Exploring the Effects of Environmental Factors on the Development of 0-4-Year Old Children in The Netherlands.

Air pollution, noise, and green space are important environmental exposures, having been linked to a variety of specific health outcomes. However, there are few studies addressing overall early life development. To assess their effects, associations between developmental milestones for a large population of 0-4-year old children in The Netherlands and environmental exposures were explored. Developmental milestones and background characteristics were provided by Preventive Child Health Care (PCHC) and supplemented with data from Statistics Netherlands. Milestones were summarized and standardized into an aggregate score measuring global development. Four age groups were selected. Environmental exposures were assigned to geocoded addresses using publicly available maps for PM2.5, PM10, PMcoarse, NO2, EC, road traffic noise, and green space. Associations were investigated using single and multiple-exposure logistic regression models. 43,916 PCHC visits by 29,524 children were available. No consistent associations were found for air pollution and road traffic noise. Green space was positively associated in single and multiple-exposure models although it was not significant in all age groups (OR 1.01 (0.95; 1.08) (1 year) to 1.07 (1.01; 1.14) (2 years)). No consistent associations were found between air pollution, road traffic noise, and global child development. A positive association of green space was indicated.

Street temperature and building characteristics as determinants of indoor heat exposure.

Higher temperatures are associated with morbidity and mortality. Most epidemiological studies use outdoor temperature data, however, people spend most of their time indoors. Indoor temperatures and determinants of indoor temperatures have rarely been studied on a large scale. We measured living room and bedroom temperature in 113 homes of elderly subjects, as well as outdoor temperatures, in two cities in the Netherlands. Linear regression was used to determine the influence of building characteristics on indoor living room and bedroom temperatures in the warm episode. During the warm episode, indoor temperatures were higher during the night and lower during the day than outdoor temperatures. Indoor temperatures on average exceeded outdoor temperatures. The weekly average indoor temperature in living rooms varied between 23.1 and 30.2 °C. Dwellings that warmed up easily, also cooled down more easily. Outdoor and indoor temperatures were moderately correlated (R2 = 0.36 and 0.34 for living rooms and bedrooms, respectively). Building year before 1930 and rooms being located on the top floor were associated with higher indoor temperatures. Green in the vicinity was associated with lower temperatures in bedrooms. This study shows that indoor temperatures vary widely between dwellings, and are determined by outdoor temperatures and building characteristics. As most people, especially the elderly, spend most of the time indoor, indoor temperature is a more exact predictor of heat exposure than outdoor temperature. The importance of mitigating high indoor temperatures will be more important in the future because of higher temperatures due to climate change.

The contribution of moped emissions to ultrafine and fine particle concentrations on bike lanes.

Although not emitting air pollution themselves, cyclists are exposed to air pollution from motorised traffic. Because of the close proximity of mopeds to cyclists, moped emissions may affect cyclist exposure. However, the quantitative contribution of mopeds to cyclists' air pollution exposures is uncertain. The aim of the research was to quantify the contribution of moped emissions to air pollution concentrations on bike lanes. Measurements of Particle Number Concentrations (PNC),1 Particulate Matter (PM)2 and Black Carbon (BC)3 on bike lanes were performed in September 2016 in four Dutch cities. Passing two- and four-stroke mopeds and other traffic were recorded and distinguished by sound by the trained field worker. One-second PNC, PM and one-minute BC concentrations were measured. Using regression analyses the contribution of passing mopeds to air pollution exposure was analysed. At 18 non-tunnel locations, two-stroke and four-stroke mopeds contributed at average 12,000 and 3000 pt./cm3 PNC per second when passing by, respectively. In a tunnel, this was 92,000 and 12,000 pt./cm3. Two- and four-strokes added 3 to 19% to total PNC at non-tunnel sites and 58% in a tunnel. Four-strokes caused at average 54% of the contribution of moped emissions to total PNC. At non-tunnel sites, the contribution of mopeds to PM was 1.2 and 0.2 µg/m3 for two- and four-strokes, respectively. In a tunnel this was 3.9 and 2.3 µg/m3. Minute-measurements of BC did not show a relation between mopeds passing by and BC. Mopeds caused substantial short-term increases in air pollution levels on bike lanes, especially in a tunnel. Two-stroke mopeds caused higher concentration peaks than four-stroke mopeds. The contribution to total air pollution concentrations of four-stroke mopeds was larger, because of the higher share of four-strokes. Because of the close proximity of mopeds to cyclists, cyclists air pollution exposure can be largely influenced by moped emissions.

In-traffic air pollution exposure and CC16, blood coagulation, and inflammation markers in healthy adults.

BACKGROUND: Exposure to traffic-related air pollution is a risk factor for cardiovascular events, probably involving mechanisms of inflammation and coagulation. Little is known about effects of the short exposures encountered while participating in traffic. OBJECTIVES: The objective of the study was to examine effects of exposure of commuters to air pollution on cardiovascular biomarkers. METHODS: Thirty-four healthy adult volunteers commuted for 2 hr by bus, car, or bicycle during the morning rush hour. During the commute, exposure to particle number, particulate matter (PM) ≤ 2.5 µm in aerodynamic diameter (PM2.5), PM ≤ 10 µm in diameter (PM10), and soot was measured. We estimated inhaled doses based on heart rate monitoring. Shortly before exposure and 6 hr after exposure, blood samples were taken and analyzed for CC16 (Clara cell protein 16), blood cell count, coagulation markers, and inflammation markers. Between June 2007 and June 2008, 352 pre- and postexposure blood samples were collected on 47 test days. We used mixed models to analyze the associations between exposure and changes in health parameters. RESULTS: We observed no consistent associations between the air pollution exposures and doses and the various biomarkers that we investigated. CONCLUSIONS: Air pollution exposure during commuting was not consistently associated with acute changes in inflammation markers, blood cell counts, or blood coagulation markers.

Improving health through policies that promote active travel: a review of evidence to support integrated health impact assessment.

BACKGROUND: Substantial policy changes to control obesity, limit chronic disease, and reduce air pollution emissions, including greenhouse gasses, have been recommended. Transportation and planning policies that promote active travel by walking and cycling can contribute to these goals, potentially yielding further co-benefits. Little is known, however, about the interconnections among effects of policies considered, including potential unintended consequences. OBJECTIVES AND METHODS: We review available literature regarding health impacts from policies that encourage active travel in the context of developing health impact assessment (HIA) models to help decision-makers propose better solutions for healthy environments. We identify important components of HIA models of modal shifts in active travel in response to transport policies and interventions. RESULTS AND DISCUSSION: Policies that increase active travel are likely to generate large individual health benefits through increases in physical activity for active travelers. Smaller, but population-wide benefits could accrue through reductions in air and noise pollution. Depending on conditions of policy implementations, risk tradeoffs are possible for some individuals who shift to active travel and consequently increase inhalation of air pollutants and exposure to traffic injuries. Well-designed policies may enhance health benefits through indirect outcomes such as improved social capital and diet, but these synergies are not sufficiently well understood to allow quantification at this time. CONCLUSION: Evaluating impacts of active travel policies is highly complex; however, many associations can be quantified. Identifying health-maximizing policies and conditions requires integrated HIAs.

Respiratory effects of commuters' exposure to air pollution in traffic.

BACKGROUND: Much time is spent in traffic, especially during rush hours, when air pollution concentrations on roads are relatively high. Controlled exposure studies have shown acute respiratory effects of short, high exposures to air pollution from motor vehicles. Acute health effects of lower real-life exposures in traffic are unclear. METHODS: Exposures of 34 healthy, nonsmoking adult volunteers were repeatedly measured while commuting for 2 hours by bus, car, or bicycle. Particle number (PN), particulate matter (PM2.5 and PM10), and soot exposures were measured. Lung function and airway resistance were measured directly before, directly following, and 6 hours after exposure. Exhaled nitric oxide (NO) was measured directly before and 6 hours after exposure. Inhaled doses were estimated based on monitored heart rates. Mixed models were used to analyze effects of exposure on changes in health parameters after exposure compared with before. RESULTS: PN, PM10, and soot were associated with decreased peak expiratory flow directly following but not 6 hours after exposure. PN doses were associated with decreases in maximum midexpiratory flow and forced expiratory flow (FEV1) 6 hours after exposure, whereas PN and soot exposures were associated with increased maximum midexpiratory flow and FEV1 directly after exposure. PN and soot were associated with increased exhaled NO after car and bus but not bicycle trips. PN was also associated with an increase in airway resistance directly following exposure but not 6 hours later. CONCLUSIONS: We found modest effects of 2-hour in-traffic exposure to air pollutants on peak flow, exhaled NO, and airway resistance.

Commuters' exposure to particulate matter air pollution is affected by mode of transport, fuel type, and route.

BACKGROUND: Commuters are exposed to high concentrations of air pollutants, but little quantitative information is currently available on differences in exposure between different modes of transport, routes, and fuel types. OBJECTIVES: The aim of our study was to assess differences in commuters' exposure to traffic-related air pollution related to transport mode, route, and fuel type. METHODS: We measured particle number counts (PNCs) and concentrations of PM2.5 (particulate matter

Respiratory health effects of ultrafine and fine particle exposure in cyclists.

OBJECTIVES: Monitoring studies have shown that commuters are exposed to high air pollution concentrations, but there is limited evidence of associated health effects. We carried out a study to investigate the acute respiratory health effects of air pollution related to commuting by bicycle. METHODS: Twelve healthy adults cycled a low- and a high-traffic intensity route during morning rush hour in Utrecht, The Netherlands. Exposure to traffic-related air pollution was characterised by measurements of PM(10), soot and particle number. Before, directly after and 6 h after cycling we measured lung function (FEV(1), FVC, PEF), exhaled NO (FE(NO)) and respiratory symptoms. The association between post- minus pre-exposure difference in health effects and exposure during cycling was evaluated with linear regression models. RESULTS: The average particle number concentration was 59% higher, while the average soot concentration was 39% higher on the high-traffic route than on the low-traffic route. There was no difference for PM(10). Contrary to our hypothesis, associations between air pollution during cycling and lung function changes immediately after cycling were mostly positive. Six hours after cycling, associations between air pollution exposure and health were mostly negative for lung function changes and positive for changes in exhaled NO, although non-significant. CONCLUSIONS: We found substantial differences in ultrafine particle number and soot exposure between two urban cycling routes. Exposure to ultrafine particles and soot during cycling was weakly associated with increased exhaled NO, indicative of airway inflammation, and decrements in lung function 6 h after exposure. A limitation of the study was the relatively small sample size.

Minute ventilation of cyclists, car and bus passengers: an experimental study.

BACKGROUND: Differences in minute ventilation between cyclists, pedestrians and other commuters influence inhaled doses of air pollution. This study estimates minute ventilation of cyclists, car and bus passengers, as part of a study on health effects of commuters' exposure to air pollutants. METHODS: Thirty-four participants performed a submaximal test on a bicycle ergometer, during which heart rate and minute ventilation were measured simultaneously at increasing cycling intensity. Individual regression equations were calculated between heart rate and the natural log of minute ventilation. Heart rates were recorded during 280 two hour trips by bicycle, bus and car and were calculated into minute ventilation levels using the individual regression coefficients. RESULTS: Minute ventilation during bicycle rides were on average 2.1 times higher than in the car (individual range from 1.3 to 5.3) and 2.0 times higher than in the bus (individual range from 1.3 to 5.1). The ratio of minute ventilation of cycling compared to travelling by bus or car was higher in women than in men. Substantial differences in regression equations were found between individuals. The use of individual regression equations instead of average regression equations resulted in substantially better predictions of individual minute ventilations. CONCLUSION: The comparability of the gender-specific overall regression equations linking heart rate and minute ventilation with one previous American study, supports that for studies on the group level overall equations can be used. For estimating individual doses, the use of individual regression coefficients provides more precise data. Minute ventilation levels of cyclists are on average two times higher than of bus and car passengers, consistent with the ratio found in one small previous study of young adults. The study illustrates the importance of inclusion of minute ventilation data in comparing air pollution doses between different modes of transport.

The environmental health of children: priorities in Europe.

OBJECTIVES: To evaluate existing research on the environmental health of children and provide a prioritised list of risk factors and policy recommendations for action, the Policy Interpretation Network on Children's Health and Environment (PINCHE) was set up within EU FP5 (QLK4-2002-02395). The project focused on air pollutants, carcinogens, neurotoxicants and noise. PINCHE was a multidisciplinary and multinational network of representatives from science, industry, NGOs, and consumer and patient organisations in Europe. MATERIALS AND METHODS: A literature search was performed using the Pubmed, Embase and Toxline databases. The quality of the gathered articles was assessed and their information and relevance was interpreted within a systematic framework. Information related to exposure, epidemiology, and toxicology was analysed separately and then a risk evaluation of particular environmental factors was made. Socioeconomic factors were specifically taken into account. The results were compiled, and considering the present regulatory situation, policy recommendations for action were made. Finally, the risk factors and policy recommendations were prioritised through a process of discussion between all the partners. RESULTS AND CONCLUSIONS: PINCHE concluded that outdoor air pollutants (especially traffic-related), environmental tobacco smoke, allergens, and mercury were high priorities with an urgent need for action. Brominated flame retardants, lead, PCBs and dioxins, ionising and solar radiation, and some noise sources were classified as being of medium priority. Some toxins were given low priority, based on few exposed children, relatively mild health effects or an improving situation due to past policy measures. We recognise the shortcomings of such a prioritisation and, though some measures are more urgent than others, emphasise that ideally all policy measures should be carried out without delay for all toxins. This priority list must be continuously revised, the precautionary principle should be central to all decisions, and the focus should be on safe exposure levels for children.

Hay fever and asthma symptoms in conventional and organic farmers in The Netherlands.

BACKGROUND: Farming has been associated with respiratory symptoms and with protection against atopy. To date, effects of organic farming on respiratory health have not been studied. AIMS: To (1) compare hay fever and asthma-like symptoms in organic and conventional farmers and (2) assess associations between current and childhood farm exposures and respiratory health effects by conducting a survey. METHODS: Questionnaire data from 1205 conventional and 593 organic farmers were evaluated. Associations between health effects and farm exposures were assessed by logistic regression analyses. RESULTS: Organic farmers reported less wheezing with shortness of breath and slightly more hay fever than conventional farmers. However, organic farming was not an independent determinant of hay fever when adjusted for farming practices and potential confounders. Livestock farmers who grew up on a farm had a threefold lower prevalence of hay fever than crop farmers without a farm childhood (odds ratio (OR) 0.3, 95% confidence interval (CI) 0.1 to 0.5). Both crop farmers who grew up on a farm and livestock farmers who did not grow up on a farm had a reduced prevalence, although less pronounced and not statistically significant. Use of disinfectants containing quaternary ammonium compounds was positively related to hay fever (OR 2.1, 95% CI 1 to 4.4). No effects of farming practices were found for asthma. CONCLUSIONS: Our study adds to the evidence that a farm childhood in combination with current livestock farming protects against allergic disorders. This effect was found for both organic and conventional farmers.

Policy Interpretation Network on Children's Health and Environment.

AIM: The main objective of PINCHE is to provide policy recommendations aiming at protecting children's health and environment based on completed scientific research. The project focused on four themes: indoor and outdoor air pollutants, carcinogens, neurotoxicants, and noise. The data were evaluated in workpackages on exposure assessment, epidemiology, toxicology, and risk and health impact assessment. The data were analysed according to a framework of questions. The workpackage on socioeconomic factors studied the influence of socioeconomic status on exposures and on health effects. In the workpackage on science-policy interface, recommendations on how to improve children's environmental health were formulated. RESULTS: The policy recommendations resulting from the analysis were grouped according to relevant policy levels: European Commission or the European Parliament, member states and other stakeholders at regional or local level. These recommendations are general guidelines for taking action. Regional differences and variation must be reflected when policy is actually implemented. In addition, recommendations related to education and personal behaviour are presented in the reports. CONCLUSIONS: The policy recommendations are important input for policy advisers, policy makers and public health authorities at all policy levels. The recommendations are also of direct relevance to interest groups, such as environmental NGOs including child health and advocacy groups. The policy recommendations for each policy level were prioritized. High priorities were given to reduce exposure to environmental tobacco smoke, transport related air pollution, indoor air and mercury.

Children's environmental health: why should social disparities be considered?

BACKGROUND/METHODS: The aim of workpackage 5 'Environmental exposures and children's health: impact of socioeconomic factors' in the EU-funded network PINCHE (Policy Interpretation Network on Children's Health and Environment) was to review and interpret the current knowledge of social inequalities in environmental exposures and children's health. Socioeconomic factors may impact on children's environmental health in two ways: 1) environmental exposures may differ according to socioeconomic status; 2) given a certain level of harmful environmental exposure, socioeconomic factors may modify the health effects by influencing the susceptibility characteristics of children. RESULTS: There is a lack of information to evaluate and quantify the effect of socioeconomic factors on environmental exposures and children's health in Europe. In most circumstances there seems to be an inverse social gradient with increased burden concerning exposures and health outcomes in children of lower social status. CONCLUSIONS: There is a need to improve research on social inequalities in children's health and environment. Because of the complexity, integrated approaches and a combination of different intervention measures and policies are necessary to reduce environmental exposure and adverse health effects in children. Paediatricians may contribute to improvement of children's environmental health by risk communication and health advocacy at community and governmental level.

Today's epidemics in children: possible relations to environmental pollution and suggested preventive measures.

BACKGROUND: Facts and hypotheses on the relationship between some children's diseases or disorders and external stressors during the developmental stage of a child, both prenatally and postnatally are described in literature. In this paper the following changes in patterns and causes of the main childhood illnesses are summarized and recommendations for actions are made. Prematurity. Intra-uterine growth restriction. Testicular dysgenesis syndrome. Type I and Type II diabetes. Asthma, atopy and hay fever. Autism. Attention deficit hyperactivity disorder (ADHD). Learning disabilities. Cancer. Obesity. Hearing problems. RESULTS: Literature provides a growing amount of information on changing patterns in childhood diseases. CONCLUSIONS: The following recommendations for action are formulated: Immediate research on endocrine disrupters in relation to prematurity. Diabetes: avoid Maillard Compounds in liquid baby food and in food in general: promote breastfeeding. Asthma: avoid exposure to smoking, the use of chemical household products, dioxin and dioxin-like chemicals, and avoid air pollution with high levels of particulate matter, especially around conception, during pregnancy and in the first years of life. Autism: more research on incidence and causes. ADHD and learning disabilities: more research on prevalence and causes. Preventions: 1) preconception counselling to avoid potentially harmful substances; 2) controlling and further lowering levels of polychlorinated biphenyls, lead and methyl mercury. Cancer: promote breastfeeding, carry out research into effects of foetal exposure to internal fission-product radionuclides. Obesity: stop smoking in pregnancy, avoid parental obesity, longer night sleep. Hearing problems: lower noise levels in discothèques, promote the day-evening-night level to avoid noise (longer night sleep).

Children's health and mercury exposure.

The reason why mercury is dangerous is that once released into the environment it cannot be removed and is rapidly transformed by microorganisms into organic compounds that tend to bioaccumulate and biomagnify in animals. The principal organic compound is methylmercury (MeHg). The primary route of exposure to MeHg for humans is consumption of fish. The safe dose (reference dose, RfD) of MeHg that can be consumed without neurotoxicological consequences is 0.1 microg per kg b.w./day. According to available data, the whole population of certain European countries or people who consume large quantities of fish are exposed to doses of MeHg that exceed the RfD. Given this level of mercury exposure, in order to avoid or reduce the expected neurotoxic consequences on foetuses we propose the following strategy: 1) At present the most reasonable solution for pregnant women (and small children) is to reduce substantially or completely avoid fish intake. 2) In the medium term the European Community should evaluate the technical and economic feasibility of breeding uncontaminated fish in order to reduce the drawbacks of banning fish consumption. 3) In the long term there is no alternative to substantially reducing mercury emissions worldwide.

Cadmium and children: exposure and health effects.

Cadmium exposure and accumulation in the body start at young age. Exposure routes in children are mainly via food, environmental tobacco smoke and house dust. Excretion from the body is limited. Cadmium accumulation in the kidney is responsible for effects such as nephrotoxicity and osteoporosis which are observed at adult age. Cadmium exposure through inhalation is also associated with lung cancer in adulthood. Although transfer to the neonate through the placenta and through breast milk is limited, teratogenic and developmental effects were observed in experimental animals. The database on human studies involving children is limited, yet effects on motoric and perceptual behaviour in children have been associated with elevated in utero cadmium exposure. In school age children urinary cadmium levels were associated with immune suppressive effects. More studies are needed to confirm these results. Experimental data in vitro and in animals refer to effects of cadmium on the hypothalamus-pituitary axis at different levels. This may lead to disorders of the endocrine and/or immune system. Cadmium exposure at early age should be limited as much as possible to prevent direct effects on children and to prevent accumulation of cadmium which may have serious health effects only becoming manifest at older age.

The effects of PCBs and dioxins on child health.

BACKGROUND/EXPOSURE: Dioxins and PCBs are highly persistent and highly toxic environmental pollutants which at present are derived mainly from waste incineration and food contamination. They are widespread in nature and pollute human food, including breast milk so that basically all children in Europe are exposed to measurable levels. RESULTS/TOXICITY IN CHILDREN: The toxicity of dioxins and PCBs are well described both from animal studies and from a number of human epidemiological studies including several large cohort studies. Especially developmental exposure has been shown to affect endocrine and cognitive systems negatively. Measurable outcomes include reduced IQ and changed behaviour. Foetotoxic effects with reduced birth weight and increased congenital anomalies such as cleft lip have also been described. Exposure to PCBs and dioxins must be considered also in the context of multiple exposure to several toxins simultaneously or sequentially. CONCLUSION/SUGGESTED ACTION: Some measures aimed at reducing exposure to dioxins have been partly successful in that the dioxin content of breast milk is going down. However, further steps to reduce exposure must be taken. We suggest legislative measures for reducing the re-entry of especially PCBs from waste into the environment. Individual pre-conception counselling is recommended in order to reduce developmental exposure and its consequences. Biomonitoring of the substances themselves in breast milk and foods is recommended as well as monitoring possible endocrine effects.

Children's exposure to polybrominated diphenyl ethers.

BACKGROUND: Polybrominated biphenyl ethers (PBDEs), a class of brominated flame retardants, are frequently used in consumer products. PBDEs levels in environmental and human samples have increased in recent decades. Children are exposed to PBDEs through diet, mainly through fish, meat and milk. Total dietary exposure of children in Europe was calculated to be 2-3 ng/kg b.w./day. For nursing infants the main source of PBDE exposure is breast milk; exposure levels are around 15 ng/kg b.w./day. PBDE exposure levels in North America are 10 to a 100 times higher. Because of their persistence and their similarity to polychlorinated biphenyls (PCBs), concern has been raised about the effects of PBDEs on human health. Exposure to penta- and octa-BDE led to learning impairment and impaired motor behaviour in rodents. Exposure to penta-, octa- and also deca-BDE caused effects on thyroid homeostasis in animals. CONCLUSIONS: The EU has banned the production and use of penta- and octa-BDE since 2004; however, exposure will continue during the coming decades. Based upon current toxicological evidence, human exposure to deca-BDEs is not expected to lead to health effects, but data on exposure to deca-BDE and data on toxicity of deca-BDE are scarce. Therefore, monitoring studies and toxicity studies on deca-BDEs and other BDEs should continue.

Environmental tobacco smoke exposure and children's health.

UNLABELLED: Almost half of the child population is involuntarily exposed to environmental tobacco smoke (ETS). The ETS exposure gives rise to an excessive risk of several diseases in infancy and childhood, including sudden infant death syndrome, upper and lower respiratory infections, asthma and middle ear diseases. It is also linked to cancer, and behavioural problems and neurocognitive deficits in children. CONCLUSIONS: Protecting children from ETS exposure is a complex and important issue. The best improvement in children's health is to be gained when parents stop smoking or, when that is not possible, they stop smoking in their children's environment. Paediatricians, because of their authority, and their frequent and regular contact with parents, play a leading role in protecting children from ETS exposure. An ideal approach to help parents to stop smoking seems to be initial minimal-contact advice provided by their paediatrician with feedback and supplemental printed materials, leading to greater intensity and duration of follow-up home visits.

Air pollution: a threat to the health of our children.

BACKGROUND/METHODS: Current air pollution levels pose a threat to the health of children starting from conception. The scientific evidence is presented for mortality, morbidity, and sub-clinical effects. The first section deals with exposure data, the following sections with the evidence of health effects from epidemiology and toxicology leading to recommendations. RESULTS: Improved air quality reduces the number of infants' deaths as well as disease and pain. CONCLUSIONS: Medical doctors have a responsibility to know the facts and to advise their patients. Doctors when visiting their patients' homes should be aware of the possibly grave impact of the indoor environment for the respiratory health of their patients. They should recognize and advise the parents on problems associated with environmental tobacco smoke, poor ventilation, mould growth, and maintenance of heating installations. With regard to outdoor air pollution, doctors could serve as role models and also advise their patients and parents on environmentally friendly behaviour. Such behaviour not only calls for personal commitment but also for the right infrastructure to be provided (e.g. public transport, district heating). Doctors should be proactive in the community and in their country as advocates for a healthier environment for our children.