Climate change adaptation across the life-course - from pregnancy to adolescence – it’s time to advance the field of climate change and child health

Children are bearing and will continue to bear a high burden from climate change, through direct and indirect pathways. Climate change adaptation interventions are essential to limit the current and projected impacts of climate change on child health. However, the perspective of children and their health with regards to adaptation in research and policy is limited. Ensuring that adaptation interventions are context specific, consider interrelated barriers to implementation and leverage existing structures including multisectoral collaboration is vital. Further, a life-course perspective on child health and well-being could serve as a template for tailoring adaptation interventions to the specific vulnerabilities and needs of specific development periods of the child. A meaningful engagement of children and young persons in the design and implementation of adaptation interventions is essential to increase effectiveness and uptake. With climate change effecting millions of children worldwide, it is high time to put child health at the center of adaptation.


Abstract
Children are bearing and will continue to bear a high burden from climate change, through direct and indirect pathways. Climate change adaptation interventions are essential to limit the current and projected impacts of climate change on child health. However, the perspective of children and their health with regards to adaptation in research and policy is limited. Ensuring that adaptation interventions are context specific, consider interrelated barriers to implementation and leverage existing structures including multisectoral collaboration is vital. Further, a life-course perspective on child health and well-being could serve as a template for tailoring adaptation interventions to the specific vulnerabilities and needs of specific development periods of the child. A meaningful engagement of children and young persons in the design and implementation of adaptation interventions is essential to increase effectiveness and uptake. With climate change effecting millions of children worldwide, it is high time to put child health at the center of adaptation.
Children have the least responsibility for climate change but are the most vulnerable to the consequences. The extent of future risks depends on the level of ambition and timing of mitigation (e.g. reducing greenhouse gas emissions) and adaptation interventions. Adaptation entails the process of adjustment to actual or expected climate and its effects, seeking to moderate or avoid harm or exploit beneficial opportunities [1]. Children have limited control over the environment in which they live and depend on care and protection from caregivers and larger society; this dynamic increases their vulnerability and leads to important implications for adaptation interventions. Children and adolescents suffer mortality and morbidity from extreme weather events, infectious diseases, respiratory diseases and other physical and mental health issues associated with climate change [2]. Climate change could also increase disease risks through eroding the basic pillars of health and well-being for children and adolescents such as nutrition, water and sanitation, education and other societal factors [3]. In low-income countries, children are likely to be hit hardest because of underlying vulnerabilities and parallel pressures from poverty, high disease burdens, weak public health infrastructures, insufficient access to safe water and improved sanitation, and undernutrition. In 2019, the Lancet Countdown on climate change and health concluded that every child is affected by climate change, that the way societies respond determines what the world we live in tomorrow will look like and that this will shape the health of children across the globe throughout their lives [4].
United Nations Children's Fund (UNICEF) launched the Children's Climate Risk Index (CCRI) in 2021, describing a composite index to monitor children's vulnerability (health, nutrition, education, water and sanitation, poverty and other social assets) and the risks of drivers of child health and environmental shocks (water scarcity, riverine floods, coastal floods, tropical cyclones, vector-borne diseases, heatwaves, air, solid and water pollution) [5]. The index concludes that one billion children, nearly half of all children in the world, are at 'extremely high risk' from climate change impacts. The impacts are unevenly distributed and expected to change over time with widening gaps between rich and poor regions and populations. Children in low-income countries particularly in sub-Saharan Africa are at higher risk. The CCRI advocates for putting the rights of the child at the center of the climate change discourse. An increased understanding of how adaptation measures can be designed and implemented to protect and promote child and adolescent health and well-being is critical.
The effects of climate change on children differ depending on the developmental stage, varying greatly from infancy to adolescence. However, this is often not acknowledged in the broader climate change literature or when designing and deploying adaptation policies and measures. A life-course approach that aims to optimize the health and well-being of a person across the lifespan, accounting for the interdependence of individual, social, environmental, temporal and intergenerational factors [6], could serve as a template for tailoring adaptation interventions to the specific vulnerabilities and needs of the different development periods of the child. Different actors and societal sectors have varied degrees of influence in protecting and promoting child health throughout a child's development. During pregnancy, infancy and early life, the health sector might have the largest possibility to limit detrimental impacts. This could be through informing about specific climate risks during prenatal visits or ensuring that health care facilities are well-equipped, have effective supply chains, and functioning care to handle temperature increases, increased precipitation variability, and increases in frequency and intensity of extreme weather events. These might in many cases lead to suboptimal educational and developmental possibilities for children. When the child becomes older, the educational sector with schools that are adapted to handle these changes allow for play and an overall enabling built environment despite the changes in environment become important. Further, with climate change leading to increased risk of various mental health issues among children that can hinder cognitive and emotional development, meaning focused coping strategies could be implemented in school settings [7]. The capacity for initiating, implementing and sustaining adaptation measures varies between countries and income-levels with no country currently in a position to provide a healthy childhood alongside a healthy environment for its children [8]. The amount of funding for climate change health adaptation increased slowly over the last decade, however only approximately 0.5% of the multilateral climate funding with regards to adaptation is directed towards health related projects [9]. According to the most recent adaptation gap report from the United Nations Environment Programme, the gap between existing adaptation needs and the financial support provided is large and increasing, resulting in the recommendation for countries to speed up the global efforts to adapt to the risks of climate change through planning, financing, and implementation [10].
There is limited understanding of adaptation and child health [11]. The published literature on this important topic is surprisingly limited. Based on a review of 1682 peer-reviewed articles in the Global Adaptation Mapping Initiative database (e.g. excluding adaptation funded under the United Nations Framework Convention on Climate Change and other development partners), Scheelbeck et al [12] concluded that the database did not include any studies detailing child health adaptation. Taking a broader scoping review approach, albeit not focusing directly on adaptation, the literature (371 documents including grey literature) provided by Helldén et al [3] offers some insights. There was a focus on water infrastructure, appropriate sanitation and hygiene at community, regional and country levels. Some adaptation mechanisms include avoiding water scarcity during droughts and reducing spread of infectious diseases through increasing water quality. A second area of climate adaptation with regards to children is combating lowered agricultural output and subsequent risk for malnutrition through close monitoring of crop yields and increasing crop diversity, cash-transfer programs to families and support of local agricultural markets. Controlled indoor air temperature adaptations that reduce indoor air pollution and estimates of the co-benefits to children of lowering ambient air pollution and physical activity were also proposed as a motivation for adaptation. More general adaptation interventions include early warning systems to provide warnings to facilitate community and societal adaptation to heatwaves and other extreme weather conditions (potentially targeting vulnerable populations such as infants); climate change knowledge of children and communities; and strengthening social protection systems particularly with a gender and equity lens. Underlying these adaptations is an emphasis on building capacity to implement the interventions at a community level and engaging multiple sectors to enhance the impact and sustainability of the interventions.
Pregnant women and infants are particularly vulnerable populations to climate change [13]. Exposure to environmental hazards during pregnancy can manifest in childhood or even become evident in adulthood. There is a significant knowledge gap when it comes to how climate change could impact the health and well-being of pregnant women and infants, particularly at the country and sub-country level. Beside heat warning systems and other forms of heat adaptation [14] and more general adaptation measures for undernutrition or diarrheal diseases, there is virtually no climate change adaptation that take into account the unique vulnerabilities and needs of pregnant women and infants [15]. Importantly, when piloting adaptation interventions these should be adapted to the local context and consider barriers to implementation. For instance, hospital accessibility for pregnant women must be a priority after tropical cyclones, floods and other extreme weather events, but when accessibility is reduced urgent obstetric needs can be responded to through outreach activities [16]. Adaptation interventions that target food insecurity should include directed efforts to reach vulnerable subgroups of foetuses and infants, including indigenous peoples and those living in poor rural and coastal areas. Showing that how climate derived in-utero agricultural shocks leading to lower child growth outcomes in Tanzania, Block et al proposed adaptations such as agricultural weather insurance, supplements targeting pregnant women and cash transfer programs for women [17].
Significant barriers to climate change adaptation exist. For example, in the Netherlands, Biesbroek et al [18] identified seven categories: (i) conflicting timescales, (ii) substantive, strategic and institutional uncertainty, (iii) institutional crowdedness and simultaneous void, (iv) institutional fragmentation, (v) lack of awareness and communication, (vi) motives and willingness to act and (vii) lack of resources. Most often barriers stem from an individual actor, the social and institutional policy process or the surrounding context including the actions of governments at different levels to restrain or enable adaptation [19]. Eisnack et al [20] further note that the barriers to adaptation are dynamic and interrelated, with stalled learning, limited awareness of the public and little public support for climate adaptation. As such, efficient, effective and sustainable adaptation measures are context specific and explicitly consider barriers to implementation [21].
Climate change is perhaps the largest global threat to the rights of the child, including the right to life, survival and development, for attaining the highest possible standard of health, adequate standard of living, education, freedom from violence or exploitation and right to recreation and play [22]. Realizing that children are active actors with agency necessities their engagement in meaningful decision-making around the design, implementation and monitoring of adaptation interventions [23,24]. A child-centered approach to climate change adaptation focuses on measures that reduces the vulnerability of children to climate change. Such an approach to climate change is likely cost effective, because children are one of the largest populations. Moreover, the economic losses from the negative impacts of climate change on child health are substantial yet the adaptations specific for children can be delivered at a low cost [25]. The perspective of protecting child health is often lacking in nationally determined contributions to the Paris Agreement and national adaptations plans [26]. Adaptation that aims to lessen the truly unjust burden of climate change on children is a moral imperative. There is an urgent need for detailed analyses at community, country and regional levels of effective adaptation measures. A life-course approach could serve as an important guidance framework for such interventions. Despite the current knowledge gaps, governments, international organizations and other stakeholders must strengthen their commitments to adaptation for child health.