Mumbai: On March 11, five-year-old Husaif Mulani returned home from his primary school in Andheri. He was coughing and his mother, 33-year-old Yasmin Mulani, gave her son a glass of water to soothe his throat. This wasn’t the first time he had returned from school doubled over with cough. Ever since physical classes began on February 21, the senior kindergarten student had been facing some difficulty breathing, but it would clear out by evening. On that day however, Husaif’s condition only worsened as dusk fell. At night, he began wheezing. He couldn’t sleep and soon, was unable to breathe properly. Mulani rushed her son to a paediatric nursing home. His oxygen saturation level was 80, instead of the normal 97-99%. Husaif, who is non-asthmatic, was put on non-invasive ventilation. He was admitted for a week.

“Husaif was extremely breathless and couldn’t talk or walk when he was brought to the hospital,” paediatric pulmonologist Dr Indu Khosla, who treated him at her Andheri clinic, said. Now stable, Husaif is on two kinds of inhalers — one to prevent another attack, which he takes twice a day, and another as an SOS medicine for relief in case he starts coughing, Khosla said.

“He was doing fine for the last two years and got the attack the moment he started going to school,” Mulani, a tuition teacher, said. Scared that the episode would recur, Mulani decided to home school Husaif till the rains begin in June [[confirm that’s why she wants to send him in June? - Yes]]. “He is doing well and continuing on the preventive inhaler,” Mulani said.

Khosla’s area of expertise is children’s lungs, and she has been practising at SRCC Hospital in South Mumbai’s Haji Ali as well as Bandra’s Lilavati Hospital for 32 years. She pointed out that ever since the lockdown-induced restrictions were removed, the number of children with respiratory illnesses she saw and treated increased. “In the pandemic, this became negligible and now, 15-20% of the children in my OPD having wheezing symptoms. Like Husaif, some children require ICU admissions too.”

Khosla attributes this to an uptick in air pollution following the opening up after lockdown.

From an annual average PM10 level of 120μg/m3 in 2015-16, Mumbai recorded a dip to 91μg/m3 in 2020-21. This is still higher than the safe limit of 60μg/m3 prescribed by the Centre’s National Ambient Air Quality Standards (NAAQS). For PM2.5, the concentration fell from about 80μg/m3 to 46μg/m3 in the same time period; the safe limit prescribed by NAAQS is 40μg/m3.

“We had stopped seeing respiratory infections, allergies, in children during the lockdown when road traffic was less and everything was shut. Even children with asthma and recurrent wheezing were doing well. Things are now back to square one as we are seeing a multi-fold rise in these cases. It only indicates how outdoor pollution is affecting our children,” Khosla said.

Children are more physiologically more susceptible to air pollution, Dr Niranjan Sit of National Allergy Ashtma Bronchitis Institute, Kolkata said, “Children are born with smaller lungs. Because their lungs are growing, they are more prone to getting respiratory infection and at higher risk of getting diseases like asthma.” He also added that one reason why children are more vulnerable to air pollution than adults is because they breathe faster. “They inhale more pollutants. Their lungs are young and immature too.”

Other city paediatricians report a similar rise in cases. Dr Amin Kaba, a paediatrician with the Sir JJ Group of Hospitals said that 80-90% of the cases coming to him currently are related to air pollutants. “During the pandemic, we saw zero cases. Suddenly there is an exponential jump and this was expected. We were living in a sterile environment. With things back to normal, children are suddenly exposed to air pollution. Construction work is happening across the city in full swing, there is vehicular traffic. Schools are open too.”

“When the Covid-19 pandemic began, many of the children stopped taking inhalers. But now, with everything opened up, we are seeing a rising number of children falling ill with very bad wheezing, pneumonias, and asthma attacks. The entire family gets unsettled when a child falls ill,” said Dr Mukesh Sanklecha, paediatrician at Bombay Hospital.

Impact on children

Medical experts said that air pollution does not only trigger respiratory illnesses among children, it can impact the brain, heart and other vital organs. A World Health Organization (WHO) report on air pollution and child health October 2018 said air pollution affects neurodevelopment, leading to lower cognitive test outcomes, negatively affecting mental and motor development and can also trigger childhood cancer. In 2016, over 600,000 children died from acute lower respiratory infections caused by polluted air around the world, the leading world health body estimated.

An article on the American Lung Association’s website mentions two studies that showed that children can be exposed to the harmful effects of air pollution while they are in the womb. One study conducted in California on 196,970 singleton pregnancies affected by pre-term births found that higher PM 2.5 pollution levels increased the risk of preterm birth. A study among 5,059 mother-infant pairs in Boston found pregnant women exposed to even low levels of particle pollution had higher risk for preterm birth.

Air pollution also has an impact on neurodevelopment and cognitive ability. Children who have been exposed to high levels of air pollution may be at greater risk for chronic diseases such as cardiovascular disease later in life. In fact, in December 2020, a court in the United Kingdom found that air pollution “made a material contribution” to a 9-year-old’s death. The court said the child’s mother was not informed of the health risks of air pollution and had she known, she could have taken steps to prevent the death of her daughter. The child was the first person in the UK for whom air pollution was listed as a cause of death in the death certificate.

First steps

Taking serious cognisance of the impact of air pollution on allergic rhinitis (inflammation of the inside of the nose) and asthma in children, last year, the Indian Academy of Paediatrics (IAP) comprising a group of paediatric pulmonologists and allergy specialists from across the country released a consensus statement on Allergy and Air pollution.

According to the IAP, poor air quality is directly correlated with respiratory allergies in children. In fact, it is the emerging contributor to respiratory allergies among children due to various mechanisms including oxidative stress (physiological stress on the body caused by free radicals) and compromised defence mechanisms against inhaled microbes and irritants.

The statement underlined the need for a multipronged strategy at various levels of healthcare infrastructure to prevent the effects of air pollution on children. This includes efforts in the field of research and publication to disseminate knowledge among healthcare professionals, colleagues, students and the community on air pollution and its effects.

Dr Bakul Parekh, a former president of the IAP and who was part of the expert committee of the IAP which formulated a consensus statement on allergy and air pollution, said that children are more vulnerable to both outdoor and indoor pollution due to their unique physiological characteristics.

“We found that a multipronged approach, targeted at community, physician and individual levels, needs to be emphasised to improve air quality and reduce economic and psychological burden of respiratory allergies. Knowledge about pollutant particle size and air quality index will help in demarcating level and extent of airway involvement,” he said.

As a paediatrician for more than four decades, Parekh said he has seen a shift in disease among children from common cough and cold to respiratory problems.

“When I began my career as a paediatrician, the common disease patterns in children were gastroenteritis-inflammation of the stomach leading to loose motion and common cough and cold. But in the last 10 years, more and more children are coming with respiratory ailments like asthma, allergic rhinitis, bronchitis and that is because of air pollution,” he said.

Seeing the rising cases, the IAP came out with the guidelines that are circulated to physicians, paediatricians and parents.

There are a few ways to help the child as air pollution threatens their lungs. To start with, building lung capacity. “Yoga and relaxation therapy have been found to increase the peak expiratory flow rate in children as well as improve the lung function and quality of life in adults. Regular aerobic activity has the potential to improve lung capacity and reduce bronchial hyper responsiveness,” Parekh said.

“Good diet, good sleep, avoiding junk food and cold stud, good hygiene can help,” he added.

IAP’s consensus statement said wearing masks should continue in children above two years who get affected with air pollution. “Although, N95 mask is most effective for filtering particulate matter 2.5 particles, a reusable 3-layer cotton cloth mask can suffice for many children. Parents should follow the air quality index. Children should be kept indoors when AQI is poor and pollen count is high,” said Dr Parmarth Chandane, paediatrician and co-author of the statement.

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