Environmental Exposures and Pediatric Cardiology: Implications for Cardiovascular Health in Children

I Ketut Alit Utamayasa*  -  Division of Pediatric Cardiology, Department of Pediatric, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, East Java, Indonesia, Indonesia
Ayurveda Zaynabila Heriqbaldi  -  Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia, Indonesia
Shabrina Nur Imanina  -  Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia, Indonesia
Prima Hari Nastiti  -  Division of Pediatric Cardiology, Department of Pediatric, Universitas Airlangga/Dr. Soetomo General Hospital, Surabaya, East Java, Indonesia, Indonesia

(*) Corresponding Author
DOI: 10.30659/sainsmed.v17i1.52124
Environmental exposures during early life are increasingly recognized as important determinants of pediatric cardiovascular health. Beyond genetic susceptibility, factors encountered during fetal development and childhood may influence the risk of both congenital and acquired cardiovascular diseases. This review summarizes epidemiological evidence and proposes biological mechanisms linking key environmental exposures to cardiovascular outcomes in children. Four major domains are highlighted: climate change–related exposures and congenital heart disease, air pollution as an environmental trigger of Kawasaki disease, early-life heavy metal exposure particularly lead and its association with childhood blood pressure, and the contribution of endocrine-disrupting chemicals to cardiometabolic risk. Available evidence suggests that maternal heat exposure and air pollution during critical developmental windows are associated with increased risk of congenital heart defects. Traffic-related air pollutants and sulfur dioxide have been implicated in Kawasaki disease through immune activation and systemic inflammation. Prenatal lead exposure has been linked to modest but clinically relevant elevations in childhood blood pressure, while endocrine-disrupting chemicals are associated with early alterations in adiposity and metabolic regulation. Together, these findings underscore the importance of environmental determinants in shaping pediatric cardiovascular risk and support the integration of environmental considerations into early prevention strategies.

Keywords: Environmental exposure; Congenital heart disease; Kawasaki disease; Air pollution; Lead exposure; Endocrine-disrupting chemicals

  1. Agay-Shay, K., Friger, M., Linn, S., Peled, A., Amitai, Y., & Peretz, C. (2013). Ambient temperature and congenital heart defects. Human Reproduction, 28(8), 2289–2297. https://doi.org/10.1093/humrep/det244
  2. Amin, M. M., Ebrahim, K., Hashemi, M., Shoshtari-Yeganeh, B., Rafiei, N., Mansourian, M., & Kelishadi, R. (2019). Association of exposure to Bisphenol A with obesity and cardiometabolic risk factors in children and adolescents. International Journal of Environmental Health Research, 29(1), 94–106. https://doi.org/10.1080/09603123.2018.1515896
  3. Amin, M. M., Ebrahimpour, K., Parastar, S., Shoshtari-Yeganeh, B., Hashemi, M., Mansourian, M., Poursafa, P., Fallah, Z., Rafiei, N., & Kelishadi, R. (2018). Association of urinary concentrations of phthalate metabolites with cardiometabolic risk factors and obesity in children and adolescents. Chemosphere, 211, 547–556. https://doi.org/10.1016/j.chemosphere.2018.07.172
  4. Auger, N., Fraser, W. D., Sauve, R., Bilodeau-Bertrand, M., & Kosatsky, T. (2017). Risk of Congenital Heart Defects after Ambient Heat Exposure Early in Pregnancy. Environmental Health Perspectives, 125(1), 8–14. https://doi.org/10.1289/EHP171
  5. Braun, J. M. (2017). Early Life Exposure to Endocrine Disrupting Chemicals and Childhood Obesity and Neurodevelopment. Nature Reviews. Endocrinology, 13(3), 161–173. https://doi.org/10.1038/nrendo.2016.186
  6. Burns, J., Heims-Waldron, D. A., Angelino, A. C., Lopez, K. N., Zachariah, J. P., & Deen, J. F. (2026). Environmental Justice in Vulnerable Populations: Climate Change and Congenital Heart Disease in American Indian/Alaska Native Children. Journal of Racial and Ethnic Health Disparities, 1–12.
  7. Buteau, S., Belkaibech, S., Bilodeau-Bertrand, M., Hatzopoulou, M., Smargiassi, A., & Auger, N. (2020). Association between Kawasaki disease and prenatal exposure to ambient and industrial air pollution: A population-based cohort study. Environmental Health Perspectives, 128(10), 107006.
  8. CDC. (2025a, August 21). About Childhood Lead Poisoning Prevention. Childhood Lead Poisoning Prevention. https://www.cdc.gov/lead-prevention/about/index.html
  9. CDC. (2025b, December 3). Clinical Overview of Heat and Pregnancy. Heat Health. https://www.cdc.gov/heat-health/hcp/clinical-overview/heat-and-pregnant-women.html
  10. Elakabawi, K., Lin, J., Jiao, F., Guo, N., & Yuan, Z. (2020). Kawasaki Disease: Global Burden and Genetic Background. Cardiology Research, 11(1), 9–14. https://doi.org/10.14740/cr993
  11. Farzan, S. F., Howe, C. G., Chen, Y., Gilbert-Diamond, D., Cottingham, K. L., Jackson, B. P., Weinstein, A. R., & Karagas, M. R. (2018). Prenatal lead exposure and elevated blood pressure in children. Environment International, 121, 1289–1296. https://doi.org/10.1016/j.envint.2018.10.049
  12. Fujii, F., Egami, N., Inoue, M., & Koga, H. (2020). Weather condition, air pollutants, and epidemics as factors that potentially influence the development of Kawasaki disease. Science of The Total Environment, 741, 140469. https://doi.org/10.1016/j.scitotenv.2020.140469
  13. Gao, H., Geng, M., Tong, J., Wang, B., Huang, K., Zhang, Y., Gan, H., Zhu, B., Ding, P., Wang, Q., Wang, J., Zhang, C., Zhu, P., & Tao, F. (2023). Combined effects of prenatal phthalate exposure on cardiometabolic risk score among 4- to 7-year-old children: MABC study. Chemosphere, 311, 137135. https://doi.org/10.1016/j.chemosphere.2022.137135
  14. Gore, A. C., Chappell, V. A., Fenton, S. E., Flaws, J. A., Nadal, A., Prins, G. S., Toppari, J., & Zoeller, R. T. (2015). EDC-2: The Endocrine Society’s Second Scientific Statement on Endocrine-Disrupting Chemicals. Endocrine Reviews, 36(6), E1–E150. https://doi.org/10.1210/er.2015-1010
  15. Güil-Oumrait, N., Stratakis, N., Maitre, L., Anguita-Ruiz, A., Urquiza, J., Fabbri, L., Basagaña, X., Heude, B., Haug, L. S., & Sakhi, A. K. (2024). Prenatal exposure to chemical mixtures and metabolic syndrome risk in children. JAMA Network Open, 7(5), e2412040–e2412040.
  16. Jin, S., Yoon, S. Z., Choi, Y. J., Kang, G., & Choi, S. U. (2024). Prenatal exposure to air pollutants and the risk of congenital heart disease: A Korean national health insurance database-based study. Scientific Reports, 14(1), 16940.
  17. Kalisch-Smith, J. I., Ved, N., & Sparrow, D. B. (2020). Environmental Risk Factors for Congenital Heart Disease. Cold Spring Harbor Perspectives in Biology, 12(3), a037234. https://doi.org/10.1101/cshperspect.a037234
  18. Katznelson, E., Navarro, M. J., Yuan, S., Kazi, D. S., & Singh, H. S. (2024). Climate Change and Congenital Heart Disease: A Narrative Review. Congenital Heart Disease, 19(6).
  19. Khalil, N., Chen, A., & Lee, M. (2014). Endocrine disruptive compounds and cardio-metabolic risk factors in children. Current Opinion in Pharmacology, Gastrointestinal • Endocrine and Metabolic Diseases, 19, 120–124. https://doi.org/10.1016/j.coph.2014.09.015
  20. Khalil, N., Ebert, J. R., Wang, L., Belcher, S., Lee, M., Czerwinski, S. A., & Kannan, K. (2014). Bisphenol A and cardiometabolic risk factors in obese children. Science of The Total Environment, 470–471, 726–732. https://doi.org/10.1016/j.scitotenv.2013.09.088
  21. Kim, B., Park, B., Kim, C. H., Kim, S., & Park, B. (2022). Association between endocrine-disrupting chemical mixture and metabolic indices among children, adolescents, and adults: A population-based study in Korea. Environmental Pollution, 315, 120399. https://doi.org/10.1016/j.envpol.2022.120399
  22. Kuo, N.-C., Lin, C.-H., & Lin, M.-C. (2022). Prenatal and early life exposure to air pollution and the incidence of Kawasaki disease. Scientific Reports, 12(1), 3415. https://doi.org/10.1038/s41598-022-07081-y
  23. Kwon, D., Choe, Y. J., Kim, S., Chun, B. C., & Choe, S. (2022). Ambient air pollution and Kawasaki disease in Korean children: A study of the national health insurance claim data. Journal of the American Heart Association, 11(9), e024092.
  24. Lava, S. A. G. (2023). Cardiovascular Disease in Children: The Future Is Now. Children, 10(5), 886. https://doi.org/10.3390/children10050886
  25. Li, C., Lei, S., Liu, L., Yuan, Y., & Tian, J. (2025). The burden of cardiovascular disease in children in Asian countries (1990–2021): Systematic analysis and projection of the burden of disease. American Journal of Preventive Cardiology, 21, 100956. https://doi.org/10.1016/j.ajpc.2025.100956
  26. Liang, Y., Zhang, M., Jin, W., Zhao, L., & Wu, Y. (2024). Association of heavy metals exposure with lower blood pressure in the population aged 8–17 years: A cross-sectional study based on NHANES. Frontiers in Public Health, 12. https://doi.org/10.3389/fpubh.2024.1411123
  27. McCrindle, B. W., Rowley, A. H., Newburger, J. W., Burns, J. C., Bolger, A. F., Gewitz, M., Baker, A. L., Jackson, M. A., Takahashi, M., & Shah, P. B. (2017). Diagnosis, treatment, and long-term management of Kawasaki disease: A scientific statement for health professionals from the American Heart Association. Circulation, 135(17), e927–e999.
  28. Pennington, A. F., Smith, M. R., Chuke, S. O., Cornwell, C. R., Allwood, P. B., & Courtney, J. G. (2024). Effects of blood lead levels <10 µg/dL in school-age children and adolescents: A scoping review. Pediatrics, 154(Suppl 2), e2024067808F. https://doi.org/10.1542/peds.2024-067808F
  29. Qiu, H., He, Y., Rong, X., Ren, Y., Pan, L., Chu, M., Wu, R., & Shi, H. (2018). Delayed intravenous immunoglobulin treatment increased the risk of coronary artery lesions in children with Kawasaki disease at different status. Postgraduate Medicine, 130(4), 442–447. https://doi.org/10.1080/00325481.2018.1468712
  30. Rowley, A. H. (2011). Kawasaki disease: Novel insights into etiology and genetic susceptibility. Annual Review of Medicine, 62, 69–77. https://doi.org/10.1146/annurev-med-042409-151944
  31. Rowley, A. H. (2018). Is Kawasaki disease an infectious disorder? International Journal of Rheumatic Diseases, 21(1), 20–25. https://doi.org/10.1111/1756-185X.13213
  32. Sanders, A. P., Svensson, K., Gennings, C., Burris, H. H., Oken, E., Amarasiriwardena, C., Basnet, P., Pizano-Zarate, M. L., Schnaas, L., Tamayo-Ortiz, M., Baccarelli, A. A., Satlin, L. M., Wright, R. O., & Tellez-Rojo, M. M. (2018). Prenatal lead exposure modifies the effect of shorter gestation on increased blood pressure in children. Environment International, 120, 464–471. https://doi.org/10.1016/j.envint.2018.08.038
  33. Shetty, N. P., & Shetty, P. S. (2009). Epidemiology of Disease in the Tropics. Manson’s Tropical Diseases, 19–34. https://doi.org/10.1016/B978-1-4160-4470-3.50007-0
  34. Sittiwangkul, R., Pongprot, Y., Silvilairat, S., & Phornphutkul, C. (2011). Delayed diagnosis of Kawasaki disease: Risk factors and outcome of treatment. Annals of Tropical Paediatrics, 31(2), 109–114. https://doi.org/10.1179/1465328111Y.0000000005
  35. Warembourg, C., Maitre, L., Tamayo-Uria, I., Fossati, S., Roumeliotaki, T., Aasvang, G. M., Andrusaityte, S., Casas, M., Cequier, E., Chatzi, L., Dedele, A., Gonzalez, J.-R., Gražulevičienė, R., Haug, L. S., Hernandez-Ferrer, C., Heude, B., Karachaliou, M., Krog, N. H., McEachan, R., … Basagaña, X. (2019). Early-life environmental exposures and blood pressure in children: An exposome approach. Journal of the American College of Cardiology, 74(10), 1317–1328. https://doi.org/10.1016/j.jacc.2019.06.069
  36. Zachariah, J. P., Jone, P.-N., Agbaje, A. O., Ryan, H. H., Trasande, L., Perng, W., Farzan, S. F., & on behalf of the American Heart Association Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Lifestyle and Cardiometabolic Health; and Council on Clinical Cardiology. (2024). Environmental Exposures and Pediatric Cardiology: A Scientific Statement From the American Heart Association. Circulation, 149(20), e1165–e1175. https://doi.org/10.1161/CIR.0000000000001234
  37. Zachariah, J. P., Wang, Y., Penny, D. J., & Baranowski, T. (2018). Relation Between Lead Exposure and Trends in Blood Pressure in Children. The American Journal of Cardiology, 122(11), 1890–1895. https://doi.org/10.1016/j.amjcard.2018.08.033
  38. Zhang, A., Hu, H., Sánchez, B. N., Ettinger, A. S., Park, S. K., Cantonwine, D., Schnaas, L., Wright, R. O., Lamadrid-Figueroa, H., & Tellez-Rojo, M. M. (2011). Association between prenatal lead exposure and blood pressure in children. Environmental Health Perspectives, 120(3), 445.
  39. Zhang, M., Liu, T., Wang, G., Buckley, J. P., Guallar, E., Hong, X., Wang, M.-C., Wills-Karp, M., Wang, X., & Mueller, N. T. (2021). In Utero Exposure to Heavy Metals and Trace Elements and Childhood Blood Pressure in a U.S. Urban, Low-Income, Minority Birth Cohort. Environmental Health Perspectives, 129(6), 067005. https://doi.org/10.1289/EHP8325

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ISSN: 2339-093X (Online) | 2085-1545 (Print)
DOI : 10.30659/sainsmed

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