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Environment International 76 (2015) 115

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Children's health and vulnerability in outdoor microclimates: A

comprehensive review
Jennifer K. Vanos
Atmospheric Sciences Research Group, Department of Geosciences, Texas Tech University, Lubbock, TX 79409-1053, USA

a r t i c l e i n f o a b s t r a c t

Article history: Background: Children are routinely identied as a vulnerable population in environmental health risk assess-
Received 19 August 2014 ments, experiencing adverse health outcomes due to exposure to a suite of atmospheric constituents.
Received in revised form 23 November 2014 Objective: To provide a substantive overview of the research literature pertaining to biometeorological effects on
Accepted 25 November 2014 children. Key information areas within urban environmental health research related to atmospheric variables
Available online 11 December 2014
(heat, air pollution, radiation) are assessed and integrated to better understand health outcomes and vulnerabil-
ities in children. Critical avenues for improvement and understanding of children's health related to such bio-
Environmental health
physical parameters are also identied.
Children Methods: This comprehensive review assesses past and current primary studies, organizational reports, educa-
Radiation tional books, and review articles. Emphasis is placed on the differential ambient exposures to temperature, air
Air pollution pollution, and radiation within urban microclimates commonly used by children (e.g., schoolyards, urban
Heat stress parks), and the resulting health impacts.
Urban climate Discussion: Exposure to heat, air pollution, and radiation are often enhanced in urban areas, specically under the
Vulnerable current design of the majority of outdoor child play places. Many heat indices, energy budget models, and health
outcome studies fail to adequately parameterize children, yet those that do nd enhanced vulnerability to ambi-
ent stressors, particularly heat and air pollution. Such environmental exposures relate strongly to behavior,
activity, asthma, obesity, and overall child well-being. Current research indicates that a changing climate, grow-
ing urban population, and unsustainable design are projected to pose increasing complications.
Conclusions: Evidence-based research to link children's health, physiology, and behavior to atmospheric extremes
is an important future research avenue, underscoring the fact that children are among the population groups
disproportionately affected by ambient extremes. However, current methods and population-based models
lack child-specic inputs and outputs, as well as designated thresholds for accurate predictions of child health
impacts. More substantive evidence is needed for applicable child-specic policies and guidelines.
2014 Elsevier Ltd. All rights reserved.


1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Observations and models of outdoor heat stress: where do children come in? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.1. Modeling: energy budget approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.2. Modeling with heat indices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.3. Observations: heat events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3. Outdoor microclimatic properties of children's urban spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.1. The biophysical environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3.2. Incorporating bioclimatic urban design in select outdoor spaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3.3. Vehicles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4. Air pollution health effects on urban-dwelling children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.1. Weather, climate, and air pollution: associations with health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.2. Respiratory health in children: childhood asthma & related issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5. UV-radiation exposure to children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Abbreviations: BSA, body surface area; eNO, exhaled nitrogen oxide; FEF, forced expiratory ow; FEV, forced expiratory volume; HRmax, maximum heart rate; PMV, predicted mean vote;
SDD, standard vitamin D dose; SVF, sky view factor; Tmrt, mean radiation temperature; Tsfc, surface temperature; UFP, ultrane particles; UVB, ultraviolet radiation B; UVR, ultraviolet radiation
E-mail address:
0160-4120/ 2014 Elsevier Ltd. All rights reserved.
2 J.K. Vanos / Environment International 76 (2015) 115

5.1. Health effects and observations in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

6. Impacts of weather on behavior, health, and well-being . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
7. Future research and conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
7.1. Future research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
7.2. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1. Introduction commonly frequented outdoor microclimates. For the purposes of

this evaluation, these include current and future levels of heat, air
Children are uniquely sensitive to their ambient environments pollution, and radiation linked to resulting health impacts early in
due to numerous physiological and psychological mechanisms. Incor- life. Specically, this review is guided by four objectives to provide
porating such mechanistic differences in biophysical models in child- insight on what we know, and need to know, about children's health
specic environmental health studies, specically related to outdoor ex- and well-being under times of physiological environmental stress.
posures of heat, air pollution, and radiation, is essential for improved These objectives include:
understanding of children's health. It has been well-established that ex-
1) Review current research related to the atmospheric stressors of heat,
posure to extreme heat and air pollution has separate and simultaneous
air pollution, and radiation, and how they differentially impact
health impacts across the globe (Luber and McGeehin, 2008; Hondula
children and adults.
and Barnett, in press; Vanos et al., 2014), with children routinely iden-
2) Classify and compare the various outdoor spaces used by children
tied as vulnerable populations in heat and air pollution health
(e.g., schoolyards), as well as how their design and associated micro-
studies (Perera, 2008; Revi et al., 2014). However, empirical re-
climates impact children both positively and negatively.
search encompassing the specic behavioral and physiological
3) Demonstrate biometeorological principles as they relate to the cur-
mechanisms of children is vital in order to provide support that is
rent state of knowledge of children's health and well-being based
substantive enough to formulate adaptation policies and guidelines
on ambient stressors, and provide insight from the literature into
for this subpopulation. As high-priority aspects of the lives of many
potential improvements of outdoor environments.
humans, the health of children can be substantially protected and im-
4) Identify the most important areas for future research for enhanced
proved through preventative environmental health measures. Here, a
understanding of the impacts of the ambient environment on
thorough literature review is provided on three of the most critical en-
children via improved observations and models.
vironmental factors impacting children's health and well-being: heat,
radiation, and air pollution (Fig. 1). The microclimatic design of outdoor spaces is a fundamental aspect
The aim of this review is to comprehensively combine knowl- of the thermal environment, which can improve or hinder a child's
edge of the various ambient exposures that children receive within overall health, functionality, and development based on learning and

Urban Growth &

Climate Variability

Enhancement of



Air & Surface UVB Health, activity,
Energy Budgets: Wind
Urban & Human exposure behavior, learning
Humidity Radiation


Child & Societal


Fig. 1. Conceptual diagram of the interacting factors related to environmental stressors on children, which synergistically act upon children in varying degrees to impact a child's energy
budget, behavior, activity levels, learning processes (e.g., cognitive development), and overall health. Arrows depict one-way or two-way interactions of the variables within an urban
J.K. Vanos / Environment International 76 (2015) 115 3

activity. The connections between energy budget modeling and mean 2010). The balance of these energy streams is best understood through
radiant temperature (Tmrt) (Mayer and Hppe, 1987)the most inu- the well-established human energy budget equation:
ential microclimatic variable in human biometeorological model-
ingare discussed in Section 2.1, yet are routinely not considered 0 M RCKES 1
in heat stress indices (Section 2.2). Connections are further
portrayed between specic types of radiation and air pollutants where S is the change in heat storage (W m2), which is 0 at energy
impacting children's skin and respiratory health, respectively, as balance, N 0 at energy surplus, and b0 at energy decit (Fanger, 1972;
well as the distinction between outcomes of heat-related morbidity Parsons, 2003; Vanos et al., 2010).
and mortality. As portrayed in Fig. 1, the interplay between these When considering the energy budget equation for children and
variables is important to understand, and works synergistically to adults, the main differences are predominantly due to surface area
impact health. and metabolism. With a much higher surface-area-to-body mass ratio,
These environmental stressors are important to understand due to the effects of heat in children are heightened (Wenger, 2003). In a
current and future urban heating effects (Harlan and Ruddell, 2011; warm-hot environment, their body relies more on dry heat loss via con-
McCarthy and Sanderson, 2011), urban land use change (Adachi et al., vection (C) than evaporative heat loss (E) as compared to adults (Falk,
2013), and increasing temperatures with projected climate change 1998). This large physiological difference in warm-hot conditions is in-
(Meehl and Tebaldi, 2004; Tebaldi et al., 2006). Negative climate im- terestingly not due to a lower number of sweat glands per surface area,
pacts have been highlighted within some of the most vulnerable popu- but a lower sweat rate per gland in children (Falk, 1998). The greater re-
lations, including children (English et al., 2009; Ebi and Paulson, 2010; liance on dry heat loss in children (and hence elevated skin blood ow)
Shefeld and Landrigan, 2011). In addition to health, understanding results in a greater need to dissipate body heat by convection, yet when
children's reactions to atmospheric conditions can also have wide- air temperatures rise above that of the skin (extreme conditions), this
reaching implications for teaching and learning, as well as behavior- convective loss becomes a heat gain, and there is a relatively higher
al issues and parenting ease (Ciucci et al., 2013). For example, im- rate of heat absorption, and a quicker path to heat stress.
plications to academic performance and behavior are related to Body surface area (BSA) must be properly taken into account for ac-
physical activity (Bessesen, 2008), and extreme heat, dehydration, curate energy ux estimations. However, many biometeorological indi-
fatigue, and air pollution can limit cognitive ability, as well as in- ces either assume an average BSA of 1.8 m2, or are derived empirically
crease aggression and irritability (Anderson, 2001; Ciucci et al., for a specic subset of the population, and subsequently applied to an
2011, 2013). Such connections are important to address upfront, entire population. The inaccuracies caused from incorrect BSA are easily
and are fully addressed in Section 6. demonstrated using the average BSA of a ve-year old child (0.72 m2).1
Within this review, children are dened as 014 years of age (Kovats The heat production of an average man at rest is 90 W using a metabol-
and Hajat, 2008). The spatial focus for urban microclimates is based on ic rate of 50 W m 2 and BSA of 1.8 m2. The same heat production
commonly frequented urban areas for active play within the developed (90 W) from a child would result in an average metabolic rate of
world (schoolyards, urban parks/playgrounds, sports elds, and back- 125 W m2, which is 2.5 times more energy per second coming from
yards), as well as the dangerous semi-outdoor environment of vehicles. each square meter of the surface.
The atmospheric variables of heat, air pollution, and radiation are com- The metabolic output is one of the strongest predictors of energy
prehensively assessed and integrated within urban play spaces to pro- balance (Vanos et al., 2012a). Children grow at greater rates, resulting
vide a new lens for assessing children's well-being associated with in a higher relative metabolism, yet with a lower surface area to release
these outdoor urban environments. heat. Hence, equations to determine a child's metabolism will differ
from an adult. Heart rate (HR) is applicable to metabolic outputs, and
2. Observations and models of outdoor heat stress: where do is linearly related to metabolism when HR N120 beats min 1
children come in? (ISO8996, 1990); however, in energy budget modeling, an average age
and metabolic output is commonly assumed. For example, the Physio-
Numerous interdisciplinary studies over the last half-century em- logical Equivalent Temperature (PET) (Hppe, 1999) is valid for individ-
phasize the need for accurate prediction of health outcomes via direct uals 2060 years of age. The Universal Equivalent Temperature Index
and indirect approaches. This includes epidemiological studies investi- (UTCI) (Brde et al., 2009; Jendritzky et al., 2009) is valid for adults,
gating relationships between health outcomes and single atmospheric and also assumes a BSA of 1.86 m2, a body weight of 73.5 kg, and a
variables, or the use of simple indices (Anderson and Bell, 2011; body fat of content of 14% for all calculations (Fiala et al., 2012). Other
Barnett et al., 2010; Hajat et al., 2006; Kovats and Hajat, 2008). Energy well-known indices utilized for outdoor heat stress prediction include
budget models convey information regarding heat uxes from an the Standard Predictive Index of human response approach (Gagge
individual, and commonly result in a nal budget value or a predicted and Berglund, 1986) and Out_SET* (Pickup and de Dear, 2000), both
mean vote (PMV) based on ambient conditions (e.g., Fanger, 1970; of which are based on Gagge's early (Gagge, 1971; Gagge and
Vanos et al., 2010). Heat indices use certain variables, mainly air tem- Gonzalez, 1974) and use the assumptions of the average man
perature and vapor pressure, to determine a human-perceived equiva- (1.8 m2), with a heat production of 90 W (or 50 W m2).
lent temperature (or how it feels). This section describes approaches An in-depth evaluation by Doherty and Arens (1988) of the physio-
used operationally and in the literature, and highlights areas where logical bases of early thermal comfort models did not address the factor
these predictive methods may or may not be applicable to children. In of age on the model accuracy, although it did emphasize its importance.
depth discussions on the theory and calculation of such indices and More recently, Grundstein et al. (2010) adapted the man-environment
models are out of the scope of this review but are found elsewhere heat exchange (MENEX) model (Blazejczyk, 1994) for modeling the en-
(Hajat et al., 2010; Vanos et al., 2010; Willett and Sherwood, 2012; ergy balance of children in cars (see Section 3.3). They use physiological
Anderson et al., 2013). characteristics of an average 2-year-old toddler (e.g., Msitting =
61 W m2), with summer clothing insulation of 0.61 clo (Blazejczyk,
2.1. Modeling: energy budget approach 1994); however evaluation against actual physiological measurements
has not yet been completed. The COMfort FormulA (COMFA) energy
The major energy uxes impacting the human energy budget within
outdoor conditions are convective heat loss (C), evaporative heat loss 1
Based on the Dubois and Dubois (1916) BSA formula (BSA = [(W0.425 H0.725)
(E), conductive heat loss (K), net radiative exchange (R), and metabolic 0.007184]), assuming weight and height of 20 kg and 101.6 cm, respectively (based on av-
heat production within the body (M) (Parsons, 2003; Vanos et al., erage height and weight for a 5-year old).
4 J.K. Vanos / Environment International 76 (2015) 115

budget model (Brown and Gillespie, 1986; Kenny et al., 2009; Vanos adult interventions (see Section 6). Overall, it is evident above that
et al., 2012a) incorporates age and tness into its metabolic value, quan- the quicker onset to heat stress in children results in vulnerability,
tifying average levels of physical activity and HR for different genders and that heat indices and energy budget models, although valuable
and ages using a general energy expenditure estimation method by tools, require child-specic inputs to provide accurate estimates
Strath et al. (2000). for children.
Despite the above-mentioned issues, the success of energy budget
modeling in application and understanding within areas of biometeorol-
2.3. Observations: heat events
ogy, urban microclimatology and bioclimatic design, exercise physiology,
heat stress, and health outcome analysis should not go unnoticed (e.g., de
Urban-dwelling children are routinely identied as vulnerable pop-
Dear and Spagnolo, 2005; Matzarakis et al., 2007; Fiala et al., 2012;
ulations in environmental health review literature related to heat-
Jendritzky et al., 2012; Vanos et al., 2012b; Ketterer and Matzarakis,
health and climate change (e.g., Ebi and Paulson, 2010; English et al.,
2014). However, the generalization of these models and lack of testing
2009; Perera, 2008), yet conclusive and direct relationships in heat mor-
on children may result in inaccurate estimates of physiological strain.
tality studies are more sparse in comparison with the elderly and gener-
This can produce inaccurate use of the model outputs when applied to
al public. However, it is well-established that children from low income
children, which can lead to serious consequences in identifying health
and minority populations are more susceptible to heat (Luber and
issues, particularly in young children.
McGeehin, 2008). The most recent National Health Statistics Report
(Berko and Ingram, 2014) detailed heat related mortality counts across
2.2. Modeling with heat indices the United States from 2006 to 2010, with 147 deaths occurring in
young children ( 4 years), 86 in infants, and 28 in children aged
The most common and widely used index in North America is the 514. These numbers are less than other age categories, particularly
apparent temperature (AT), or the heat index (HI), used by the National the elderly, yet all heat related deaths are preventable.
Weather Service (NWS) as well as in environmental health studies There is varying evidence of excess heat-related mortality in children
(Smoyer-Tomic and Rainham, 2001). This bivariate index, in the form (Basu and Ostro, 2008; Kovats and Hajat, 2008), with some studies nd-
utilized by the NWS, incorporates both air temperature and moisture. ing low risk and others an increased risk. For example, studies have
This index was developed based on indoor conditions (entitled the found minimal risk of mortality during heat waves in developed coun-
Simple Indoor AT) (Steadman, 1984, 1994) yet is applied outdoors, tries (Paixao and Nogueira, 2002; Garcia et al., 1999). These researchers
neglecting to use the word Indoor in front of the apparent temperature evidenced this through time-series and episode analysis, indicating no
title (Jendritzky et al., 2012). This index is applied to the entire public excess mortality in children due to heat waves (excluding minimal in-
along a caution-to-extreme danger continuum, with categories describ- creases in the 1981 and 1991 Portugal heat waves). Studies nding an
ing potential physiological heat stress (NOAA, 2014)2 (e.g., 40.6 C (105 increased heat-mortality risk in children (Empereur-Bissonnet et al.,
F) represents an excessive heat warning). However, this index is not 2006; Paixao and Nogueira, 2002) determined that cumulative, rather
suitable to capture the experience and effects of heat on children as the than single-day high temperature effects, caused excess mortality dur-
initial AT development by Steadman (1979) used physiological data ing the France heat waves of 2003 and 2006. Similar epidemiological
from healthy, college-age students based on work the of Fanger analyses of extreme heat events have generally found insignicant in-
(1970). The further assumption of model human body dimensions by creases in mortality among children (Kovats and Hajat, 2008), with a
Steadman (1979) used a height of 57 (1.7 m) and a weight of 148 lb systematic review by Xu et al. (2014) revealing that the existing litera-
(67 kg) (Anderson et al., 2013); thus the higher surface-area-to-body ture is inconsistent and does not suggest signicant increase in child
mass ratio in children would result in the current HI underestimating mortality during heat waves.
the heightened heat impacts to children under extreme heat. Many studies highlight the signicant negative effects on the elderly
The Humidex (humidity index) (Masterton and Richardson, 1979) from heat exposure also due to inefcient thermoregulation (Basu and
is a simplied version of the rst heat stress index (HSI) put forth by Samet, 2002; Klinenberg, 2003); hence, heavy focus is given to the el-
Belding and Hatch (1955), which was developed for acclimatized derly, subdividing the age groups as those b65 years of age, and those
men. This is a similar bivariate index to the HI based on vapor pressure 65 years, thus missing specic outcomes in the vulnerable child pop-
and temperature, and is used by Environment Canada to alert the pop- ulation. This approach is commonly utilized, such as in studying the
ulation to heat stress danger. The two indices (Humidex and HI) result 1995 Chicago heat wave (Semenza et al., 1996, 1999; Naughton et al.,
in different outputs, which has been demonstrated many times in the 2002) and the 2003 European heat wave (e.g., Conti et al., 2007;
literature in relation to health (e.g., Smoyer-Tomic and Rainham, Vandentorren et al., 2006).
2001; Hajat et al., 2010). For example, a heat-health study by Smoyer- Interestingly, studies addressing child vulnerability point to a higher
Tomic and Rainham (2001) demonstrated discrepancies between the risk of morbidity rather than mortality in children due to their heat vul-
two indices, as well as inaccuracies in predicting heat related mortality nerability (e.g., Kovats and Hajat, 2008; Knowlton et al., 2009; Rhea
based on heat warning thresholds with the Humidex. et al., 2012). During the July 15Aug 1, 2006 California heat wave, a
The reasons for discrepancies within and between such empirical in- total of one child death was reported by the California of Health Services
dices are numerous (e.g., not accounting for radiation (see Sections 3.1 soon after the heat wave, stating that:
and 5)), yet when applied to children, the accuracies are likely to be-
come even greater as the lower body size and age are not accounted Despite research literature identifying children as a high-risk popula-
for. Finally, children do not individually interpret the values from the tion, only one child death occurred in the California heat wave. We have
HI and Humidex; it is left up to the parents to interpret this information no information on heat-related morbidity in this or other age groups.
and to make decisions on the child's behalf. The differences in thermal [Trent (2007)]
comfort psychology in adults (expectations and experience, perception,
personal preference, etc. (Parsons, 2003; Metje et al., 2008; Knez et al., Following this, a study by Knowlton et al. (2009) determined that in
2009)) also affect their interpretation of a child's physical state. this heat wave, there were 49,800 emergency department visits among
Children, particularly infants and toddlers, do not have such experi- children aged 0 to 4 years, a 5% signicant increase in risk, emphasizing
ences, knowledge, or ability to modify behavior properly without the dangerous nature of heat risk to children. Conversely, in North Car-
olina heat waves, children aged 09 represented a considerably lower
Many National Weather Service ofces across the US will use location specic thresh- morbidity incidence (2.94 per 100,000 people) than the adults
olds based on climatology that differ from the heat index chart (NOAA, 2014). (Lippmann et al., 2013); hence inconsistencies exist in child heat risk,
J.K. Vanos / Environment International 76 (2015) 115 5

potentially due to spatial differences (e.g., climate zones, preparation, variables are important in understanding outdoor ambient conditions
acclimatization), as well as behavioral and cultural effects. Many studies affecting child physiology and psychology.
focus on mortality as a health outcome, as do the majority of heat-health Specic to children's play, providing safe, thermally comfortable,
studies on children; hence, we may be missing the continuum of heat functional, accessible, and healthy spaces is of paramount importance
stress issues and illnesses affecting children. in maintaining health and well-being (Fjrtoft, 2004; Wolch et al.,
The higher risk of heat illness present may also have future implica- 2011; Ciucci et al., 2013). This section discusses the physical parameters
tions due to chronic heat exposure that have not been studied. More- involved in understanding the biophysical environment of the outdoor
over, minimal research exists on the impacts of early season, closely spaces in the current review: schoolyards, urban parks/playgrounds,
spaced, and concomitant extreme heat events on children (Karl et al., sports elds, and backyards. An example is given in Fig. 2 of two outdoor
2009). Although children have the ability to acclimate to the same mag- playgrounds depicting stark contrasts in design and space, specically
nitude as adults, it occurs at a slower rate (Bytomski and Squire, 2003); vegetation, surface type, and shade cover. Depending on city and loca-
hence, early season heat waves are also a greater risk factor to the child tion within an urban area, outdoor play places can be found within a
population in some locations (Anderson and Bell, 2011). combination of built types, from placement within and open low-rise
to a compact high-rise area. In built-up areas, sky view factors (SVF)
are used to express the ratio between radiation received by a planar sur-
3. Outdoor microclimatic properties of children's urban spaces face and that from the entire hemispheric radiating environment
(Watson and Johnson, 1987). High rise compact areas display a SVF
3.1. The biophysical environment 0.20.4 (resulting in radiative trapping) and 0.20.6 for compact
midrise (Stewart and Oke, 2012). The urban spaces of interest in the
The micrometeorological parameters input into energy budget current study would result in SVFs ranging from 0.8 for single houses
models of humans and outdoor spaces include air temperature, vapor to N0.95 for open sports elds. A low SVF traps longwave radiation,
pressure, wind velocity, and short- and long-wave radiation. Thermal yet is benecial or cooling on hot, sunny days by blocking shortwave ra-
comfort is inuenced specically by the mean radiant temperature diation (based on orientation) to cool the street or nearby ground
(Tmrt) in warm conditions (Mayer and Hppe, 1987; Matzarakis et al., surface.
2007; Kenny et al., 2008; Johansson et al., in press), which is dened Land cover types in these areas generally represent a range from
simply as the combination of all short- and long-wave radiant uxes open park and low brush to dense urban forest (Oke, 2004; Stewart
(Thorsson et al., 2007) (further discussed in Section 5). Shortwave radi- and Oke, 2012), acknowledging that characteristics of these spaces
ation is the main component of environmental heat load leading to po- vary widely. The dominant land cover type greatly inuences the energy
tential heat stress (Brotherhood, 2008); however, all atmospheric uxes experienced by a child, and can differ greatly from a soccer eld

Fig. 2. Visual comparison of two schoolyard parks, depicting stark contrasts in design and space. School yards displayed for A: Lubbock, Texas, USA (33.6 N, 101.9 W) ; B: Berlin, Germany
(52.5 N, 13.4 E). Photos by Vanos (2014).
6 J.K. Vanos / Environment International 76 (2015) 115

to an urban park. Built-up areas generally have b10% pervious material, incident radiation, with air temperature and relative humidity more dif-
such as soil and grass, and the most common surfaces in parks and play- cult to control (Brown and Gillespie, 1995). For wind modication, de-
grounds include grass, pebbles, sand, and impervious materials of as- sign of outdoor play spaces can incorporate the use of local wind
phalt, concrete, and dark rubber. Commonly a high abundance of direction climatology to block cooler, harsh winter winds (e.g., north
impermeable surfaces is used (e.g., asphalt, brick, concrete, rubber, winds), and allow the inow of winds in the warm season to aid convec-
and articial turf), which reduce moisture availability, partitioning in- tive and evaporative cooling.
coming solar energy toward enhanced sensible heating of the urban Incident radiation dramatically impacts air and surface tempera-
airshed. The energy uxesand hence the Bowen Ratio (ratio of tures, which are the most prominent characteristics of an urban climate,
sensible-to-latent heat)with dry impermeable surfaces, or very dry with the Tmrt being the most important factor in the human energy bud-
grass, are dominated by a high sensible heat ux from a hot surface. Sat- get (Section 3.1). The micro-scale models of the PET (Hppe, 1999;
ellite observations have displayed the temperature of dry, short grass to Matzarakis et al., 1999; Mayer and Hppe, 1987) using Rayman
be similar to asphalt on a hot day in schoolyards (Moogk-Soulis, 2010). (Matzarakis et al., 2007), and COMFA using a radiant temperature
It is within these hot locations where children are encouraged to play, (Brown and Gillespie, 1986; Kenny et al., 2009; Vanos et al., 2012b) cal-
and the fact that children are closer to these hot surfaces than adults culate the thermal comfort of humans, outputting and incorporating a
is a cause for greater concern for heat stress (Moogk-Soulis, 2010), Tmrt (C) or absorbed radiation (Rabs) by a human (W m2), respective-
due mainly to radiative heat uxes from the surfaces and corresponding ly. The Tmrt and Rabs were found to have the greatest inuence on the
high temperatures in closer proximity. PET and energy budget, respectively, on sunny days. Ketterer and
Matzarakis (2014) found the PET to be signicantly greater (up to 58
3.2. Incorporating bioclimatic urban design in select outdoor spaces C) above sealed surfaces with low albedo, high solar irradiation, and
low wind speed, corresponding to very hot.3
Research is abundant in the urban climate literature on how to Fig. 3 displays the surface temperatures of an outdoor soccer/football
modify the landscape to improve thermal comfort, perception, and pop- eld and running track taken in Guelph, ON, Canada (June 21, 2013) on
ulation attendance (e.g., Eliasson et al., 2007; Watkins et al., 2007; a warm-hot day (Ta = 25 C; RH = 62%; clear skies), in both the visible
Ketterer and Matzarakis, 2014). This subsection focuses on how the ef- and the infrared spectrum (Brown, 2013). The inner eld is articial turf
fective modication of the biophysical properties of the urban spaces of grass, the track is a dark pink/red rubber, and the outer area is natural
interest (Section 3.1) can enhance these environments and improve vegetation. Both unnatural surfaces display surface temperatures in
child comfort and health. It is uncommon to nd children's play places the range of 4255 C; however, the surfaces within the shade of
in cities designed to ameliorate the impacts of climate and urban maple trees (e.g., concrete and brick) display a Tsfc range of 2427 C,
heating effects on health and thermal comfort. Urban parks and school and portions of vegetation (trees, grass, shrubs) in the surroundings
yards with adequate vegetation, shade, and green space have the poten- have Tsfc ranging from 25 to 30 C. Such contrasts are due to the radia-
tial to provide thermally comfortable environments, and help reduce tive properties of the surface, where both a lack of evapotranspiration
vulnerability to heat stress to those active within or nearby. However, from the articial surfaces and higher absorption of heat result in higher
in order to provide this function, outdoor spaces, including parks and temperatures. Evaporative cooling in the surrounding areas results in a
schoolyards, must be designed within the context of the prevailing lower surface and near-surface temperature, highlighting the potential
urban climate (i.e., climate-responsive bioclimatic design principles) benets of conserving natural and permeable surfaces.
and projected future climates (Brown et al., 2014). The latest IPCC report Leaves of trees have the ability to intercept and absorb all direct
noted that projected warming may negatively affect urban recreational shortwave radiation, including ultraviolet radiation, as there is zero
sites (Revi et al., 2014), yet in combination with the amplied rates of ur- transmittance through a single leaf (Cox, 2013); however, an entire
banization, the value and importance of the services provided by urban tree canopy rarely approaches 0% transmission of radiation. The pres-
ecosystems and green infrastructure for adaptation will be greatly accen- ence of shade can result in two forms of temperature lowering: 1) limit-
tuated (Smith et al., 2014). Such green infrastructure within urban areas ing the direct solar radiation; and 2) lowering the ground surface
includes green roofs, urban parks with ample shade, and porous pave- temperature, thus reducing the amount of longwave radiation. For ex-
ments or surfaces to allow for increased evaporation (Santamouris, ample, on a hot day in a mid-latitude climate, if a shaded grass surface
2013), all of which aid in cooling and in preserving functionality of a city. is 30 C, the same sunlit surface is several degrees Celsius warmer.
Differentiating between commonly found open vegetated (un- Hence, the mere difference in surface conditions results in a signicant
treed) schoolyards, parks, or playgrounds versus those with effective difference in surface temperature, in turn exponentially increasing the
tree cover demonstrate potential use of evidence-based bioclimatic de- longwave radiation emitted. Moreover, tree shaded surfaces have
sign principles to aid in both urban sustainability and community shown to decrease the local and surrounding air temperatures in
health. A study completed in South-central Canada examined the sur- parks with abundant tree cover (Moogk-Soulis, 2010; Slater, 2010;
face temperatures of 275 schoolyards and 529 public spaces using Vanos et al., 2012b). Such treed parks also result in cooling from evapo-
Landsat 7 satellite imagery. Schoolyards were found to represent tiny transpiration with moisture available, which also increases the relative
hot spots within the larger urban area, commonly displaying signi- humidity. Buildings, shade sails, overhangs, portable vegetative plat-
cantly higher surface temperatures than surrounding streets (Moogk- forms, pavilions, and other landscape objects (oriented to maximize
Soulis, 2010). For example, with an air temperature of 27 C, the un- shade at the hottest time of the day) are examples that also reduce over-
shaded surface temperatures were 52.8 C on average (maximum of all shortwave radiation, and hence surface temperature (Santamouris,
61.6 C), which was 20 C hotter than that of the shaded surfaces. 2013). For example, Dobbinson et al. (2014) demonstrated that in a
These temperature differences are consistent with those found in previ- sunny, warm climate, shade sails increased school students' use of the
ous studies (Oke, 1988; Akbari et al., 2001), with recent work demon- newly shaded areas. Shaded spaces result in non-direct radiation (com-
strating the Tmrt imposed on a human (Section 3.1) to be lowest under monly diffuse or emitted at longer, less harmful wavelengths), which is
the shadow of trees, 3 C higher in the shadow of buildings, and 45 safer for outdoor use/activity for longer periods of time.
C higher in open courtyards within the city of Stuttgart, Germany Knowledge of warm and cold season transmissivity ranges of trees
(Ketterer and Matzarakis, 2014). aids greatly in designing for comfort, addressed by Brown and Gillespie
Principles of outdoor design, when combined with knowledge of
local climates, can have a powerful inuence on the overall use (type, 3
The threshold for very hot is 41 C and indicates extreme heat stress, and 20 C is con-
amount, intensity) of an outdoor space. The variables that can be best sidered comfortable (Hppe, 1999); hence 58 C, being is 17 C warmer than this thresh-
controlled through microclimatic design include wind speed and old, is indicative of abnormally extreme conditions.
J.K. Vanos / Environment International 76 (2015) 115 7

Fig. 3. Visible and infrared spectrum images of an outdoor soccer/football eld and running track in taken in Guelph, ON, Canada (43.55 N, 80.25 W) on June 21, 2013, on a warm-hot day
(Ta = 25 C; RH = 62%; clear skies). Copyright Dr. Robert Brown (2013).

(1995) who list the average, maximum, and minimum transmissivities pollution (Cakmak et al., 2002; Reid and Gamble, 2009; Vanos et al.,
for 32 common trees worldwide. For example, a Norway maple ranges 2014). Researchers in Lisbon, Portugal quantied the economic value of
from 9.5% (summer) to 67.5% (winter) transmissivity. Brown et al. trees for the city, nding that for every $1 invested in tree management,
(2014) modeled the energy budget modifying effects of adding 50% residents benetted $4.48, based on factors such as energy savings, CO2
shade as compared to clear skies. Results demonstrated an average reduction, and air pollutant deposition (Soares et al., 2011).
decrease of 78 W m2 (range: 71 to 87 W m2) on hot summer
days in ve cities worldwide. It has been further demonstrated that 3.3. Vehicles
employing proper design strategies for urban parks through the use of
shade can decrease the air temperature imposed on a human by 16 C While outdoors in open sun, vehicles pose substantial heat stress
(Chow et al., 2011; Vanos et al., 2012b; Declet-Barreto et al., 2013), with hazard to unattended children during the warm season, and although
the magnitude dependent on location (climate zone). Trees have a rela- not a fully outdoor space, cannot go ignored as a critical area of research
tively larger impact in playgrounds and parks when used in highly in ambient heat exposures to children. The US National Weather Service
dense urban areas with impervious materials. This was demonstrated emphasizes this danger (NWS, 2014), yet minor attention is given in the
by Gulys et al. (2006), nding that street canyons with the addition of literature to energy budget estimations specic to children in such
trees have a Tmrt value of 4.6 C, as opposed to 7.0 C without trees. A unique environments. According to McLaren et al. (2005), a reason for
lower Tmrt substantially decreases the physiological stress to children on sparse literature in this area may be due to the fact that intuitively it
warm-hot days, with Ketterer and Matzarakis (2014) measuring a 10 C would seem unconscionable to subject a child to temperatures of 117
lower PET compared to open green areas (PET = 38 C) and low-albedo F (47.2 C); however this assumed intuition is not present in all actions,
impermeable surfaces (PET = 58 C). and 27% of hyperthermia cases involve care givers intentionally leaving
Further, a positive outcome of reducing the surface and air tem- a child in a car (Guard and Gallagher, 2005). In 2013, there we 32 deaths
peratures of overheated schoolyards, backyards, and parks is the due to heat stroke of children in cars in the US alone, down from 42 in
reduced cooling costs of the nearby buildings (as less heat would be con- 2003 (McLaren et al., 2005; NWS, 2014). More recently, Null (2014) ob-
ducted through the walls and roof). However, many other benets of served an average of 38 heatstroke deaths per year during the years
implementing more urban vegetation in parks, specically trees, must 19982014 in the US, with 44 in 2012, and 17 in 2013.
be accounted for through a cost-benet analysis in any given climate The physical nature of a vehicle sets up a unique situation for heat
(Harlan and Ruddell, 2011) (see Table 1). For example, in arid climates, entrapment. Vehicles heat up rapidly as shortwave radiation entering
planting trees may be problematic and have high costs (Jenerette et al. through the glass is absorbed by and heats objects inside the vehicle
2011) and increased pollen can confound or enhance impacts of air and the adjacent air. As glass is not transparent to the emitted longwave

Table 1
Benets and challenges of incorporating trees into outdoor schoolyards, parks, and urban areas.

Area Benets Challenges

Urban park & schoolyard Decrease in shaded surface temperatures by up to 25 C2 Expendituresb (tree management (TM): planting,
Decrease temperature of shaded air2,4 pruning, removals, control of pests & diseases,
Lower risk of heat stress, UV radiation, and dehydration to children4 watering); administration (ADM) (inspections &
Improved air quality3 other services); other costs (O) (infrastructure
Surrounding a sports eld Increased physiological ability in children for intense play for a longer duration4 repairs, liability, claims)3
Areas of relief (shade) from intense radiation for physical rest and viewing Potential risks of low visibility of children to
Lower odds of heat stress and dehydration4 teachers, or due to climbing trees
Surrounding buildings Decrease cooling costs (~25%)2 from shade trees; urban energy savings (~$6.20/tree)3 Roots potentially impacting surface structure
Decrease cooling costs due to cooling of intake air (~40% of cost) by as much as 10 C2 Aeroallergens affecting asthma
Block cold winter winds to decrease heating load1 Shade increase heating load (coniferous trees)
Neighborhood & city Decrease radiant and convective heat gains to nearby areas/properties within 80100 m4 VOCa emission (isoprene) as ozone precursor3
Contribute to local city cooling as a natural air conditioner4
Property value3
Storm water runoff reductions3

Sources: [1] Brown and Gillespie (1995), [2] Moogk-Soulis (2010), [3] Soares et al. (2011), and [4] Vanos et al., 2012b.
Volatile organic compound, biogenic emissions from select trees.
Expenditures = (TM + ADM + O)3.
8 J.K. Vanos / Environment International 76 (2015) 115

radiation (as it is to shortwave radiation), this heat (as well as vapor (2013a) found that vehicle emissions were the main source of particle
generated by the child) is trapped inside the car and unable to mix concentration exposure in Cassino (Italy) at schoolyards when measuring
with the outside relatively cooler air (NWS, 2014). Studies have at various spatial and temporal scales, and these concentration peaks co-
displayed that an outdoor temperature of 30 C (86 F) quickly increases incided with NOX pollution from vehicles (see Section 4.2 for connections
the in-vehicle temperatures to 5768 C (134154 F) within the rst to health outcomes).
5 min (King et al., 1981). The accumulation of radiative and sensible The overall air quality is often quantied via indices, such as the
heat, as well as vapor, leads to a unique opportunity to quantify such ef- Air Quality Index (AQI) (based on six pollutants: O 3 , PM 2.5, NO 2 ,
fects on the energy budget of a child, as completed by Grundstein et al. CO, SO2, and total reduced sulfur), where the nal AQI reported is
(2010). These researchers assessed variations in humidity and sun ex- based on the single highest pollutant value (EPA, 2009a). More re-
posure on levels of heat stress using high-temporal-resolution temper- cently, Health Canada and Environment Canada established the Air
ature sensors and nearby weather station data, and further successfully Quality Health Index (AQHI) based on the combined impact those
modeled the energy budget components (specic to child parameters) pollutants and direct relationship to health risks based on NO2, O3,
with MENEX (Blazejczyk, 1994). Energy budget components and a PM2.5 (Environment Canada, 2014); hence, guidelines pertain to spe-
table of maximum vehicle temperature changes under various situa- cic health risk reduction actions, with children considered more
tions were created at 5-, 10-, 30-, and 60-min of exposure, which pro- vulnerable (Environment Canada, 2013). A more impactful way to
vides an invaluable guide for predicting and preventing vehicle related protect children and other vulnerable populations may require low-
hyperthermia (Grundstein et al., 2010). McLaren et al. (2005) found ering the AQI or AQHI thresholds, and thus aid in avoiding issues
the greatest temperature rise to occur within the rst 1520 min (1.8 such stunted lung development due to air pollution from childhood
C per 5-min on average). In this time, the energy budget of the child into adulthood, as found by Gauderman et al. (2004).
can be overwhelmed by convective and radiative heat gain, and due to The IPCC Special Report on Emissions Scenarios (Nakicenovic
no wind ow and a child's lower ability to sweat (Falk, 1998), there is et al., 2000) emphasizes the importance of understanding vulnera-
very little ability to cool off; hence, heat stroke can occur when the bilities to air quality changes related to socioeconomic class (Ray-
core temperature reaches N40 C (104 F). Furthering the research in Bennett, 2009), as well as health conditions and age (both the elderly
this area, particularly energy budget modeling, can help link tempera- and children) (Bartlett, 2008) associated with air quality changes.
tures with explicit warnings of heat strokes and dehydration, such as The IPCC also report that climate change may change the spatiotem-
temperature thresholds and data tables specic to conditions poral distribution, quantity, and quality of pollen in urban areas
(e.g., vehicles in sunny open areas (Grundstein et al., 2010)). This can (Revi et al., 2014), with a positive outcome for overall vegetative
provide information to policy makers, and create educational materials, growth increasing due to higher carbon dioxide (CO2). Yet this also
all of which can result in fewer tragedies. results in increased pollen counts by 61% to 90% in select ragweed
types (Wayne et al., 2002), longer allergy seasons, and an increase
4. Air pollution health effects on urban-dwelling children in overall pollen allergenicity (Beggs and Bambrick, 2006; Smith
et al., 2014). This is a concern for children's health as air-borne aller-
4.1. Weather, climate, and air pollution: associations with health gens may increase the prevalence of asthma, allergic rhinitis, con-
junctivitis, and other respiratory diseases (Beggs, 2010), to which
Child growth and development represent the stages of greatest children are particularly susceptible (Schmier and Ebi, 2009).
vulnerability to air pollution (Perera, 2008), and children have been Synergistic mechanisms with meteorological parameters, such as
demonstrated conclusively as a more vulnerable group to the negative high air temperatures and radiation levels, also inuence air quality
health effects of ambient outdoor air pollution exposure (Islam et al., and the formation of secondary pollutions (e.g., ozone, hydrocar-
2007; Kovats and Hajat, 2008; O'Neill and Ebi, 2009). Current exposure bons). The relationship between ozone concentrations and lung
to air pollution is exacerbated by meteorological parameters, and the function (testing peak expiratory ow rate tests) was studied in
incidence of asthma (Section 4.2) in children may be exacerbated by 287 children, nding an inverse relationship with increasing O3 con-
increased anthropogenic emissions due to population growth and centrations (Krzyzanowski et al., 1992). Climate interactions were
climate-change related enhancement of ground level ozone (O'Neill demonstrated by Shefeld et al. (2011) who projected (based on
and Ebi, 2009; Reid et al., 2009; Shefeld et al., 2011). the SRES A2 scenario) an increase in summer ozone-related asthma
An increased breathing rate relative to body size and an under- emergency department visits for children (017 years) across New
developed respiratory tract results in this heightened sensitivity, York City by the 2020s compared to the 1990s. Variation in ground
which acts in combination with the harmful effects of extreme air level ozone production is of concern at the regional-to-local urban
temperatures (Karl et al., 2009). Hence, children experience the neg- scale level due to meteorological interactions, increased urban tem-
ative impacts of air pollution at lower concentrations (e.g., onset of peratures, heightened anthropogenic pollution, and abundant day-
inammation and immune stimulants), commonly in combination time radiation trapping, acting in synergy to impact human health
with extreme heat. In a 4-year study of children ( 14 years of age) (Knowlton et al., 2008; Vanos et al., 2014; Watkins et al., 2007).
in Toronto, Canada, associations between hospitalization for respira- Other built environmental characteristics (e.g., height-to-width ra-
tory infections were found at relatively low levels of ambient partic- tios, proximity to trafc, vehicle trafc distribution, presence of
ulate matter (PM) and gaseous pollutants as compared to adults, trees) can be directly linked to pollution exposure and the onset of
especially PM b 2.5 m and b10 m in diameter (PM2.510) and nitro- negative health conditions that limit physical activity, such as asth-
gen dioxide (NO2) (Lin et al., 2005), thus conrming a lower thresh- ma (Jerrett et al., 2010; McConnell et al., 2010; Buonanno et al.,
old response to air pollution. Islam et al. (2007) found that in 2013a).
children 910 years of age, the ability for the body to protect itself Ozone, although a short-lived pollutant, can also reduce exposure
against asthma was attenuated due to exposure to high of ultraviolet radiation by absorbing the harmful rays. Further it has
(13.729.5 mg m 3) levels of PM2.5. A large recent international pro- been demonstrated that O3 concentrations below a tree canopy are
ject entitled UPTECH (Ultrane Particles from Trafc Emissions and generally lower than those above the canopy (UK Forestry Service,
Children's Health) focused on the effects to children of ultrane 2002), indicating some canopy uptake and less photochemical crea-
particulate matter (UFP, diameter b 0.100 m) emitted by motor vehicles tion. Moving forward, land use changes will be a key factor to incor-
(International Laboratory for Air Quality and Health, 2014). Studies dem- porate in such studies, which can offset or enhance the effects of
onstrated association of UFP exposure with negative health impacts to anthropogenic emissions, and hence health, into the 21st century
children (Buonanno et al., 2012; Mazaheri et al., 2013). Buonanno et al. (Tai et al., 2013).
J.K. Vanos / Environment International 76 (2015) 115 9

4.2. Respiratory health in children: childhood asthma & related issues children (Mazaheri et al., 2013; Shefeld and Ebi, 2013; Shefeld
et al., 2011; Sunyer et al., 1999), the personal exposure factors, both in-
The Center for Disease Control and Prevention (CDC) estimate that 1 door and out (especially allergenic bioaerosols: mold and pollen spores)
in 10 children suffers from asthma (CDC, 2011), and asthma incidence is are not fully understood (Nolte et al., 2001). The average human spends
on the rise (approximately 160% increase among preschool children; 90% of their time indoors (Klepeis et al., 2001). Indoor air pollution is a
Mannino et al., 1998), with 12.7% of children aged 017 years in the greater challenge worldwide than outdoor and results in differing pol-
US diagnosed with asthma (Akinbami, 2006). The connections between lutants (endotoxins, bioaerosols, UFPs, black carbon) and associated
air pollution, lung functions, and childhood asthma incidence are yet to health effects than the criteria outdoor air pollutants (Thorne et al.,
be convincingly established (McConnell et al., 2002; Gauderman et al., 2006; Buonanno et al., 2013c; Mazaheri et al., 2013; Morawska et al.,
2004). Areas of emphasis in the literature regarding children's respira- 2013). As the focus of this manuscript is to understand and provide out-
tory health revolve largely around asthma incidence and prevalence in door ambient environments conducive to children's health and physical
association with enhanced urban exposures related to living near activity, addressing indoor air pollution is outside the scope; however,
major roadways, single and multiple pollutant exposures, and impacts the indoor-to-outdoor exposure connection is acknowledged as an im-
on physically active children. portant area of research (Table 3).
Many recent studies have examined the relationship between air The higher risk of children to air pollution and aeroallergen exposure
quality and asthma (e.g., Barnett et al., 2005; Liu et al., 2009; To et al., is connected with overall health, exercise, and well-being. As intense
2013; Weinmayr et al., 2010), as asthma is the most serious and wide- exercise can increase ventilation rates by 17-fold (Katch et al., 1996),
spread chronic disease among children (Bryant-Stephens, 2009). The children exercising in the presence of air pollution are a larger concern.
AQHI was shown to signicantly predict the number of asthma related In a 5-year study of 3,535 children with no history of asthma in commu-
health visits across Ontario, Canada (20032006), increasing the nities with high ozone concentrations, children playing 3 sports were
asthma outpatient visits by 5.6% (95% CI 1.0531.058) for same day, 1- 30% more likely to develop asthma than those not playing sports
and 2-day lags to high exposures (To et al., 2013). These researchers (McConnell et al., 2002). More importantly, there was a signicant
also found the highest annual incidence of new asthma cases in the 20% decrease in risk of asthma in low ozone communities whether a
04 and 59 age groups, resulting in 41.72 and 13.54 new cases per child played sports or not. Buonanno et al. (2013b) found that the vari-
1000 individuals, respectively. Preschool-aged children represented 3- ation in a child's activity over time is strongly related to respiratory out-
fold the amount of outpatient visits for asthma health services compared comes due to particulate exposure based on doseresponse testing.
to the 2059 age group, with prevalence (sum of current and new asthma However, such results should not deter parents from allowing sports
cases) highest within the 1019 age group (To et al., 2013). to be played, as the onset of asthma was also shown to increase in
Asthma prevalence aligns closely with variations in local trafc pat- areas of high ozone independent of exercise intensity. Alternately,
terns (Brauer et al., 2002; McConnell et al., 2002; Gauderman et al., such research highlights the need for reduction in air pollution, and
2004). There is emerging consensus that anthropogenic emissions should inform environmental health ofcials and policy makers that
from trafc pollution is associated with overall increased respiratory ill- current levels of pollution are routinely too high for healthy exercise
ness, specically asthma and ventilator function in children (Janssen in children. There is substantive support highlighting the need to formu-
et al., 2003; Kim et al., 2004; Gauderman et al., 2005; Cakmak et al., late and adopt policies and guidelines to improve children's respiratory
2012; Buonanno et al., 2013a,b). Cakmak et al. (2012) assessed the re- health (e.g., Cakmak et al., 2012; Shefeld and Ebi, 2013; To et al., 2013).
spiratory health of 2328 school children (ages 911) in Windsor, As evidenced in this section, asthma incidence is increasing, and is
Canada. These researchers found that children living within a 200 m ra- exacerbated by environmental factors. Hence, it is important to combat
dius of a busy roadway experienced increased respiratory symptoms this issue now and how it pertains specically to children's health, and
and statistically signicant pulmonary function decrements, such as also project future outcomes related to the environment. Studies to
forced expiratory volume (FEV)a value closely tied to asthma inci- determine potential future air pollution exposures to children ll an im-
dence. Similarly in the same city, Dales et al. (2009) discovered that portant area of research (e.g., Shefeld et al., 2011), in addition to fur-
each kilometer of roadway within 200 m of a child's house was associ- ther information pertaining to the long-term trends of air pollution
ated with wheezing, wheezing and asthma, and an increase in exhaled and asthma in relation to projected temperature and greenhouse gas
nitric oxide (eNO), a measure of airway inammation in asthma. Com- emissions (Revi et al., 2014).
paring the two studies (i.e., Dales et al., 2009; Cakmak et al., 2012) re-
veals that trafc counts may be a better representation of exposure 5. UV-radiation exposure to children
effects to the magnitude of trafc than the road density. Similarly,
Buonanno et al. (2013b) found high correlation in asthmatic children This section builds on the role of radiation in urban play spaces in
in Italy who were exposed to particulates, experiencing signicantly connection with air pollution and temperature, focusing on exposure
higher eNO. These researchers also found that children exposed to traf- to radiation mainly in the ultraviolet B (UVB) wavelength range
c jams and those living within urban areas were subject to 41% and 25% (280320 nm). With radiative trapping more predominant in urban
higher particulate concentrations (P b 0.01), respectively. areas, lesser number of trees (particularly few large shade trees), and
Further studies addressing PM2.5 and PM10 exposure demonstrate higher temperatures in the urban heat island (UHI), the risk to urban
associations with decreased lung functions at all ages of the population dwellers is high. Moreover, the child subset is at even greater risk due
(Anderson et al., 2012; Barnett et al., 2005; Weinmayr et al., 2010). In to less adaptive behavior, more sensitive skin, intermittent exposures,
children aged 9 to 14, Liu et al. (2009) found that average interquartile and more sensitive skin the younger the age (Oliveria et al., 2006).
range (IQR) increases of 5.4 g m3 in 3-day average PM2.5 resulted in a
signicantly decreased forced expiratory ow (FEF) ( 3.0% (95% CI, 5.1. Health effects and observations in children
4.7 to 1.2)), yet no association with FEF was found due to an IQR
3-day increase of 5.3 ppb in O3 concentration. The study's ndings are The effect of UVB radiation on health generally represents a U
interesting in the fact that nearly all PM levels were below National Am- shaped exposure response function, where small doses are benecial,
bient Air Quality Standards, yet signicant health effects in children and large doses can be detrimental. What classies a large or small
were found, hence providing likely evidence for the need for lower dose depends on location as well as individual characteristics such as
thresholds for children in indices and guidelines. skin type, age, weight, and genetic factors (Oliveria et al., 2006;
Although there has been a sustained focus on identifying the causa- Fioletov et al., 2010). An acknowledged benet of UVB exposure is the
tive environmental factors of asthma and other respiratory illnesses in synthesis of vitamin D in the skin, along with further benets associated
10 J.K. Vanos / Environment International 76 (2015) 115

with bone, cardiovascular, and overall health (Holick, 2004). However, it a select wavelength of light (i.e., UVA (315400 nm), UVB (280315
is well-established that melanoma skin cancer is an increasing issue nm)). There are considerable opportunities for the use of such monitoring
worldwide, and although rare in children, the overall incidence is rising tools in child health studies to determine UVR exposures and vitamin D
(Balk, 2011), and can be traced to adolescent exposures (Oliveria et al., absorption, linked to various urban landscape parameters and locations.
2006). For example, from 1973 to 2001, the incidence of melanoma in This can aid in understanding how to minimize the risk of incident radia-
US children (b20 years) rose 2.9% annually (Strouse et al., 2005). A tion exposure to children yet optimize child health.
cross sectional study completed by Geller et al. (2002) on 10,079 children
conclusively demonstrated that the incidence of burning and skin cancer 6. Impacts of weather on behavior, health, and well-being
is on continual increase, and 36% of the subjects reported burning in the
sun three or more times in the summer of 1999. Evidence is mounting portraying benets to children and families of
Biophysical variables such as solar zenith angle, cloud cover, distance living in close proximity to parks, as positive associations are found with
from sun, altitude, stratospheric ozone, and tropospheric ozone, aero- activity levels and behavior, particularly in children (Wolch et al., 2011).
sols, and other gases have a large inuence on the amount of UVB radi- Characteristics of the built environment in a child's neighborhood or
ation exposure (Madronich et al., 1998; Kerr and Fioletov, 2008). school are signicant factors in physical activity and thus health out-
Although not directly modiable by humans at the surface, it is critical comes (Powell, 2005; Sallis et al., 2012; Besenyi et al., 2014), with
that we understand the inuence that these variables have on UVB ex- parks receiving the most attention (Bedimo-Rung et al., 2005). In a lon-
posure, and hence can incorporate this knowledge in urban site design. gitudinal cohort study (19931996; 3173 children aged 912) by Wolch
The albedo of a ground surface or building also inuences the amount of et al. (2011), it was determined that when a park existed within 500 m
UV radiation redirected toward a child's skin; therefore, if trying to re- of the child's home, there was a signicant decline in body mass index,
duce the shortwave exposure, high albedo surfaces are discouraged controlling for potentially confounding variables such as of asthma,
(however encouraged at roof height as an UHI mitigation technique). other respiratory conditions, neighborhood socio-economic indicators,
Alternatively, UVB exposure in certain climate zones and seasons and parental smoking.
can be far too low to achieve adequate vitamin D synthesis in children. A child spends 19% of their time during childhood at school (Tsang
The Standard Vitamin D Dose (SDD) from solar radiation corresponding and Klepeis, 1996; EPA, 2009b). Although mainly indoor, school
to the UV equivalent of the oral average daily requirements (1000 Inter- recesses are where many children are able to play and exercise. The pur-
nationals Units (IU)) can be calculated based on the biophysical princi- pose of recess is to provide students with a chance to break for active
ples listed in the previous paragraph and physiological principles. A physical play and time to socialize (Ginsburg, 2007); however, for ade-
method entitled FastRT by Engelsen and KyUing (2005) allows for quate play and physical activity, a healthy environment and comfort-
the SDD to be calculated. Exposure times at any time and place can be able microclimatic is needed. The effects of oppressively hot weather
determined, including time for recommended equivalent dose to gain and uncomfortable conditions lead to lethargy, decreased work and ath-
all possible benets of vitamin D (Holick, 2004). Example results are letic performance, poor behavior (Eliasson et al., 2007; Eliasson, 2000;
listed in Table 2 at ve latitudes and four times of the year. Even at Johansson and Rohinton, 2006; Watkins et al., 2007), and ultimately a
60 N latitude, it is possible for a skin type II individual to synthesize deterioration of social and outdoor activity (Johansson and Rohinton,
the equivalent of 400 IU vitamin D in 6 min or less for approximately 2006).
half the year (Webb and Engelsen, 2008). A recent report suggests the critical need for sufcient opportunities
For overexposure estimates of ultraviolet radiation (UVR) to the to use recess for play to promote cognitive development (Wenner,
public, the UV index is widely used. This is determined by dividing the 2009). The amount of time spent outdoors is shown to be a strong cor-
dose rate from the sun reaching earth's surface (in mW m2) by a stan- relate of physical activity in children (Ciucci et al., 2013) and reduces the
dard value of 25 mW m 2. This results in a number ranging from 0 likelihood of childhood obesity and type II diabetes, which are a major
(where there is no sunlight) to mid-teens (NOAA, 2007). A value N 12 concern, particularly in the United States. Improved academic perfor-
indicates skin damage occurring as low as 716 min of exposure time mance and behavior is also found to relate to physical activity during re-
(NOAA, 2007), or less time with more sensitive skin of children. These cess (Bessesen, 2008); however, the positive feedback reaches a point of
values are for open sky (100% SVF); however, the UV levels (and high diminishing returns when children are exposed to hot conditions
radiant temperatures) can be reduced given small-to-large scale design during play (leading to potential dehydration, heat exhaustion, and fa-
interventions (e.g., shaded play areas) to increase skin safety and out- tigue), which can limit cognitive ability. Aggression and irritability in
door play, as expanded on in Sections 3.1 and 3.2. children also increase with temperature and increasing heat duration
A study by Cox (2013) addressed the UVB dose received by children in (Anderson, 2001; Ciucci et al., 2011, 2013).
schoolyard landscapes in the wintertime in Waterloo, Canada (~43.5 N Many studies address adult behavior associated with weather,
latitude)a location where vitamin D dose in the winter is limited. Per- however few have addressed children. One such study by Ciucci et al.
sonal UV exposure monitors (dosimeters) were used (Scienceterra Ltd., (2013) found that weather variables that affect children's behavior
2014), which are miniature electronic sensors that measure the dose of tend to be those presenting extreme values during a given season
(e.g., higher temperature and relative humidity in summer; low tem-
Table 2 peratures in winter). Evidence also exists showing the effect of humidity
Approximate time in minutes during mid-June, mid-March/mid-September, and on school and work performance and aggressive behavior in children
mid-December at varying latitudes required to synthesize the oral equivalent of 400 IU (Lagac-Sguin and d'Entremont, 2005; Ciucci et al., 2011, 2013).
vitamin Da for skin type IIb exposing hands, face, neck, arms and legs (57.5% skin area).
Based on FastRT (Engelsen and KyUing, 2005;
There are ample avenues to take when modifying a microclimate
fastrt.html) and results of Webb and Engelsen (2008). based on season for increased activity and improved child behavior,
where factors such as sun orientation, plant characteristics, ground sur-
Latitude ( N) Summer Autumn/Spring Winter
face type, climate zones, precipitation, temperature and humidity can
0 b1.0 b1.0 1.2 impact year-round type and amount of physical activity in children, as
20 b1.0 1.1 2.1
depicted by Ciucci et al. (2011). This research employed an innovative
40 1.1 1.6 9.0
60 1.5 6.0 300 and objective measurement method entitled Behavioral Mapping (lo-
80 4.5 120 600 cation and activity), demonstrating that specic attributes of the built
Amount to gain all possible benets of vitamin D (Holick, 2004).
environment are associated with physical activity levels. They found
Skin types range from I to VI, where the average child would fall on the lower end of that activity levels varied with the biophysical settings, such as open
the spectrum having a lower tolerance to UV radiation (Fitzpatrick, 1988). versus play structure, ground surface, shade, and presence of paths.
J.K. Vanos / Environment International 76 (2015) 115 11

The dissemination and application of knowledge pertaining to relation- the current and future health impacts to children due to exposure to
ships of behavior and environmental controls can result in increased enhanced levels ambient stressors in outdoor spaces. Main ndings re-
awareness for teachers and childcare providers to the potentially nega- lated to differences in child-specic physiology and health outcomes
tive (and positive) effects of the physical environment and its role to indicate:
hinder or support children's physical activity (Ciucci et al., 2011).
Potential model inaccuracies (e.g., heat indices, energy budget, air
7. Future research and conclusions quality health index) when applied to children, for which they were
not initially intended.
7.1. Future research Important inuences of the mean radiant temperature, which in-
cludes UVR, enhancing surface and air temperatures, and hence heat
Drawing upon a wide spectrum of research areas to cohesively as- stress in numerous instances (e.g., poorly designed play spaces, vehi-
sess and understand the state of environmental health sciences in this cles).
area, this review has identied several important research gaps Signicant child morbidity in epidemiological analyses of extreme
(Table 3). It is critical to provide constructive, accurate, and applicable heat events, yet generally insignicant increased mortality among
research techniques (under changing climates, societies, and demo- children.
graphics) that are substantive enough to formulate adaptation policies Associations of heat and air pollution exposure with child asthma,
and guidelines to protect children's health. obesity, behavior, and cognitive development.

7.2. Conclusions Although existing literature acknowledges such important consider-

ations, there is little evidence of these ndings being taken into account
Children are uniquely sensitive to the ambient environment. Illness in current biometeorological models and urban design practices, partic-
and death due to heat, air pollution, and radiation are completely avoid- ularly with respect to considerations for children's health. This review
able in children when correct precautions are taken. The current review uses urban schoolyards and parks as the main example for a space
aimed to convey the state of the research literature depicting the biome- where children play. The consensus remains from the research that
teorological effects on children, and to comprehensively combine the open design (given the title of green space) of such spaces do not
knowledge of the differential exposures that children receive within lend well to physical activity, where a case can be made in the urban cli-
commonly frequented outdoor microclimates. Of central focus were mate literature for a distinction between biophysically effective green

Table 3
Avenues of future research in children's health related to human biometeorology related to heat and air pollution presented in the current study, and supported by further references.

Research area Specic need

A. Heat
(A.1) Energy budget modeling Adapting human energy budget models to children
(A.2) Heat stress indices Assessing the cause-specic morbidity of children associated with heat stress index levels
Address differences between adult and child (also for (A.1)) for a more objective assessment
(A.3) Observations Satellite remote sensing techniques to characterize neighborhood scale, enabling land use and thermal proles (Mackey et al.,
Superspectral high resolution data acquired over urban parks/schoolyards of surface temperature and vegetation density
(Stefanov et al., 2004)
(A.4) Health outcome associations Mortality versus morbidity responses in children
Project future impacts under changing climates (Patz et al., 2005; Ebi and Paulson, 2010)
(A.5) Vehicle studies Temperature thresholds and awareness, policy and guidelines (Grundstein et al., 2010)

B. Air pollution
(B.1) Health impacts Age group specic air quality standards
Identify inuential factors that may cause a child to be vulnerable to trafc pollution and aeroallergens (Cakmak et al., 2002,
2012; Gauderman et al., 2004)
Identify impacts under a changing climate (Ebi and Paulson, 2010; McConnell et al., 2010)
(B.2) Spatiotemporal studies Account for potential autocorrelation and time dependency of air pollution data (Baxter et al., 2007)
AQI or AQHI adapted to the at- risk child population (To et al., 2013)
Improved localized observations and understanding of more precise air pollution estimations and connections with health
outcomes in both children and the full population (Jerrett et al., 2004)
(B.3) Individual child exposure assessments Link indoor-to-outdoor levels for children (EPA, 1996, 2009b; Institute of Medicine, 2011)

C. Urban design
(C.1) Radiation exposure Incorporate individual UVB exposure into design of outdoor spaces spatiotemporally, and exposure-health assessments (Balk,
2011; Cox, 2013)
(C.2) Shading Research and policy to mandate and protect or implement natural trees vegetation to shade and cool schoolyards and parks
(Vanos et al., 2012b)
Impact of mobile shading objects (Dobbinson et al., 2014)
Cost-benet analysis of trees (e.g., Soares et al., 2011)
(C.3) Bioclimatic design Green infrastructure; evidence-based bioclimatic design for cooling (Brown, 2011; Noble et al., 2014)

D. Behavior
Studies addressing the effects of weather localized playground climates on children's learning and behavior, moods, aggres-
sion; across seasons (Ciucci et al., 2013)
Address implications for parenting and teaching practices

E. Child health stressors related to climate change

Provide and determine the essential services of public health concerning environmental and biometeorological risk factors to
address the child health risks of climate change (Ebi and Paulson, 2010)
Understand uncertainty in ozone concentrations based on climate change, emissions, precursors, and child vulnerability
(Ebi and McGregor, 2008)
12 J.K. Vanos / Environment International 76 (2015) 115

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