Frank Gonzalez is an attending physician at Children’s Hospital Los Angeles and an assistant professor of clinical pediatrics at Keck School of Medicine of USC.

Frank Gonzalez, MD

Managing Climate Change-Induced Sickle Cell Pain Crises With Frank Gonzalez, MD

Clinicians should be aware of the influence of extreme weather events on pain episodes in high risk pediatric patients with 

, according to an analysis of 48,885 emergency department visits.

 reported an independent association between extreme cold temperatures and increased vasocclusive episodes, as well as a suggested protective effect of extreme heat on acute chest syndrome.

The retrospective case-crossover study of weather-related emergency department encounters involved low risk and high risk patients 0 to 21 years of age at 40 US children’s hospitals.

In high risk patients, Gonzalez and colleagues observed elevated rates of emergency department visits for vasoocclusive crisis with increased temperature, heat index, and wet bulb globe temperature. In turn, with acute chest syndrome, these same variables were associated with decreased rates of visits. There were no significant associations in the low risk group.

“That allows you the opportunity to say, ‘Maybe last week there was a heat wave in the Los Angeles area, and we had patients coming in,’” study investigator Frank Gonzalez, MD, an attending physician in the emergency department at Children’s Hospital Los Angeles, told 

. “You can then make sure patients understand: try to stay hydrated, limit outdoor stress or exertional activity, and essentially create an environmental anticipatory guidance plan, an environmental care plan, to try to limit morbidity.”

Sickle cell disease itself sensitizes patients to cold and heat exposure. Often, the cold triggers vasoconstriction, reducing blood velocity, and increasing the likelihood of sickle-shaped red blood cells forming microvascular occlusions. On the other hand, hot temperatures lead to dehydration, increasing blood viscosity, raising the concentration of hemoglobin and sickle cells. These occlusions lead to local tissue hypoxia and ischemic pain similar to cold-induced crises.

While these environmental factors allowed investigators to glean insight into proactive clinical management strategies, Gonzalez believes there’s potential for a forecast-informed preventative model to prevent these complications from occurring beforehand, using the example of the Asthma Action Plan.

With the reality of climate change and the rising rates of extreme weather, there are other areas of environmentally related factors and sickle cell disease management left to be explored.

“Moving forward, one important area is wildfire-specific fine particulate matter or air pollution, related to wildfires and air pollution in general,” said Gonzalez. “Another important next step involves looking at multiple levels of risk factors, including patient-level or individual factors that could add to a patient’s vulnerability to environmental stressors.”

Gonzalez F, Hall M, Habre R, et al. Weather-Related Exposures and Emergency Department Visits for Pediatric Sickle Cell Complications. 

. Published online 2026:10.1097/PEC.0000000000003561. doi:

https://doi.org/10.1097/PEC.0000000000003561

Brandow AM, Stucky CL, Hillery CA, Hoffmann RG, Panepinto JA. Patients with sickle cell disease have increased sensitivity to cold and heat. 

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Gonzalez explains how new findings in weather-related emergency department visits and pain in pediatric sickle cell disease can guide clinicians. 


Extreme Cold Independently Associated with Pain Episodes in Pediatric Sickle Cell Disease

With rates of extreme weather events rising due to climate change, clinicians may need to take additional measures to prevent pain episodes in pediatric patients with 

, as a new study suggests severe cold temperatures are independently associated with increased risk.

The findings highlight the association between extreme weather, both hot and cold, and vaso-occlusive crises (VOC), while also suggesting a potential protective effect of higher temperatures on acute chest syndrome (ACS).

“We've known for a while that there does seem to be some sensitivity to weather changes, but a lot of the studies have been done in adult, single-center populations,” study investigator Frank Gonzalez, MD, an attending physician in the emergency department at Children’s Hospital Los Angeles, said in an interview with 

 “How do these weather-related factors affect the odds of someone coming in with health complications?”

In pediatric patients with SCD, VOC is the leading cause of emergency department visits, with 96% experiencing an episode by age 8, and as many as 60% having ≥ 1 attack per year. In total, the average stay for hospitalization with VOC is 8 days, significantly impacting pediatric patients’ quality of life. These crises can occur suddenly or be triggered by extreme cold, hard work, heat and sun, psychological factors, and deficiency of ingested fluids, according to previous research.

To address the association between weather-related exposures and odds of emergency department visits for acute complications in youth with sickle cell disease, Gonzales and investigators conducted a retrospective case crossover study.

They examined emergency department encounters at 40 US children’s hospitals from 2015 to 2020. They categorized patients as low risk or high risk based on the number of emergency department visits in the preceding year, with high-risk patients defined a priori as > 3 visits.

Investigators constructed a single-variable conditional logistic regression model to identify the odds of emergency department visit in association with weather-related exposures of temperature, heat index, and wet bulb globe temperature.

The study included a total of 48,885 emergency department visits for VOC and/or ACS in patients between 0 to 21 years of age.

Upon analysis of increased temperature, heat index, and wet bulb globe temperature among high-risk pediatric patients, investigators observed an associated increased odds of emergency department visits for VOC. In contrast, investigators observed a decreased risk for emergency department visit rates in ACS, with increased markers of heat stress or temperature exhibiting a protective effect.

Notably, there were no significant associations found for low-risk patients.

“This suggests that colder temperatures are actually a risk factor for developing acute chest syndrome, which is a very important finding,” said Gonzales. “Previous studies have thought that it's the more infectious risk factors during the colder months that are leading to the development of acute chest but we're thinking that just cold weather on its own is an independent risk factor.”

As for Gonzalez’s advice to clinicians managing this pediatric population, he recommends finding ways to prevent pain episodes by advising their patients to adapt incrementally to the extreme weather. For example, during hotter periods, patients should decrease outdoor exertional time, prioritize air conditioning, and ensure they are staying hydrated. During the colder months, clinicians should encourage patients to limit quick changes into cold temperatures by staying bundled up and staying inside during weather advisories.

Future areas of research will continue to evaluate the association between pain episodes in pediatric patients with sickle cell disease and wildfires, particularly in the Los Angeles area.

Editor’s Note: Gonzalez reports no relevant disclosures. 

Jacob SA, Mueller EL, Cochrane AR, Carroll AE, Bennett WE. Variation in hospital admission of sickle cell patients from the emergency department using the Pediatric Health Information System. 

Abdo S, Nuseir KQ, Altarifi AA, Barqawi M, Ayoub NM, Mukkatash TL. Management of Sickle Cell Disease Pain among Adolescent and Pediatric Patients. 

A retrospective study found an independent association between increased pain episodes in sickle cell disease and the cold in light of increasingly extreme weather.


Frank Gonzalez, MD

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