1. Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers James R. Roberts, MD, MPH Associate Professor Medical University of South Carolina NEETF Children’s Environmental Health Faculty Champions Initiative

2. Pediatric Asthma Most prevalent chronic medical condition in childhood Most prevalent chronic medical condition in childhood 6 million US children annually 6 million US children annually – Low income children more likely to have increased morbidity from asthma – Less likely to receive preventive care

3. Barriers to Asthma Care Health Care System Health Care System – Lack of health insurance, primary care, coordination of care – High cost of medications and services Health care providers Health care providers – Lack of recognition and severity – Suboptimal compliance with guidelines Family Family – Confusion about symptoms and therapies

4. Pediatric Asthma Care 1997 NAEPP Asthma Guidelines Stepwise approach to managing asthma Stepwise approach to managing asthma – Gaining control – Maintaining control Classifying asthma severity Classifying asthma severity – Controller medication for persistent asthma Provide WRITTEN asthma action plan Provide WRITTEN asthma action plan Control of factors contributing to severity Control 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

5. Control of Allergens NAEPP guidelines emphasize allergens NAEPP guidelines emphasize allergens – House dust mite – Animal dander – Cockroaches – Pollen Other environmental triggers exist Other environmental triggers exist Relationship clearest for these indoor allergens Relationship clearest for these indoor allergens Examples of some of the evidence supporting the control of these environmental triggers Examples of some of the evidence supporting the control of these environmental triggers

6. Dust Mite Control Rx group vinyl covers for pillows, mattresses, and laundered bedding every 2 weeks Rx group vinyl covers for pillows, mattresses, and laundered bedding every 2 weeks – control no changes in child’s room Treatment group Treatment group – Fewer days of wheezing – Decreased use of “rescue” medications – Decreased number of low peak flows – Bronchial responsiveness to histamine decreased 4x, compared to 2x in control group Murray AB, Ferguson AC. Pediatrics 1983;71418-23.

7. Dust Mite Control Randomized controlled trial Randomized controlled trial – Group 1-- polyurethane casings for bedding, tannic acid on the carpets – Group 2-- Benzyl benzoate on mattresses and carpets at time 0, and 4 & 8 months – Group 3-- Placebo foam on the mattresses and carpets at time 0, and 4 & 8 months Decreased mite allergen on Gp 1 mattresses Decreased mite allergen on Gp 1 mattresses Children of Group 1 with reduced airway reactivity Children of Group 1 with reduced airway reactivity Enhert B, et al. Allergy Clin Immunology 1992;90:135-8

8. Dust Mite Control Multi-center, double blind, placebo controlled trial in 1122 adults with pillow and mattress encasements Multi-center, double blind, placebo controlled trial in 1122 adults with pillow and mattress encasements – Dust mite concentration lower at 6 months, but not 12 months – AM peak flow rate improved in both (not between groups) Allergen-impermeable covers, as a single intervention seem clinically ineffective in adults Allergen-impermeable covers, as a single intervention seem clinically ineffective in adults Critique of study Critique of study – Population is adult not children, so not generalizable – Up to 50% reported “ever smoked” – Relatively modest dust mite exposure Woodcock et al. New England J Med 2003;349:225-36.

9. Dust Mite Control Danish study in children Danish study in children – Same mattress covers as Woodcock study – Smaller sample size (60) Significant reduction in dust mite concentration for intervention group Significant reduction in dust mite concentration for intervention group Significant decrease in effective dose of inhaled steroid Significant decrease in effective dose of inhaled steroid Halken S, et al. J Allergy Clin Immunol 2003;112:220

10. Cats Stick with You Classrooms with many (>25% of class) cat owners had cat allergen than other classrooms Classrooms with many (>25% of class) cat owners had cat allergen than other classrooms Allergen levels in non-cat owners’ clothes increased after one day in that classroom Allergen levels in non-cat owners’ clothes increased after one day in that classroom Exposure through school can exacerbate asthma in sensitized children even if they don’t own a cat Exposure through school can exacerbate asthma in sensitized children even if they don’t own a cat Almqvist C. J Allergy Clin Immunol 1999;103:1002-4 Almqvist C et al. Am J Respir Crit Care Med 2001;163:694-8

11. Control of Cat Ag RCT with 35 cat-allergic (and owner) subjects RCT with 35 cat-allergic (and owner) subjects – HEPA room air cleaner – Mattress and pillow covers – Cat exclusion from bedroom Reduced airborne cat allergen levels Reduced airborne cat allergen levels No effect on disease activity No effect on disease activity In cat allergic individuals with asthma, intranasal steroids were effective In cat allergic individuals with asthma, intranasal steroids were effective Wood RA Am J Respir Crit Care Med 1998;158:115-20 Wood RA, Eggleston PA. Am J Respir Crit Care Med 1995;15:315-20

12. Mouse Ag 18 homes of children with persistent asthma and positive mouse allergen 18 homes of children with persistent asthma and positive mouse allergen Integrated pest management Integrated pest management – Filled holes – Vacuum and cleaning – Low-toxicity pesticides and traps Mouse allergen levels significantly reduced during 5 month period Mouse allergen levels significantly reduced during 5 month period Phipatanakul W et al. Ann Allergy Asthma Immunol 2004;92:420-5

14. Cockroach Ag Control Occupant education, professional cleaning Occupant education, professional cleaning Insecticide bait Insecticide bait Substantial reductions in cockroach allergy levels achieved 1 Substantial reductions in cockroach allergy levels achieved 1 Second Study– Professional cleaning Second Study– Professional cleaning – Bait traps with insecticide – Bait traps without insecticide – Significant reduction in cockroach allergen 2 Arbes SJ et al. J Allergy Clin Immunol 2003;112:339-45 McConnell R et al. Ann Allergy Asthma Immunol 2003;91:546-52

15. Cockroach Ag Control Home extermination– 2 applications Home extermination– 2 applications – Abamectin, Avert Directed education on cockroach allergen removal Directed education on cockroach allergen removal 50% of families followed cleaning instructions, no greater effect was found in these homes 50% of families followed cleaning instructions, no greater effect was found in these homes At 12 months, allergen had returned to or exceeded baseline levels At 12 months, allergen had returned to or exceeded baseline levels Gergen PJ et al. J allergy Clin Immunol 1999;103:501-6

16. Inner City Asthma Study Follows 937 urban children with asthma Follows 937 urban children with asthma – 1 year of intervention, 1 additional year of follow up Evaluation --questionnaire and skin testing Evaluation --questionnaire and skin testing Home sampling --dust, cockroach, cat and dog allergen Home sampling --dust, cockroach, cat and dog allergen Interventions aimed at patient-specific triggers Interventions aimed at patient-specific triggers – Allergen impermeable mattress and pillow covers – HEPA air filters and vacuum cleaners – Professional pest control Morgan WJ, et al. New Engl J Med 2004;351:1068-80

17. Inner City Asthma Study Results and Cost Effectiveness Fewer days with symptoms Fewer days with symptoms Greater decline in level of allergens at home Greater decline in level of allergens at home – Persisted through 2 nd “follow up” year – Dust and cockroach Ag correlated with fewer complications of asthma *Cost Effectiveness analysis *Cost Effectiveness analysis – 38 more symptom free days – Under $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

18. Who takes the Advice? Patients seen by an allergist had greater knowledge of environmental allergens Patients seen by an allergist had greater knowledge of environmental allergens – Dust mite knowledge (71% v. 18%) – Need for mattress encasements (61% v. 13%) – Need for pillow encasements (51% v. 11%) Increased knowledge, but not statistically significant Increased knowledge, but not statistically significant – More knowledge about carpet removal (23% v. 11%) – Stuffed animal removal (10% v. 2%) Made some changes in their home Made some changes in their home – Use of mattresses encasements (38% v. 11%) – Use of pillow encasements (36% v. 16%) Callahan KA, et al. Annals Aller Asthma Immunol 2003;90:302-7.

19. Overview 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

20. Overview of Asthma Guidelines Developed for children 0-18 years, already diagnosed with asthma Developed for children 0-18 years, already diagnosed with asthma Applies to all settings where children spend time Applies to all settings where children spend time – Homes, schools, and daycare centers – Cars, school buses – Camps, relatives’/friends’ homes, other recreational or housing settings – Occupational environments Available online, in hard copy, and on CD-ROM Available online, in hard copy, and on CD-ROM http://www.neetf.org/Health/asthma.htm

21. Components of Asthma Guidelines Educational competencies Educational competencies Environmental history form Environmental history form Environmental intervention guidelines Environmental intervention guidelines Sample Patient Flyers and References Sample Patient Flyers and References Supplemented by online list of resources with web-links Supplemented by online list of resources with web-links – http://www.neetf.org/health/AsthmaResources.pdf http://www.neetf.org/health/AsthmaResources.pdf – Web-links begin on page 2 on this PDF site

22. Competencies I. Knowledge of Environmental Triggers of Asthma II. Identification of Environmental Triggers of Asthma III. Environmental Intervention and Treatment IV. Ability to Counsel Caregivers and Pediatric Asthma Patients on the Reduction of Environmental Asthma Triggers V. Effective Communication and Follow up Skills VI. Advocacy

23. Environmental History Form (P. 17) Quick intake form Quick intake form Administered by health care provider Administered by health care provider Available online as PDF and Word document Available online as PDF and Word document Can be pasted into electronic medical record template Can be pasted into electronic medical record template Questions are in yes/no format Questions are in yes/no format – Follow up yes answer with in-depth questions on Intervention Guidelines fact sheets

24. Environmental History Form Intended for child already diagnosed with asthma Intended for child already diagnosed with asthma Parent or child will likely answer questions about exposure with own home in mind Parent or child will likely answer questions about exposure with own home in mind – Remember to consider other places the child spends time: school, daycare, car, work Designed to capture major trigger areas Designed to capture major trigger areas – Once identified as a problem, (i.e. dust mites) the intervention sheet provides additional questions http://www.neetf.org/Health/asthmahistoryform.htm

26. Intervention Guidelines Two-visit concept Two-visit concept Short introduction Short introduction Additional in-depth questions Additional in-depth questions – Explore exposure sources – Parents’ current practices Intervention recommendations Intervention recommendations Sample patient handouts to download Sample patient handouts to download Additional resources on initiative’s website Additional resources on initiative’s website http://www.neetf.org/Health/asthma.htm

27. Allergy Referral? In vitro testing for allergens can be considered In vitro testing for allergens can be considered – Should focus on allergens identified in history – Should not replace timely allergy referral Low cost environmental interventions are reasonable, especially where wide spread exposure occurs (i.e. dust mites in SE) Low cost environmental interventions are reasonable, especially where wide spread exposure occurs (i.e. dust mites in SE) – Costly interventions should be done after you have referred for skin testing

28. Get Rid of the Dust Mites

29. Dust Mites Simple, but Effective Interventions Encase all pillows and mattresses of the beds the child sleeps on with allergen impermeable encasings Encase all pillows and mattresses of the beds the child sleeps on with allergen impermeable encasings Wash bedding weekly to remove allergen Wash bedding weekly to remove allergen Wash in HOT water (130F) to kill mites Wash in HOT water (130F) to kill mites Results generally seen in 1 month Results generally seen in 1 month Avoid ozone generators and some ionic air cleaners Avoid ozone generators and some ionic air cleaners P. 20

30. Dust Mites Other Interventions Synthetic materials in bedding Synthetic materials in bedding Remove or wash and dry stuffed toys weekly Remove or wash and dry stuffed toys weekly Vacuum with a HEPA vacuum cleaner Vacuum with a HEPA vacuum cleaner Avoid humidifiers Avoid humidifiers P. 20

31. Dust Mites Possible Interventions Replace draperies with blinds Replace draperies with blinds Remove carpet from child’s bedroom Remove carpet from child’s bedroom Remove upholstered furniture Remove upholstered furniture Use portable HEPA air cleaner Use portable HEPA air cleaner These are higher cost and it is recommended that the child have skin test proven allergy to dust mites prior to implementation These are higher cost and it is recommended that the child have skin test proven allergy to dust mites prior to implementation P. 20

32. Animal Allergens Additional 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

33. Animal Allergens Effective Interventions Find a new home for indoor pets Find a new home for indoor pets Keep pet outside Keep pet outside If these aren’t possible… If these aren’t possible… – Similar interventions as with dust mites – Encasings, HEPA air cleaner, HEPA Vacuum, – Keep pet out of bedroom Takes 24-30 weeks before allergen levels reach those of non-cat households 1 Takes 24-30 weeks before allergen levels reach those of non-cat households 1 P. 21 Wood RA et al. J Allergy Clin Immunol 1989;83:730-4

34. Animal Allergens Possible Interventions Bathing cats MAY be effective at reducing allergen (n = 8 cats) Bathing cats MAY be effective at reducing allergen (n = 8 cats) – However, the reduction was not maintained by 1 week 1 – Therefore 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 cats However, A more recent study of 12 cats suggests the decrease in cat dander suggests the decrease in cat dander after bathing lasts about 1 day 2 after bathing lasts about 1 day 2 Avner DB et al. J Allergy Clin Immunol 1997;100:307-12 Ownby D et al. J Allergy Clin Immunol 2006:In Press

35. Cockroach Allergen Do’s and Don’ts of Roach Control Integrated pest management (IPM) Integrated pest management (IPM) – Least toxic methods first Clean up food/spills Clean up food/spills Food and trash storage in closed containers Food and trash storage in closed containers Fix water leaks Fix water leaks Clean counter tops daily Clean counter tops daily Boric acid Boric acid Bait stations/ gels Bait stations/ gels Don’t!! Don’t!! – Spray liquids in house, especially play and sleep space – Use industrial strength pesticide sprays that require dilution P. 22

36. Mold and Mildew Interventions Ways to control moisture and/or decrease humidity to < 50% Ways to control moisture and/or decrease humidity to < 50% – Dehumidifier or central air conditioner – Do not use a humidifier – Vent bathrooms/clothes dryers to outside – Use exhaust fan in bathroom/ other damp areas – Check faucets and pipes for leaks and repair P. 23

37. Mold and Mildew Cleaning up the Mess Items too moldy to clean should be discarded Items too moldy to clean should be discarded An area larger than 3 ft x 3 ft should be professionally cleaned An area larger than 3 ft x 3 ft should be professionally cleaned Chlorine solution 1:10 with water Chlorine solution 1:10 with water is acceptable for smaller areas is acceptable for smaller areas – Don’t mix with cleaners containing ammonia! Quaternary ammonium compounds are good fungicides if bleach isn’t used Quaternary ammonium compounds are good fungicides if bleach isn’t used

38. Environmental Tobacco Smoke Possible Interventions Keep home and care smoke free Keep home and care smoke free Encourage support to quit smoking Encourage support to quit smoking – Recommend aids such as nicotine gum/patch – Medication from physician to assist in quitting Choose smoke free social settings Choose smoke free social settings At the very least, do not smoke around your child or in the car! At the very least, do not smoke around your child or in the car! P. 24

39. Air Pollution Possible Indoor Air Interventions Eliminate tobacco smoke Eliminate tobacco smoke Install exhaust fan close to source of contaminants Install exhaust fan close to source of contaminants Ventilate room if fuel burning appliance used Ventilate room if fuel burning appliance used Avoid use of products emitting irritants Avoid use of products emitting irritants See control of dust mites and animal allergens See control of dust mites and animal allergens P. 25

40. Air Pollution Possible Outdoor Air Interventions Monitor air quality index levels Monitor air quality index levels – Ozone, Particulate Matter, NOx, SO2 – Reduce 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 needed the day after AQI level is high Contact health care provider if more albuterol is needed the day after AQI level is high When particle pollution is high outdoors, do not vacuum as this increases indoor particle levels When particle pollution is high outdoors, do not vacuum as this increases indoor particle levels P. 26 www.epa.gov/airnow

41. Summary Asthma that is at least mild-persistent should be treated with controller medication as per NAEPP guidelines Asthma that is at least mild-persistent should be treated with controller medication as per NAEPP guidelines Environmental management can and should supplement good medical care Environmental management can and should supplement good medical care Low cost interventions are effective Low cost interventions are effective Ask about environmental exposures and seek ways to intervene Ask about environmental exposures and seek ways to intervene

42. Contact Information Leyla Erk McCurdy Senior Director, Health & Environment National Environmental Education & Training Foundation (NEETF) Email: mccurdy@neetf.org Phone: 202.261.6488 NEETF is tracking pediatric environmental health education activities for health care providers and requests your feedback http://www.neetf.org/health