Systematic Review: Neurodevelopmental Benefits of Active/Passive School Exposure to Green and/or Blue Spaces in Children and Adolescents.

Today more than half of the world's population lives in urban areas. Children spend about 40 h a week in the school environment. Knowing the influence of school exposure to green/blue spaces could improve the children's health, creating healthier environments and preventing exposure to legal/illegal drugs. This systematic review summarized the main results of published studies on active or passive exposure to green or blue spaces in different domains of child neurodevelopment. In August 2022, five databases were searched and twenty-eight eligible studies were included in the analysis. Cognitive and/or academic performance was the most frequently studied (15/28). Most studies evaluate passive exposure to green/blue spaces (19/28) versus active exposure (9/28). Only three studies addressed the relationship between blue space and neurodevelopment. The main results point toward mixed evidence of a protective relationship between green/blue space exposure and neurodevelopment, especially in improving cognitive/academic performance, attention restoration, behavior, and impulsivity. Renaturalizing school spaces and promoting "greener" capacities for school environmental health could improve children's neurodevelopment. There was great heterogeneity in methodologies and adjustment for confounding factors across studies. Future research should seek a standardized approach to delivering school environmental health interventions beneficial to children's development.

Confirmation of radiant catalytic ionization efficacy for airborne SARS-CoV-2 elimination indoors using "COVID19 traps".

Radiant catalytic ionization (RCI) is a novel technology that uses the appropriate wavelength (240-260 nm) and the phenomenon of photo-oxidation leading to permanent removal of viruses, bacteria, and fungi. Here, two analyses were performed. The first of them was a complete analysis of environmental biosecurity in a hospital environment. The second one was a longitudinal study with 40 patients with confirmed COVID19 and high viral load to assess the efficacy of RCI technology eliminating airborne SARS-CoV-2 indoors. A significant decrease in the number of bacteria and fungi colony-forming units (CFUs) was found in rooms with RCI when compared with rooms without it (p=0.03 for both of them). In the second part of the study, 16 samples out of 40 (40%) were positives when RCI technology was absent; whereas, these samples were negative when the equipment was on. Incidence rates (IR) with their Poisson 95% Confidence Intervals (CI) were calculated as the number of positive tests with the purifier or without it, showing an IR difference of 48.5% [CI(15.9-81), p=0.004]. Furthermore, the IR ratio was calculated obtaining a value of 3.3, confirming that RCI diminished more than 3-fold the presence of the SARS-CoV-2 in the air of the patients' rooms, thus laying the first stone in the fight for prevention of SARS-CoV-2 dissemination indoors.

Exploring Blue Spaces' Effects on Childhood Leukaemia Incidence: A Population-Based Case-Control Study in Spain.

BACKGROUND: Blue spaces have been a key part of human evolution, providing resources and helping economies develop. To date, no studies have been carried out to explore how they may be linked to paediatric oncological diseases. OBJECTIVES: To explore the possible relationship of residential proximity to natural and urban blue spaces on childhood leukaemia. METHODS: A population-based case-control study was conducted in four regions of Spain across the period 2000-2018. A total of 936 incident cases and 5616 controls were included, individually matched by sex, year of birth and place of residence. An exposure proxy with four distances (250 m, 500 m, 750 m, and 1 km) to blue spaces was built using the geographical coordinates of the participants' home residences. Odds ratios (ORs) and 95% confidence intervals (95%CIs) for blue-space exposure were calculated for overall childhood leukaemia, and the acute lymphoblastic (ALL) and acute myeloblastic leukaemia (AML) subtypes, with adjustment for socio-demographic and environmental covariates. RESULTS: A decrease in overall childhood leukaemia and ALL-subtype incidence was found as we came nearer to children's places of residence, showing, for the study as a whole, a reduced incidence at 250 m (odds ratio (OR) = 0.77; 95%CI = 0.60-0.97), 500 m (OR = 0.78; 95%CI = 0.65-0.93), 750 m (OR = 0.80; 95%CI = 0.69-0.93), and 1000 m (OR = 0.84; 95%CI = 0.72-0.97). AML model results showed an increasing incidence at closest to subjects' homes (OR at 250m = 1.06; 95%CI=0.63-1.71). CONCLUSIONS: Our results suggest a possible association between lower childhood leukaemia incidence and blue-space proximity. This study is a first approach to blue spaces' possible effects on childhood leukaemia incidence; consequently, it is necessary to continue studying these spaces-while taking into account more individualised data and other possible environmental risk factors.

Looking Towards 2030: Strengthening the Environmental Health in Childhood-Adolescent Cancer Survivor Programs.

Childhood and adolescent cancer survivors (CACS) are a high-risk population for non-communicable diseases and secondary carcinogenesis. The Environmental and Community Health Program for Longitudinal Follow-up of CACS in the region of Murcia, Spain, is an ongoing pioneering program that constitutes a model for social innovation. This study aims to present the program tools and protocol as a whole, as well as a profile of the incidence, survival, and spatiotemporal distribution of childhood cancer in the region of Murcia, Spain, using 822 sample cases of cancer diagnosed in children under 15 years of age (1998-2020). While the crude incidence rate across that entire period was 149.6 per 1 million, there was an increase over that time in the incidence. The areas with a higher standardized incidence ratio have shifted from the northwest (1998-2003) to the southeast (2016-2020) region. Overall, the ten-year survival rate for all tumor types was 80.1% over the entire period, increasing the five-year survival rate from 76.1 (1998-2003) to 85.5 (2014-2018). CACS living in areas with very poor outdoor air quality had lower survival rates. Furthermore, integrating environmental health into clinical practice could improve knowledge of the etiology and prognosis, as well as the outcomes of CACS. Finally, monitoring individual carbon footprints and creating healthier lifestyles, alongside healthier environments for CACS, could promote wellbeing, environmental awareness, and empowerment in order to attain Sustainable Development Goals for non-communicable diseases in this population.

Environment, lifestyle behavior and health-related quality of life in childhood and adolescent cancer survivors of extracranial malignancies.

BACKGROUND: Childhood cancer is a chronic disease with high survival rates. Childhood cancer survivors (CCS) can still face health effects later in their lives. Health-related quality of life (HRQoL) and the factors that modify it allow CCS and their families to improve care in the long-term follow-up. This study aims to: (1) examine the differences in HRQoL between CCS of extracranial malignancies and a comparison group, and (2) explore the clinical, environmental and lifestyles factors implicated in the HRQoL of CCS. METHODS: In this cross-sectional study with a case vs. non-case comparison, the HRQoL of 117 CCS between 8 and 18 years old was compared with healthy non-cases paired by sex and age. The Pediatric Environmental History (PEHis) was applied to obtain information on sociodemographic, clinical, environmental and lifestyle factors. The PedsQL™ Generic Core Scales questionnaire was used to evaluate HRQoL. RESULTS: In the multivariate analysis among the CCS, the following variables were significantly associated with HRQoL: Poor outdoor air quality (Total, Psychosocial, Emotional, Social and School domains); household income (Total, Psychosocial and School domains); and the presence of late effects (Total, Physical, Psychosocial, and Social domains); regular contact with nature (Physical domain); and the daily hours of screen-time (Emotional domain). CCS present HRQoL results superior to the non-cases group in the physical domain (86.10 vs. 80.34; p=0.001), finding no differences in the other domains evaluated. CONCLUSIONS: An environmental and community health approach, such as PEHis, in CCS long-term programs promoting the creation of healthier environments and lifestyles contributes to improving their HRQoL and secondarily other chronic diseases.

Social distancing at health care centers early in the pandemic helps to protect population from COVID-19.

The impact of COVID-19 outbreak has been unequal across Spanish regions. The epidemic wave has been smoother in the Region of Murcia (RM) (6 deaths/100,000 residents). Physical distance from health centers from day 0 is an additional social distancing measure that confers an advantageous starting position in the fight against COVID-19. Late healthcare distancing measures are not as powerful as the early ones.

My partner and my neighbourhood: The built environment and social networks' impact on alcohol consumption during early pregnancy.

Maternal alcohol consumption during pregnancy is responsible for negative health outcomes. The literature shows that socio-economic and lifestyle factors are both related with alcohol consumption during pregnancy; nevertheless, the role of other factors is unclear. The objective of this study is to assess the role that partners' alcohol consumption plays, that played by accessibility to alcohol, and by social influence - when considering pregnant women's behaviour as regards alcohol. It presents the results from a follow-up study of children at risk of negative health outcomes associated with prenatal alcohol exposure; it shows that 68% of pregnant women included in the study reported alcohol consumption during early pregnancy. Results of the analysis showed association with partners' alcohol use, with density of bars and/or restaurants and with the number of pregnant women who drank in the neighbourhood. We concluded that the involvement of men in pregnancy healthcare, and urban policies which target the built environment and improve social networks could be important aspects for the control and prevention alcohol consumption during pregnancy in public health programs. Interventions and recommendations should include an ecological perspective on prenatal community-health programs - focusing on individual, social, and natural factors as well as the built environment.

Secondhand smoke: A new and modifiable prognostic factor in childhood acute lymphoblastic leukemias.

BACKGROUND: The 5-year overall survival (OS) in childhood acute lymphoblastic leukemia (ALL) has reached 90% in high-income countries, levels that can no be longer overcome with strategies based on intensification of treatment. Other approaches in the search for new and modifiable prognostic factors are necessary to continue to improve these rates. The importance of environmental factors in the etiopathogenesis of childhood ALL has been regaining interest but its role in the prognosis and survival of this disease is not well explored. We aim to investigate the association between secondhand smoke (SHS) and survival in children diagnosed with ALL. METHODS: We analyzed survival rates in 146 patients under the age of 15 years diagnosed with ALL between January 1998 and May 2016 in the Region of Murcia, Spain. Evaluation of parental SHS and other known prognostic factors (sex, age, white blood cell count at diagnosis, cytogenetics, NCI/Rome Criteria, early response to therapy, and relapse) were assessed for impact on OS, event-free survival (EFS), cumulative incidence of relapse (CIR), and treatment-related mortality (CITRM) using Kaplan-Meier analysis, Cox regression, and Fine-Gray model. RESULTS: The mean follow-up time was 105.3 months (±66.5). Prenatal exposure to SHS due to parental smoking was highly prevalent. Of the mothers, 44.4% and 55.5% of the fathers smoked at some point during pregnancy. After the child's diagnosis of ALL 39.7% of mothers and 45.9% of fathers reported smoking. The Cox proportional hazards model showed that maternal smoking during pregnancy and after diagnosis (HR = 4.396, 95% CI: 1.173-16.474, p = 0.028); and relapse (HR = 7.919; 95% CI: 2.683-21.868; p < 0.001) are independent prognostic factors in determining survival. The Fine-Gray model showed that maternal smoking during pregnancy and after diagnosis (HR = 14.525, 95% CI: 4.228-49.90, p < 0.001) is an independent prognostic factor in CITRM. CONCLUSIONS: Persistent SHS worsens OS and TRM in children with ALL. This negative impact contributes to a different prognosis and may possibly provide an exceptional insight into new therapeutic approaches, including environmental aspects such as prevention and smoking cessation to improve survival outcomes.

Spatial clustering of childhood leukaemia with the integration of the Paediatric Environmental History.

BACKGROUND: Leukaemia remains the most common type of paediatric cancer and its aetiology remains unknown, but considered to be multifactorial. It is suggested that the initiation in utero by relevant exposures and/or inherited genetic variants and, other promotional postnatal exposures are probably required to develop leukaemia. This study aimed to map the incidence and analyse possible clusters in the geographical distribution of childhood acute leukaemia during the critical periods and to evaluate the factors that may be involved in the aetiology by conducting community and individual risk assessments. MATERIALS AND METHODS: We analysed all incident cases of acute childhood leukaemia (<15 years) diagnosed in a Spanish region during the period 1998-2013. At diagnosis, the addresses during pregnancy, early childhood and diagnosis were collected and codified to analyse the spatial distribution of acute leukaemia. Scan statistical test methodology was used for the identification of high-incidence spatial clusters. Once identified, individual and community risk assessments were conducted using the Paediatric Environmental History. RESULTS: A total of 158 cases of acute leukaemia were analysed. The crude rate for the period was 42.7 cases per million children. Among subtypes, acute lymphoblastic leukaemia had the highest incidence (31.9 per million children). A spatial cluster of acute lymphoblastic leukaemia was detected using the pregnancy address (p<0.05). The most common environmental risk factors related with the aetiology of acute lymphoblastic leukaemia, identified by the Paediatric Environmental History were: prenatal exposure to tobacco (75%) and alcohol (50%); residential and community exposure to pesticides (62.5%); prenatal or neonatal ionizing radiation (42.8%); and parental workplace exposure (37.5%) CONCLUSIONS: Our study suggests that environmental exposures in utero may be important in the development of childhood leukaemia. Due to the presence of high-incidence clusters using pregnancy address, it is necessary to introduce this address into the childhood cancer registers. The Paediatric Environmental History which includes pregnancy address and a careful and comprehensive evaluation of the environmental exposures will allow us to build the knowledge of the causes of childhood leukaemia.

Childhood cancer in small geographical areas and proximity to air-polluting industries.

AIM: Pediatric cancer has been associated with exposure to certain environmental carcinogens. The purpose of this work is to analyse the relationship between environmental pollution and pediatric cancer risk. METHOD: We analysed all incidences of pediatric cancer (<15) diagnosed in a Spanish region during the period 1998-2015. The place of residence of each patient and the exact geographical coordinates of main industrial facilities was codified in order to analyse the spatial distribution of cases of cancer in relation to industrial areas. Focal tests and focused Scan methodology were used for the identification of high-incidence-rate spatial clusters around the main industrial pollution foci. RESULTS: The crude rate for the period was 148.0 cases per 1,000,0000 children. The incidence of pediatric cancer increased significantly along the period of study. With respect to spatial distribution, results showed significant high incidence around some industrial pollution foci group and the Scan methodology identify spatial clustering. We observe a global major incidence of non Hodgkin lymphomas (NHL) considering all foci, and high incidence of Sympathetic Nervous System Tumour (SNST) around Energy and Electric and organic and inorganic chemical industries foci group. In the analysis foci to foci, the focused Scan test identifies several significant spatial clusters. Particularly, three significant clusters were identified: the first of SNST was around energy-generating chemical industries (2 cases versus the expected 0.26), another of NHL was around residue-valorisation plants (5 cases versus the expected 0.91) and finally one cluster of Hodgkin lymphoma around building materials (3 cases versus the expected 2.2) CONCLUSION: Results suggest a possible association between proximity to certain industries and pediatric cancer risk. More evidences are necessary before establishing the relationship between industrial pollution and pediatric cancer incidence.

Congenital fibrosarcoma and history of prenatal exposure to petroleum derivatives.

Congenital fibrosarcoma (CFS) is a rare fibrous tissue malignancy that usually presents in the first few years of life. It is unique among human sarcomas in that it has an excellent prognosis. We describe a temporal clustering of a number of cases of CFS and investigate the possible associated prenatal risk factors. The Pediatric Environmental History, a questionnaire developed in our clinic that is instrumental in determining environmental risk factors for tumor-related disease, was essential in documenting the presence or absence of risk factors considered as human carcinogens. We found a history of exposure to petroleum products in four cases of CFS that occurred at a greater than expected rate in a short time frame-an apparent cancer cluster. We call attention to the possibility that exposure to petroleum products raises the risk of developing CFS. While future studies should focus on systematic investigation of CFS and its underlying mechanisms, this report suggests the need for proactive measures to avoid exposure to solvents and petroleum products during pregnancy.

Head circumference at birth and exposure to tobacco, alcohol and illegal drugs during early pregnancy.

AIMS: We aimed to assess the effects of exposure to tobacco smoke, alcohol and illegal drugs during early pregnancy on the head circumference (HC) at birth of otherwise healthy neonates. METHODS: A follow-up study from the first trimester of pregnancy to birth was carried out in 419 neonates. An environmental reproductive health form was used to record data of substance exposure obtained during the first obstetric visit at the end of the first trimester. A multiple linear regression model was created for this purpose. RESULTS: Alcohol intake during pregnancy and medical ionizing radiation exposure were the most significant predictors of HC. The mothers' alcohol consumption increased with the mothers' and fathers' education level, net family income and fathers' alcohol consumption. In contrast, maternal smoking decreased with increasing mothers' and fathers' education level and net family income. About 13% of the surveyed embryos were exposed to illegal drugs. CONCLUSIONS: Mild to moderate alcohol consumption diminishes the at-birth HC of theoretically healthy newborns in a linear form. There was no threshold dose. We perceived a need for increasing the awareness, and for training, of health care professionals and parents, in regard to risks of alcohol consumption and for recommending abstinence of these substances in both parents during pregnancy. It should also be remembered that medical ionizing radiation should be performed only during the first half of the cycle in fertile women. We think that our study has an important social impact as it affords data for implementing policies for promoting "healthy pregnancies".

Space-time clustering in childhood nervous system tumors in the Region of Murcia, Spain, 1998-2009.

AIMS: The aims of this study are the following: first, to analyze incidence, trends, and survival of nervous system tumors in children under the age of 15 in the Region of Murcia, Spain, during the years 1998-2009 and second, to evaluate if certain environmental exposures may be involved in the etiology of childhood nervous system tumors. The study was performed on the spatial and temporo-spatial distribution of the observed cases. METHODS: The Environment and Pediatric Cancer in the Region of Murcia is an ongoing research project aimed at carefully collecting pediatric environmental history (PEH) and to use geographical information systems to map the incidence and to analyze the geographical distribution of pediatric cancer incidence in our region. Between 1998 and 2009, 125 patients were diagnosed with nervous system tumors. The spatial and temporal space clusters were evaluated using Kulldorff's statistics. Address at diagnosis was the main feature evaluated. RESULTS: The incidence (cases/million children) for central nervous system (CNS) tumors was 34.2, that for sympathetic nervous system tumors was 10.9, and that for retinoblastoma was 1.9. There was evidence of space clustering for medulloblastoma and space-time clustering for all tumors, CNS tumors, astrocytoma, and neuroblastoma. CONCLUSIONS: The incidence and survival for each type and subtype of nervous system tumors were within the reported values for the European region. There is evidence that spatial and spatial-temporal distribution in these cases is not random. The development of a careful PEH in these patients will help to reinforce geographical information system studies and to ascertain the importance of associated risk factors.

Prenatal exposure of a girl with autism spectrum disorder to 'horsetail' (Equisetum arvense) herbal remedy and alcohol: a case report.

INTRODUCTION: Autism is a complex neurodevelopmental disorder in which the interactions of genetic, epigenetic and environmental influences are thought to play a causal role. In humans, throughout embryonic and fetal life, brain development is exquisitely susceptible to injury caused by exposure to toxic chemicals present in the environment. Although the use of herbal supplements during pregnancy is relatively common, little information is available on their association with fetal neurodevelopment. This is, to the best of our knowledge, the first report in the literature to associate a new plausible mechanism of neurodevelopmental toxicity with a case of autism spectrum disorder through a vitamin deficiency potentiated by concomitant use of herbal supplements and ethanol exposure. CASE PRESENTATION: We describe the pediatric environmental history of a three-year-old Caucasian girl with an autism spectrum disorder. We utilized her pediatric environmental history to evaluate constitutional, genetic, and environmental factors pertinent to manifestation of neurodevelopment disorders. Both parents reported prenatal exposure to several risk factors of interest. A year prior to conception the mother began a weight loss diet and ingested 1200 mg/day of 'horsetail' (Equisetum arvense) herbal remedies containing thiaminase, an enzyme that with long-term use can lead to vitamin deficiency. The mother reported a significant weight loss during the pregnancy and a deficiency of B-complex vitamins. Thiamine (vitamin B1) deficiency could have been potentiated by the horsetail's thiaminase activity and ethanol exposure during pregnancy. No other risk factors were identified. CONCLUSIONS: A detailed and careful pediatric environmental history, which includes daily intake, herbal remedies and ethanol exposure, should be obtained from all patients with autism spectrum disorder. Maternal consumption of ethanol and of herbal supplements with suspected or potential toxicity should be avoided during pregnancy. The prospective parents should perform preconception planning before pregnancy.

Transgenerational tobacco smoke exposure and childhood cancer: an observational study.

AIM: Although tobacco smoke is an established risk factor for adult cancer, studies of the association between parental smoking and childhood cancer have produced inconsistent results. To investigate the transgenerational relationship between pre-natal and post-natal tobacco smoke exposure from the grandmother's pregnancies until after the post-natal period and childhood cancer. METHODS: Exposure to tobacco smoke was recorded for three generations. Data were collected through personal interviews using the paediatric environmental history, and were compared among 128 children with cancer and 128 matched controls. The contingency tables and a logistic multivariable regression model were used to control for possible confounding factors. RESULTS: Smoke exposure during oogenesis (maternal grandmother smokers)--odds ratio (OR) 2.2 (95% confidence interval (CI) 1.1-4.9)--and during the mother' pregnancies--OR 1.8 (95% CI 1.1-3.3)--were significantly associated with an increased risk of childhood cancer. CONCLUSIONS: Tobacco smoke exposure during the grandmother's and mother's pregnancies increase the risk of cancer in the descendants. The results suggest that the biological plausibility of the association between parental smoking and paediatric cancer can be explained by the large latency period of paediatric carcinogenesis.

Full breastfeeding and paediatric cancer.

AIM: It has been suggested that there is an inverse association between breastfeeding and the risk of childhood cancer. We investigated the association between full breastfeeding and paediatric cancer (PC) in a case control study in Spain. METHODS: Maternal reports of full breastfeeding, collected through personal interviews using the Paediatric Environmental History, were compared among 187 children 6 months of age or older who had PC and 187 age-matched control siblings. RESULTS: The mean duration of full breastfeeding for cases were 8.43 and 11.25 weeks for controls. Cases had been significantly more often bottle-fed than controls (odds ratio (OR) 1.8; 95% confidence interval (CI) 1.1-2.8). Cases were significantly less breastfed for at least 2 months (OR 0.5; 95% CI 0.3-0.8), for at least 4 months (OR 0.5; 95% CI 0.3-0.8), and for 24 weeks or more (OR 0.5; 95% CI 0.2-0.9). CONCLUSIONS: Breastfeeding was inversely associated with PC, the protection increasing with the duration of full breastfeeding. Additional research on possible mechanisms of this association may be warranted. Meanwhile, breastfeeding should be encouraged among mothers.