environmental tools, and others. trails, safe crossings, and school risks that affect young children in crossing guards, in line with global the community context, such as •• Child-friendly urban planning. best practice and WHO Guidance. responsible recycling, as well as Based on health assessment of planning of services, open street key risks and opportunities, urban initiatives, green spaces and leaders can design more walkable Communities, families and caregivers corridors that support safe, communities, based around healthy physical activity and make neighbourhoods of homes, Many community fora exist where a neighbourhoods more child-friendly. schools, fresh food stores and broad spectrum of environmental services linked by safe pedestrian health needs, risks and solutions can •• Childcare and other early networks and public transport. be addressed. These include: childhood institutions. Work with This supports active outdoors community centres, childcare teachers and caregivers to ensure movement and exploration by centres, primary and nursery clean drinking water and safe young children with caregivers schools, and other early childhood lavatories and latrines on premises; during daily routines. Key principles education programmes, as well as healthy indoor air quality, healthy, of child-friendly cities include: civil society institutions. Community nutritious fresh foods; and access promoting safe, healthy institutions can incubate and support to safe, clean, green spaces for environments, where crucial local leadership on priority issues – outdoor play, wherever feasible, services are proximal, and where acting as a vital link between local adapted to local environmental responsive interactions with loving authorities, the health sector and conditions, e.g. water-resistant 14 adults are possible. Green spaces, families and caregivers and forging plants and attention to shade in including shade, water and initiatives aimed at households, hot, arid countries. community cultivation of healthy, schools and community-wide. fresh foods provide children with •• Physical activity and play. diverse outdoor experiences, points Here are some indicative examples Incorporate awareness about the of early childhood social interaction, of themes that may be prioritized: importance of physical activity and as well as shielding cities from heat access to outdoor play spaces into island impacts – whereby urban •• Safe, healthy home environments. parental education as well as temperatures are much warmer than Build awareness of risks and nursery/childcare and school surrounding areas in heat waves. opportunities into community-based programmes, with reference to WHO courses and seminars for families Guidelines on physical activity, •• Healthy housing. Local and caregivers: covering themes sedentary behaviour and sleep for governments can play a leading role such as home safety risks, safe children under 5 years of age. in enforcing local housing code storage of chemicals, and clean This should include awareness of provisions for healthy housing as cooking solutions, to ensure that children’s health risks from physical per WHO Housing and Health infant and young children can safely inactivity, including increased risk guidelines, with clean energy; their most immediate environment. of obesity and diabetes. Creating clean, safe, and secure environments Did you know?15 for early childhood - Selected resources  The human brain develops faster from pregnancy to age Institutions and networks three than at any other time. Children’s Environmental Health - World Health Organization:  Over 80% of a human brain is https://www.who.int/health-topics/children’s-environmental-health formed by the age of three years. Clean Cooking Alliance - UN Foundation: https://www.cleancookingalliance.org/home/index.html  The care and support Environment and Climate Change - UNICEF: provided to children in the https://www.unicef.org/environment-and-climate-change earliest years by parents and Urban95, Cities for Young Children - Bernard van Leer Foundation: caregivers is critical for healthy https://bernardvanleer.org/solutions/urban95/ brain development.

 In the first years of life, Resources by topic parents, intimate family Air Pollution – Risks, data and guidance, WHO: https://www.who.int/health-topics/air-pollution members and caregivers are the closest to the young child Air Pollution – Household energy, WHO: https://www.who.int/airpollution/household/en/ and thus the best providers of Artisanal and small-scale mining and health, WHO, 2016: Nurturing Care. In order to https://apps.who.int/iris/bitstream/handle/10665/247195/9789241510271-eng.pdf?sequence=1 provide caregivers with time Basel, Rotterdam and Stockholm Chemicals Conventions: http://www.brsmeas.org/ and resources to provide Children’s environmental health training modules, WHO: nurturing care, policies, https://www.who.int/ceh/capacity/training_modules/en/ services and community Children’s environmental health units, WHO: supports need to be in place. https://www.who.int/publications-detail/children’s-environmental-health-units Clean household energy solutions (CHEST), WHO:  Nurturing care increases https://www.who.int/airpollution/household/chest/en/ health, productivity and Global Action Plan on Physical Activity, WHO: social cohesion throughout a https://www.who.int/ncds/prevention/physical-activity/global-action-plan-2018-2030/en/ lifetime, and the benefits Guidelines on physical activity, sedentary behaviour and sleep for children under 5 years of age, continue into the next WHO: https://apps.who.int/iris/handle/10665/311664 generation. Healthier Environments for healthier populations: Why do they matter and what can we do? WHO, 2019: https://www.who.int/sustainable-development/urban/guidance-tools/en/  250 million children under Housing and Health Guidelines, WHO: the age of five in low- and https://www.who.int/sustainable-development/publications/housing-health-guidelines/en/ middle-income countries – Inheriting a sustainable world: Atlas on children’s health and the environment. WHO, 2017. more than four out of every https://www.who.int/ceh/publications/inheriting-a-sustainable-world/en/ ten children – are at greater Minamata Convention on Mercury: http://www.mercuryconvention.org/ risk of not reaching their development potential due Nutrient requirements and dietary guidelines, including guidance on healthy diets, trans-fats and sugars intake for adults and children, WHO: https://www.who.int/nutrition/publications/nutrient/en/ to poverty and neglect. Open Streets Initiative, 8 80 Cities and Streets Plans: https://openstreetsproject.org/  Research shows that Paediatric environmental history record, WHO: https://www.who.int/ceh/capacity/paedenvhistory/en/ for every US$1 spent on Physical activity and young people, WHO: early childhood https://www.who.int/dietphysicalactivity/factsheet_young_people/en/ development Preventing disease through healthy environments: a global assessment of the burden of disease interventions, the return from environmental risks, WHO, 2016: on investment can be as https://www.who.int/quantifying_ehimpacts/publications/preventing-disease/en/ high as US$13. Reducing global health risks through mitigation of short-lived climate pollutants, WHO/Climate and Clean Air Coalition, 2015: https://www.who.int/phe/publications/climate-reducing-health-risks/en/  Nurturing, protecting Urban Health Initiative, WHO: https://www.who.int/sustainable-development/cities/en/ and supporting caregivers and Urban health and sustainable development, guidance and tools, WHO: https://www.who.int/sustainable-development/urban/guidance-tools/en/ children is essential to achieve the Urban95 – Design of safe, healthy urban environments for early childhood. Bernard Van Leer Foundation: https://bernardvanleer.org/solutions/urban95/ Sustainable Development Goals. WASH- Water Sanitation and Hygiene, WHO: https://www.who.int/water_sanitation_health/en/ WASH in Health Care Facilities, WHO: https://www.who.int/water_sanitation_health/facilities/healthcare/en/ References 1. Air pollution and child health. Geneva, World Health Organization, 2018. Nurturing care framework for https://www.who.int/publications-detail/air-pollution-and-child-health 2. Danger in the air, how air pollution may be affecting the brain early childhood development development of young children around the world. New York, UNICEF, 2017. https://www.unicef.org/environment/files/Danger_in_the_Air.pdf The Nurturing care framework for early 3. WHO physical activity guidelines for children under 5. Geneva, World childhood development: A framework for Health Organization, 2019. https://apps.who.int/iris/handle/10665/311664 helping children SURVIVE and THRIVE to 4. WHO 2010: Childhood lead poisoning. Geneva: World Health Organization; TRANSFORM health and human potential 2010. (http://www.who.int/ceh/publications/leadguidance.pdf) builds upon state-of-the art evidence of 5. Children’s environmental health atlas. Geneva, World Health Organization, 2016. how child development unfolds and of the https://www.who.int/ceh/publications/inheriting-a-sustainable-world/en/ effective policies and interventions that 6. Training package for health care providers. Geneva, World Health can improve early childhood development. Organization. (Accessed 25 November 2019) https://www.who.int/ceh/capacity/training_modules/en/ The Framework was developed by WHO, 7. WHO global strategy on health, environment and climate change: the UNICEF, and the World Bank Group, in transformation needed to improve lives and well-being sustainably through collaboration with the Partnership for healthy environments (WHA A72/15). Geneva, World Health Assembly, Maternal, Newborn and Child Health the 2019. https://www.who.int/phe/publications/global-strategy/en/ Early Childhood Development Action 8. Air Quality Guidelines, global update 2005. Geneva, World Health Organization, 2006. Network and many other partners to https://www.who.int/phe/health_topics/outdoorair/outdoorair_aqg/en/ provide a roadmap for ensuring attainment 9. The Minamata Convention on Mercury. http://www.mercuryconvention.org/ of the Sustainable Development Goals and 10. SDG Target 12.4 https://sustainabledevelopment.un.org/sdg12; [Note: The survive, thrive and transform goals of the SDG target calls for countries “achieve the environmentally sound management of chemicals and all wastes throughout their life cycle, in Global Strategy on Women’s, Children’s accordance with agreed international frameworks, and significantly reduce and Adolescents’ Health. Launched their release to air, water and soil in order to minimize their adverse alongside the 71st World Health Assembly impacts on human health and the environment,” with reference to Basel, Rotterdam, and Stockholm chemicals conventions]. Basel, Rotterdam and in May 2018, it outlines: i) why efforts to Stockholm Chemicals Conventions. http://www.brsmeas.org/ improve health and wellbeing must begin in 11. Basel, Rotterdam and Stockholm Chemicals Conventions. the earliest years, from pregnancy to age 3; http://www.brsmeas.org/ ii) the major threats to early childhood 12. Health as the Pulse of the New Urban Agenda. Geneva, World Health development; iii) how nurturing care Organization, 2017. https://www.who.int/phe/publications/urban-health/en/ 13. “Global Strategy on women’s children’s and adolescents’ health and protects young children from the worst environmental health policies.” Neira M, Fletcher E, Brune-Drisse MN, effects of adversity and promotes physical, Pfeiffer M, Adair-Rohani H, Dora C. “Environmental health policies for emotional and cognitive development; and women’s, children’s and adolescents’ health.” Bulletin of the World Health Organization. Vol. 95:8, August 2017. iv) what families and caregivers need to https://www.who.int/bulletin/volumes/95/8/16-171736.pdf provide nurturing care for young children. 14. Urban95, Bernard Van Leer Foundation. https://bernardvanleer.org/solutions/urban95/ 15. Black MM, Walker SP, Fernald LCH, et al., Early childhood development coming of age: science through the life course. For more information: Lancet. 2017, 389(10064):77-90. https://nurturing-care.org https://ecdan.org/

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