Environment International 76 (2015) 115

Contents lists available at ScienceDirect

Environment International
journal homepage: www.elsevier.com/locate/envint

Review

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-
Keywords:
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.

Contents

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: jennifer.vanos@ttu.edu.

http://dx.doi.org/10.1016/j.envint.2014.11.016
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

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

Urban Growth &

Climate Variability

Enhancement of
Stressors

BIOCLIMATE PARAMETERS &

ENVIRONMENT-HEALTH INDICATORS

Temperatures:
Air & Surface UVB Health, activity,
Energy Budgets: Wind
Urban & Human exposure behavior, learning
outcomes
Humidity Radiation
(Tmrt)

Air
Pollution

Child & Societal

Adaptation;
Mitigation

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
microclimate.
 J.K. Vanos / Environment International 76 (2015) 115
activity. The connections between energy budget modeling and mean
radiant temperature (Tmrt) (Mayer and Hppe, 1987)the most inu-
ential microclimatic variable in human biometeorological model-
ingare discussed in Section 2.1, yet are routinely not considered
in heat stress indices (Section 2.2). Connections are further
portrayed between specic types of radiation and air pollutants
impacting children's skin and respiratory health, respectively, as
well as the distinction between outcomes of heat-related morbidity
and mortality. As portrayed in Fig. 1, the interplay between these
variables is important to understand, and works synergistically to
impact health.
These environmental stressors are important to understand due to
current and future urban heating effects (Harlan and Ruddell, 2011;
McCarthy and Sanderson, 2011), urban land use change (Adachi et al.,
2013), and increasing temperatures with projected climate change
(Meehl and Tebaldi, 2004; Tebaldi et al., 2006). Negative climate im-
pacts have been highlighted within some of the most vulnerable popu-
lations, including children (English et al., 2009; Ebi and Paulson, 2010;
Shefeld and Landrigan, 2011). In addition to health, understanding
children's reactions to atmospheric conditions can also have wide-
reaching implications for teaching and learning, as well as behavior-
al issues and parenting ease (Ciucci et al., 2013). For example, im-
plications to academic performance and behavior are related to
physical activity (Bessesen, 2008), and extreme heat, dehydration,
fatigue, and air pollution can limit cognitive ability, as well as in-
crease aggression and irritability (Anderson, 2001; Ciucci et al.,
2011, 2013). Such connections are important to address upfront,
and are fully addressed in Section 6.
Within this review, children are dened as 014 years of age (Kovats
and Hajat, 2008). The spatial focus for urban microclimates is based on
commonly frequented urban areas for active play within the developed
world (schoolyards, urban parks/playgrounds, sports elds, and back-
yards), as well as the dangerous semi-outdoor environment of vehicles.
The atmospheric variables of heat, air pollution, and radiation are com-
prehensively assessed and integrated within urban play spaces to pro-
vide a new lens for assessing children's well-being associated with
these outdoor urban environments.
2. Observations and models of outdoor heat stress: where do
children come in?
Numerous interdisciplinary studies over the last half-century em-
phasize the need for accurate prediction of health outcomes via direct
and indirect approaches. This includes epidemiological studies investi-
gating relationships between health outcomes and single atmospheric
variables, or the use of simple indices (Anderson and Bell, 2011;
Barnett et al., 2010; Hajat et al., 2006; Kovats and Hajat, 2008). Energy
budget models convey information regarding heat uxes from an
individual, and commonly result in a nal budget value or a predicted
mean vote (PMV) based on ambient conditions (e.g., Fanger, 1970;
Vanos et al., 2010). Heat indices use certain variables, mainly air tem-
perature and vapor pressure, to determine a human-perceived equiva-
lent temperature (or how it feels). This section describes approaches
used operationally and in the literature, and highlights areas where
these predictive methods may or may not be applicable to children. In
depth discussions on the theory and calculation of such indices and
models are out of the scope of this review but are found elsewhere
(Hajat et al., 2010; Vanos et al., 2010; Willett and Sherwood, 2012;
Anderson et al., 2013).
2.1. Modeling: energy budget approach
The major energy uxes impacting the human energy budget within
outdoor conditions are convective heat loss (C), evaporative heat loss
(E), conductive heat loss (K), net radiative exchange (R), and metabolic
heat production within the body (M) (Parsons, 2003; Vanos et al.,
3
2010). The balance of these energy streams is best understood through
the well-established human energy budget equation:
0 M RCKES 1
where S is the change in heat storage (W m2), which is 0 at energy
balance, N 0 at energy surplus, and b0 at energy decit (Fanger, 1972;
Parsons, 2003; Vanos et al., 2010).
When considering the energy budget equation for children and
adults, the main differences are predominantly due to surface area
and metabolism. With a much higher surface-area-to-body mass ratio,
the effects of heat in children are heightened (Wenger, 2003). In a
warm-hot environment, their body relies more on dry heat loss via con-
vection (C) than evaporative heat loss (E) as compared to adults (Falk,
1998). This large physiological difference in warm-hot conditions is in-
terestingly not due to a lower number of sweat glands per surface area,
but a lower sweat rate per gland in children (Falk, 1998). The greater re-
liance on dry heat loss in children (and hence elevated skin blood ow)
results in a greater need to dissipate body heat by convection, yet when
air temperatures rise above that of the skin (extreme conditions), this
convective loss becomes a heat gain, and there is a relatively higher
rate of heat absorption, and a quicker path to heat stress.
Body surface area (BSA) must be properly taken into account for ac-
curate energy ux estimations. However, many biometeorological indi-
ces either assume an average BSA of 1.8 m2, or are derived empirically
for a specic subset of the population, and subsequently applied to an
entire population. The inaccuracies caused from incorrect BSA are easily
demonstrated using the average BSA of a ve-year old child (0.72 m2).1
The heat production of an average man at rest is 90 W using a metabol-
ic rate of 50 W m 2 and BSA of 1.8 m2. The same heat production
(90 W) from a child would result in an average metabolic rate of
125 W m2, which is 2.5 times more energy per second coming from
each square meter of the surface.
The metabolic output is one of the strongest predictors of energy
balance (Vanos et al., 2012a). Children grow at greater rates, resulting
in a higher relative metabolism, yet with a lower surface area to release
heat. Hence, equations to determine a child's metabolism will differ
from an adult. Heart rate (HR) is applicable to metabolic outputs, and
is linearly related to metabolism when HR N120 beats min 1
(ISO8996, 1990); however, in energy budget modeling, an average age
and metabolic output is commonly assumed. For example, the Physio-
logical Equivalent Temperature (PET) (Hppe, 1999) is valid for individ-
uals 2060 years of age. The Universal Equivalent Temperature Index
(UTCI) (Brde et al., 2009; Jendritzky et al., 2009) is valid for adults,
and also assumes a BSA of 1.86 m2, a body weight of 73.5 kg, and a
body fat of content of 14% for all calculations (Fiala et al., 2012). Other
well-known indices utilized for outdoor heat stress prediction include
the Standard Predictive Index of human response approach (Gagge
and Berglund, 1986) and Out_SET* (Pickup and de Dear, 2000), both
of which are based on Gagge's early (Gagge, 1971; Gagge and
Gonzalez, 1974) and use the assumptions of the average man
(1.8 m2), with a heat production of 90 W (or 50 W m2).
An in-depth evaluation by Doherty and Arens (1988) of the physio-
logical bases of early thermal comfort models did not address the factor
of age on the model accuracy, although it did emphasize its importance.
More recently, Grundstein et al. (2010) adapted the man-environment
heat exchange (MENEX) model (Blazejczyk, 1994) for modeling the en-
ergy balance of children in cars (see Section 3.3). They use physiological
characteristics of an average 2-year-old toddler (e.g., Msitting =
61 W m2), with summer clothing insulation of 0.61 clo (Blazejczyk,
1994); however evaluation against actual physiological measurements
has not yet been completed. The COMfort FormulA (COMFA) energy
1
Based on the Dubois and Dubois (1916) BSA formula (BSA = [(W0.425 H0.725)
0.007184]), assuming weight and height of 20 kg and 101.6 cm, respectively (based on av-
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
et al., 2012a) incorporates age and tness into its metabolic value, quan-
tifying average levels of physical activity and HR for different genders
and ages using a general energy expenditure estimation method by
Strath et al. (2000).
Despite the above-mentioned issues, the success of energy budget
modeling in application and understanding within areas of biometeorol-
ogy, urban microclimatology and bioclimatic design, exercise physiology,
heat stress, and health outcome analysis should not go unnoticed (e.g., de
Dear and Spagnolo, 2005; Matzarakis et al., 2007; Fiala et al., 2012;
Jendritzky et al., 2012; Vanos et al., 2012b; Ketterer and Matzarakis,
2014). However, the generalization of these models and lack of testing
on children may result in inaccurate estimates of physiological strain.
This can produce inaccurate use of the model outputs when applied to
children, which can lead to serious consequences in identifying health
issues, particularly in young children.
2.2. Modeling with heat indices
The most common and widely used index in North America is the
apparent temperature (AT), or the heat index (HI), used by the National
Weather Service (NWS) as well as in environmental health studies
(Smoyer-Tomic and Rainham, 2001). This bivariate index, in the form
utilized by the NWS, incorporates both air temperature and moisture.
This index was developed based on indoor conditions (entitled the
Simple Indoor AT) (Steadman, 1984, 1994) yet is applied outdoors,
neglecting to use the word Indoor in front of the apparent temperature
title (Jendritzky et al., 2012). This index is applied to the entire public
along a caution-to-extreme danger continuum, with categories describ-
ing potential physiological heat stress (NOAA, 2014)2 (e.g., 40.6 C (105
F) represents an excessive heat warning). However, this index is not
suitable to capture the experience and effects of heat on children as the
initial AT development by Steadman (1979) used physiological data
from healthy, college-age students based on work the of Fanger
(1970). The further assumption of model human body dimensions by
Steadman (1979) used a height of 57 (1.7 m) and a weight of 148 lb
(67 kg) (Anderson et al., 2013); thus the higher surface-area-to-body
mass ratio in children would result in the current HI underestimating
the heightened heat impacts to children under extreme heat.
The Humidex (humidity index) (Masterton and Richardson, 1979)
is a simplied version of the rst heat stress index (HSI) put forth by
Belding and Hatch (1955), which was developed for acclimatized
men. This is a similar bivariate index to the HI based on vapor pressure
and temperature, and is used by Environment Canada to alert the pop-
ulation to heat stress danger. The two indices (Humidex and HI) result
in different outputs, which has been demonstrated many times in the
literature in relation to health (e.g., Smoyer-Tomic and Rainham,
2001; Hajat et al., 2010). For example, a heat-health study by Smoyer-
Tomic and Rainham (2001) demonstrated discrepancies between the
two indices, as well as inaccuracies in predicting heat related mortality
based on heat warning thresholds with the Humidex.
The reasons for discrepancies within and between such empirical in-
dices are numerous (e.g., not accounting for radiation (see Sections 3.1
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
for. Finally, children do not individually interpret the values from the
HI and Humidex; it is left up to the parents to interpret this information
and to make decisions on the child's behalf. The differences in thermal
comfort psychology in adults (expectations and experience, perception,
personal preference, etc. (Parsons, 2003; Metje et al., 2008; Knez et al.,
2009)) also affect their interpretation of a child's physical state.
Children, particularly infants and toddlers, do not have such experi-
ences, knowledge, or ability to modify behavior properly without
2
Many National Weather Service ofces across the US will use location specic thresh-
olds based on climatology that differ from the heat index chart (NOAA, 2014).
adult interventions (see Section 6). Overall, it is evident above that
the quicker onset to heat stress in children results in vulnerability,
and that heat indices and energy budget models, although valuable
tools, require child-specic inputs to provide accurate estimates
for children.
2.3. Observations: heat events
Urban-dwelling children are routinely identied as vulnerable pop-
ulations in environmental health review literature related to heat-
health and climate change (e.g., Ebi and Paulson, 2010; English et al.,
2009; Perera, 2008), yet conclusive and direct relationships in heat mor-
tality studies are more sparse in comparison with the elderly and gener-
al public. However, it is well-established that children from low income
and minority populations are more susceptible to heat (Luber and
McGeehin, 2008). The most recent National Health Statistics Report
(Berko and Ingram, 2014) detailed heat related mortality counts across
the United States from 2006 to 2010, with 147 deaths occurring in
young children ( 4 years), 86 in infants, and 28 in children aged
514. These numbers are less than other age categories, particularly
the elderly, yet all heat related deaths are preventable.
There is varying evidence of excess heat-related mortality in children
(Basu and Ostro, 2008; Kovats and Hajat, 2008), with some studies nd-
ing low risk and others an increased risk. For example, studies have
found minimal risk of mortality during heat waves in developed coun-
tries (Paixao and Nogueira, 2002; Garcia et al., 1999). These researchers
evidenced this through time-series and episode analysis, indicating no
excess mortality in children due to heat waves (excluding minimal in-
creases in the 1981 and 1991 Portugal heat waves). Studies nding an
increased heat-mortality risk in children (Empereur-Bissonnet et al.,
2006; Paixao and Nogueira, 2002) determined that cumulative, rather
than single-day high temperature effects, caused excess mortality dur-
ing the France heat waves of 2003 and 2006. Similar epidemiological
analyses of extreme heat events have generally found insignicant in-
creases in mortality among children (Kovats and Hajat, 2008), with a
systematic review by Xu et al. (2014) revealing that the existing litera-
ture is inconsistent and does not suggest signicant increase in child
mortality during heat waves.
Many studies highlight the signicant negative effects on the elderly
from heat exposure also due to inefcient thermoregulation (Basu and
Samet, 2002; Klinenberg, 2003); hence, heavy focus is given to the el-
derly, subdividing the age groups as those b65 years of age, and those
65 years, thus missing specic outcomes in the vulnerable child pop-
ulation. This approach is commonly utilized, such as in studying the
1995 Chicago heat wave (Semenza et al., 1996, 1999; Naughton et al.,
2002) and the 2003 European heat wave (e.g., Conti et al., 2007;
Vandentorren et al., 2006).
Interestingly, studies addressing child vulnerability point to a higher
risk of morbidity rather than mortality in children due to their heat vul-
nerability (e.g., Kovats and Hajat, 2008; Knowlton et al., 2009; Rhea
et al., 2012). During the July 15Aug 1, 2006 California heat wave, a
total of one child death was reported by the California of Health Services
soon after the heat wave, stating that:
Despite research literature identifying children as a high-risk popula-
tion, only one child death occurred in the California heat wave. We have
no information on heat-related morbidity in this or other age groups.
[Trent (2007)]
Following this, a study by Knowlton et al. (2009) determined that in
this heat wave, there were 49,800 emergency department visits among
children aged 0 to 4 years, a 5% signicant increase in risk, emphasizing
the dangerous nature of heat risk to children. Conversely, in North Car-
olina heat waves, children aged 09 represented a considerably lower
morbidity incidence (2.94 per 100,000 people) than the adults
(Lippmann et al., 2013); hence inconsistencies exist in child heat risk,
 J.K. Vanos / Environment International 76 (2015) 115
potentially due to spatial differences (e.g., climate zones, preparation,
acclimatization), as well as behavioral and cultural effects. Many studies
focus on mortality as a health outcome, as do the majority of heat-health
studies on children; hence, we may be missing the continuum of heat
stress issues and illnesses affecting children.
The higher risk of heat illness present may also have future implica-
tions due to chronic heat exposure that have not been studied. More-
over, minimal research exists on the impacts of early season, closely
spaced, and concomitant extreme heat events on children (Karl et al.,
2009). Although children have the ability to acclimate to the same mag-
nitude as adults, it occurs at a slower rate (Bytomski and Squire, 2003);
hence, early season heat waves are also a greater risk factor to the child
population in some locations (Anderson and Bell, 2011).
3. Outdoor microclimatic properties of children's urban spaces
3.1. The biophysical environment
The micrometeorological parameters input into energy budget
models of humans and outdoor spaces include air temperature, vapor
pressure, wind velocity, and short- and long-wave radiation. Thermal
comfort is inuenced specically by the mean radiant temperature
(Tmrt) in warm conditions (Mayer and Hppe, 1987; Matzarakis et al.,
2007; Kenny et al., 2008; Johansson et al., in press), which is dened
simply as the combination of all short- and long-wave radiant uxes
(Thorsson et al., 2007) (further discussed in Section 5). Shortwave radi-
ation is the main component of environmental heat load leading to po-
tential heat stress (Brotherhood, 2008); however, all atmospheric
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).
5
variables are important in understanding outdoor ambient conditions
affecting child physiology and psychology.
Specic to children's play, providing safe, thermally comfortable,
functional, accessible, and healthy spaces is of paramount importance
in maintaining health and well-being (Fjrtoft, 2004; Wolch et al.,
2011; Ciucci et al., 2013). This section discusses the physical parameters
involved in understanding the biophysical environment of the outdoor
spaces in the current review: schoolyards, urban parks/playgrounds,
sports elds, and backyards. An example is given in Fig. 2 of two outdoor
playgrounds depicting stark contrasts in design and space, specically
vegetation, surface type, and shade cover. Depending on city and loca-
tion within an urban area, outdoor play places can be found within a
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-
face and that from the entire hemispheric radiating environment
(Watson and Johnson, 1987). High rise compact areas display a SVF
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
current study would result in SVFs ranging from 0.8 for single houses
to N0.95 for open sports elds. A low SVF traps longwave radiation,
yet is benecial or cooling on hot, sunny days by blocking shortwave ra-
diation (based on orientation) to cool the street or nearby ground
surface.
Land cover types in these areas generally represent a range from
open park and low brush to dense urban forest (Oke, 2004; Stewart
and Oke, 2012), acknowledging that characteristics of these spaces
vary widely. The dominant land cover type greatly inuences the energy
uxes experienced by a child, and can differ greatly from a soccer eld
6 J.K. Vanos / Environment International 76 (2015) 115
to an urban park. Built-up areas generally have b10% pervious material,
such as soil and grass, and the most common surfaces in parks and play-
grounds include grass, pebbles, sand, and impervious materials of as-
phalt, concrete, and dark rubber. Commonly a high abundance of
impermeable surfaces is used (e.g., asphalt, brick, concrete, rubber,
and articial turf), which reduce moisture availability, partitioning in-
coming solar energy toward enhanced sensible heating of the urban
airshed. The energy uxesand hence the Bowen Ratio (ratio of
sensible-to-latent heat)with dry impermeable surfaces, or very dry
grass, are dominated by a high sensible heat ux from a hot surface. Sat-
ellite observations have displayed the temperature of dry, short grass to
be similar to asphalt on a hot day in schoolyards (Moogk-Soulis, 2010).
It is within these hot locations where children are encouraged to play,
and the fact that children are closer to these hot surfaces than adults
is a cause for greater concern for heat stress (Moogk-Soulis, 2010),
due mainly to radiative heat uxes from the surfaces and corresponding
high temperatures in closer proximity.
3.2. Incorporating bioclimatic urban design in select outdoor spaces
Research is abundant in the urban climate literature on how to
modify the landscape to improve thermal comfort, perception, and pop-
ulation attendance (e.g., Eliasson et al., 2007; Watkins et al., 2007;
Ketterer and Matzarakis, 2014). This subsection focuses on how the ef-
fective modication of the biophysical properties of the urban spaces of
interest (Section 3.1) can enhance these environments and improve
child comfort and health. It is uncommon to nd children's play places
in cities designed to ameliorate the impacts of climate and urban
heating effects on health and thermal comfort. Urban parks and school
yards with adequate vegetation, shade, and green space have the poten-
tial to provide thermally comfortable environments, and help reduce
vulnerability to heat stress to those active within or nearby. However,
in order to provide this function, outdoor spaces, including parks and
schoolyards, must be designed within the context of the prevailing
urban climate (i.e., climate-responsive bioclimatic design principles)
and projected future climates (Brown et al., 2014). The latest IPCC report
noted that projected warming may negatively affect urban recreational
sites (Revi et al., 2014), yet in combination with the amplied rates of ur-
banization, the value and importance of the services provided by urban
ecosystems and green infrastructure for adaptation will be greatly accen-
tuated (Smith et al., 2014). Such green infrastructure within urban areas
includes green roofs, urban parks with ample shade, and porous pave-
ments or surfaces to allow for increased evaporation (Santamouris,
2013), all of which aid in cooling and in preserving functionality of a city.
Differentiating between commonly found open vegetated (un-
treed) schoolyards, parks, or playgrounds versus those with effective
tree cover demonstrate potential use of evidence-based bioclimatic de-
sign principles to aid in both urban sustainability and community
health. A study completed in South-central Canada examined the sur-
face temperatures of 275 schoolyards and 529 public spaces using
Landsat 7 satellite imagery. Schoolyards were found to represent tiny
hot spots within the larger urban area, commonly displaying signi-
cantly higher surface temperatures than surrounding streets (Moogk-
Soulis, 2010). For example, with an air temperature of 27 C, the un-
shaded surface temperatures were 52.8 C on average (maximum of
61.6 C), which was 20 C hotter than that of the shaded surfaces.
These temperature differences are consistent with those found in previ-
ous studies (Oke, 1988; Akbari et al., 2001), with recent work demon-
strating the Tmrt imposed on a human (Section 3.1) to be lowest under
the shadow of trees, 3 C higher in the shadow of buildings, and 45
C higher in open courtyards within the city of Stuttgart, Germany
(Ketterer and Matzarakis, 2014).
Principles of outdoor design, when combined with knowledge of
local climates, can have a powerful inuence on the overall use (type,
amount, intensity) of an outdoor space. The variables that can be best
controlled through microclimatic design include wind speed and
incident radiation, with air temperature and relative humidity more dif-
cult to control (Brown and Gillespie, 1995). For wind modication, de-
sign of outdoor play spaces can incorporate the use of local wind
direction climatology to block cooler, harsh winter winds (e.g., north
winds), and allow the inow of winds in the warm season to aid convec-
tive and evaporative cooling.
Incident radiation dramatically impacts air and surface tempera-
tures, which are the most prominent characteristics of an urban climate,
with the Tmrt being the most important factor in the human energy bud-
get (Section 3.1). The micro-scale models of the PET (Hppe, 1999;
Matzarakis et al., 1999; Mayer and Hppe, 1987) using Rayman
(Matzarakis et al., 2007), and COMFA using a radiant temperature
(Brown and Gillespie, 1986; Kenny et al., 2009; Vanos et al., 2012b) cal-
culate the thermal comfort of humans, outputting and incorporating a
Tmrt (C) or absorbed radiation (Rabs) by a human (W m2), respective-
ly. The Tmrt and Rabs were found to have the greatest inuence on the
PET and energy budget, respectively, on sunny days. Ketterer and
Matzarakis (2014) found the PET to be signicantly greater (up to 58
C) above sealed surfaces with low albedo, high solar irradiation, and
low wind speed, corresponding to very hot.3
Fig. 3 displays the surface temperatures of an outdoor soccer/football
eld and running track taken in Guelph, ON, Canada (June 21, 2013) on
a warm-hot day (Ta = 25 C; RH = 62%; clear skies), in both the visible
and the infrared spectrum (Brown, 2013). The inner eld is articial turf
grass, the track is a dark pink/red rubber, and the outer area is natural
vegetation. Both unnatural surfaces display surface temperatures in
the range of 4255 C; however, the surfaces within the shade of
maple trees (e.g., concrete and brick) display a Tsfc range of 2427 C,
and portions of vegetation (trees, grass, shrubs) in the surroundings
have Tsfc ranging from 25 to 30 C. Such contrasts are due to the radia-
tive properties of the surface, where both a lack of evapotranspiration
from the articial surfaces and higher absorption of heat result in higher
temperatures. Evaporative cooling in the surrounding areas results in a
lower surface and near-surface temperature, highlighting the potential
benets of conserving natural and permeable surfaces.
Leaves of trees have the ability to intercept and absorb all direct
shortwave radiation, including ultraviolet radiation, as there is zero
transmittance through a single leaf (Cox, 2013); however, an entire
tree canopy rarely approaches 0% transmission of radiation. The pres-
ence of shade can result in two forms of temperature lowering: 1) limit-
ing the direct solar radiation; and 2) lowering the ground surface
temperature, thus reducing the amount of longwave radiation. For ex-
ample, on a hot day in a mid-latitude climate, if a shaded grass surface
is 30 C, the same sunlit surface is several degrees Celsius warmer.
Hence, the mere difference in surface conditions results in a signicant
difference in surface temperature, in turn exponentially increasing the
longwave radiation emitted. Moreover, tree shaded surfaces have
shown to decrease the local and surrounding air temperatures in
parks with abundant tree cover (Moogk-Soulis, 2010; Slater, 2010;
Vanos et al., 2012b). Such treed parks also result in cooling from evapo-
transpiration with moisture available, which also increases the relative
humidity. Buildings, shade sails, overhangs, portable vegetative plat-
forms, pavilions, and other landscape objects (oriented to maximize
shade at the hottest time of the day) are examples that also reduce over-
all shortwave radiation, and hence surface temperature (Santamouris,
2013). For example, Dobbinson et al. (2014) demonstrated that in a
sunny, warm climate, shade sails increased school students' use of the
newly shaded areas. Shaded spaces result in non-direct radiation (com-
monly diffuse or emitted at longer, less harmful wavelengths), which is
safer for outdoor use/activity for longer periods of time.
Knowledge of warm and cold season transmissivity ranges of trees
aids greatly in designing for comfort, addressed by Brown and Gillespie
3
The threshold for very hot is 41 C and indicates extreme heat stress, and 20 C is con-
sidered comfortable (Hppe, 1999); hence 58 C, being is 17 C warmer than this thresh-
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
for 32 common trees worldwide. For example, a Norway maple ranges
from 9.5% (summer) to 67.5% (winter) transmissivity. Brown et al.
(2014) modeled the energy budget modifying effects of adding 50%
shade as compared to clear skies. Results demonstrated an average
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
employing proper design strategies for urban parks through the use of
shade can decrease the air temperature imposed on a human by 16 C
(Chow et al., 2011; Vanos et al., 2012b; Declet-Barreto et al., 2013), with
the magnitude dependent on location (climate zone). Trees have a rela-
tively larger impact in playgrounds and parks when used in highly
dense urban areas with impervious materials. This was demonstrated
by Gulys et al. (2006), nding that street canyons with the addition of
trees have a Tmrt value of 4.6 C, as opposed to 7.0 C without trees. A
lower Tmrt substantially decreases the physiological stress to children on
warm-hot days, with Ketterer and Matzarakis (2014) measuring a 10 C
lower PET compared to open green areas (PET = 38 C) and low-albedo
impermeable surfaces (PET = 58 C).
Further, a positive outcome of reducing the surface and air tem-
peratures of overheated schoolyards, backyards, and parks is the
reduced cooling costs of the nearby buildings (as less heat would be con-
ducted through the walls and roof). However, many other benets of
implementing more urban vegetation in parks, specically trees, must
be accounted for through a cost-benet analysis in any given climate
(Harlan and Ruddell, 2011) (see Table 1). For example, in arid climates,
planting trees may be problematic and have high costs (Jenerette et al.
2011) and increased pollen can confound or enhance impacts of air
pollution (Cakmak et al., 2002; Reid and Gamble, 2009; Vanos et al.,
2014). Researchers in Lisbon, Portugal quantied the economic value of
trees for the city, nding that for every $1 invested in tree management,
residents benetted $4.48, based on factors such as energy savings, CO2
reduction, and air pollutant deposition (Soares et al., 2011).
3.3. Vehicles
While outdoors in open sun, vehicles pose substantial heat stress
hazard to unattended children during the warm season, and although
not a fully outdoor space, cannot go ignored as a critical area of research
in ambient heat exposures to children. The US National Weather Service
emphasizes this danger (NWS, 2014), yet minor attention is given in the
literature to energy budget estimations specic to children in such
unique environments. According to McLaren et al. (2005), a reason for
sparse literature in this area may be due to the fact that intuitively it
would seem unconscionable to subject a child to temperatures of 117
F (47.2 C); however this assumed intuition is not present in all actions,
and 27% of hyperthermia cases involve care givers intentionally leaving
a child in a car (Guard and Gallagher, 2005). In 2013, there we 32 deaths
due to heat stroke of children in cars in the US alone, down from 42 in
2003 (McLaren et al., 2005; NWS, 2014). More recently, Null (2014) ob-
served an average of 38 heatstroke deaths per year during the years
19982014 in the US, with 44 in 2012, and 17 in 2013.
The physical nature of a vehicle sets up a unique situation for heat
entrapment. Vehicles heat up rapidly as shortwave radiation entering
through the glass is absorbed by and heats objects inside the vehicle
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
Surrounding a sports eld
Surrounding buildings
Neighborhood & city
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
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
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)
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.
a
Volatile organic compound, biogenic emissions from select trees.
b
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
generated by the child) is trapped inside the car and unable to mix
with the outside relatively cooler air (NWS, 2014). Studies have
displayed that an outdoor temperature of 30 C (86 F) quickly increases
the in-vehicle temperatures to 5768 C (134154 F) within the rst
5 min (King et al., 1981). The accumulation of radiative and sensible
heat, as well as vapor, leads to a unique opportunity to quantify such ef-
fects on the energy budget of a child, as completed by Grundstein et al.
(2010). These researchers assessed variations in humidity and sun ex-
posure on levels of heat stress using high-temporal-resolution temper-
ature sensors and nearby weather station data, and further successfully
modeled the energy budget components (specic to child parameters)
with MENEX (Blazejczyk, 1994). Energy budget components and a
table of maximum vehicle temperature changes under various situa-
tions were created at 5-, 10-, 30-, and 60-min of exposure, which pro-
vides an invaluable guide for predicting and preventing vehicle related
hyperthermia (Grundstein et al., 2010). McLaren et al. (2005) found
the greatest temperature rise to occur within the rst 1520 min (1.8
C per 5-min on average). In this time, the energy budget of the child
can be overwhelmed by convective and radiative heat gain, and due to
no wind ow and a child's lower ability to sweat (Falk, 1998), there is
very little ability to cool off; hence, heat stroke can occur when the
core temperature reaches N40 C (104 F). Furthering the research in
this area, particularly energy budget modeling, can help link tempera-
tures with explicit warnings of heat strokes and dehydration, such as
temperature thresholds and data tables specic to conditions
(e.g., vehicles in sunny open areas (Grundstein et al., 2010)). This can
provide information to policy makers, and create educational materials,
all of which can result in fewer tragedies.
4. Air pollution health effects on urban-dwelling children
4.1. Weather, climate, and air pollution: associations with health
Child growth and development represent the stages of greatest
vulnerability to air pollution (Perera, 2008), and children have been
demonstrated conclusively as a more vulnerable group to the negative
health effects of ambient outdoor air pollution exposure (Islam et al.,
2007; Kovats and Hajat, 2008; O'Neill and Ebi, 2009). Current exposure
to air pollution is exacerbated by meteorological parameters, and the
incidence of asthma (Section 4.2) in children may be exacerbated by
increased anthropogenic emissions due to population growth and
climate-change related enhancement of ground level ozone (O'Neill
and Ebi, 2009; Reid et al., 2009; Shefeld et al., 2011).
An increased breathing rate relative to body size and an under-
developed respiratory tract results in this heightened sensitivity,
which acts in combination with the harmful effects of extreme air
temperatures (Karl et al., 2009). Hence, children experience the neg-
ative impacts of air pollution at lower concentrations (e.g., onset of
inammation and immune stimulants), commonly in combination
with extreme heat. In a 4-year study of children ( 14 years of age)
in Toronto, Canada, associations between hospitalization for respira-
tory infections were found at relatively low levels of ambient partic-
ulate matter (PM) and gaseous pollutants as compared to adults,
especially PM b 2.5 m and b10 m in diameter (PM2.510) and nitro-
gen dioxide (NO2) (Lin et al., 2005), thus conrming a lower thresh-
old response to air pollution. Islam et al. (2007) found that in
children 910 years of age, the ability for the body to protect itself
against asthma was attenuated due to exposure to high
(13.729.5 mg m 3) levels of PM2.5. A large recent international pro-
ject entitled UPTECH (Ultrane Particles from Trafc Emissions and
Children's Health) focused on the effects to children of ultrane
particulate matter (UFP, diameter b 0.100 m) emitted by motor vehicles
(International Laboratory for Air Quality and Health, 2014). Studies dem-
onstrated association of UFP exposure with negative health impacts to
children (Buonanno et al., 2012; Mazaheri et al., 2013). Buonanno et al.
(2013a) found that vehicle emissions were the main source of particle
concentration exposure in Cassino (Italy) at schoolyards when measuring
at various spatial and temporal scales, and these concentration peaks co-
incided with NOX pollution from vehicles (see Section 4.2 for connections
to health outcomes).
The overall air quality is often quantied via indices, such as the
Air Quality Index (AQI) (based on six pollutants: O 3 , PM 2.5, NO 2 ,
CO, SO2, and total reduced sulfur), where the nal AQI reported is
based on the single highest pollutant value (EPA, 2009a). More re-
cently, Health Canada and Environment Canada established the Air
Quality Health Index (AQHI) based on the combined impact those
pollutants and direct relationship to health risks based on NO2, O3,
PM2.5 (Environment Canada, 2014); hence, guidelines pertain to spe-
cic health risk reduction actions, with children considered more
vulnerable (Environment Canada, 2013). A more impactful way to
protect children and other vulnerable populations may require low-
ering the AQI or AQHI thresholds, and thus aid in avoiding issues
such stunted lung development due to air pollution from childhood
into adulthood, as found by Gauderman et al. (2004).
The IPCC Special Report on Emissions Scenarios (Nakicenovic
et al., 2000) emphasizes the importance of understanding vulnera-
bilities to air quality changes related to socioeconomic class (Ray-
Bennett, 2009), as well as health conditions and age (both the elderly
and children) (Bartlett, 2008) associated with air quality changes.
The IPCC also report that climate change may change the spatiotem-
poral distribution, quantity, and quality of pollen in urban areas
(Revi et al., 2014), with a positive outcome for overall vegetative
growth increasing due to higher carbon dioxide (CO2). Yet this also
results in increased pollen counts by 61% to 90% in select ragweed
types (Wayne et al., 2002), longer allergy seasons, and an increase
in overall pollen allergenicity (Beggs and Bambrick, 2006; Smith
et al., 2014). This is a concern for children's health as air-borne aller-
gens may increase the prevalence of asthma, allergic rhinitis, con-
junctivitis, and other respiratory diseases (Beggs, 2010), to which
children are particularly susceptible (Schmier and Ebi, 2009).
Synergistic mechanisms with meteorological parameters, such as
high air temperatures and radiation levels, also inuence air quality
and the formation of secondary pollutions (e.g., ozone, hydrocar-
bons). The relationship between ozone concentrations and lung
function (testing peak expiratory ow rate tests) was studied in
287 children, nding an inverse relationship with increasing O3 con-
centrations (Krzyzanowski et al., 1992). Climate interactions were
demonstrated by Shefeld et al. (2011) who projected (based on
the SRES A2 scenario) an increase in summer ozone-related asthma
emergency department visits for children (017 years) across New
York City by the 2020s compared to the 1990s. Variation in ground
level ozone production is of concern at the regional-to-local urban
scale level due to meteorological interactions, increased urban tem-
peratures, heightened anthropogenic pollution, and abundant day-
time radiation trapping, acting in synergy to impact human health
(Knowlton et al., 2008; Vanos et al., 2014; Watkins et al., 2007).
Other built environmental characteristics (e.g., height-to-width ra-
tios, proximity to trafc, vehicle trafc distribution, presence of
trees) can be directly linked to pollution exposure and the onset of
negative health conditions that limit physical activity, such as asth-
ma (Jerrett et al., 2010; McConnell et al., 2010; Buonanno et al.,
2013a).
Ozone, although a short-lived pollutant, can also reduce exposure
of ultraviolet radiation by absorbing the harmful rays. Further it has
been demonstrated that O3 concentrations below a tree canopy are
generally lower than those above the canopy (UK Forestry Service,
2002), indicating some canopy uptake and less photochemical crea-
tion. Moving forward, land use changes will be a key factor to incor-
porate in such studies, which can offset or enhance the effects of
anthropogenic emissions, and hence health, into the 21st century
(Tai et al., 2013).
 J.K. Vanos / Environment International 76 (2015) 115
4.2. Respiratory health in children: childhood asthma & related issues
The Center for Disease Control and Prevention (CDC) estimate that 1
in 10 children suffers from asthma (CDC, 2011), and asthma incidence is
on the rise (approximately 160% increase among preschool children;
Mannino et al., 1998), with 12.7% of children aged 017 years in the
US diagnosed with asthma (Akinbami, 2006). The connections between
air pollution, lung functions, and childhood asthma incidence are yet to
be convincingly established (McConnell et al., 2002; Gauderman et al.,
2004). Areas of emphasis in the literature regarding children's respira-
tory health revolve largely around asthma incidence and prevalence in
association with enhanced urban exposures related to living near
major roadways, single and multiple pollutant exposures, and impacts
on physically active children.
Many recent studies have examined the relationship between air
quality and asthma (e.g., Barnett et al., 2005; Liu et al., 2009; To et al.,
2013; Weinmayr et al., 2010), as asthma is the most serious and wide-
spread chronic disease among children (Bryant-Stephens, 2009). The
AQHI was shown to signicantly predict the number of asthma related
health visits across Ontario, Canada (20032006), increasing the
asthma outpatient visits by 5.6% (95% CI 1.0531.058) for same day, 1-
and 2-day lags to high exposures (To et al., 2013). These researchers
also found the highest annual incidence of new asthma cases in the
04 and 59 age groups, resulting in 41.72 and 13.54 new cases per
1000 individuals, respectively. Preschool-aged children represented 3-
fold the amount of outpatient visits for asthma health services compared
to the 2059 age group, with prevalence (sum of current and new asthma
cases) highest within the 1019 age group (To et al., 2013).
Asthma prevalence aligns closely with variations in local trafc pat-
terns (Brauer et al., 2002; McConnell et al., 2002; Gauderman et al.,
2004). There is emerging consensus that anthropogenic emissions
from trafc pollution is associated with overall increased respiratory ill-
ness, specically asthma and ventilator function in children (Janssen
et al., 2003; Kim et al., 2004; Gauderman et al., 2005; Cakmak et al.,
2012; Buonanno et al., 2013a,b). Cakmak et al. (2012) assessed the re-
spiratory health of 2328 school children (ages 911) in Windsor,
Canada. These researchers found that children living within a 200 m ra-
dius of a busy roadway experienced increased respiratory symptoms
and statistically signicant pulmonary function decrements, such as
forced expiratory volume (FEV)a value closely tied to asthma inci-
dence. Similarly in the same city, Dales et al. (2009) discovered that
each kilometer of roadway within 200 m of a child's house was associ-
ated with wheezing, wheezing and asthma, and an increase in exhaled
nitric oxide (eNO), a measure of airway inammation in asthma. Com-
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
effects to the magnitude of trafc than the road density. Similarly,
Buonanno et al. (2013b) found high correlation in asthmatic children
in Italy who were exposed to particulates, experiencing signicantly
higher eNO. These researchers also found that children exposed to traf-
c jams and those living within urban areas were subject to 41% and 25%
higher particulate concentrations (P b 0.01), respectively.
Further studies addressing PM2.5 and PM10 exposure demonstrate
associations with decreased lung functions at all ages of the population
(Anderson et al., 2012; Barnett et al., 2005; Weinmayr et al., 2010). In
children aged 9 to 14, Liu et al. (2009) found that average interquartile
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,
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
interesting in the fact that nearly all PM levels were below National Am-
bient Air Quality Standards, yet signicant health effects in children
were found, hence providing likely evidence for the need for lower
thresholds for children in indices and guidelines.
Although there has been a sustained focus on identifying the causa-
tive environmental factors of asthma and other respiratory illnesses in
9
children (Mazaheri et al., 2013; Shefeld and Ebi, 2013; Shefeld
et al., 2011; Sunyer et al., 1999), the personal exposure factors, both in-
door and out (especially allergenic bioaerosols: mold and pollen spores)
are not fully understood (Nolte et al., 2001). The average human spends
90% of their time indoors (Klepeis et al., 2001). Indoor air pollution is a
greater challenge worldwide than outdoor and results in differing pol-
lutants (endotoxins, bioaerosols, UFPs, black carbon) and associated
health effects than the criteria outdoor air pollutants (Thorne et al.,
2006; Buonanno et al., 2013c; Mazaheri et al., 2013; Morawska et al.,
2013). As the focus of this manuscript is to understand and provide out-
door ambient environments conducive to children's health and physical
activity, addressing indoor air pollution is outside the scope; however,
the indoor-to-outdoor exposure connection is acknowledged as an im-
portant area of research (Table 3).
The higher risk of children to air pollution and aeroallergen exposure
is connected with overall health, exercise, and well-being. As intense
exercise can increase ventilation rates by 17-fold (Katch et al., 1996),
children exercising in the presence of air pollution are a larger concern.
In a 5-year study of 3,535 children with no history of asthma in commu-
nities with high ozone concentrations, children playing 3 sports were
30% more likely to develop asthma than those not playing sports
(McConnell et al., 2002). More importantly, there was a signicant
20% decrease in risk of asthma in low ozone communities whether a
child played sports or not. Buonanno et al. (2013b) found that the vari-
ation in a child's activity over time is strongly related to respiratory out-
comes due to particulate exposure based on doseresponse testing.
However, such results should not deter parents from allowing sports
to be played, as the onset of asthma was also shown to increase in
areas of high ozone independent of exercise intensity. Alternately,
such research highlights the need for reduction in air pollution, and
should inform environmental health ofcials and policy makers that
current levels of pollution are routinely too high for healthy exercise
in children. There is substantive support highlighting the need to formu-
late and adopt policies and guidelines to improve children's respiratory
health (e.g., Cakmak et al., 2012; Shefeld and Ebi, 2013; To et al., 2013).
As evidenced in this section, asthma incidence is increasing, and is
exacerbated by environmental factors. Hence, it is important to combat
this issue now and how it pertains specically to children's health, and
also project future outcomes related to the environment. Studies to
determine potential future air pollution exposures to children ll an im-
portant area of research (e.g., Shefeld et al., 2011), in addition to fur-
ther information pertaining to the long-term trends of air pollution
and asthma in relation to projected temperature and greenhouse gas
emissions (Revi et al., 2014).
5. UV-radiation exposure to children
This section builds on the role of radiation in urban play spaces in
connection with air pollution and temperature, focusing on exposure
to radiation mainly in the ultraviolet B (UVB) wavelength range
(280320 nm). With radiative trapping more predominant in urban
areas, lesser number of trees (particularly few large shade trees), and
higher temperatures in the urban heat island (UHI), the risk to urban
dwellers is high. Moreover, the child subset is at even greater risk due
to less adaptive behavior, more sensitive skin, intermittent exposures,
and more sensitive skin the younger the age (Oliveria et al., 2006).
5.1. Health effects and observations in children
The effect of UVB radiation on health generally represents a U
shaped exposure response function, where small doses are benecial,
and large doses can be detrimental. What classies a large or small
dose depends on location as well as individual characteristics such as
skin type, age, weight, and genetic factors (Oliveria et al., 2006;
Fioletov et al., 2010). An acknowledged benet of UVB exposure is the
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
is well-established that melanoma skin cancer is an increasing issue
worldwide, and although rare in children, the overall incidence is rising
(Balk, 2011), and can be traced to adolescent exposures (Oliveria et al.,
2006). For example, from 1973 to 2001, the incidence of melanoma in
US children (b20 years) rose 2.9% annually (Strouse et al., 2005). A
cross sectional study completed by Geller et al. (2002) on 10,079 children
conclusively demonstrated that the incidence of burning and skin cancer
is on continual increase, and 36% of the subjects reported burning in the
sun three or more times in the summer of 1999.
Biophysical variables such as solar zenith angle, cloud cover, distance
from sun, altitude, stratospheric ozone, and tropospheric ozone, aero-
sols, and other gases have a large inuence on the amount of UVB radi-
ation exposure (Madronich et al., 1998; Kerr and Fioletov, 2008).
Although not directly modiable by humans at the surface, it is critical
that we understand the inuence that these variables have on UVB ex-
posure, and hence can incorporate this knowledge in urban site design.
The albedo of a ground surface or building also inuences the amount of
UV radiation redirected toward a child's skin; therefore, if trying to re-
duce the shortwave exposure, high albedo surfaces are discouraged
(however encouraged at roof height as an UHI mitigation technique).
Alternatively, UVB exposure in certain climate zones and seasons
can be far too low to achieve adequate vitamin D synthesis in children.
The Standard Vitamin D Dose (SDD) from solar radiation corresponding
to the UV equivalent of the oral average daily requirements (1000 Inter-
nationals Units (IU)) can be calculated based on the biophysical princi-
ples listed in the previous paragraph and physiological principles. A
method entitled FastRT by Engelsen and KyUing (2005) allows for
the SDD to be calculated. Exposure times at any time and place can be
determined, including time for recommended equivalent dose to gain
all possible benets of vitamin D (Holick, 2004). Example results are
listed in Table 2 at ve latitudes and four times of the year. Even at
60 N latitude, it is possible for a skin type II individual to synthesize
the equivalent of 400 IU vitamin D in 6 min or less for approximately
half the year (Webb and Engelsen, 2008).
For overexposure estimates of ultraviolet radiation (UVR) to the
public, the UV index is widely used. This is determined by dividing the
dose rate from the sun reaching earth's surface (in mW m2) by a stan-
dard value of 25 mW m 2. This results in a number ranging from 0
(where there is no sunlight) to mid-teens (NOAA, 2007). A value N 12
indicates skin damage occurring as low as 716 min of exposure time
(NOAA, 2007), or less time with more sensitive skin of children. These
values are for open sky (100% SVF); however, the UV levels (and high
radiant temperatures) can be reduced given small-to-large scale design
interventions (e.g., shaded play areas) to increase skin safety and out-
door play, as expanded on in Sections 3.1 and 3.2.
A study by Cox (2013) addressed the UVB dose received by children in
schoolyard landscapes in the wintertime in Waterloo, Canada (~43.5 N
latitude)a location where vitamin D dose in the winter is limited. Per-
sonal UV exposure monitors (dosimeters) were used (Scienceterra Ltd.,
2014), which are miniature electronic sensors that measure the dose of
Table 2
Approximate time in minutes during mid-June, mid-March/mid-September, and
mid-December at varying latitudes required to synthesize the oral equivalent of 400 IU
vitamin Da for skin type IIb exposing hands, face, neck, arms and legs (57.5% skin area).
Based on FastRT (Engelsen and KyUing, 2005; http://nadir.nilu.no/~olaeng/fastrt/
fastrt.html) and results of Webb and Engelsen (2008).
Latitude ( N) Summer Autumn/Spring
0 b1.0 b1.0
20 b1.0 1.1
40 1.1 1.6
60 1.5 6.0
80 4.5 120
a
Amount to gain all possible benets of vitamin D (Holick, 2004).
b
Skin types range from I to VI, where the average child would fall on the lower end of
the spectrum having a lower tolerance to UV radiation (Fitzpatrick, 1988).
a select wavelength of light (i.e., UVA (315400 nm), UVB (280315
nm)). There are considerable opportunities for the use of such monitoring
tools in child health studies to determine UVR exposures and vitamin D
absorption, linked to various urban landscape parameters and locations.
This can aid in understanding how to minimize the risk of incident radia-
tion exposure to children yet optimize child health.
6. Impacts of weather on behavior, health, and well-being
Evidence is mounting portraying benets to children and families of
living in close proximity to parks, as positive associations are found with
activity levels and behavior, particularly in children (Wolch et al., 2011).
Characteristics of the built environment in a child's neighborhood or
school are signicant factors in physical activity and thus health out-
comes (Powell, 2005; Sallis et al., 2012; Besenyi et al., 2014), with
parks receiving the most attention (Bedimo-Rung et al., 2005). In a lon-
gitudinal cohort study (19931996; 3173 children aged 912) by Wolch
et al. (2011), it was determined that when a park existed within 500 m
of the child's home, there was a signicant decline in body mass index,
controlling for potentially confounding variables such as of asthma,
other respiratory conditions, neighborhood socio-economic indicators,
and parental smoking.
A child spends 19% of their time during childhood at school (Tsang
and Klepeis, 1996; EPA, 2009b). Although mainly indoor, school
recesses are where many children are able to play and exercise. The pur-
pose of recess is to provide students with a chance to break for active
physical play and time to socialize (Ginsburg, 2007); however, for ade-
quate play and physical activity, a healthy environment and comfort-
able microclimatic is needed. The effects of oppressively hot weather
and uncomfortable conditions lead to lethargy, decreased work and ath-
letic performance, poor behavior (Eliasson et al., 2007; Eliasson, 2000;
Johansson and Rohinton, 2006; Watkins et al., 2007), and ultimately a
deterioration of social and outdoor activity (Johansson and Rohinton,
2006).
A recent report suggests the critical need for sufcient opportunities
to use recess for play to promote cognitive development (Wenner,
2009). The amount of time spent outdoors is shown to be a strong cor-
relate of physical activity in children (Ciucci et al., 2013) and reduces the
likelihood of childhood obesity and type II diabetes, which are a major
concern, particularly in the United States. Improved academic perfor-
mance and behavior is also found to relate to physical activity during re-
cess (Bessesen, 2008); however, the positive feedback reaches a point of
diminishing returns when children are exposed to hot conditions
during play (leading to potential dehydration, heat exhaustion, and fa-
tigue), which can limit cognitive ability. Aggression and irritability in
children also increase with temperature and increasing heat duration
(Anderson, 2001; Ciucci et al., 2011, 2013).
Many studies address adult behavior associated with weather,
however few have addressed children. One such study by Ciucci et al.
(2013) found that weather variables that affect children's behavior
tend to be those presenting extreme values during a given season
(e.g., higher temperature and relative humidity in summer; low tem-
peratures in winter). Evidence also exists showing the effect of humidity
on school and work performance and aggressive behavior in children
(Lagac-Sguin and d'Entremont, 2005; Ciucci et al., 2011, 2013).
There are ample avenues to take when modifying a microclimate
based on season for increased activity and improved child behavior,
where factors such as sun orientation, plant characteristics, ground sur-
Winter
face type, climate zones, precipitation, temperature and humidity can
1.2 impact year-round type and amount of physical activity in children, as
2.1
depicted by Ciucci et al. (2011). This research employed an innovative
9.0
300 and objective measurement method entitled Behavioral Mapping (lo-
600 cation and activity), demonstrating that specic attributes of the built
environment are associated with physical activity levels. They found
that activity levels varied with the biophysical settings, such as open
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-
ships of behavior and environmental controls can result in increased
awareness for teachers and childcare providers to the potentially nega-
tive (and positive) effects of the physical environment and its role to
hinder or support children's physical activity (Ciucci et al., 2011).
7. Future research and conclusions
7.1. Future research
Drawing upon a wide spectrum of research areas to cohesively as-
sess and understand the state of environmental health sciences in this
area, this review has identied several important research gaps
(Table 3). It is critical to provide constructive, accurate, and applicable
research techniques (under changing climates, societies, and demo-
graphics) that are substantive enough to formulate adaptation policies
and guidelines to protect children's health.
the current and future health impacts to children due to exposure to
enhanced levels ambient stressors in outdoor spaces. Main ndings re-
lated to differences in child-specic physiology and health outcomes
indicate:
Potential model inaccuracies (e.g., heat indices, energy budget, air
quality health index) when applied to children, for which they were
not initially intended.
Important inuences of the mean radiant temperature, which in-
cludes UVR, enhancing surface and air temperatures, and hence heat
stress in numerous instances (e.g., poorly designed play spaces, vehi-
cles).
Signicant child morbidity in epidemiological analyses of extreme
heat events, yet generally insignicant increased mortality among
children.
Associations of heat and air pollution exposure with child asthma,
obesity, behavior, and cognitive development.

7.2. Conclusions Although existing literature acknowledges such important consider-

Children are uniquely sensitive to the ambient environment. Illness
and death due to heat, air pollution, and radiation are completely avoid-
able in children when correct precautions are taken. The current review
aimed to convey the state of the research literature depicting the biome-
teorological effects on children, and to comprehensively combine
knowledge of the differential exposures that children receive within
commonly frequented outdoor microclimates. Of central focus were
ations, there is little evidence of these ndings being taken into account
in current biometeorological models and urban design practices, partic-
ularly with respect to considerations for children's health. This review
uses urban schoolyards and parks as the main example for a space
where children play. The consensus remains from the research that
the open design (given the title of green space) of such spaces do not
lend well to physical activity, where a case can be made in the urban cli-
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.,
2012)
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
space (as well as cost-effective), versus open ineffective green space
that does not provide thermal benets.
Guidelines and policies remain difcult to create due to the lack of
observational data concerning children's exposure. However, man-
dating a certain amount of shade cover conserved/implemented in
schoolyards, as well as public parks, can provide numerous benets to
children via mitigating extremely high temperature, UVB radiation,
and certain air pollutant exposures, enabling healthier and safer out-
door activity. By providing evidence-based research on specic outdoor
atmospheric stressors, society can be better prepared for preventing
unwanted health outcomes in children, identify the most dangerous sit-
uations and locations where adverse outcomes are possible, and under-
stand what the ramications of not taking action may be. Promising
opportunities to generate such evidence-based research largely center
on child-specic physiological parameters in meteorological-based
heat and air pollution models, and incorporation of effective urban
design in outdoor spaces based on bioclimatic principles to lessen
exposures and improve health. This overarching focus of the interconnec-
tedness between the atmospheric environment and children's health can
aid in adaptation, hence protecting children from the immediate and cu-
mulative consequences of ambient environmental stressors, improving
health and well-being throughout life.
Acknowledgments
The author would like to thank the numerous reviewers for helpful
comments (namely Drs. Terry Gillespie, Robert Brown, David Hondula,
and Josette Chen), as well as Dr. Robert Brown for photographs and in-
sight, and Carol Moogk-Soulis for bringing to light the importance of
children's health. There was no involvement of funding sources for
this review. Many thanks to the reviewers whose feedback considerably
improved this manuscript. Author has performed consulting services for
Applied Climatologists, Inc. in the past for work not related to the con-
tent of this manuscript.
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