PEHSU program data between October 1, 2014 and September 30, 2019 were reported quarterly by PEHSU program staff to the National Program Office. Study data related to consultations and education & outreach (E&O) activities were collected and managed using Research Electronic Data Capture (REDCap) electronic data capture tools hosted at the American Academy of Pediatrics.^18,19 Use of the REDCap data collection tool began late in fiscal year 2015. REDCap (Vanderbilt University, Nashville, Tenn) is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture, 2) audit trails for tracking data manipulation and export procedures, 3) automated export procedures for seamless data downloads to common statistical packages, and 4) procedures for data integration and interoperability with external sources. Study data also included extracted “impact stories” documented in a free text format. These stories were analyzed using structured tables in Microsoft Excel (Microsoft Corporation, Redmond, Wash). The purpose of the impact stories was to explicitly connect activities conducted with observed outcomes.

PEHSUs build capacity by supporting environmental health infrastructure, training, and mentorship. PEHSUs train community health workers, make presentations at medical practices, conduct grand rounds, and arrange for medical residents to shadow environmental home assessments. Community health workers and other health professionals have been trained by PEHSUs to understand, recognize, and respond to risks associated with exposure to extreme heat, lead, nitrates in well water, and numerous other topics. PEHSU staff have presented at medical practices on the importance of lead screening for children and people who are pregnant. PEHSUs have conducted grand rounds on the topics of pediatric environmental health, exposure history-taking, lead poisoning, mercury exposure, bisphenol A and phthalates, flame retardants, and in-home assessment training.

PEHSUs create and publish outreach materials to educate families and communities on a wide range of environmental health topics, including exposure prevention. Resources convey information in ways that are creative and engaging, while providing tools for community members to effect their own changes and influence local policy discussion. PEHSU staff also deliver community presentations on a wide range of environmental health topics; such presentations have brought about systems-level changes, for example, screening practices in health care settings (eg, better compliance with governmental recommendations for lead testing and screening at well-child care visits for preschool children).

Another critical service that PEHSUs provide is assistance and coordination of response when there has been an actual or potential exposure. This kind of support typically involves activities like collecting and analyzing community reports, briefing state and local public health officials and health professionals, coordinating with other experts and agencies, and providing guidance on remediation planning. PEHSUs also respond to a surge in consultation requests from communities and may also identify and then fill needs for additional educational resources.

Data were analyzed using SAS v.9.4 (SAS Institute Inc, Cary, NC) and Stata v.15 (Stata Corp, College Station, Tex). Numbers of consultations performed are presented by federal region and federal fiscal year (“FY”), and numbers of individuals educated are presented by audience type and FY. For reference, FY2015 began October 1, 2014 and ended September 30, 2015. The number of consultations referencing top concerns is presented among cases where a potential exposure occurred, stratified by consultation type (community member or health care professional). Concerns are listed if they appeared in the top 10 agents of concern or top 5 health concerns for any stratum. The number of activities referencing top topics (top 10 environmental health issues and top 5 health concerns) is presented overall.

Impact stories were compiled into a compendium using Microsoft Excel and sorted by region and date of report. Each region’s activities were reviewed chronologically to identify themes and key initiatives, emphasizing the identification of ongoing collaborations and engagement, evidence of sustained capacity building, and trends in environmental health concerns.

This study was found to be exempt from Institutional Review Board review.

Regional PEHSUs operated in all 10 federal regions of the United States, including its territories. Each regional PEHSU was funded annually ranging from $155,000 in 2015 (or $1,550,500 total) to $185,000 in 2019 (or $1,850,000 total). The AAP and the American College of Medical Toxicology together formed a partnership that received funding to serve as the National Program Office at $450,000 in 2015 or 22.5%, a percentage that remained constant during the 5-year period.

All PEHSUs were deeply involved in the training of health professionals at every level from students to community-level clinicians and community health workers. For example, region 2 PEHSU offers short-term trainings and clinical rotations to an average of 15 students, residents, and other nursing and other health professional trainees annually (C. Bernardi, personal communication, February, 2024). PEHSU faculty and staff published 462 articles, reviews, book chapters, fact sheets, commentaries, short informational pieces, and other materials (eg, infographics, brochures, blogs, brochures, etc.) between 2014 and 2019. These included 190 articles in scientific peer-reviewed journals and 29 textbook chapters to increase professional capacity in pediatric and reproductive environmental health.

This is the first published accounting of the activities of the national PEHSU program during the period 2014–19. PEHSUs have successfully sustained their efforts and expanded their services over the past 25 years. This continuity enables PEHSUs’ staff and faculty to form relationships with other health professionals, community health workers, and local, state, tribal, and federal public health personnel, which contributes to PEHSUs’ ability to make sustained improvements in children’s environmental health. Remarkably, PEHSUs have accomplished these ambitious aims with limited federal core funding which, during this time period of 2014–19, was never more than $185,000 per year. Most faculty and staff receive only a portion of their salary from direct PEHSU funding, often less than 25%. While supplementary grants have been made available to the regional units more recently, such complementary funding was limited during the period under study. Some units have had success in securing additional funding from other public and private sources to support their activities. However, limited government funding has continued to pose a challenge to the national PEHSU program since its inception; funding challenges pose constraints as to what the PEHSU units can accomplish.

The data presented here on the productivity of PEHSUs over a recent 5-year period document a growing demand for their services. The 6102 clinical consultations recorded by PEHSUs during this period, representing an annual mean of 1220 consults, were approximately 60% higher than a previous report of PEHSU activity from years 2004–14, during which 7640 total consultations were documented over 10 years.²⁰ Moreover, this increase is likely an underestimate because of the substantial underreporting apparent in FY2015 before the data collection system came online. Leading topics of interest to both health professionals and the public continue to be lead poisoning, insecticides and pesticides, and environmentally related asthma. Drugs of abuse, when aggregated into a category, rose into the top 3 concerns communicated during consultations. This increased demand may be due to greater knowledge by health professionals and the general public about the services PEHSUs provide and a greater understanding by these groups of the role the environment plays in children’s health and the health of pregnant people.

Primary goals in the national PEHSU program include professional training and educational outreach in an effort to build capacity. By educating health professionals—physicians, nurses, nurse practitioners, physician assistants, pharmacists, and others working in environmental justice communities—we increase their comfort level in addressing environmental threats with their patients. PEHSUs also have a critical role in training the next generation of specialists in children’s environmental health. The Institute of Medicine (now known as the National Academies of Science, Engineering, and Medicine) in a 1995 report recommended expanding the environmental health curriculum in schools training health professionals.²¹ Others have also advocated for changes in the preparation of clinicians during training,^22–24 but progress in integrating environmental health and related topics, such as environmental justice or climate change into formal medical school and residency curricula has been slow. Environmental pediatrics is still considered to be an “emerging” specialty topic in medicine internationally,²⁵ although there have been efforts to offer advanced training to health professionals to increase capacity and expertise in pediatric environmental health as a new medical subspecialty.^26,27 PEHSU faculty recently published an outline of curricular competencies in pediatric environmental health intended to guide curricular development for students at all levels of training as well as for health professionals in practice.²⁸

Between 2015 and 2019, PEHSUs reached over 92,000 health professionals, through presentations and social media and published more than 190 articles in professional journals. PEHSUs still need to work on capacity building in terms of educating the next generation of health professionals to attain expertise in counseling around pediatric and reproductive environmental health issues. PEHSUs have still not sufficiently responded to the rising interests of high school and college students and health professional trainees. These students and trainees are interested in children’s environmental toxicology and health issues, environmental justice, and climate change. PEHSUs need the resources, faculty, and commitment to respond to these interests, and they need to set time-based goals for accomplishing this. PEHSUs need to train the next generation of health professionals with expertise in the discipline of pediatric environmental health.

To help the public recognize and prevent exposures of their children to environmental threats, PEHSUs offer fact sheets, social media posts, website-based educational outreach, and community presentations at town halls and other venues, among other activities. By helping individuals and families, PEHSU staff increase their resilience and lower their vulnerability. Between 2015 and 2019, PEHSUs reached over 130,000 audience members through presentations, social media, and publications. Enduring materials like fact sheets offer a valuable resource to health professionals, families, and communities. Education and outreach focused on increasing general knowledge around children’s environmental health issues and addressed topics such as lead and drugs of abuse, reflecting needs identified during consultations.

In addition, PEHSUs documented practical, on-the-ground activities such as coordinating care to protect an individual family’s health and providing education and technical assistance for a community. These activities also demonstrate the varied expertise of each regional PEHSU and how their response is shaped by environmental health priorities in their respective regions. In the future, all PEHSUs will continue to be involved in educational outreach to families, communities, and health professionals regarding such issues as the threat of pollutants such as perfluoroalkyl substances and the growing existential threat of climate change. PEHSUs must address the urgent need of health professionals on how to counsel families to prepare for and mitigate the effects of climate change on their children’s health.

The results presented here have several limitations. Utilization of PEHSUs for clinical consultation is voluntary, and these data do not represent the incidence of hazardous environmental exposures in the United States. Not all reports of toxic exposures were confirmed by a toxicology laboratory. The accuracy and completeness of the consultations and E&O data are dependent on data entry proficiency by PEHSU staff, and the low recorded numbers of consultations and E&O activities in FY2015 can be attributed to the late arrival of the reporting tool rather than low activity. There was wide variability in how each region reported their impact stories. For example, in some PEHSU regions, comparatively few reports were submitted; in other regions, the level of detail was insufficient to identify impacts.

In many cases, a lack of resources precluded long-term follow-up that might have documented sustained positive changes attributable to the PEHSU’s educational outreach activities. Without follow-up metrics, it is difficult to tell what medical knowledge “sticks” after a grand rounds or another type of didactic presentation and how knowledge, attitudes, and clinical behaviors are subsequently changed. The data presented here document only the number of individuals who were exposed to the content of pediatric environmental health topics. Longitudinal measures of change in knowledge, attitudes, or clinical behaviors over time were not collected and are an acknowledged limitation of this study. But we also would argue that, even absent these quantitative estimates of change, it is still worthwhile to document the educational efforts undertaken, given the importance of these topics.

With modern-day ubiquitous chemical exposures and increasing concern about how environmental issues like climate change might affect children’s health, the work of the PEHSU has never been more important. As mentioned previously in this paper, the annual direct and indirect costs to the US economy of children’s exposures to cumulative environmental pollutants such as lead, mercury, and air pollutants are staggering. PEHSUs offer important resources to help communities address such incredibly costly concerns with a very small amount of federal funding, an extraordinarily positive “return on investment.” PEHSUs’ strengths in identifying local pressing environmental concerns and developing innovative strategies to meet regional needs are critical to protecting children from hazardous environmental exposures, especially in disproportionately affected communities. Education of health professionals to increase their capacity to recognize and manage exposed children and families will continue to be a key component in future work. Increased training of medical and nursing students, as well as health professionals in practice, is essential to recognizing environmental contributions to disease and decreasing morbidity and mortality related to such exposures. Expanded community education and outreach will empower more communities to make choices that will protect their families’ health. PEHSUs will continue to grow partnerships with schools, community groups, and public health officials at all levels of government to protect reproductive and children’s health.