Environmental Management Environmental Management of Pediatric Asthma:of Pediatric Asthma:

Guidelines for Health Care Guidelines for Health Care ProvidersProviders

James R. Roberts, MD, MPH Associate Professor Medical University of South Carolina

NEETF Children’s Environmental Health Faculty Champions Initiative

Pediatric AsthmaPediatric Asthma

• Most prevalent chronic medical condition Most prevalent chronic medical condition in childhoodin childhood

• 6 million US children annually6 million US children annually– Low income children more likely to have Low income children more likely to have

increased morbidity from asthmaincreased morbidity from asthma– Less likely to receive preventive careLess likely to receive preventive care

Barriers to Asthma CareBarriers to Asthma Care

• Health Care SystemHealth Care System– Lack of health insurance, primary care, coordination Lack of health insurance, primary care, coordination

of careof care– High cost of medications and servicesHigh cost of medications and services

• Health care providersHealth care providers– Lack of recognition and severityLack of recognition and severity– Suboptimal compliance with guidelinesSuboptimal compliance with guidelines

• FamilyFamily– Confusion about symptoms and therapiesConfusion about symptoms and therapies

Pediatric Asthma CarePediatric Asthma Care1997 NAEPP Asthma Guidelines1997 NAEPP Asthma Guidelines

• Stepwise approach to managing asthmaStepwise approach to managing asthma– Gaining controlGaining control– Maintaining controlMaintaining control

• Classifying asthma severityClassifying asthma severity– Controller medication for persistent asthmaController medication for persistent asthma

• Provide WRITTEN asthma action planProvide WRITTEN asthma action plan

• Control of factors contributing to severityControl of factors contributing to severity

National Institutes of Health. Practical Guide for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program (NAEPP) 1997

Control of AllergensControl of Allergens

• NAEPP guidelines emphasize allergensNAEPP guidelines emphasize allergens– House dust miteHouse dust mite– Animal danderAnimal dander– CockroachesCockroaches– PollenPollen

• Other environmental triggers existOther environmental triggers exist• Relationship clearest for these indoor allergensRelationship clearest for these indoor allergens• Examples of some of the evidence supporting Examples of some of the evidence supporting

the control of these environmental triggersthe control of these environmental triggers

Dust Mite ControlDust Mite Control• Rx group vinyl covers for pillows, mattresses, Rx group vinyl covers for pillows, mattresses,

and laundered bedding every 2 weeksand laundered bedding every 2 weeks– control no changes in child’s roomcontrol no changes in child’s room

• Treatment groupTreatment group– Fewer days of wheezingFewer days of wheezing– Decreased use of “rescue” medicationsDecreased use of “rescue” medications– Decreased number of low peak flowsDecreased number of low peak flows– Bronchial responsiveness to histamine decreased Bronchial responsiveness to histamine decreased

4x, compared to 2x in control group4x, compared to 2x in control group

Murray AB, Ferguson AC. Pediatrics 1983;71418-23.

Dust Mite ControlDust Mite Control

• Randomized controlled trialRandomized controlled trial– Group 1-- polyurethane casings for bedding, tannic Group 1-- polyurethane casings for bedding, tannic

acid on the carpetsacid on the carpets– Group 2-- Benzyl benzoate on mattresses and Group 2-- Benzyl benzoate on mattresses and

carpets at time 0, and 4 & 8 monthscarpets at time 0, and 4 & 8 months– Group 3-- Placebo foam on the mattresses and Group 3-- Placebo foam on the mattresses and

carpets at time 0, and 4 & 8 monthscarpets at time 0, and 4 & 8 months

• Decreased mite allergen on Gp 1 mattressesDecreased mite allergen on Gp 1 mattresses

• Children of Group 1 with reduced airway reactivityChildren of Group 1 with reduced airway reactivity

Enhert B, et al. Allergy Clin Immunology 1992;90:135-8

Dust Mite ControlDust Mite Control

• Multi-center, double blind, placebo controlled trial in Multi-center, double blind, placebo controlled trial in 1122 adults with pillow and mattress encasements1122 adults with pillow and mattress encasements– Dust mite concentration lower at 6 months, but not 12 Dust mite concentration lower at 6 months, but not 12

monthsmonths– AM peak flow rate improved in both (not between groups)AM peak flow rate improved in both (not between groups)

• Allergen-impermeable covers, as a single intervention Allergen-impermeable covers, as a single intervention seem clinically ineffective in adultsseem clinically ineffective in adults

• Critique of studyCritique of study– Population is adult not children, so not generalizablePopulation is adult not children, so not generalizable– Up to 50% reported “ever smoked” Up to 50% reported “ever smoked” – Relatively modest dust mite exposureRelatively modest dust mite exposure

Woodcock et al. New England J Med 2003;349:225-36.

Dust Mite ControlDust Mite Control

• Danish study in childrenDanish study in children– Same mattress covers as Woodcock studySame mattress covers as Woodcock study– Smaller sample size (60)Smaller sample size (60)

• Significant reduction in dust mite Significant reduction in dust mite concentration for intervention groupconcentration for intervention group

• Significant decrease in effective dose of Significant decrease in effective dose of inhaled steroidinhaled steroid

Halken S, et al. J Allergy Clin Immunol 2003;112:220

Cats Stick with YouCats Stick with You

• Classrooms with many (>25% of class) cat Classrooms with many (>25% of class) cat owners had cat allergen than other owners had cat allergen than other classroomsclassrooms

• Allergen levels in non-cat owners’ clothes Allergen levels in non-cat owners’ clothes increased after one day in that classroomincreased after one day in that classroom

• Exposure through school can exacerbate Exposure through school can exacerbate asthma in sensitized children even if they asthma in sensitized children even if they don’t own a catdon’t own a cat

Almqvist C. J Allergy Clin Immunol 1999;103:1002-4Almqvist C et al. Am J Respir Crit Care Med 2001;163:694-8

Control of Cat AgControl of Cat Ag

• RCT with 35 cat-allergic (and owner) subjectsRCT with 35 cat-allergic (and owner) subjects– HEPA room air cleanerHEPA room air cleaner– Mattress and pillow coversMattress and pillow covers– Cat exclusion from bedroomCat exclusion from bedroom

• Reduced airborne cat allergen levelsReduced airborne cat allergen levels• No effect on disease activityNo effect on disease activity• In cat allergic individuals with asthma, In cat allergic individuals with asthma,

intranasal steroids were effectiveintranasal steroids were effectiveWood RA Am J Respir Crit Care Med 1998;158:115-20Wood RA, Eggleston PA. Am J Respir Crit Care Med 1995;15:315-20

Mouse AgMouse Ag

• 18 homes of children with persistent 18 homes of children with persistent asthma and positive mouse allergenasthma and positive mouse allergen

• Integrated pest managementIntegrated pest management– Filled holesFilled holes– Vacuum and cleaningVacuum and cleaning– Low-toxicity pesticides and trapsLow-toxicity pesticides and traps

• Mouse allergen levels significantly Mouse allergen levels significantly reduced during 5 month periodreduced during 5 month period

Phipatanakul W et al. Ann Allergy Asthma Immunol 2004;92:420-5

Cockroach Ag ControlCockroach Ag Control

• Occupant education, professional cleaningOccupant education, professional cleaning• Insecticide baitInsecticide bait• Substantial reductions in cockroach allergy Substantial reductions in cockroach allergy

levels achievedlevels achieved11

• Second Study– Professional cleaningSecond Study– Professional cleaning– Bait traps with insecticideBait traps with insecticide– Bait traps without insecticideBait traps without insecticide– Significant reduction in cockroach allergenSignificant reduction in cockroach allergen22

Arbes SJ et al. J Allergy Clin Immunol 2003;112:339-45McConnell R et al. Ann Allergy Asthma Immunol 2003;91:546-52

Cockroach Ag ControlCockroach Ag Control

• Home extermination– 2 applicationsHome extermination– 2 applications– Abamectin, AvertAbamectin, Avert

• Directed education on cockroach allergen Directed education on cockroach allergen removalremoval

• 50% of families followed cleaning instructions, 50% of families followed cleaning instructions, no greater effect was found in these homes no greater effect was found in these homes

• At 12 months, allergen had returned to or At 12 months, allergen had returned to or exceeded baseline levelsexceeded baseline levels

Gergen PJ et al. J allergy Clin Immunol 1999;103:501-6

Inner City Asthma StudyInner City Asthma Study• Follows 937 urban children with asthmaFollows 937 urban children with asthma

– 1 year of intervention, 1 additional year of follow up1 year of intervention, 1 additional year of follow up

• Evaluation --questionnaire and skin testingEvaluation --questionnaire and skin testing

• Home sampling --dust, cockroach, cat and dog Home sampling --dust, cockroach, cat and dog allergenallergen

• Interventions aimed at patient-specific triggersInterventions aimed at patient-specific triggers– Allergen impermeable mattress and pillow coversAllergen impermeable mattress and pillow covers– HEPA air filters and vacuum cleanersHEPA air filters and vacuum cleaners– Professional pest controlProfessional pest control

Morgan WJ, et al. New Engl J Med 2004;351:1068-80

Inner City Asthma StudyInner City Asthma StudyResults and Cost EffectivenessResults and Cost Effectiveness

• Fewer days with symptomsFewer days with symptoms• Greater decline in level of allergens at homeGreater decline in level of allergens at home

– Persisted through 2Persisted through 2ndnd “follow up” year “follow up” year– Dust and cockroach Ag correlated with fewer Dust and cockroach Ag correlated with fewer

complications of asthmacomplications of asthma

• *Cost Effectiveness analysis*Cost Effectiveness analysis– 38 more symptom free days38 more symptom free days– Under $30 per symptom free dayUnder $30 per symptom free day

Morgan WJ, et al. New Engl J Med 2004;351:1068-80*Kattan M, et al. J allergy Clin Immunol 2005;116:1058-63

Who takes the Advice?Who takes the Advice?

• Patients seen by an allergist had greater knowledge of Patients seen by an allergist had greater knowledge of environmental allergensenvironmental allergens– Dust mite knowledge (71% v. 18%)Dust mite knowledge (71% v. 18%)– Need for mattress encasements (61% v. 13%)Need for mattress encasements (61% v. 13%)– Need for pillow encasements (51% v. 11%)Need for pillow encasements (51% v. 11%)

• Increased knowledge, but not statistically significantIncreased knowledge, but not statistically significant– More knowledge about carpet removal (23% v. 11%)More knowledge about carpet removal (23% v. 11%)– Stuffed animal removal (10% v. 2%)Stuffed animal removal (10% v. 2%)

• Made some changes in their homeMade some changes in their home– Use of mattresses encasements (38% v. 11%)Use of mattresses encasements (38% v. 11%)– Use of pillow encasements (36% v. 16%)Use of pillow encasements (36% v. 16%)

Callahan KA, et al. Annals Aller Asthma Immunol 2003;90:302-7.

Overview of Asthma GuidelinesOverview of Asthma Guidelines

• Founded upon NAEPP Guidelines

• Meant to complement its clinical and pharmacological components

• Developed for pediatric primary care providers– Pediatricians, family physicians, internists

– Nurse practitioners, physician assistants

• Authored by expert steering committee and peer reviewed

• Built on scientific literature and best

current practices

Overview of Asthma GuidelinesOverview of Asthma Guidelines

• Developed for children 0-18 years, already Developed for children 0-18 years, already diagnosed with asthmadiagnosed with asthma

• Applies to all settings where children spend timeApplies to all settings where children spend time– Homes, schools, and daycare centersHomes, schools, and daycare centers– Cars, school busesCars, school buses– Camps, relatives’/friends’ homes, other recreational Camps, relatives’/friends’ homes, other recreational

or housing settings or housing settings– Occupational environmentsOccupational environments

• Available online, in hard copy, and on CD-ROMAvailable online, in hard copy, and on CD-ROM

http://www.neetf.org/Health/asthma.htmhttp://www.neetf.org/Health/asthma.htm

Components of Asthma Components of Asthma GuidelinesGuidelines

• Educational competenciesEducational competencies

• Environmental history formEnvironmental history form

• Environmental intervention guidelinesEnvironmental intervention guidelines

• Sample Patient Flyers and ReferencesSample Patient Flyers and References

• Supplemented by online list of resources with Supplemented by online list of resources with web-linksweb-links– http://www.neetf.org/health/AsthmaResources.pdfhttp://www.neetf.org/health/AsthmaResources.pdf– Web-links begin on page 2 on this PDF siteWeb-links begin on page 2 on this PDF site

CompetenciesCompetencies

I.I. Knowledge of Environmental Triggers of Knowledge of Environmental Triggers of AsthmaAsthma

II.II. Identification of Environmental Triggers of Identification of Environmental Triggers of AsthmaAsthma

III.III. Environmental Intervention and TreatmentEnvironmental Intervention and TreatmentIV.IV. Ability to Counsel Caregivers and Pediatric Ability to Counsel Caregivers and Pediatric

Asthma Patients on the Reduction of Asthma Patients on the Reduction of Environmental Asthma TriggersEnvironmental Asthma Triggers

V.V. Effective Communication and Follow up SkillsEffective Communication and Follow up SkillsVI.VI. AdvocacyAdvocacy

Environmental History Form (P. 17) Environmental History Form (P. 17)

• Quick intake formQuick intake form• Administered by health care providerAdministered by health care provider• Available online as PDF and Word Available online as PDF and Word

documentdocument• Can be pasted into electronic medical Can be pasted into electronic medical

record templaterecord template• Questions are in yes/no formatQuestions are in yes/no format

– Follow up yes answer with in-depth questions on Follow up yes answer with in-depth questions on Intervention Guidelines fact sheetsIntervention Guidelines fact sheets

Environmental History FormEnvironmental History Form

• Intended for child Intended for child already diagnosedalready diagnosed with with asthmaasthma

• Parent or child will likely answer questions about Parent or child will likely answer questions about exposure with own home in mindexposure with own home in mind– Remember to consider other places the child spends Remember to consider other places the child spends

time: school, daycare, car, worktime: school, daycare, car, work

• Designed to capture major trigger areasDesigned to capture major trigger areas– Once identified as a problem, (i.e. dust mites) the Once identified as a problem, (i.e. dust mites) the

intervention sheet provides additional questionsintervention sheet provides additional questions

http://www.neetf.org/Health/asthmahistoryform.htm

Intervention GuidelinesIntervention Guidelines

• Two-visit conceptTwo-visit concept

• Short introductionShort introduction

• Additional in-depth questionsAdditional in-depth questions– Explore exposure sourcesExplore exposure sources– Parents’ current practicesParents’ current practices

• Intervention recommendationsIntervention recommendations

• Sample patient handouts to downloadSample patient handouts to download

• Additional resources on initiative’s websiteAdditional resources on initiative’s website

http://www.neetf.org/Health/asthma.htmhttp://www.neetf.org/Health/asthma.htm

Allergy Referral?Allergy Referral?

• In vitro testing for allergens can be consideredIn vitro testing for allergens can be considered– Should focus on allergens identified in historyShould focus on allergens identified in history– Should not replace timely allergy referral Should not replace timely allergy referral

• Low cost environmental interventions are Low cost environmental interventions are reasonable, especially where wide spread reasonable, especially where wide spread exposure occurs (i.e. dust mites in SE)exposure occurs (i.e. dust mites in SE)– Costly interventions should be done after you Costly interventions should be done after you

have referred for skin testinghave referred for skin testing

Get Rid of the Dust MitesGet Rid of the Dust Mites

Dust MitesDust MitesSimple, but Effective InterventionsSimple, but Effective Interventions

• Encase all pillows and mattresses of the beds Encase all pillows and mattresses of the beds the child sleeps on with allergen impermeable the child sleeps on with allergen impermeable encasingsencasings

• Wash bedding weekly to remove allergen Wash bedding weekly to remove allergen

• Wash in HOT water (130F) to kill mitesWash in HOT water (130F) to kill mites

• Results generally seen in 1 monthResults generally seen in 1 month

• Avoid ozone generators and some ionic air Avoid ozone generators and some ionic air cleanerscleaners

P. 20

Dust MitesDust MitesOther InterventionsOther Interventions

• Synthetic materials in beddingSynthetic materials in bedding

• Remove or wash and dry stuffed toys Remove or wash and dry stuffed toys weeklyweekly

• Vacuum with a HEPA vacuum cleanerVacuum with a HEPA vacuum cleaner

• Avoid humidifiersAvoid humidifiers

P. 20

Dust MitesDust MitesPossible InterventionsPossible Interventions

• Replace draperies with blindsReplace draperies with blinds• Remove carpet from child’s bedroomRemove carpet from child’s bedroom• Remove upholstered furnitureRemove upholstered furniture• Use portable HEPA air cleanerUse portable HEPA air cleaner

• These are higher cost and it is recommended These are higher cost and it is recommended that the child have skin test proven allergy to that the child have skin test proven allergy to dust mites prior to implementationdust mites prior to implementation

P. 20

Animal AllergensAnimal AllergensAdditional QuestionsAdditional Questions

• What type of pet and how many of each?What type of pet and how many of each?

• Indoor v. Outdoor pet?Indoor v. Outdoor pet?

• Child sleep with pet?Child sleep with pet?

• Was asthma improved when pet outside?Was asthma improved when pet outside?

• Furry pet in child’s classroom?Furry pet in child’s classroom?

P. 21

Animal AllergensAnimal AllergensEffective InterventionsEffective Interventions

• Find a new home for indoor petsFind a new home for indoor pets• Keep pet outsideKeep pet outside• If these aren’t possible…If these aren’t possible…

– Similar interventions as with dust mitesSimilar interventions as with dust mites– Encasings, HEPA air cleaner, HEPA Vacuum,Encasings, HEPA air cleaner, HEPA Vacuum,– Keep pet out of bedroomKeep pet out of bedroom

• Takes 24-30 weeks before allergen levels Takes 24-30 weeks before allergen levels reach those of non-cat householdsreach those of non-cat households11

P. 21

Wood RA et al. J Allergy Clin Immunol 1989;83:730-4

Animal AllergensAnimal AllergensPossible InterventionsPossible Interventions

• Bathing cats MAY be effective at reducing Bathing cats MAY be effective at reducing allergen (n = 8 cats)allergen (n = 8 cats)– However, the reduction was not maintained by 1 However, the reduction was not maintained by 1

weekweek1 1

– Therefore it has been recommendedTherefore it has been recommended to bathe the cat twice a week…to bathe the cat twice a week…

• However, A more recent study of 12 catsHowever, A more recent study of 12 cats suggests the decrease in cat dander suggests the decrease in cat dander after bathing lasts about 1 dayafter bathing lasts about 1 day22

Avner DB et al. J Allergy Clin Immunol 1997;100:307-12Ownby D et al. J Allergy Clin Immunol 2006:In Press

Cockroach AllergenCockroach AllergenDo’s and Don’ts of Roach ControlDo’s and Don’ts of Roach Control

• Integrated pest Integrated pest management (IPM)management (IPM)– Least toxic methods Least toxic methods

firstfirst

• Clean up food/spillsClean up food/spills• Food and trash Food and trash

storage in closed storage in closed containerscontainers

• Fix water leaksFix water leaks

• Clean counter tops daily Clean counter tops daily • Boric acidBoric acid• Bait stations/ gelsBait stations/ gels• Don’t!!Don’t!!

– Spray liquids in house, Spray liquids in house, especially play and sleep especially play and sleep spacespace

– Use industrial strength Use industrial strength pesticide sprays that pesticide sprays that require dilutionrequire dilution

P. 22

Mold and MildewMold and MildewInterventionsInterventions

• Ways to control moisture and/or decrease Ways to control moisture and/or decrease humidity to < 50%humidity to < 50%– Dehumidifier or central air conditioner Dehumidifier or central air conditioner – Do not use a humidifierDo not use a humidifier– Vent bathrooms/clothes dryers to outsideVent bathrooms/clothes dryers to outside– Use exhaust fan in bathroom/ other damp Use exhaust fan in bathroom/ other damp

areasareas– Check faucets and pipes for leaks and repairCheck faucets and pipes for leaks and repair

P. 23

Mold and MildewMold and MildewCleaning up the MessCleaning up the Mess

• Items too moldy to clean should be discardedItems too moldy to clean should be discarded

• An area larger than 3 ft x 3 ft should be An area larger than 3 ft x 3 ft should be professionally cleanedprofessionally cleaned

• Chlorine solution 1:10 with waterChlorine solution 1:10 with water

is acceptable for smaller areasis acceptable for smaller areas– Don’t mix with cleaners containing ammonia!Don’t mix with cleaners containing ammonia!

• Quaternary ammonium compounds are good Quaternary ammonium compounds are good fungicides if bleach isn’t usedfungicides if bleach isn’t used

Environmental Tobacco SmokeEnvironmental Tobacco SmokePossible InterventionsPossible Interventions

• Keep home and care smoke freeKeep home and care smoke free

• Encourage support to quit smokingEncourage support to quit smoking– Recommend aids such as nicotine gum/patchRecommend aids such as nicotine gum/patch– Medication from physician to assist in quittingMedication from physician to assist in quitting

• Choose smoke free social settingsChoose smoke free social settings

• At the very least, do not smoke around At the very least, do not smoke around your child or in the car!your child or in the car!

P. 24

Air PollutionAir PollutionPossible Indoor Air InterventionsPossible Indoor Air Interventions

• Eliminate tobacco smokeEliminate tobacco smoke• Install exhaust fan close to source of Install exhaust fan close to source of

contaminantscontaminants• Ventilate room if fuel burning appliance Ventilate room if fuel burning appliance

usedused• Avoid use of products emitting irritantsAvoid use of products emitting irritants• See control of dust mites and animal See control of dust mites and animal

allergensallergens

P. 25

Air PollutionAir PollutionPossible Outdoor Air InterventionsPossible Outdoor Air Interventions

• Monitor air quality index levelsMonitor air quality index levels– Ozone, Particulate Matter, NOx, SO2Ozone, Particulate Matter, NOx, SO2– Reduce child’s outdoor activities if unhealthyReduce child’s outdoor activities if unhealthy

• Orange AQI of 101-150 (unhealthy for sensitive groups)Orange AQI of 101-150 (unhealthy for sensitive groups)

• Red AQI of 151-199 (unhealthy for all)Red AQI of 151-199 (unhealthy for all)

• Contact health care provider if more albuterol is Contact health care provider if more albuterol is needed the day after AQI level is highneeded the day after AQI level is high

• When particle pollution is high outdoors, do not When particle pollution is high outdoors, do not vacuum as this increases indoor particle levelsvacuum as this increases indoor particle levels

P. 26

www.epa.gov/airnow

SummarySummary

• Asthma that is at least Asthma that is at least mild-persistentmild-persistent should be treated with controller medication should be treated with controller medication as per NAEPP guidelinesas per NAEPP guidelines

• Environmental management can and Environmental management can and should supplement good medical careshould supplement good medical care

• Low cost interventions are effectiveLow cost interventions are effective• Ask about environmental exposures and Ask about environmental exposures and

seek ways to interveneseek ways to intervene

Contact InformationContact InformationLeyla Erk McCurdyLeyla Erk McCurdySenior Director, Health & EnvironmentSenior Director, Health & EnvironmentNational Environmental Education & Training National Environmental Education & Training

Foundation (NEETF)Foundation (NEETF)Email: mccurdy@neetf.orgEmail: mccurdy@neetf.orgPhone: 202.261.6488Phone: 202.261.6488

NEETF is tracking pediatric environmental healthNEETF is tracking pediatric environmental healtheducation activities for health care providers and education activities for health care providers and

requests your feedbackrequests your feedback

http://www.neetf.org/healthhttp://www.neetf.org/health