by Stuart L. Abramson, M.D., Ph.D., AE-C, FAAP
Two mothers who don’t know each other complain about their kids getting sick when they returned to elementary school from summer vacation. Both children had significant worsening of asthma, and their parents wanted to home-school them because of this problem. Environmental assessment showed extremely high levels of dust mite allergen and mold in carpeted areas. After remediation, the children returned to school without further significant asthma problems.
Another parent discusses her 3-year-old son with uncontrolled asthma and problems with cockroaches in her apartment, despite her attempts to control them. Patient assessment showed class VI-specific immunoglobulin E (IgE) level to cockroach (the highest level), and the patient has insect bites on his legs. After threatened medical-legal intervention, the landlord consented to integrated pest management. Six months later, the patient had class II IgE level to cockroach, no more insect bites and much improved asthma associated with the pest remediation.
These actual cases are dramatic examples of how implementation of environmental control measures made a major difference in the asthma control of children. The focus of a new AAP clinical report, Indoor Environmental Control Practices and Asthma Management, is to help pediatricians raise awareness of, identify and address indoor environmental issues with families of asthma patients. The report provides information on specific indoor allergens and indoor pollutants and discusses salient features of environmental histories and management plans. A wide range of studies that involve environmental assessments and interventions are referenced.
The report, from the AAP Section on Allergy and Immunology and the Council on Environmental Health, is available at http://dx.doi.org/10.1542/peds.2016-2589 and will be published in the November issue of Pediatrics.
In addition to poor asthma control, allergen and irritant exposures also can contribute to the co-morbidities of uncontrolled rhinitis, sinusitis and recurrent otitis media. Indoor environmental exposures can be more bothersome as children spend considerably more time indoors relative to outdoors.
Guidance for pediatricians
- The main indoor environmental contributors to asthma symptoms are pets, dust mites, mice, rats, cockroaches, molds and pollutants such as secondhand smoke, particulate matter and nitrogen dioxide.
- Tailored individual plans for environmental control measures based on exposures and sensitivities may be as effective as medications in controlling asthma.
- Tailored plans can be developed from an environmental history that addresses exposures to pets, pests and pollutants. Interventions include source removal, source control and mitigation strategies.
- A multifaceted approach to environmental control often is warranted. A sample environmental control plan is provided in the clinical report to assist with implementation of effective measures.
- Collaboration with a board-certified allergist may be helpful with management of suspected severe allergic asthma.
- In addition to homes, both schools and child care facilities are relevant indoor environments to be considered for children. Public and private resources are available, including potential medical-legal partnership, to help physicians and patients with environmental remediation efforts in various settings.