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ECHO Project Uncovers How the Environment Shapes Kids’ Health

Danny Nelson and Sophia Friesen

Determining causes in children's health is never straightforward. While trends like the concerning surges in childhood obesity and asthma cases across the nation call for investigation, children’s unique physiology and the wide array of environmental factors that can affect them make investigating such issues complex. To find answers to these tough problems, researchers first need large amounts of data. 

Developing a data set that can analyze the connections between a child’s unique experiences and their health has taken multiple local and national studies spanning the course of decades, culminating in the Environmental influences on Child Health Outcomes (ECHO) study. The study, led by University of Utah researchers, has resulted in more than a hundred published papers since its inception in 2016. 

Now, powered by a $14 million National Institutes of Health grant renewal that began in August 2023, ECHO continues to enable vital research on how social and environmental factors shape children’s health. The ECHO project’s steadfast provision of essential data, despite many hurdles over the years, is a testament to the tenacity and rigor of University of Utah researchers.

ECHO's Ancestors

Three people with light skin wearing suits and smiling at the camera
Left to right: the late Ed Clark, MD, former chair of pediatrics, Christy Porucznik, PhD, and Joseph Stanford, MD, at a reception for the Utah Children's Project in 2019. Image credit: Charlie Ehlert.

The story of ECHO began in 2000, amidst mounting evidence suggesting that toxins and other environmental influences had long-lasting impacts on children’s health. The federal Children’s Health Act called for a nationwide study of the impact of physical, chemical, biological, and psychosocial influences on pregnancy and child development. That study, the National Children’s Study (NCS), set out to follow 100,000 children from conception to age 21, carefully mapping their exposures and health outcomes using questionnaires, assessments, biological samples, and physical examinations.

Researchers at the U and throughout Salt Lake Valley came together to run one of the first pilot sites of the study. Collaborating to identify and enroll participants was critical, says Christy Porucznik, PhD, epidemiologist at U of U Health and one of the lead researchers on the ECHO project. “When we work together, we can get enough numbers to find statistical significance with relationships between exposures and outcomes that there’s no way we could have done on our own,” Porucznik says. “By working together, we have a greater variety of participants and more diversity than any one site could have on its own.”

While the national study ended in 2014 due to budget and enrollment issues, the Utah-based NCS team continued their work, taking up the name of the Utah Children’s Project under the leadership of principal investigator and family and preventive medicine professor Joseph Stanford, MD. Operating under a reduced scope and a shoestring budget, the Utah Children’s Project continued to gather data and biospecimens from participants already enrolled in the NCS, and ultimately maintained the core NCS goal of tracking children’s health from gestation to age 21. It was the only NCS pilot site to do so.

Beginning in 2011, the tracking done by the Utah Children’s Project was joined by the efforts of the Home Observation of Periconceptual Exposures (HOPE) study, led by Porucznik. Over the course of the study, over three hundred heterosexual couples reported on exposures and had biospecimens collected during fertilization, implantation, and early pregnancy, providing an even wider repository of data for exposure research in Utah.

Undergirding these studies was the understanding that pediatric health requires a large data set to make meaningful conclusions. “A lot of things that we’re interested in, in relation to environmental exposures and children’s health, are thankfully rare outcomes in children,” says Porucznik. But the rarity of negative health outcomes can make it harder to spot the unique risk factors that children experience—such as more severe health impacts of heavy airborne particles, because children are closer to the ground. 

Home Field Advantage

Porucznik and Stanford’s efforts to gather data on Utah’s couples and children underscored pediatric researchers’ continued need for reliable data on the long-term impacts of environmental exposures on fertility and development.

Enter the ECHO project, which began in 2016 and which Porucznik describes as “the grandchild of the National Children’s Study”: built on the same lines as the NCS, but leaner and more focused, with greater oversight and accountability measures built into the study’s design. Researchers focused specifically on five key outcomes of neonatal and children’s health: respiratory, neurodevelopment, obesity, birth outcomes, and the overall ability to engage in life. 

Springboarding off of the Utah site of the NCS program, ECHO’s success hinged upon high levels of community engagement across the state.

“Utah has a great reputation of being a really good site where the community is interested in signing up for these studies,” says Angelo Giardino, MD, PhD, chair of pediatrics at U of U Health and one of the ECHO project leads. “We have the reputation of having one of the highest success rates in enrollment efforts. The families in Utah stay engaged. That’s a really good thing, scientifically.”

The Utah ECHO cohort began at once to recruit families into the program, folding many of those who had previously been part of HOPE and the Utah Children’s Project into the national study, collecting biospecimens, and submitting information to the national database.

All seemed to be going well with the program when the Utah ECHO team encountered another existential threat to their study with the outbreak of COVID.

Man with light skin smiles at the camera. He's wearing a suit and a red tie.
Angelo Giardino, MD, PhD, chair of pediatrics and an ECHO project lead. Image credit: Charlie Ehlert.

COVID: Challenges and Opportunities

“Our focus before had always been to bring people in for a clinic visit to do the assessments,” Stanford says. When the COVID pandemic shut down much of the world in 2020, clinic visits ground to a halt. “There were about two years where we could not do in-person visits.” But the researchers didn’t slow down.

“There was a lot of ingenuity and creativity,” says Giardino. “It turns out there was still a lot of data we could collect remotely via telehealth, so we just got more creative—and, I think, more functional.”

“One thing we pioneered within the ECHO consortium was remote collection of biospecimens,” Porucnzik says. “You can send people an envelope and they can snip a little bit of hair—or if their child loses a tooth they can put it in the envelope and send it back to us. The remote collection of urine samples was a little bit more challenging because you don’t want to ship liquids through the mail. So, we sent kits to people and then sent our workers out by zip codes to collect the samples. It actually worked really well.”

And even during the pandemic, the unique pattern of participant retention continued. “Among all of the sites nationally, I think we did the best job of keeping our participants engaged,” Porucznik says. “We had very low attrition even during the pandemic.” 

Child wearing a face mask looks out the window of a bus
Despite the pandemic, the ECHO project has continued to collect valuable data.

ECHO Discoveries

If COVID streamlined the data collection arm of the ECHO project, it also provided another important scientific benefit. The lockdowns gave even greater insights into how neonatal and children’s health are affected by environmental exposures and conditions. 

“The pandemic ended up being kind of like a natural experiment,” Giardino says. “There were many months where kids stayed home for the most part. In the early part of the pandemic people weren’t driving as much and there wasn’t as much air pollution in the Salt Lake valley. For a couple of months, the surveillance of the environment had fewer pollutants—so for the next ten years, we can look at that period of time to see if that really did have any health-promoting effect we could measure.”

Data from the ECHO project has resulted in more than a hundred published papers covering a wide variety of disciplines. While the project itself centers on data collection, the goal has always been to use that data in service of increasing health in pregnancy and early life. “The focus is on solution-oriented results,” Stanford says. “A relatively recent finding was looking at whether antidepressants in pregnancy were associated with autism in children. Turns out they’re not—in our study, at least—which is good news for women with depression. And that’s just one example of many findings that have been published.”

For Giardino, the data gathered by ECHO gives Utah researchers exactly the kind of interdisciplinary science needed to improve pediatric health. The variety of biospecimens and measurements allows researchers in a wide variety of fields to identify trends and work together. “One of the things that is a hallmark of our program is that we have adopted the One U mentality,” he says. “Some of the most remarkable things that have happened in our cohort reflects that unique approach. We’re really proud that we have a lot of University of Utah faculty and teams who are participating which goes beyond the public health research. We found the opportunities for our university faculty to study child health and the environmental influence on it, and they saw the opportunity of having this huge network.”

Parents lying on a bed with their baby, smiling down.
Discoveries resulting from the ECHO project help support kids' health in early life.

Into the Future

The first phase of the ECHO project concluded in August 2023 after gathering data from over 100,000 participants and more than 50,000 children. A second phase of the project seeks to add information from another 50,000 participants by 2030. While many ECHO sites closed after the first phase, the University of Utah’s program is still going strong. 

In the months since the project’s renewal, its amassed data has continued to propel impactful pediatric health research, from studies on how the physical and social characteristics of kids’ neighborhoods impact asthma risk, to investigations into the relationship between maternal BMI, breastfeeding, and child BMI.

The researchers credit Utah’s reputation as a site where study participants take their commitments seriously as an enormous benefit in the program’s continuation, along with the investigators’ track record of research excellence. “The scientific rigor we were able to demonstrate during the setup of the (first) study and the follow-up Utah Children’s Study really positioned people like Dr. Stanford and Dr. Porucznik to be taken seriously,” Giardino says.  

Those involved in the ECHO project see the selection of the University of Utah as a site for continued funding as a testament to the importance of staying committed to a scientific ideal, despite challenges.

“If we had not weathered the storm and stayed committed, we would not have been in the running,” Giardino says. “There was this huge commitment made, and when the going got tough we didn’t stop. It demonstrates that persistence in scientific work is really important.”