Skip to main content

Developing and implementing core competencies in children’s environmental health for students, trainees and healthcare providers: a narrative review


Knowledge of the health impacts of environmental exposures (such as pollution disasters, poor air quality, water contamination, climate change) on children’s health has dramatically increased in the past 40 years. The World Health Organization (WHO) estimated that 23% of all deaths worldwide were attributable to the environment, and 26% of deaths in children less than 5 years old could be prevented with removal of environmental risks factors. Yet, little has permeated medical education, leaving pediatric providers ill equipped to address these issues. To address this gap, members from the Pediatric Environmental Health Specialty Units, a United States nationwide network of academically affiliated experts who have created numerous environmental health educational materials and programs, have identified fifteen core environmental health (EH) competencies needed by health care providers to enable them to effectively address environmental health concerns. These competencies can serve as the foundation for the development and implementation of relevant educational programs. The core EH competencies are based upon these foundational elements: 1) Definition of “children’s environmental health” that describes how environmental exposures (positive and negative) in early life influence the health and development in childhood and across the entire human life span 2) Children are not “little adults” and so have unique vulnerabilities to environmental hazards; 3) Environmental health inequities exist, causing some children to have a disproportionate amount of unhealthy exposures and consequently a greater risk of adverse effects; 4) Climate change will translate to numerous adverse health effects that will particularly affect children worldwide. In this article, the authors describe the core environmental health competencies and provide resources, online tools, strategies, and examples targeted to all levels of training and practice to better enable leaders and educators to bring this important content to the forefront.

Peer Review reports


Pollution disasters, particularly since the 1980’s, have brought greater attention to the effects of environmental contamination on communities and children. The world’s largest industrial accident, the Union Carbide plant methyl isocyanate gas leak in Bhopal, India in 1984, sent 170,000 people to the hospital, with estimated deaths as high as 8000, including 3000 in those less than 15 years of age, and caused severe health effects in 13,000 small children [1]. In the United States, communities living near hazardous waste sites, such as “Love Canal,” raised concerns about adverse impacts to their children from chronic exposure to polluted environments and toxicants, and formed advocacy groups [2]. An appreciation grew that children may be more vulnerable to toxic environments due to greater opportunities for exposures (given their lower breathing zone, oral exploratory and other behaviors), greater physiological impacts and potential for delayed manifestations [3,4,5,6]. A World Health Organization (WHO) 2016 report noted that 23% of all deaths worldwide were attributable to the environment, and 26% of deaths in children less than 5 years old could be prevented with removal of environmental risks factors [5]. Children in industrializing (Low-and Middle-Income Countries, LMIC) suffer from both the traditional environmental health risk factors and diseases (such as indoor air pollution from solid fuels and contaminated water leading to diarrhea, pneumonia and infectious diseases) along with some hazardous exposures more associated with high income countries (HIC) [7, 8]. For example, children in LMIC’s are now exposed to higher levels of outdoor air pollution due to increased combustion of fossil fuels from growing industrial activities and car exhaust accompanying increased car ownership, as well as exposures to metals, e-waste, pesticides, inadequate water availability and quality, and extreme pollution events [7, 9, 10]. Environmental problems for children of HIC’s tend to be linked to chronic, non-communicable diseases that are increasing, such as asthma, neurodevelopmental disorders (dyslexia, attention deficit/hyperactivity disorders, autism), childhood obesity, and cancer (leukemia, brain) [3, 4, 7, 8, 11,12,13,14]. For all children, there are concerns regarding the relationship of environmental factors and the COVID-19 pandemic [15], impacts of climate change [16,17,18], and exposure to manmade ubiquitous long lasting chemicals, such as per- and polyfluoroalkyl substances (PFAS) found in contaminated water and consumer products [19,20,21].

Children in more low income and minority areas in HIC’s and LIMC’s experience inequalities related to environmental exposures and subsequent adverse outcomes [22]. In the United States, the environmental justice movement raised public awareness about inequities of pollution, racism and effects on communities and children [23, 24]. These forces helped to stimulate the 1997 Executive Order “Protection of Children from Environmental Health Risks and Safety Risks” which charged U.S. federal agencies to consider and address environmental risks to children [25]. In 1998 the Agency for Toxic Substances Disease Registry (Centers for Disease Control and Prevention), an agency tasked with assessing, reducing, and preventing hazardous exposures at Superfund sites, established the Pediatric Environmental Health Specialty Units (PEHSUs). The PEHSUs are a network of experts who provide consultations (telephone and clinic), education, and referral services for reproductive and children’s environmental health (EH) [26]. Further supported by the United States Environmental Protection Agency (USEPA), there are now 10 PEHSU sites across the United States [27, 28]. Comparable entities have been developing in some other countries as well [29].

The concept of children’s environmental health has grown beyond exposures from nearby toxic external environments to encompasses those aspects of children’s health, including quality of life, that are determined by interactions with physical, chemical, biological and social factors in the environment [3]. The field focuses on environmental exposures that span the period from parents’ pre-conception through pregnancy, infancy, childhood, and adolescence. It includes inhaled air, as well as ingested water and food, housing conditions, consumer products, e-waste and other materials encountered in one’s built or social environments as well as the effects of climate change.

It is imperative that clinicians taking care of children and pregnant women, whether in HIC’s or LMIC’s, improve their environmental health literacy, access and utilize existing resources that address factors in their relevant environments, be able to take an environmental history, give anticipatory guidance, and in some cases, act as a resource for their communities [3, 7, 30]. The American Academy of Pediatrics (AAP) developed the Council On Environmental Health to address the effects of radiation, chemicals and environment in general, and has created important publications [3]. WHO has created training modules related to children’s exposures to various agents, such as heavy metals, radiation, and noise, and ones that address broader environmental health topics such as developmental and environmental origins of adult disease and the pediatric environmental history [31]. The US EPA and National Institute of Environmental Health Sciences (NIEHS)-sponsored Children’s Environmental Health Research Centers have expanded the scientific evidence base of children’s unique vulnerability to environmental toxicants [32].

Despite these efforts, deficiencies have been reported and still exist in the training of physicians and other health care providers regarding environmental health factors, starting at the medical school curriculum level [33,34,35,36,37], and extending to those in practice. For example, pediatricians surveyed in the U.S. state of Georgia in 2002 reported that they strongly believed in the importance of environmental exposures in children’s health, yet less than one in five received training in taking the environmental health history [38]. Similarly, pediatric oncology providers at a variety of U.S. sites rarely take a history about environmental exposures and are uncomfortable answering questions about them from their patient’s families [39]. In a study of 72 Egyptian pediatricians attending two education sessions 1 month apart, over half reported some awareness of pediatric health topics, but very low appreciation of the value of the environmental health history in practice [40]. A post education intervention survey revealed a higher proportion were including questions about environmental toxic exposures and parents’ occupation in the medical history and revealed the need for further awareness and attention to pediatric environmental health issues in practice [40].

Our paper addresses this education gap by first identifying core competencies needed by health care providers to enable them to effectively address EH concerns and issues (Table 1). These EH competencies can then serve as the foundation for development and implementation of relevant educational programs, targeted to all levels of training and practice, and to location priorities. The EH competencies in the areas of foundational knowledge, patient care and community health are reflective of established core competencies in medical education that address population health, including social and environmental determinants of health, community health, and health disparities [41]. We also provide examples and resources to assist in fulfilling these competencies that can be applied at various levels of training and practice.

Table 1 Core Competencies in Children’s Environmental Health

Foundation of the core competencies in children’s environmental health

A committee of pediatric environmental health experts from the PEHSU network developed core competencies in children’s environmental health, based upon these foundational elements:

Definition of “children’s environmental health”

Children’s environmental health has been defined as “the academic discipline that studies how environmental exposure in early life--chemical, nutritional, and social--influence health and development in childhood and across the entire human life span” [12]. Environmental health in clinical practice involves diagnosis, treatment and prevention of illnesses associated with harmful exposures in the environment, but also encompasses fostering the healthy aspects of an environment that are important for a child’s development, such as opportunities for exercise and the safe exploration of surroundings and nature [3, 42]. There is also growing evidence that social stressors can act synergistically with chemical exposures to harm children’s health and development [43, 44]. Environmental exposures are relevant not only to general pediatrics but also to subspecialties such as pediatric nephrology, cardiology, neurology/developmental, pediatrics pulmonary and oncology [45,46,47,48].

Children are not “little adults” [3, 4]

Children have unique “vulnerabilities” to environmental hazards, that vary with their developmental stage, behavior, and types of activities, and involve such factors as routes of exposure, metabolism, oxygen consumption, respiratory rates and target organ susceptibility and developmental “windows of vulnerability” [3, 4, 12].

Environmental justice and health inequities

Some children have a disproportionate share of unhealthy exposures in their environment, and consequently a greater risk of adverse effects [22, 23]. Many of these children lack access to healthy homes and physical environments (some resulting from historical discriminatory practices), as well as enriched and supportive social environments that would contribute to healthy development. Environmental justice and health inequalities is a global problem [49]. These children, who are confronted by the cumulative impacts of unhealthy exposures and limited services, face barriers in overcoming these exposures, and consequently suffer negative health outcomes [50].

Climate change and children’s health

Climate change is bringing about different changes in different regions of the globe that will translate to numerous adverse health effects as the results of disasters, increased heat stress, worse storms, floods, draught, decreased air quality, food and water shortages, and psychological stress, and children will be particularly vulnerable to these threats [16, 17, 51, 52]. Pediatricians can play an important role as protectors of the health and safety of children, and as advocates for changes that address both the mitigation and adaptation to climate change [17, 53, 54] . Climate change has been highlighted as an important topic for medical school and residency curricula [55,56,57].

In consideration of these factors, Table 1 presents proposed competencies in the categories of medical knowledge, patient care, and systems-based practice (community health).

Environmental health resources and experiences that fulfill the core competencies

In the last decade, more educational materials, clinical experiences, and online tools related to pediatric environmental health have been developed to fulfill EH competencies. These resources have contributed to the education of medical students, nurses, health professionals, trainees and providers, and serve as models for the development of future experiences and materials (Table 2: Resources). The following is a brief description of some of these pediatric EH resources and initiatives.

Table 2 Pediatric Environmental Health Resources

Health care providers can access online tools, even during a patient encounter, such as the Pediatric Environmental Health Toolkit (PEHT), endorsed by American Academy of Pediatrics (AAP) [58]. This resource provides succinct evidence-based information which includes provider and patient educational materials tailored to developmental stages. One hundred pediatric providers and trainees who were trained to use the PEHT in different primary care settings, reported substantial improvements in provider knowledge and confidence with counseling about EH issues. After 6 months of use, most participants responded that they “intended to continue to use the materials,” (96%) and advise patients on environmental health issues more often (86%). The original PEHT has been converted to a web-app for wider availability. Of the more than 13,000 users over the past 2 years (August 2019–2021), greater than 500 were from 60 countries outside of North America, indicating a broad international interest in these kinds of products.

In 2019 AAP released the 4th edition of the “Green Book” Pediatric Environmental Health, in both paper and electronic versions, which provides practical information for both clinical care, patient education, and teaching [3]. Galvez and Balk provide an outline of select environmental health priority areas for clinicians, along with key environmental health questions and messaging that can be incorporated into appointments [30].

The Pediatric Environmental Health Specialty Unit (PEHSU) web site offers free access to numerous resources (fact sheets, webinars, electronic eLearning modules), some translated into other languages, as well as contact information to regional experts [26]. As of August, 2021, the PEHSU National Classroom, launched in 2015, has provided 99 webinars and 26 eLearning modules, covering many of the core competencies. Over 21,000 participants (from the U.S, Canada, Israel, Australia, India and Spain), including nurses, residents, practitioners from pediatrics, family medicine, toxicology, emergency medicine, obstetrics/gynecology, medical and nursing students, paramedics, pharmacists and others have completed post-test assessments, which consisted of at least 5 questions (multiple choice and true/false) based on the learning objectives for each activity, with 80% receiving a passing score of 80% correct. For 12 interactive modules, 994 participants (representing various levels of physicians and students and non-clinical professionals) completed pre-tests and post-tests questionnaires on at least one module (5–15 multiple choice or true /false questions) [59]. Post-test scores were significantly higher than pre-test scores, demonstrating an improvement of 30.74%. There was a small response to a 6-month post-test survey, and so this assessment was not possible to determine the actual clinical impact of the eLearning modules on actual clinical practice [59].

Medical institutions such as University of California San Francisco (UCSF), Harvard Medical School (HMS), and the Icahn School of Medicine at Mount Sinai (ISMMS) offer EH electives that provide experience with the prevention, diagnosis, and management of EH concerns in the clinical and community settings. The Western States PEHSU (WS-PEHSU) developed an Interactive Pediatric Environmental Health Curriculum, an easy to administer environmental health curriculum, which meets ACGME requirements, is adaptable to multiple educational sites, and does not require expertise in environmental health to administer (a comprehensive faculty guide is provided) [60]. It includes three modules: a neighborhood visit to explore community environmental factors, a home visit to explore the intersection of housing and health, and a critical evaluation of information in a mainstream publication. The New England PEHSU developed a case-based interactive lecture on pediatric environmental health that was given at Simmons School of Nursing, and then developed into an online module for their students. The ISMMS elective has adapted to offer a virtual elective experience during the COVID-19 pandemic, including telephone screening of high-risk patients for environmental and social determinants of health.

Narrative approaches and storytelling are powerful health promotion tools that can increase understanding of determinants of health, translate complex science, and improve care. A Story of Health (SOH), a multimedia eBook, harnesses the power of storytelling to improve environmental health literacy for health professionals, health educators and advocates [61]. It addresses multiple environmental contributors to health and illness and their interactions across the lifespan in chapters on asthma, developmental disabilities, childhood leukemia, infertility/reproductive health, and cognitive decline. By grounding the science of health in stories of fictional people, their families, and communities, readers can explore risk factors and prevention strategies. Chapter stories address environmental justice and communities of color to encourage and improve “culturally responsive care.” The eBook is intended to foster the use of anticipatory guidance around environmental exposures in clinical and community practice. Over 16,000 health professionals have registered through the CDC for free CE credits using the Story of Health module. In the feedback survey, more than 85% of users have reported they will incorporate the information into their practice and provide interventions [61]. SOH has been adapted for use in clinical education of doctors, nurses and public health professionals.

Strategies to build competence

It would be unrealistic to expect every graduating medical/health professional student and practitioner to be an expert in environmental medicine. However, by introducing key EH topics in a more substantial way during pre-clinical and clinical years for trainees, and through continuing education for practitioners, healthcare providers could become better prepared to address parent and patient concerns, access EH resources, address exposures, and provide anticipatory guidance on EH. Given the climate crisis, and its multiple effects particularly on children, it is imperative for institutions training health professionals to increase their educational initiatives related to climate change [55, 57, 62] The following are some examples of existing strategies for integrating EH that can increase foundational knowledge, enhance clinical skills, and address community health concerns.

  1. 1.

    Preclinical foundational coursework: Integrate EH topics into relevant existing curriculum sessions and associated assessment (e.g. written examinations, problem-based learning exercises). Some examples include a discussion of environmental triggers and air pollution’s impact on lung development in pulmonology sessions on asthma, discussion of endocrine disrupting chemicals in relevant endocrinology course, and discussion of climate change-related expanding range of vector-borne diseases in infectious disease courses.

  2. 2.

    Clinical clerkships and residency training: Medical schools and residencies have begun to incorporate social determinants of health and advocacy training in clerkships and residencies across specialties [63,64,65]. EH (including environmental justice) is an important component to include among the social determinants and can be a focus for advocacy training and case studies. For clerkships and residencies, it is important to teach fundamentals, such as taking an environmental history and a targeted environmental history for key conditions such as asthma (environmental triggers) and lead poisoning. Standardized patient (SP) cases and assessments could be created that include contributing environmental factor that could be relevant to that location. In one example, a SP case used in a medical student clerkship involved a person with asthma exacerbation triggered by wildfire, which stimulated increased awareness of health impacts of climate change on individual patients, and connections to public health actions such as mitigation and adaptation [66].

For residency, EH topics could be included in numerous ways, incorporating case studies into Morning Report, ambulatory wrap up rounds and other resident educational sessions. Philipsborn et al. [57] provide a comprehensive framework for how to include relevant climate change topics into residency education. Such a framework could be applied to other EH topics. Clinical preceptors can encourage the inclusion of environmental histories as routine part of patient care, both as part of diagnostic reasoning as well as for preventive care (example: screening for radon).

  1. 3.

    Curriculum enhancement for medical (and other health profession) students. Medical Centers with established EH expertise and faculty, can create and offer EH electives for medical students or residents (example curricula are available). The centers can also provide opportunities for students to get involved in EH research or service projects, participate in rotations with clinical or environmental public health faculty. For Centers without an EH program, encourage trainees to participate in away electives, rotations or projects at established programs as offered, for example, through the PEHSU network. Trainees and providers can join committees or working groups based in a professional organization (e.g., AAP Council on Environmental Health) or through their local institutions (e.g., Social Determinants of Health Committee).

  2. 4.

    Postgraduate training opportunities: A Pediatric Environmental Health Fellowship is available at several institutions [26, 67]. Additional training opportunities exist for non-physician allied health professionals, such as the Association of Schools & Programs of Public Health Environmental Health Fellowship Program (ASPPH/USEPA [68] and the Environmental Health Nurse Fellowship [69].

  3. 5.

    Continuing Medical Education (CME) and Maintenance of Certification (MOC) for practicing clinicians, and other Continuing Education requirements: Practitioners in various aspects of patient care are usually required to perform continuing education. EH topics could be incorporated into local “Grand Rounds”, departmental lectures, professional conferences, and online continuing education learning modules. For example, providers can access and participate in existing CME events and modules as provided on the PEHSU national classroom [26]. In the U.S., pediatric organizations can offer MOC Part 2 or Part 4 credits that focus on EH issues. The AAP offers EH-related Project ECHO (Extension for Community Health Care Outcomes) Series.

  4. 6.

    Clinical tools available to help integrate EH into routine patient care: Providers can utilize existing tools to enhance capacity to address EH in clinical care (see Table 2). As clinics are beginning to incorporate social determinants of health into the electronic medical record (EMR) [70, 71], efforts could be made to include relevant EH history questions and anticipatory guidance.

  5. 7.

    Partnerships: It is also possible to leverage relationships with key partner organizations to include EH topics into existing meetings and conferences (e.g., AAP Chapters (USA), State Medical Societies, Public Health Conferences, Nursing Events and other professional organizations in relevant geographic locations).

Potential barriers to implementing the competencies

Challenges for insertion and implementation of these competencies and curricula into medical school and health care curricula include the already pre-existing compression of medical school curricula and lack of appreciation of this topic as an important component for medical education, as well as the shortage of knowledgeable champions who have access and input into the curricula. Although there is limited funding for development of new materials, there are already numerous resources that could be deployed, with sufficient recognition of the need of this important education.

Future directions

A major goal is to utilize these core pediatric competencies and framework to stimulate and guide relevant learning initiatives in a variety of geographical locations worldwide. Increasingly the PEHSU members and staff have been involved in consultations and educational programs with colleagues in many countries, including Korea, Japan, Israel, Spain, Chile, Argentina, Vietnam, Mexico and others [29]. To support these efforts, the PEHSU network has been creating public educational materials in multiple languages. For example, the Safer Disinfectants fact sheet has been translated in Korean, Portuguese (Brazilian), Russian, Somali, Spanish Vietnamese and more. Resources that are in English could be easily adapted to other specific languages, cultural and needs of other countries.

The USEPA and PEHSU program have worked in other countries to promote an adoption or adaptation of a PEHSU model that comprises a network of experts and staff who can offer medical education, outreach, and consultative services to communities and other health professionals. There have been presentations regarding environmental health and the PEHSU model at international meetings sponsored by the International Pediatric Associations (IPA) and International Society for Environmental Epidemiology (ISEE).

More can be done to identify “champions” of children’s environmental health in various locations and institutions, who can then inspire and train others [72].


It is critical that practitioners who care for children have the knowledge and experience to address pediatric environmental health factors. Our list of competencies, coupled with access to available EH resources, provide a structure for organizing education and resources to meet the needs of all levels (medical students, residents, practitioners, allied health care providers). Many of the key pediatric environmental health topics can be woven into existing curriculum and structures for medical students and residency training, and into continuing education courses for practitioners. Leaders and educators at all levels need to take a more active role in bringing this content to the forefront worldwide.

Availability of data and materials

Not applicable since no references made to data sets.



American Academy of Pediatrics


Environmental Health Toolkit


Pediatric Environmental Health Specialty Units


Polyfluoroalkyl substances


Environmental health


  1. Eckerman I. Bhopal gas catastrophe 1984: causes and consequences. In: Nriagu J, editor. Encyclopedia of environmental health. Oxford: Elsevier Publishers; 2011. p. 272–87.

    Chapter  Google Scholar 

  2. Center for Health EJ. Love Canal [ August 17, 2021.

  3. American Academy of Pediatrics Council on Environmental Health. Pediatric environmental health. 4th ed. Itasca: American Academy of Pediatrics; 2019.

    Google Scholar 

  4. Landrigan PJ, Goldman LR. Children’s vulnerability to toxic chemicals: a challenge and opportunity to strengthen health and environmental policy. Health Aff (Millwood). 2011;30(5):842–50.

    Article  Google Scholar 

  5. Prüss-Ustün A, Wolf J, Corvalán C, Bos R, Neira M. Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks. Geneva: World Health Organization; 2016.

    Google Scholar 

  6. World Health Organization (W.H.O.). 10 facts on children’s environmental health , 2017 [ January 27. 2019.

    Google Scholar 

  7. Miller MD, Marty MA, Landrigan PJ. Children’s environmental health: beyond National Boundaries. Pediatr Clin N Am. 2016;63(1):149–65.

    Article  Google Scholar 

  8. Suk WA, Ahanchian H, Asante KA, Carpenter DO, Diaz-Barriga F, Ha EH, et al. Environmental pollution: an under-recognized threat to Children’s health, especially in low- and middle-income countries. Environ Health Perspect. 2016;124(3):A41–5.

    Article  Google Scholar 

  9. World Health Organization (W.H.O.). Ambient air pollution 2021

    Google Scholar 

  10. American Academy of Pediatrics Council on Environmental Health. Considerations for Children from Low-and Middle-Income Countries. In: Etzel RA, Balk SJ, editors. Pediatric Environmental Health. 4th ed. Itasca: American Academy of Pediatrics; 2019. p. 221–35.

    Google Scholar 

  11. Environmental Protection Agency. NIEHS/EPA Children’s Environmental Health and Disease Prevention Research Centers Impact Report: Protecting children’s health where they live, learn, and play; 2017. p. 120.

    Google Scholar 

  12. Landrigan PJ, Etzel RA. Textbook of Children’s environmental health. London: Oxford University Press; 2014.

    Book  Google Scholar 

  13. Metayer C, Dahl G, Wiemels J, Miller M. Childhood leukemia: a preventable disease. Pediatrics. 2016;138(Suppl 1):S45–s55.

    Article  Google Scholar 

  14. Volk HE, Lurmann F, Penfold B, Hertz-Picciotto I, McConnell R. Traffic-related air pollution, particulate matter, and autism. JAMA Psychiatry. 2013;70(1):71–7.

    Article  Google Scholar 

  15. Woolf AD, Pingali H, Hauptman M. The COVID-19 pandemic and Children’s environmental health. Pediatr Ann. 2020;49(12):e537–e42.

    Article  Google Scholar 

  16. American Academy of Pediatrics Council on Environmental Health. Global climate change and Children’s health. Pediatrics. 2015;136(5):992–7.

    Article  Google Scholar 

  17. Sheffield PE, Landrigan PJ. Global climate change and children’s health: threats and strategies for prevention. Environ Health Perspect. 2011;119(3):291–8.

    Article  Google Scholar 

  18. Intergovernmental Panel on Climate Change (IPCC). Special report: Global Warming of 1.5°C: Summary for Policymakers. Geneva: World Meteorological Organization; 2018.

    Google Scholar 

  19. Agency for Toxic Substances and Disease Registry (ATSDR). PFAS: An Overview of the Science and Guidance for Clinicians on Per- and Polyfluoroalkyl Substances (PFAS), Center for Disease Control, ATSDR; 2019. p. 21.

    Google Scholar 

  20. Agency for Toxic Substances and Disease Registry (ATSDR). Per-and Polyfluoroalkyl Substances (PFAS) and Your Health: Center for Disease Control; 2020

    Google Scholar 

  21. Agency for Toxic Substances and Disease Registry (ATSDR). Toxicological Profile for Perfluoroalkyls. Atlanta: Department of Health and Human Services, Public Health Service; 2020.

    Google Scholar 

  22. Gouveia N. Addressing Environmental Health Inequalities. Int J Environ Res Public Health. 2016;13(9):858.

    Article  Google Scholar 

  23. Brulle RJ, Pellow DN. Environmental justice: human health and environmental inequalities. Annu Rev Public Health. 2006;27(1):103–24.

    Article  Google Scholar 

  24. Environmental Protection Agency. Environmental Justice: United States Environmental Protecction Agency; 2021.

    Google Scholar 

  25. Payne-Sturges D, Kemp D. Ten years of addressing children’s health through regulatory policy at the U.S. Environmental Protection Agency. Environ Health Perspect. 2008;116(12):1720–4.

    Article  Google Scholar 

  26. Pediatric Environmental Health Specialty Units. PEHSU: Pediatric Environmental Health Specialty Units 2019

    Google Scholar 

  27. Paulson JA, Karr CJ, Seltzer JM, Cherry DC, Sheffield PE, Cifuentes E, et al. Development of the pediatric environmental health specialty unit network in North America. Am J Public Health. 2009;99(Suppl 3):S511–6.

    Article  Google Scholar 

  28. Woolf AD, Sibrizzi C, Kirkland K. Pediatric environmental health specialty units: an analysis of operations. Acad Pediatr. 2016;16(1):25–33.

    Article  Google Scholar 

  29. Zachek CM, Karr CJ, Daniell W, Sweeney C, Miller MD. A network of pediatric environmental health specialty units (PEHSU’s): filling a critical gap in the health care system. Medycyna Srodowiskowa – Environmental Medicine. 2012;15(3):9–20.

    Google Scholar 

  30. Galvez MP, Balk SJ. Environmental risks to children: prioritizing health messages in pediatric practice. Pediatr Rev. 2017;38(6):263–79.

    Article  Google Scholar 

  31. World Health Organization (W.H.O.). Training modules and instructions for health care providers 2021.

    Google Scholar 

  32. U.S. Environmental Protection Agency. NIEHS/EPA Children’s Environmental Health and Disease Prevention Research Centers Impact Report: Protecting children’s health where they live, learn, and play. 2017.

    Google Scholar 

  33. Gehle KS, Crawford JL, Hatcher MT. Integrating environmental health into medical education. Am J Prev Med. 2011;41(4 Suppl 3):S296–301.

    Article  Google Scholar 

  34. Institute of Medicine. Environmental medicine and the medical school curriculum. Washington, D.C.: National Academy Press; 1993.

    Google Scholar 

  35. Institute of Medicine. Environmental medicine: integrating a missing element into medical education. Washington, DC: The Natonal Academies Press; 1995. p. 975.

    Google Scholar 

  36. Schenk M, Popp SM, Neale AV, Demers RY. Environmental medicine content in medical school curricula. Acad Med. 1996;71(5):499–501.

    Article  Google Scholar 

  37. Pelletier SG. Experts see gorwing importance of adding environmental health content to medical school curricula. AAMC News. 2016 August 21, 2021.

    Google Scholar 

  38. Kilpatrick N, Frumkin H, Trowbridge J, Escoffery C, Geller R, Rubin L, et al. The environmental history in pediatric practice: a study of pediatricians’ attitudes, beliefs, and practices. Environ Health Perspect. 2002;110(8):823–7.

    Article  Google Scholar 

  39. Zachek CM, Miller MD, Hsu C, Schiffman JD, Sallan S, Metayer C, et al. Children’s Cancer and environmental exposures: professional attitudes and practices. J Pediatr Hematol Oncol. 2015;37(7):491–7.

    Article  Google Scholar 

  40. Abbas RA, Alghobashy AA. Effect of an environmental health educational programme for paediatricians in an Egyptian University hospital: before and after study. JRSM Short Rep. 2012;3(12):86.

    Article  Google Scholar 

  41. Byrne LM, Nasca TJ. Population health and graduate medical education: updates to the ACGME’s common program requirements. J Grad Med Educ. 2019;11(3):357–61.

    Article  Google Scholar 

  42. Tillmann S, Clark AF, Gilliland JA. Children and nature: linking accessibility of natural environments and Children’s health-related quality of life. Int J Environ Res Public Health. 2018;15(6):1072.

    Article  Google Scholar 

  43. Clougherty JE, Levy JI, Kubzansky LD, Ryan PB, Suglia SF, Canner MJ, et al. Synergistic effects of traffic-related air pollution and exposure to violence on urban asthma etiology. Environ Health Perspect. 2007;115(8):1140–6.

    Article  Google Scholar 

  44. Wright RJ, Brunst KJ. Social determinants in Children’s environmental health: the stress health paradigm. In: Landrigan PJ, Etzel RA, editors. Textbook of Children’s environmental health. New York: Oxford University Press; 2014. p. 43–8.

    Chapter  Google Scholar 

  45. Gauderman WJ, Urman R, Avol E, Berhane K, McConnell R, Rappaport E, et al. Association of improved air quality with lung development in children. N Engl J Med. 2015;372(10):905–13.

    Article  Google Scholar 

  46. Jacobson MH, Wu Y, Liu M, Attina TM, Naidu M, Karthikraj R, et al. Serially assessed bisphenol a and phthalate exposure and association with kidney function in children with chronic kidney disease in the US and Canada: a longitudinal cohort study. PLoS Med. 2020;17(10):e1003384.

    Article  Google Scholar 

  47. Trasande L, Urbina EM, Khoder M, Alghamdi M, Shabaj I, Alam MS, et al. Polycyclic aromatic hydrocarbons, brachial artery distensibility and blood pressure among children residing near an oil refinery. Environ Res. 2015;136:133–40.

    Article  Google Scholar 

  48. Whitehead TP, Metayer C, Wiemels JL, Singer AW, Miller MD. Childhood leukemia and primary prevention. Curr Probl Pediatr Adolesc Health Care. 2016;46(10):317–52.

    Article  Google Scholar 

  49. Claudio L. Standing on principle: the global push for environmental justice. Environ Health Perspect. 2007;115(10):A500–A3.

    Article  Google Scholar 

  50. Morello-Frosch R, Pastor M. Environmental Justice and Vulnerable Populations. In: Frumkin H, editor. Environmental Health: from Global to Local. 3rd ed. San Francisco: Jossey-Bass, A Wiley Brand; 2016. p. 251–72.

    Google Scholar 

  51. Haines A, Ebi K. The imperative for climate action to protect health. N Engl J Med. 2019;380(3):263–73.

    Article  Google Scholar 

  52. Intergovernmental Panel on Climate Change (IPCC). Climate change widespread, rapid, and intensifying-IPCC Press Release. 2021. Accessed 14 Sept 2021.

  53. Solomon CG, LaRocque RC. Climate change - a health emergency. N Engl J Med. 2019;380(3):209–11.

    Article  Google Scholar 

  54. The Medical Society Consortium on Climate and Health. Accessed 21 Aug 2021.

  55. Wellbery C, Sheffield P, Timmireddy K, Sarfaty M, Teherani A, Fallar R. It’s time for medical schools to introduce climate change into their curricula. Acad Med. 2018;93(12):1774–7.

    Article  Google Scholar 

  56. Bell EJ. Climate change: what competencies and which medical education and training approaches. BMC Med Educ. 2010;10(1):31.

    Article  Google Scholar 

  57. Philipsborn RP, Sheffield P, White A, Osta A, Anderson MS, Bernstein A. Climate change and the practice of medicine: essentials for resident education. Acad Med. 2021;96(3):355–67.

    Article  Google Scholar 

  58. Miller MD, Newman N, Zajac L, Dunn M. Pediatric Environment Toolkit: University of California San Francisco; 2016 December 22, 2019.

    Google Scholar 

  59. Wong KH, Allen A, Durrani TS. Evaluating effectiveness of online learning modules in pediatric environmental health education. J Med Toxicol. 2020;16(3):269–75.

    Article  Google Scholar 

  60. Western States PEHSU (Pediatric Environmental Health Specialty Unit). Pediatric Environmental Health Interactive Curriculum: University of California, San Franciso.; 2020.

    Google Scholar 

  61. Miller MD, Valenti M, Schettler T, Tencza B. A multimedia E-book-A story of health: filling a gap in environmental health literacy for health professionals. Environ Health Perspect. 2016;124(8):A133–6.

    Article  Google Scholar 

  62. Salas RN. The climate crisis and clinical practice. N Engl J Med. 2020;382(7):589–91.

    Article  Google Scholar 

  63. Marsh MC, Supples S, McLaurin-Jiang S, Brown CL, Linton JM. Introducing the concepts of advocacy and social determinants of health within the pediatric clerkship. MedEdPORTAL. 2019;15(1):10798.

    Article  Google Scholar 

  64. Moffett SE, Shahidi H, Sule H, Lamba S. Social determinants of health curriculum integrated into a Core emergency medicine clerkship. MedEdPORTAL. 2019;15(1):10789.

    Article  Google Scholar 

  65. Scott MD, McQueen S, Richardson L. Teaching health advocacy: a systematic review of educational interventions for postgraduate medical trainees. Acad Med. 2020;95(4):644–56.

    Article  Google Scholar 

  66. Ramkumar J, Rosencranz H, Herzog L. Asthma exacerbation triggered by wildfire: a standardized patient case to integrate climate change into medical curricula. MedEdPORTAL. 2021;17(1):11063.

    Article  Google Scholar 

  67. National Institute of Environmental Health Sciences. A day in the Life of a Pediatric Environmental Health Fellow: Partnerships for Environmental Public Health 2019 2019.

    Google Scholar 

  68. (ASPPH) AoSPoPH. ASPPH/EPA Environmental Health Fellowship Program 2019 February 17, 2020.

    Google Scholar 

  69. Alliance of Nurses for Healthy Environments. ANHE Environmental Health Nurse Fellowship 2019 February 17, 2020.

    Google Scholar 

  70. Cantor MN, Thorpe L. Integrating data on social determinants of health into electronic health records. Health Aff (Millwood). 2018;37(4):585–90.

    Article  Google Scholar 

  71. Gold R, Bunce A, Cowburn S, Dambrun K, Dearing M, Middendorf M, et al. Adoption of social determinants of health EHR tools by community health centers. Ann Fam Med. 2018;16(5):399–407.

    Article  Google Scholar 

  72. Rogers B, McCurdy LE, Slavin K, Grubb K, Roberts JR. Children’s environmental health faculty champions initiative: a successful model for integrating environmental health into pediatric health care. Environ Health Perspect. 2009;117(5):850–5.

    Article  Google Scholar 

Download references


The authors wish to thank Carrie Dickenson for her help in organizing meetings and communications among the authors and providing data and information, along with Cassandra Bernardi who provided information from the PEHSU National Website classroom.


This article was supported by the American Academy of Pediatrics (AAP) and funded (in part) by a cooperative agreement with the Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry (CDC/ATSDR). The U.S. Environmental Protection Agency (EPA) supports the PEHSUs by providing partial funding to CDC/ATSDR through an Inter-Agency Agreement. The findings and conclusions presented have not been formally disseminated by CDC/ATSDR or EPA and should not be construed to represent any agency determination or policy. Use of trade names that may be mentioned is for identification only and does not imply endorsement by the CDC/ATSDR or EPA.

Author information

Authors and Affiliations



All of the authors contributed to formulating the competencies, conducting the literature review, and writing the manuscript. The author(s) read and approved the final manuscript.

Authors’ information

The authors are members of the Pediatric Environmental Health Specialty Units, a nationwide network of academically affiliated environmental health experts, funded by the U.S. Centers for Disease Control (CDC) Agency for Toxic Substances and Disease Registry (ATSDR) and the U.S. Environmental Protection Agency through a cooperative agreement with the American Academy of Pediatrics. For two decades we have been creating educational materials and programs (see and teaching at all levels of medical education.

Corresponding author

Correspondence to Rose Hannah Goldman.

Ethics declarations

Ethics approval and consent to participate

Not applicable since no human subjects in this review.

Consent for publication

Not applicable since no individual person data.

Competing interests

The authors declare they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Goldman, R.H., Zajac, L., Geller, R.J. et al. Developing and implementing core competencies in children’s environmental health for students, trainees and healthcare providers: a narrative review. BMC Med Educ 21, 503 (2021).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Environmental health
  • Pediatric environmental health
  • Health disparities
  • Climate change
  • Medical education
  • Competencies
  • Environmental social determinates of health
  • Environmental justice