Wildfire Smoke and Pediatric Lung Health: What the Clinician Needs to Know

ABSTRACT

Introduction

Wildfires are increasing over time due to climate change, resulting in increased human exposure to harmful particulate matter and other toxicants in wildfire smoke (WFS).

Methods

A narrative review of literature indexed in PubMed was performed, focusing on studies of the respiratory health effects of wildfire smoke in children, clinical and public health management strategies, and advocacy opportunities for clinicians.

Results

Children are particularly susceptible to the harmful effects of WFS, which include exacerbation of asthma and other underlying pulmonary disease, as well as lower respiratory tract infection, sinonasal allergies, and decrements in lung function. As trusted healthcare professionals, pediatric pulmonary providers have a unique opportunity to help children with chronic respiratory disease and their families protect against WFS exposure.

Conclusions

This paper provides a primer on the epidemiology and pathophysiology of WFS as it relates to respiratory health, gives the reader tools to help children and families prevent and manage exposure, and describes opportunities for advocacy to both protect child health and address climate change.

1. Introduction

Over recent decades, there has been increased forest fire activity in a number of regions across the globe, including in the western continental United States (U.S.) [1]. A number of factors have contributed to this increase in wildfires and wildfire smoke (WFS), including natural climate variability, fire suppression strategies, and human‐caused climate change [1, 2]. The so‐called “fire triangle” of fuel, oxygen, and an ignition source is required for wildfires to start [3].

Importantly and concerningly, the effects of climate change can increase the likelihood that each component of the “fire triangle” is present. For example, summers are becoming hotter and drier, increasing the amount of flammable vegetation that can fuel wildfires [4, 5], and changes in global surface wind speeds (increasing over the last decade) can provide more oxygen to wildfires and aid in their rapid spread [6, 7, 8]. Other climate change‐related factors include earlier and longer wildfire seasons (thus reducing the window for prescribed or deliberate burning) and increasing frequency and intensity of heat waves, providing more ignition sources (including lightning) for wildfires [2].

Longer wildfire seasons are now exposing more and more people to smoke from fires of forests and bushlands [9], so much so that some regions have designated the period when wildfires are common as a “fifth season” [10]. The experience of recent years has made it clear that one does not need to live in a wildfire‐prone area to be exposed, because smoke can travel hundreds or even thousands of miles [11].

Children are among those most vulnerable to the negative health effects of WFS, which can both cause and exacerbate a variety of respiratory and non‐respiratory concerns. As providers responsible for the preventive care and treatment of children with respiratory diseases, pediatric pulmonologists play a pivotal role in addressing environmental exposures such as WFS. This review aims to give a primer on the epidemiology and pathophysiology of WFS as it relates to respiratory health, give the reader tools to help children and families prevent and manage exposure, and describe opportunities for advocacy to both protect child health and address climate change, the driving force behind worsening risk from fires [12, 13].

2. Epidemiology

WFS represents a mixture of noxious particulates and gases which is variable and dependent on the composition of the material burned [14]. As wildfires can involve a variety of landscapes (comprising both vegetation and man‐made materials), composition can vary widely from one fire to the next. Components can include particulate matter of various sizes including particulate matter smaller than 10 microns (PM₁₀), 2.5 microns (PM_2.5), and ultrafine particles; nitrogen dioxide, methane, carbon monoxide, volatile organic compounds (VOCs), ozone, trace metals, water vapor, and potentially thousands of other chemicals [15]. Most investigations into health effects of WFS have used PM_2.5 as a proxy measure for exposure, although it is notable that PM_2.5 from WFS is associated with health risks multiple times higher than risks of PM_2.5 from other ambient air pollution sources (e.g., traffic‐related air pollution) [16, 17].

As mentioned above, the incidence of wildfires globally has climbed dramatically in recent years. Over the last two decades, exposure to landscape fire‐sourced air pollution (e.g., wildfires) has increased the most in Central Africa, Southeast Asia, South America and Siberia [9]. The area burned within the U.S. has quadrupled between 1985 and 2020 [18]. A recent review looking at the economic impact of wildfires on Southern Europe found that an average wildfire season leads to a yearly production loss of 13‐21 billion euros for Southern Europe alone [19]. In addition, analysis of regulatory monitor data and satellite smoke plume data showed that prior gains in U.S. air quality made by the Clean Air Act have been reduced by 25% from 2016 to 2022, and by greater than half in some Western states [20].

It is important to note that WFS exposure can result from geographically remote fires due to long range transport of smoke. For example, smoke from the severe Canadian wildfires of 2023 significantly impacted the U.S Northeast and Midwest and reached as far as Europe and Asia [11], and smoke from the Australian bushfires in 2020 reached across the Pacific Ocean to Argentina and Chile [21].

Approximately 7.4 million children (including an estimated 700,000 with asthma) were exposed to WFS in the U.S. yearly between 2008 and 2012 [22], and current levels of exposure are likely much higher due to increasing fires. Modeling based on climate‐change scenarios predicts that exposure will continue to increase significantly decade over decade, particularly in the Northwest, Southeast, North‐central and Northeastern U.S [12, 23]. By the end of the 21st century, WFS is predicted to account for more than half of the ambient PM_2.5 in the U.S [23], and carbon emissions from wildfires will increase by 23% globally, with the greatest relative increases predicted in middle‐ to high‐latitude regions [24].

Although WFS originates outdoors, it may infiltrate into buildings with a “leaky” building envelope (i.e., leaky windows, doors, etc.), making indoor environments another important setting of WFS exposure. Indoor WFS concentrations depend on the interplay of infiltration, ventilation, and indoor air filtration, and may approach outdoor concentrations when those factors are unfavorable [25]. Indoor concentrations of WFS PM_2.5 have been found to range from 30% to 82% of those outdoors, and vary significantly depending on building characteristics and occupant behavior [26, 27, 28].

Importantly, the epidemiology of exposure to WFS, both indoors and outdoors, is influenced by social determinants of health, with historically marginalized populations at higher risk of exposure. We discuss these issues further under the “Wildfire Smoke and Health Disparities” section below.

3. Pathophysiology

Children are especially sensitive to environmental insults compared to adults due to increased biologic susceptibility and other factors. Children have higher respiratory rates and tidal volumes relative to body weight, resulting in potential inhalation of larger volumes of noxious particles relative to their body size [29, 30]. They spend much more of their time outdoors, increasing exposure duration [29]. Early life exposure may be associated with increased risk of incident disease [30] and reduced lung volume in adolescence [31], while acute exposure to WFS has been associated with increases in respiratory‐related emergency department visits [32] and hospitalizations [16]. The recent trends of increased WFS exposure over time imply that children born recently will have a greater lifetime exposure to WFS compared to previous generations.

WFS enters the respiratory tract through the mouth and nose. Large particles (e.g., PM₁₀) are captured in the upper respiratory tract while smaller particles (PM_2.5 and ultrafine particles) and gases end up in the lower respiratory tract where they may cross into the bloodstream via the alveolar capillaries and be transported to various organ systems; some toxins may ultimately cross the blood‐brain barrier [33].

A variety of mechanisms have been proposed to explain the respiratory effects of WFS, including increased oxidative stress, alteration of immune responses and increased inflammation, and alteration of respiratory epithelial barrier function [34]. There may also be alterations in immune responses to viral and bacterial infection, as evidenced by coincident increased risk of COVID‐19 [34] and increased incidence of lower respiratory tract infection in children [35, 36] after WFS events.

4. Health Impacts in Respiratory Disease

Most studies examining health effects of WFS in children are observational population‐based studies, primarily using health outcomes data from insurance or pharmacy benefits claims or diagnostic codes from health system encounters [37]. The vast majority examine the acute respiratory effects of short‐term WFS exposure, particularly as it relates to asthma; studies looking at other respiratory conditions or non‐respiratory concerns are less common [38, 39]. Where data specific to WFS exposure is not available, some parallels can be drawn from studies investigating exposures to other air pollution sources.

4.1. Asthma

Strong evidence has accumulated linking air pollution (primarily PM_2.5) from wildfires with short‐term increases in a variety of measures of asthma morbidity in children, including asthma symptoms, inhaler prescriptions or usage (including both relievers and oral steroids), unplanned healthcare visits, emergency department encounters, and hospitalizations [37, 38, 39].

The scant evidence available regarding lung function points toward short‐term negative effects in children both with and without asthma. Two separate studies analyzed associations between spirometry data and WFS exposure in children with asthma attending ambulatory clinic visits [40, 41]. One of these studies found associations between reduced forced expiratory volume in 1 s (FEV1) following exposure to wildfire PM_2.5 in people ages 12‐21 years, but not in those aged 4‐11. This decrement was noted at 1 day following exposure, but FEV1 subsequently increased on day 2, which the authors hypothesize is due to use of reliever medications [40]. Another study noted a 5 percentage point drop on average in forced vital capacity (FVC) on bushfire smoke‐affected days compared to non‐affected days, but did not find a reduction in FEV1; this finding was attenuated during bronchodilator responsiveness testing, supporting a hypothesis of pseudorestriction due to hyperinflation [41].

The potential link between WFS exposure and later development of new asthma is an area of active study. Studies in wildland firefighters have shown an increased incidence of new diagnosis of asthma and decreased FEV1 and FVC compared to controls [42, 43]. Interestingly, healthy infant rhesus monkeys incidentally exposed to WFS from local fires were later found to have impaired lung function in adolescence (reduced inspiratory capacity, residual volume, vital capacity, and functional residual capacity), but no evidence of airway hyperreactivity on methacholine challenge [31]. Whether WFS exposure in children confers increased risk of new‐onset asthma or other pulmonary disease remains to be elucidated.

4.2. Cystic Fibrosis

For people with cystic fibrosis (CF), an autosomal recessive, life‐limiting condition characterized by chronic endobronchial bacterial infection and obstructive lung disease [44], limited data exists linking WFS to clinical outcomes. Only one study has sought to examine the effects of air pollution from WFS on CF‐clinical outcomes [45]. This observational study of more than 500 people with CF looked at PM_2.5 exposure generated during WFS season in the Northwestern U.S. Among adults with CF, exposure to wildfire smoke was associated with a 50% higher odds of pulmonary exacerbation, but there was no increased risk of pulmonary exacerbation for children with CF in this study.

Observational studies evaluating the effects of non‐wildfire sources of air pollution (e.g., PM₁₀, PM_2.5, NO₂ and ozone) have found that both short‐ and long‐term air pollution exposure is associated with an increased risk of pulmonary exacerbation [46, 47] and a decline in lung function [46, 48, 49, 50]. In addition, studies using the CF Foundation Patient Registry have found that an increase in PM_2.5 exposure of 10 μg/m3 is associated with a 68% increased risk of methicillin resistant Staphylococcus aureus [51] and, in children, a 24% increased risk of Pseudomonas aeruginosa acquisition [52]. More studies are needed to determine if WFS in particular is associated with worse clinical outcomes compared to non‐wildfire sources of air pollution, and whether highly effective CFTR modulators might blunt its effects in people with CF.

4.3. Bronchopulmonary Dysplasia

Few studies have examined the effect of WFS in children with BPD. We identified one survey study of former extremely preterm or extremely low birth weight infants exposed to wildfires at 17‐19 years of age, which showed they were more likely to have respiratory symptoms, health service usage, and respiratory medication use than matched non‐exposed controls [53]. Some literature exists pointing to an association between exposure to both indoor and outdoor air pollution and morbidity from BPD [54, 55, 56, 57], suggesting that WFS is likely to follow a similar pattern, but more study is needed.

4.4. Respiratory Infection

WFS exposure may increase the risk of both upper and lower respiratory tract infection. One study found increased numbers of individuals presenting to the ED with upper airway complaints, croup, and dysphonia during WFS‐impacted periods versus matched non‐WFS affected control periods [58]. A large case‐crossover study utilizing Demographic and Health Surveys in 48 low‐ and middle‐income countries found that WFS‐sourced PM_2.5 exposure was associated with increased likelihood of acute respiratory infection, as defined by cough plus short rapid breaths at any point in the prior 2 weeks [35]. A time series analysis from Chile showed an increased risk of ED visits for bronchitis in children less than 1 year of age, and for pneumonia in children from birth to 4 years [36].

4.5. Other Notable Health Impacts

In addition to the above, WFS exposure can cause a variety of minor health complaints, even in those with no known underlying disease (including cough, nasal congestion, sore throat, eye irritation, and dermatitis) [37, 38, 39]. Increased incidence of sinonasal symptoms, itchy/watery eyes, and sneezing or runny nose has been reported [34], indicating possible association with allergic rhinitis. Wildfires have also been linked to increased risk of anxiety, depression, post‐traumatic distress, insomnia and sleep disturbances in both adults and children [2, 37]; however, the effects of smoke exposure are difficult to disentangle from the stress of fire danger and evacuation. For those not in immediate danger from fire, child mental health may be impacted by cancellation of social and recreational events, and reduced opportunities for outdoor physical activity.

Pregnant individuals with prenatal WFS exposure are more likely to give birth prematurely and to have a child with low birth weight [59, 60]. The relationship between this finding and incidence of bronchopulmonary dysplasia or other respiratory disease in infancy has not been explored. In adults, WFS has been shown to result in increased morbidity from cardiovascular disease [61], kidney disease [62], and diabetes [2, 62]; implications of these findings for children are unclear.

To identify research gaps and opportunities for future research, the American Thoracic Society convened a group of experts who published a 2021 workshop report titled “Respiratory Impacts of Wildland Fire Smoke: Future Challenges and Policy Opportunities” [63]. This workshop concluded that future studies are needed evaluating the effects of both short‐ and long‐term wildland smoke exposure on children, adults, and highly exposed occupational groups (e.g., firefighters). In addition, these experts identified other research priorities, including improved wildland fire data collection and modeling along with studying which particular health protective measures are most effective at minimizing the deleterious effects of wildland smoke exposure.

5. Wildfire Smoke and Health Disparities

The epidemiology of exposure to WFS, and the ability to act to prevent or respond to it, are likely mediated by social determinants of health. For example, populations with higher social vulnerability due to rates of pre‐existing chronic disease (diabetes, hypertension, adult and pediatric asthma, COPD), and indicators of socioeconomic status have been found to experience greater numbers of days of exposure to unhealthy levels of smoke from wildfires [22]. Additionally, many of the actions recommended to reduce risk of WFS exposure are less accessible to individuals with barriers related to cost, language, or literacy. Agricultural workers and unhoused individuals are exceedingly vulnerable to WFS due to increased exposure as well as decreased access to preventative actions [64, 65]. Many of the social determinants of health that are well known to influence disease control in asthma [66] can also influence likelihood of exposure to WFS, which may in turn further worsen outcomes (e.g., old “leaky” housing stock, lack of proper home ventilation/filtration, lack of access to air quality information) [67]. Interventions on both an individual and community level are needed to address barriers and increase ability to adapt to increasing threat of fires.

6. Management Approaches

6.1. Understanding Air Quality

The mainstay of reducing individual exposure to WFS is a collection of personal protective behaviors that can be implemented by children and/or their families [68, 69, 70] (summarized in Table 1). Because these protective actions must be taken when air quality is poor, they require an understanding of what air quality is and how to determine local conditions.

Table 1.

Recommended actions for caregivers to protect their child from wildfire smoke.

Recommended actions	Details
Monitoring air quality
Check the Air Quality Index (AQI) frequently	Air quality should be checked frequently using trusted sources, even when smoke is not visible.
Set up air quality alerts	Alerts can notify families of poor air quality when smoke occurs unexpectedly.
Reducing smoke exposure outdoors
Use the AQI to plan physical activity	Depending on AQI level, activity intensity should be reduced, moved indoors, or avoided.
Have children ages 7 and up wear an N95 mask	Children 7 and up are likely to fit an adult size small N95 mask. Cloth masks offer a small benefit.
Reducing smoke exposure in the car
Keep vehicle windows closed and set air conditioning unit to “recirculate”
Reducing smoke exposure at home
Close windows, doors, and chimney flues, and block other points of air entry	In homes without air conditioning, families should seek other ways to keep cool during heatwaves, such as covering windows, using fans, spraying cool mist, using ice packs, and staying hydrated.
Use a filtration device to clean indoor air	Examples include: HVAC system with MERV‐13 or higher filter Portable HEPA air cleaner Do‐it‐yourself box fan filter with MERV‐13 or higher filter
Ensure HVAC systems and window A/C units are set to “recirculate” mode to prevent intake of outdoor air	Window A/C units that can't be set to recirculate should be avoided, and other cooling methods should be used.
Set up and use a “clean room”	Useful when it is difficult to control air quality in the whole home.
Avoid creating additional sources of indoor air pollution	Avoid smoking, vaping, frying food, using candles, and burning incense.
Going elsewhere for clean air
Identify “clean air spaces” in the community	Clean air spaces include locations specifically designated for relief of poor air quality, as well as other public spaces like libraries, community centers, and indoor shopping malls.
Consider evacuation	Evacuation may be necessary if unable to control indoor air pollution, and when there is local threat of fire. Families should always follow mandates of local authorities.
Recommendations for children with respiratory disease
Update the child's care plan with their physician	Ideally this should occur before wildfire season starts.
Stock up on essential medications	Both maintenance and rescue medications are important, in case of difficulty traveling due to severe smoke or active fires and/or disease exacerbations.

Air quality in the U.S. is monitored by a network of ground‐level sensors maintained by the Environmental Protection Agency (EPA) and reported on the government‐maintained website www.airnow.gov (also reported are data from thousands of personal sensors owned by private individuals). Air quality is reported as the Air Quality Index (AQI), which uses a formula to account for pollution from the six criterion pollutants regulated by the Clean Air Act: particulate matter (including PM_2.5 and PM₁₀), ground‐level ozone, carbon monoxide, sulfur dioxide, nitrogen dioxide, and lead [71]. The AQI uses both number and color scales to correspond to levels of air pollution that confer increasing levels of risk to human health.

Air quality during wildfires can change rapidly throughout the day and from one day to the next. Poor air quality can be signaled by haze or odor in the air, but these sensory cues are not always reliable [72, 73]. Therefore, we recommend that families check the AQI frequently and proactively during WFS season (generally early summer to late fall, depending on the location). There are a multitude of websites and mobile device apps available, and our preference is to use https://fire.airnow.gov/ due to its reliance on regulatory EPA monitors and quality‐controlled data from Purple Air low‐cost sensors [74]. Other apps may use less transparent methods: for example, both Google Maps and the Apple iPhone Weather App use the same proprietary air quality model incorporating a variety of data sources to produce an air quality map with “hyper‐local” imputed AQI values [75]. Users should be aware that these differences may lead to variability in the AQI reported by these apps. In addition to checking the AQI frequently, we recommend setting up air quality alerts either through an app or via the EPA‐run www.enviroflash.info, which offers text or e‐mail alerts.

6.2. Reducing Personal Exposure to WFS

Once poor air quality is identified, individuals should proactively adjust their outdoor activity and take steps to keep their indoor air clean. Importantly, families must not wait until their child has symptoms, as this may be too late to prevent progression [76]. Activity recommendations are described by the AQI, which has recommended changes to intensity and location of physical activity for each level [77]. The recommended actions are more conservative for those who are considered “sensitive groups,” which includes all children, older adults, pregnant individuals, and those with chronic health conditions. N95 masks can also be helpful for reducing outdoor exposure to WFS; these can be safely and effectively worn by children ages 7 and up (who would likely fit an adult size small mask) [30]. Surgical‐style masks may provide a small benefit depending on fit, but cloth masks cannot be relied upon to be effective in reducing inhaled WFS [30].

Steps should also be taken to improve indoor air quality due to risk of infiltration of WFS into the home, including closing points of entry such as windows, doors, and chimney flues. However, this alone will not be sufficient during significant WFS events [27, 28], and some sort of filtration method should be employed. Examples include a central heating/ventilation/air conditioning (HVAC) system using MERV‐13 or higher filters, a portable air cleaner with HEPA‐rated filter, or a lower‐cost do‐it‐yourself (DIY) box fan filter [78]. Window air conditioning units should be used only if they can be set to recirculate air from indoors (not pull air from outside) and any window openings are tightly sealed; most window unit filters will not remove WFS pollutants, so use of an additional filtration device is recommended.

Portable HEPA air cleaners and DIY box fan filters are most efficient in smaller spaces, and should be placed where the child spends most of their time, and moved to the child's sleeping area at night. During extreme WFS events where it is difficult to control indoor air quality, families can set up a “clean air room” which can be closed off from the rest of the home, where the air cleaner is placed and the child can spend most of their time [79]. Families should also avoid creating any additional sources of indoor air pollution, such as smoking, frying food, or using candles or incense.

Families can also identify clean air spaces outside their home. Some fire‐prone communities have seasonally designated clean air spaces (which may also be designated cooling centers), and other public spaces such as libraries, community centers, malls, and recreational centers. While traveling in a vehicle, windows should stay closed, and the air conditioning unit should be placed on “recirculate.” When families are unable to control indoor air pollution, or when there is local threat of fire, evacuation may be the best option.

A variety of personal air quality monitors are available for purchase by those interested in monitoring their indoor or outdoor AQI. These monitors can provide local, real‐time data to aid decision‐making. Preliminary research shows that such information can be useful for triggering protective actions [80, 81, 82], but the expense can be prohibitive for low‐resourced families.

6.3. Role of the Pediatric Pulmonologist

Pediatric pulmonary providers hold a unique position as both longitudinal care providers for many children who are especially vulnerable to WFS and highly trusted sources of information on both health and climate change [83, 84].

Despite the existence of public health recommendations to address WFS exposure, a large proportion of pulmonary providers do not feel confident in their ability to address WFS exposure with their patients [85]. Pulmonary providers must educate themselves on the health impacts of WFS and protective actions in order to communicate these to children and their families. The U.S. EPA provides a web course to educate healthcare providers about WFS, which, while not specific to children, serves as an excellent starting point [86].

Providers can help families understand the risks of WFS exposure in the context of their child's pulmonary condition and provide insight on the relative safety of various outdoor activities during WFS season. They can provide guidance on signs and symptoms which may indicate a need to implement stricter precautions. Perhaps most importantly, they can recommend specific actions families can take to reduce their child's exposure risk. These recommendations should be made with consideration of potential barriers faced by low‐resourced families (such as financial constraints or language barriers). A variety of materials exist that can facilitate these conversations, including multiple handouts developed by the Pediatric Environmental Health Specialty Units [69], and the Wildfire Smoke Action Plan for Children with Asthma developed by our team [87]. The U.S. EPA also provides an excellent set of resources (not specific to children) including ways to keep indoor air clean [70].

Determination of environmental risk factors (both WFS‐related and in general) must be a part of the pulmonologist's routine assessment [88], and will require providers to be aware of conditions local to a child's home. When disease control or lung function decline, recent air quality must be considered. The timing of WFS season should also be considered when making decisions regarding stepping therapies up or down, particularly among children who have asthma or a history of symptoms with WFS exposure.

To date, there have been no published studies evaluating the efficacy of medications in mitigating the health risks of WFS exposure. One randomized controlled trial of non‐smoking adults with asthma evaluated preemptive use of budesonide‐formoterol 160 mcg‐4.5 mcg twice daily on days with severe non‐WFS air pollution in Beijing [89]. The intervention group experienced significantly fewer asthma exacerbations and unplanned outpatient visits (21% and 16%, respectively) compared to controls, despite the same total number of doses of ICS or ICS/LABA in both groups. This evidence suggests that prophylactic increases in ICS dosing during WFS season may be a promising strategy, but these findings require further study.

Finally, pediatric pulmonologists can facilitate communication about a child's susceptibility to WFS with the child's school and provide guidance on physical activity limitations. Such information could be included along with an asthma management plan. The EPA and some state health departments have issued guidelines for schools on how to manage outdoor physical activity during poor air quality [90, 91, 92], and this guidance can be a resource for providers in advocating for children.

7. Opportunities for Advocacy

Pediatric pulmonologists can use their trusted voices to advocate for changes to both protect populations vulnerable to WFS and slow the pace of climate change. As mentioned above, climate change plays a large role in the development and severity of wildfires globally; thus, along with providing families with education about WFS protective actions, physicians can and should identify climate change as a large contributor to increasing frequency of wildfires, and discuss climate solutions when feasible [93, 94]. Potential solutions include reducing personal carbon emissions by adopting a plant‐based diet, using public or active modes of transport, or increasing home energy efficiency [93, 95]. Physicians can also model these changes themselves to increase impact and credibility [93].

Physicians and trainees continue to regard WFS and climate change as topics with which they feel less comfortable [85, 96]. These topics should be included in curricula for medical students, trainees, and continuing medical education.

Physicians can also advocate for policy changes to reduce barriers to WFS protective actions for the children and families they care for, such as expansion of state Medicaid coverage to include air cleaners as durable medical equipment, funding of home weatherization services for low income families, expansion of availability of public clean air spaces, and improved oversight of school adherence to activity guidelines. Within local school districts, physicians can advocate for implementation of the EPA Air Quality Flag Program, which uses colored flags to notify staff and the community about poor air quality and when to reduce or avoid outdoor physical activity [97]. Within the healthcare system, physicians can call for measures to reduce hospital emissions [93] and can choose to prescribe dry powder inhalers over inhalers containing hydrofluoroalkanes (HFAs) when medically and developmentally appropriate [98].

Physicians should also speak out publicly about the health impacts of WFS and its connection to climate change through local news outlets, op‐eds, social media, or community speaking engagements. Physicians and scientists can also advocate to preserve funding for research on climate and health, which is currently under threat due to recent cancellation of hundreds of federal grants related to environmental justice, health effects of climate change, and health disparities [99]. The National Institutes of Health has also recently ended all new climate‐related funding opportunities [100]. Physicians must speak out about the dangers of halting work in these important areas.

U.S. policies regulating carbon emissions and major sources of air pollution are also under threat. The U.S. EPA has proposed the reversal of a long list of such regulations, including the Particulate Matter National Ambient Air Quality Standards which regulate PM_2.5, rules for measuring and reporting carbon emissions, and the 2009 Endangerment Finding, which ruled that greenhouse gases are detrimental to human health [101]. Such proposed rule changes often undergo a public comment period, during which physicians can attest to the harm resulting from such policy changes; comments may also be entered into evidence for use in future lawsuits challenging rule changes [102]. While not specific to WFS, improvements in air quality have clearly been shown to improve children's health [103], including positive effects on lung‐function growth in children [104], and thus it is imperative that we as a medical community continue to strongly advocate for healthy, breathable air for ourselves and future generations.

8. Conclusions

WFS exposure is expected to continue to increase over time, and children are especially susceptible to its negative health effects. While acute impacts on asthma have been well characterized, much additional work is needed to better understand health effects in children with other chronic respiratory conditions, as well as the role of WFS in the development of new onset disease. The roles of patterns of exposure (chronic vs. episodic) and critical periods of exposure have yet to be clarified.

Currently available strategies to reduce WFS exposure in children hinge on checking and understanding the local AQI, and taking action to reduce exposure. Potential mitigation strategies may not be familiar to either patients or physicians, and most could benefit from education on this topic. Additionally, many protective actions are expensive or difficult to access for marginalized groups.

Pediatric pulmonary providers are excellently positioned to advise families on how to protect from WFS, and should take advantage of all locally available resources to help families overcome financial and other barriers. Providers can also work toward mitigating climate change, a major underlying factor in the progression of wildfire activity, through both advocacy and reducing personal carbon emissions. If WFS is here to stay, pediatric pulmonologists can rise to meet the challenge.

Author Contributions

Mary E. Crocker conceptualized the manuscript and created an outline. Mary E. Crocker and Jonathan D Cogen performed an evidence review, created the original draft of the paper, reviewed and edited the paper, and approved the final version of the manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Crocker M. E., and Cogen J. D., “Wildfire Smoke and Pediatric Lung Health: What the Clinician Needs to Know,” Pediatric Pulmonology 61 (2026): e71484, 10.1002/ppul.71484.

Data Availability Statement

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.