Indoor Environmental Control Practices and Asthma Management
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CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care
Indoor Environmental Control
Practices and Asthma Management
Elizabeth C. Matsui, MD, MHS, FAAP, Stuart L. Abramson, MD, PhD, AE-C, FAAP, Megan T. Sandel, MD,
MPH, FAAP, SECTION ON ALLERGY AND IMMUNOLOGY, COUNCIL ON ENVIRONMENTAL HEALTH
Indoor environmental exposures, particularly allergens and pollutants, are abstract
major contributors to asthma morbidity in children; environmental control
practices aimed at reducing these exposures are an integral component
of asthma management. Some individually tailored environmental
control practices that have been shown to reduce asthma symptoms and
exacerbations are similar in efficacy and cost to controller medications.
As a part of developing tailored strategies regarding environmental
This document is copyrighted and is property of the American
control measures, an environmental history can be obtained to evaluate Academy of Pediatrics and its Board of Directors. All authors have
filed conflict of interest statements with the American Academy
the key indoor environmental exposures that are known to trigger of Pediatrics. Any conflicts have been resolved through a process
asthma symptoms and exacerbations, including both indoor pollutants approved by the Board of Directors. The American Academy of
Pediatrics has neither solicited nor accepted any commercial
and allergens. An environmental history includes questions regarding involvement in the development of the content of this publication.
the presence of pets or pests or evidence of pests in the home, as well as Clinical reports from the American Academy of Pediatrics benefit from
knowledge regarding whether the climatic characteristics in the community expertise and resources of liaisons and internal (AAP) and external
reviewers. However, clinical reports from the American Academy of
favor dust mites. In addition, the history focuses on sources of indoor air Pediatrics may not reflect the views of the liaisons or the organizations
pollution, including the presence of smokers who live in the home or care or government agencies that they represent.
for children and the use of gas stoves and appliances in the home. Serum The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
allergen-specific immunoglobulin E antibody tests can be performed into account individual circumstances, may be appropriate.
or the patient can be referred for allergy skin testing to identify indoor All clinical reports from the American Academy of Pediatrics
allergens that are most likely to be clinically relevant. Environmental control automatically expire 5 years after publication unless reaffirmed,
revised, or retired at or before that time.
strategies are tailored to each potentially relevant indoor exposure and are
DOI: 10.1542/peds.2016-2589
based on knowledge of the sources and underlying characteristics of the
exposure. Strategies include source removal, source control, and mitigation PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
strategies, such as high-efficiency particulate air purifiers and allergen- Copyright © 2016 by the American Academy of Pediatrics
proof mattress and pillow encasements, as well as education, which can be FINANCIAL DISCLOSURE: The authors have indicated they do not have
delivered by primary care pediatricians, allergists, pediatric pulmonologists, a financial relationship relevant to this article to disclose.
other health care workers, or community health workers trained in asthma FUNDING: No external funding.
environmental control and asthma education. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they
have no potential conflicts of interest to disclose.
To cite: Matsui EC, Abramson SL, Sandel MT, AAP SECTION ON
ALLERGY AND IMMUNOLOGY AAP COUNCIL ON ENVIRONMENTAL
HEALTH. Indoor Environmental Control Practices and Asthma
Management. Pediatrics. 2016;138(5):e20162589
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PEDIATRICS Volume 138, number 5, November 2016:e20162589 FROM THE AMERICAN ACADEMY OF PEDIATRICSINTRODUCTION the management of asthma and, furry pets or pests or evidence of
Asthma is one of the most common thereof, to provide guidance. The pests in the home. Understanding
chronic childhood illnesses, affecting recently published manual Pediatric whether the climatic characteristics of
as many as 10% of children across the Environmental Health, known as a community favor dust mite growth is
United States, with prevalence rates the “Green Book” (third edition, important for assessing the likelihood
as high as 25% in some communities.1 2012) from the American Academy that the patient has significant
Self-reported black race, Puerto of Pediatrics (AAP), has 2 chapters exposure to dust mites. Except for
Rican ethnicity, and poverty are the devoted to the discussion of topics arid climates, exposure to dust mites
major risk factors for asthma in US included in this report: chapter 20, is an important consideration. For all
populations.1 Children with asthma “Air Pollutants, Indoor,” and chapter children, both allergic and nonallergic,
who are sensitized and exposed 43, “Asthma.”16 These chapters the environmental history focuses
to indoor allergens, including dust provide additional reference material on nonallergen exposures as well.
mite,2 rodent,3,4 cockroach, and pet that supports a number of findings Allergens only affect a subset of those
allergens,5,6 have worse asthma discussed in this report. There are who are sensitized to the specific
control and lung function and greater no contradictions evident between allergen(s), whereas irritants affect
airway inflammation and morbidity the 2 resources, but the current all children to variable degrees.
than those who are either not report includes some updated For pollutants, the history focuses
sensitized or not exposed to these references and commentary (eg, on sources of indoor air pollution,
allergens. In addition, exposure to electronic nicotine delivery systems including smokers who live in the
common indoor pollutants, including [e-cigarettes], practice parameters home or care for the child and the
secondhand smoke (SHS)7 and regarding environmental assessment use of gas stoves and appliances.
nitrogen dioxide (NO2),8 exacerbates of and exposure reduction to rodent Household chemicals, such as those
asthma, regardless of the presence of and cockroach allergens, etc). found in air fresheners and cleaning
allergic sensitization. agents, also can be respiratory
Environmental control strategies
irritants and trigger asthma
Children may be vulnerable to these are tailored to each potentially
symptoms.16 The specific strategies
environmental exposures for several relevant indoor exposure on the
used to target an exposure depend
potential reasons. First, perhaps basis of knowledge of the patient’s
on knowledge about the sources
because of their airway physiology, allergic sensitivities and relevant
and underlying characteristics of the
they may be exposed to larger doses indoor exposures. Serum allergen-
exposure. Environmental control
of airborne pollutants.9–11 Second, specific immunoglobulin E (IgE)
strategies include source removal
it is possible that their exposure to antibody tests may be performed,
(eradication of the allergen source),
pollutants, chemicals, and/or allergens or the patient may be referred to a
source control (controlling the
is greater because of their proximity to board-certified allergist for allergy
population/amount of the allergen
the floor, which can be a reservoir for skin testing to identify indoor
source), and mitigation strategies
these exposures.12 It is also noteworthy allergens that are most likely to be
(reducing the amount of allergen
that most children with asthma who clinically relevant for a patient who
in the air, dust, bedding, etc, that is
are at least school-aged have evidence meets National Asthma Education
produced by the source), such as
of allergic sensitization, so that allergen and Prevention Program criteria for
using high-efficiency particulate
exposure likely plays a significant persistent asthma, which include
air (HEPA) purifiers and allergen-
role in childhood asthma. However, patients taking a long-term controller
proof mattress/box spring and
an estimated 20% of school-aged medication as well as patients
pillow encasements. Individually
children with persistent asthma are having symptoms >2 days per week
tailored, multifaceted environmental
not atopic,13–15 and although they are or nocturnal symptoms more than
interventions are endorsed by
not susceptible to allergen exposure, twice per month.17 Serum IgE testing
the National Asthma Education
they are susceptible to pollutants and allergy skin testing are both
and Prevention Program guidelines
and irritants, as are children with appropriate methods of assessing
and may be similar in terms of
atopic diseases. For all children with allergic sensitivities; neither is clearly
efficacy to controller medications.9
asthma, viruses are a major trigger of better than the other in identifying
Although a multifaceted approach
exacerbations. clinically important sensitizations,18
makes intuitive sense and reflects
and there is no lower age limit for
The purpose of this report is to raise clinical practice, much of the
either of these tests.
awareness among pediatricians foundational research has focused
regarding the need to assess for and For allergic children, an on single allergens; therefore, each
implement indoor environmental environmental history includes allergen will be discussed individually
control practice measures in questions regarding the presence of in this report.
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e2 FROM THE AMERICAN ACADEMY OF PEDIATRICSINDOOR ALLERGENS include measures that target the bed, dust mite–driven asthma found that
including frequent washing of all bed dust mite interventions that resulted
Dust Mites linens in hot water and the use of in a substantial reduction in dust
The major dust mite allergens are allergen-impermeable mattress and mite allergen levels had a beneficial
Der f 1 and Der p 1, from the 2 most pillow encasements, and measures clinical effect. For example, of the
common house dust mite species, that target other allergen reservoirs, 15 studies of bedding encasements
Dermatophagoides farinae and such as vacuuming, removal of carpet in dust mite–sensitized children
Dermatophagoides pteronyssinus, and stuffed toys from the bed, and included in the meta-analysis, 14
respectively. Dust mites, microscopic application of acaricides or allergen- included assessments of dust mite
members of the Arachnid class, are denaturing agents.24 Applications of allergen exposure, and 7 found at
rare in arid environments, because acaricides and allergen-denaturing least an 80% reduction in dust mite
they require moisture to survive; agents are cumbersome and allergen in the active intervention
humid environments such as those ineffective, sustained reduction in groups. Of these 7 studies, 5
found in the southeastern United indoor relative humidity is difficult found that the active intervention
States and along the coasts are most to achieve, and carpet removal is group had improvements in
conducive to dust mite growth. In expensive and of unclear benefit.24 asthma.21,24,26–29
more humid climates, dust mites are There are also potential risks when
found not only in homes but also in applying chemicals to the indoor Cat and Dog Allergens
public places such as schools. environment, and although these
risks are small when the agents are The most common furry pets found
Dust mite allergen exposure has handled according to instructions, in homes are cats and dogs; the major
been repeatedly linked to worse they are an important consideration. dog allergen is Can f 1 and the major
asthma among those who are dust More information about the risks cat allergen is Fel d 1. Exposure to
mite sensitized2; and many, but not of chemical agents, including these allergens has been linked to
all, studies indicate that effective pesticides, can be found in the AAP worse asthma among pet-sensitized
reduction in dust mite allergen publication Pediatric Environmental asthmatics, and approximately 25%
exposure improves asthma in this Health.16 Because the major dust to 65% of children with persistent
patient group.2,19–21 Approximately mite allergens are carried on larger asthma are sensitized to cat or dog
30% to 62% of children with particles (>10 μm), they quickly allergens.2,3,22,23 When patients are
persistent asthma are sensitized to settle to dependent surfaces after asked about the presence of a pet in
dust mite allergens,2,22,23 and it is disturbance of the reservoir. For this the home (or in other places where
this population who are susceptible reason, air filtration is not likely to the child spends significant time),
to the effects of dust mite allergen have any meaningful effect on dust an affirmative response confirms
exposure. Unlike patients who may mite allergen exposure. Because significant exposure, but the absence
describe allergic reactions to furry dust mites feed on shed human skin, of a pet does not ensure that the
pet exposure, patients who are which is abundant in the bed, first- patient does not have clinically
allergic to dust mites are unable line approaches to reduce dust mite meaningful pet allergen exposure.
to identify dust mites, which are allergen exposure include washing It is also important to note that a
microscopic, as an allergic trigger. of bed linens and the use of allergen- child with clinically relevant pet
Therefore, the pediatrician can impermeable mattress and pillow sensitization may not have acute
only rely on an understanding of encasements, which can be highly allergic symptoms with exposure, so
whether the climatic conditions of effective in reducing dust mite that the absence of these symptoms
the community are conducive to allergen in the bed. does not rule out a role for the pet
dust mite growth. As an alternative, in the child’s asthma. Although
a family can have a home dust Although the most recent meta- pet allergens are found in higher
sample tested for dust mite content analysis of dust mite interventions concentrations in homes with pets,
with the use of a commercially concluded that dust mite they are ubiquitous and detected
available kit, although this test is not interventions had no effect on in places such as schools, child care
currently reimbursed by third-party asthma, this meta-analysis included centers, and public transportation.
payers. studies whose interventions had little Furry animal allergens adhere to
Dust mite allergen exposure to no effect on dust mite exposure clothing, walls, furniture, etc, and, in
reduction strategies focus on source and whose populations may not contrast to dust mite and cockroach
removal (ie, killing the dust mites) have been dust mite allergic.25 In allergens, are predominantly carried
and/or removal of the allergen. contrast, most of the studies in on smaller particles (periods of time. As a result, they are allergen exposure as an attempt at a minor mouse infestation can be
carried on clothing of people who inducing tolerance is unlikely to be handled without rodenticide, some
have a cat or dog and are transferred effective, but pet removal is quite homes with serious infestation
to environments that do not contain effective.32 may require a rodenticide; in this
a cat or dog. Indirect exposure to pet circumstance, bait blocks may be
allergens through this mechanism Rodents associated with the risk of accidental
can also cause asthma symptoms in ingestion by children and pets,
Rodent allergens have been
sensitized children. For example, cat and families may have greater
recognized as a cause of occupational
allergen brought into classrooms by benefit from professionally applied
allergy and asthma for many
students with cats has been linked to rodenticide.
decades but have only recently
worsening of asthma in cat-sensitized
been recognized as an exacerbator
classmates with asthma.5 Although there has yet to be a
of asthma in rodent-sensitized
study testing the clinical efficacy
community populations.38 Mus
Clinically significant reductions of intervention on mouse allergen,
m 1, the major mouse allergen, is
in animal allergen levels require mouse-sensitized patients who
found primarily on small particles,
source removal, or relocating the have any evidence of infestation
like other furred animal allergens,
pet.30 Even after removing the pet may benefit from integrated pest
so it is readily airborne.39,40 It
from the home, it can take several management, because reducing
is found in virtually all inner-
months before significant reductions mouse allergen would be expected
city homes, particularly in the
in allergen levels are observed,31 to be clinically efficacious. Integrated
northeastern and Midwestern
so it is important that parents are pest management targets mice and
United States.41–43 Although 75% to
counseled accordingly. In the only other pests, such as cockroaches,
80% of US homes have detectable
prospective (but nonrandomized) and includes sealing up entry points
mouse allergen, concentrations in
study of pet removal, asthma for pests and removing sources of
inner-city homes are as much as
improved significantly and controller food, shelter, and water for pests
1000-fold higher than those found
medication needs were reduced by storing food in chew-proof
in suburban homes.44,45 A report
substantially in the group who containers, cleaning up immediately
of any evidence of infestation,
removed the pet but not in the group after eating, fixing leaky faucets and
particularly from a patient living in
who kept the pet.32 Because of the pipes, and taking the trash out on a
an urban neighborhood, suggests
reluctance of patients to give up regular basis. For patients living in
that there are clinically significant
their pets, there have been several rental units, families can work with
levels of mouse allergen in the home.
studies examining the efficacy of air landlords and/or property managers
However, a report of absence of
filtration in reducing airborne pet to address the infestation. Patients
infestation is not a reassurance that
allergen levels and improving asthma with mouse sensitization are very
there is not clinically significant
in sensitized patients.33–35 Overall, likely to be cat sensitized as well,
exposure when the patient resides
these studies have found that this so the acquisition of a cat may not
in an urban neighborhood. Mouse
approach is ineffective at improving be a prudent approach to mouse
allergen exposure has repeatedly
asthma outcomes and, at best, only infestation. Rat allergen exposure
been linked to an increased risk of
modestly reduces airborne allergen is less common, because it is
a range of markers of uncontrolled
levels. A common patient question detected in approximately one-third
and more severe asthma among
is whether certain dog breeds are of inner-city homes; so, although
sensitized children.3,4,42,43
“hypoallergenic.” A recent study it is associated with worse
found that homes with dogs believed A substantial reduction in mouse asthma, a smaller proportion of
to be hypoallergenic had levels of allergen levels can be achieved with children are affected by rat allergen
dog allergen similar to homes with a professionally delivered integrated exposure than mouse allergen
dogs that were not considered to be pest-management intervention that exposure.
hypoallergenic.36 The “Thanksgiving includes trap placement, sealing
effect” refers to the phenomenon of holes and cracks that can serve Rodents are also kept as pets, and
when cat-allergic asthma patients as entry points into the home, and the more common rodent pets are
living with, and apparently application of rodenticide.46 It is gerbils, guinea pigs, and hamsters.
tolerating, a cat go away to college important to weigh the potential Rabbits and ferrets, which are not
in the fall and then return home for benefits of rodenticide against the rodents, are also common furry
Thanksgiving and, on reexposure to potential risks, and a discussion of pets. Exposure to these animals can
the cat, develop significant asthma these risks can be found in Pediatric contribute to worse asthma among
symptoms.37 Sustained animal Environmental Health.16 Although patients who are sensitized.
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e4 FROM THE AMERICAN ACADEMY OF PEDIATRICSCockroach exposed are Alternaria, Aspergillus, Organization’s Guidelines for Indoor
Cladosporium, and Penicillium.52 Air Quality: Dampness and Mould.58
The most common cockroaches in
Although Alternaria and Aspergillus
US inner cities are the German and
are derived from outdoor sources,
American cockroaches; the major INDOOR POLLUTANTS
they are present indoors and may
German cockroach allergens, Bla g
be clinically relevant.53 The National
1 and Bla g 2, are the best studied in Particulate Matter and SHS
Survey of Lead and Allergens in
terms of health effects. Cockroach Exposure
Housing found that 56% of homes
allergen exposure among sensitized Particulate matter (PM) simply
had levels of some molds above
inner-city children with asthma was means airborne particles, and it
thresholds observed to be associated
first linked to asthma morbidity in is often expressed as either PM2.5,
with asthma symptoms.54 Children
the National Cooperative Inner-City which is the portion of PM that is
sensitized and exposed to the major
Asthma Study report published 2.5 μm in diameter or less, or PM10,
indoor molds appear to be at greater
in 1997.47 Since then, the link which is the portion of PM that is
risk of asthma exacerbations.52
with asthma morbidity has been 10 μm or less. Both allergic and
Remediation of mold has been shown
replicated, and highly effective nonallergic children with asthma are
to reduce symptoms and medication
methods based on integrated pest- susceptible to the effects of indoor
use in several populations, and its
management principles to reduce PM and SHS.59 PM2.5, also known as
effects may not depend on whether
cockroach allergen levels have been fine PM, penetrates further into the
the population is sensitized to
identified. Pesticides that come in airways than larger-sized particles
mold.55,56
gel form are preferred to aerosolized and is capable of entering the alveoli.
pesticides, which likely result in Indoor PM is composed partly of
The evaluation of a patient with
greater pesticide exposure.48,49 outdoor PM but mostly of particles
persistent asthma includes an
Moreover, in a successful generated indoors by smoking and
assessment of sensitization to the
multifaceted environmental other activities, such as cooking
major indoor molds, which can
intervention in inner-city children and sweeping.60–63 PM exposure is
be accomplished with specific
with asthma, the degree of reduction associated with lung inflammation,
IgE testing performed on a blood
in cockroach allergen was correlated decreased lung function, and
sample or through referral to a
with the degree of improvement in respiratory symptoms in children
board-certified allergist for skin
asthma symptoms, providing support with asthma, regardless of whether
testing. Air sampling, thermography,
for cockroach allergen environmental they have allergic sensitization. Other
moisture meters, environmental
control measures, which include sources of indoor PM include wood-
history, and direct observation are
integrated pest management, as an burning stoves, fireplaces, biomass
all useful techniques to identify
integral part of asthma management burning, electronic nicotine delivery
moisture problems. Although
in cockroach-sensitized children with systems (e-cigarettes),64 cigar
more sophisticated techniques for
asthma.19,50 smoke, incense, bus idling outside of
assessing home dampness and mold
exposure are ideal, parental report of school, and other substances that are
Dampness and Mold smoked, such as marijuana.16
dampness, leaks, or mold is helpful
Excessive moisture in homes can and, in a child with sensitization to
SHS
contribute to asthma through an the major indoor molds, suggests
increase in mold exposure as well as that the parents be counseled to Cigarette smoke is a major
increased cockroach and dust mite intervene on the home environment contributor to indoor PM in US
allergen. Excessive moisture may (some simple measures are listed homes, because each half-pack of
be present because of inadequate in the Supplemental Appendix). A cigarettes smoked in the home is
ventilation or other building common tool used to assess home estimated to contribute 4.0 μg/m3 of
problems or because of a flooding mold exposure is air sampling, but PM,7,60 and approximately 30% of all
event. Mold exposure occurs mainly it is important to note that molds US children and 40% to 60% of US
as spores become aerosolized, and a are ubiquitous, so reports from air children in low-income households
substantial number of asthma cases sampling are uninterpretable without are exposed to SHS in their
may be attributed to dampness and concomitant indoor and outdoor homes.7,65,66 Smoking cessation by
mold exposure.51 The prevalence of sampling. More detailed information close family members and caregivers
mold sensitization in children with about dampness and mold can be is the most effective way to reduce or
persistent asthma is approximately found in the Institute of Medicine’s eliminate tobacco smoke exposure.
50%, and the most common species report Damp Indoor Spaces and Although tobacco dependence
to which children are sensitized and Health57 and the World Health can be a very severe addiction,
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PEDIATRICS Volume 138, number 5, November 2016 e5tobacco-dependence treatment Portable HEPA Purifiers Although data are scant regarding
medications approved by the US The use of portable HEPA purifiers effective interventions for reducing
Food and Drug Administration are has been shown to reduce indoor indoor NO2, ensuring that the stove
very effective in treating tobacco PM concentrations by approximately is properly vented and using the
dependence and allowing the 25% to 50% and to reduce asthma vent while the stove is in use would
tobacco smoker to stop smoking.67 symptoms and exacerbations.7,71 be expected to reduce indoor NO2
State-of-the-art approaches to Portable HEPA purifiers appear to be concentrations. One randomized
treating tobacco dependence initiate effective in reducing PM from tobacco controlled trial found reductions
therapy on the basis of severity and nontobacco smoke sources, but of 40% to 50% in indoor NO2
of the tobacco dependence and there is little evidence to support concentrations when a gas stove
adjust therapy to control nicotine their efficacy in reducing airborne was replaced with an electric one.74
withdrawal symptoms. The AAP animal allergens or pollen. Although Whether this degree of indoor NO2
Section on Tobacco Control recently HEPA purifiers are expected to be reduction results in improvements in
published documents that address much less effective than the first-line asthma remains unclear, however.
clinical practice policy as well as approach of source removal, if they
public policy to protect children from are suggested, nonionizing HEPA
tobacco, nicotine, and tobacco smoke ENVIRONMENTAL EVALUATION AND
purifiers with clean air delivery MANAGEMENT FOR THE PEDIATRIC
and provided an accompanying rates that are appropriate for the
technical report to support evidence- PATIENT WITH ASTHMA
size of the room in which they will
based approaches.68–70 be used may be most effective. This An assessment of environmental
information is indicated on the air triggers and education regarding
If tobacco-dependent family purifier packaging. It is important evidence-based approaches to
members are not ready to stop to note that cigarette smoke also exposure reduction are an integral
smoking or initiate tobacco- produces nonparticle, gaseous part of asthma management in
dependence treatment, smoke-free pollutants, such as nicotine and the pediatric patient.75 Children
home and car policies can reduce others, and that HEPA purifiers do are vulnerable to the respiratory
but not eliminate a child’s tobacco not appear to have any effect on air effects of indoor environmental
smoke exposure. For families nicotine and possibly other gaseous exposures because of their
who are not willing to consider components of tobacco smoke.7 As a respiratory physiology and because
smoking cessation, starting tobacco- result, HEPA purifiers will not offer any pulmonary effects from
dependence treatment, or keeping any protection from the adverse these exposures may affect their
the home smoke free, 2 randomized health effects of these nonparticle respiratory health in adulthood. An
controlled trials suggest that the use components of SHS. assessment of allergic sensitization
of portable HEPA purifiers in the to a panel of indoor allergens is
home may be of some benefit7,71 useful for determining whether
but would not be as effective as NO2 indoor allergens may be clinically
if occupants of the home stopped NO2 is a gas that is a byproduct of relevant for a patient and, if so, for
smoking or instituted a home combustion, so it is found outdoors identifying which allergens may be
smoking ban. HEPA purifiers are also as a result of traffic and other relevant. Allergen-specific IgE tests
costly, so whether the expenditure is combustion activities, and affects can be performed at commercial
worth the benefit will vary depending both allergic and nonallergic children laboratories, so they can be ordered
on the child’s clinical picture, with asthma.73 It can be found in by a primary care provider. Testing
progress in smoking cessation or concentrations associated with to large panels of allergens is not
institution of a home smoking ban, adverse health effects in homes, helpful, because there may be many
and the financial resources available. where the most important source is positive results to allergens that
It is also important to note that gas heat and appliances.8,73 are not relevant to the individual
homes are not the only indoor spaces In addition, older wood-burning patient’s environment and history;
where children are exposed to SHS. stoves, unvented space heaters, and instead, testing to selected relevant
SHS exposure in public places has other sources of combustion can allergens is preferred. The clinical
been targeted by legislation that produce NO2 and other pollutants. scenario guides which allergens
bans smoking in public places, and Higher indoor NO2 concentrations to include in testing; for pediatric
this legislation has been associated have been linked to worse asthma patients with persistent asthma,
with significant decreases in asthma in children with asthma,8 although testing to common indoor allergens,
morbidity in children, including 1 study found that only nonatopic including cat, dog, dust mites (if in
asthma hospitalizations.72 children with asthma were affected.73 a nonarid area of the country), and
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e6 FROM THE AMERICAN ACADEMY OF PEDIATRICSmolds, is appropriate. For children resources for addressing the school Because each child has his or her
living in a community in which pest environment (http://www.epa. own profile of relevant exposures,
infestation is common, testing for gov/iaq/schools/managingasthma. it is important that the strategies
mouse and cockroach sensitization html and http://www.cdc.gov/ regarding environmental control be
would also be appropriate. More HealthyYouth/asthma/creatingafs/, tailored to each patient. In addition,
information about allergy testing respectively). each of the child’s exposures affects
can be found in a recent AAP clinical his or her asthma, so targeting
report on the subject.18 Alternatively, The environmental history and all of the exposures, to the extent
the patient can be referred to an assessment of allergic sensitization possible, is important to achieve
allergist-immunologist for allergy will inform a tailored environmental the maximal benefit. A sample
skin testing, interpretation of results, control plan for the patient. It is environmental control plan is
and education of the family about important to note that environmental provided (Supplemental Appendix),
environmental triggers. interventions that target all relevant which can be used to indicate the
exposures are more likely to be child’s allergic status, to provide
In most cases, a careful exposure successful than those that target basic background information about
history, combined with knowledge only 1 or 2 exposures. For patients indoor environmental exposures,
about the community and allergy sensitized to an allergen, the first- and to list the environmental
testing, is sufficient to identify line strategies for targeting indoor control practices that the family
the major exposures that may be exposures discussed previously can implement to reduce the child’s
clinically relevant. The history are likely to result in a reduction exposure to indoor allergens and
includes asking parents and patients in relevant indoor exposures and irritants that are contributing to the
about exposure to pets, dampness, improvements in asthma. Although child’s asthma.
or mold and whether they have seen the role of allergen-proof mattress
evidence of pest infestation. Relevant and pillow encasements has been Although public and private
exposures occur at schools, child debated,76,77 their efficacy may insurers may cover environmental
care centers, cars/transportation, be greater for children than for assessments and control measures,
and relatives’ homes, so these other adults,20,21,26–28 and they have been most do not, despite evidence of their
locations of potential exposure an integral part of successful, cost-effectiveness. Public and private
are included in the environmental individually tailored, multifaceted resources are available, including
history. Understanding whether the home environmental interventions.19 legal assistance (such as through
patient lives in an area conducive For patients with SHS exposure, medical-legal partnerships; www.
to dust mite growth or to mouse helping the smoker obtain effective medical-legalpartnerships.org), to
or cockroach infestation is also an tobacco-dependence treatment so help primary care pediatricians,
important component of determining that he or she can stop smoking is the asthma and allergy specialists,
the potentially relevant allergens for most effective approach, because it and patients with environmental
the patient. For pollutants, which eliminates the source of the tobacco remediation efforts pertinent to
are relevant for both allergic and smoke. A home smoking ban can various residential settings. In some
nonallergic children with asthma, the reduce, but does not eliminate, the states, Medicaid may cover some
history includes asking parents and tobacco smoke exposure. In some components of an environmental
patients first about SHS exposure. An cases, the parent may not be able to intervention, such as a home visit
additional history elicits the presence influence the smoking behavior of for an environmental assessment
of gas heat and/or appliances, household members and may not and education, which can be
because this finding would suggest be able to move to another home. delivered by health care workers or
that the patient may have clinically In that situation, the use of portable community health workers trained
relevant NO2 exposure. Because HEPA purifiers may be better than in asthma environmental control. It
relevant exposures occur in schools no intervention. Insurance coverage is important to note, however, that
and child care centers, it is important for air purifiers and other goods and insurance coverage differs from state
to elicit potential relevant exposures services for environmental control is to state and among insurers and is
that occur in other settings outside being reevaluated and may be more expected to change over time, so it is
of the home. Often, families can work widespread in the future. For patients best to seek information from your
with schools and child care centers with gas heat and appliances, the first- AAP Chapter, the AAP Department
to address relevant exposures, and line environmental control strategies of Practice, or the Asthma and
both the Environmental Protection would include ensuring that the gas Allergy Foundation to understand
Agency and the Centers for Disease stove is properly vented and the vent what resources, including insurance
Control and Prevention have online is used when the stove is on. coverage, are available to support
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PEDIATRICS Volume 138, number 5, November 2016 e7environmental control goods and are most likely to be clinically Todd Brubaker, DO – AAP Section on Medical
services. relevant. Students, Residents, and Fellowship Trainees
Ruth A. Etzel, MD, PhD, FAAP – US Environmental
6. Environmental control strategies Protection Agency
are tailored to each potentially Mary Ellen Mortensen, MD, MS – Centers for
KEY POINTS
relevant indoor exposure and are Disease Control and Prevention/National Center
1. Individually tailored based on knowledge of the sources for Environmental Health
environmental control and underlying characteristics of Nathaniel G. DeNicola, MD, MSC – American
Congress of Obstetricians and Gynecologists
measures have been shown to the exposure. Strategies include
Mary H. Ward, PhD – National Cancer Institute
reduce asthma symptoms and source removal, source control,
exacerbations, are similar in and mitigation strategies. STAFF
efficacy to controller medications,
and appear to be cost-effective Paul Spire
LEAD AUTHORS
when the aim is to reduce days of
Elizabeth C. Matsui, MD, MHS, FAAP
symptoms and their associated Stuart L. Abramson, MD, PhD, AE-C, FAAP ABBREVIATIONS
costs.75,78 The efficacy of Megan T. Sandel, MD, MPH, FAAP AAP: American Academy of
environmental control measures
Pediatrics
has been sustained for up to 1 SECTION ON ALLERGY AND IMMUNOLOGY
EXECUTIVE COMMITTEE, 2015–2016 HEPA: high-efficiency particulate
year after the intervention.19
air
Elizabeth C. Matsui, MD, MHS, FAAP, Chair
2. As a part of developing IgE: immunoglobulin E
Stuart L. Abramson, MD, PhD, AE-C, FAAP
tailored strategies regarding NO2: nitrogen dioxide
Chitra Dinakar, MD, FAAP
environmental control measures, Anne-Marie Irani, MD, FAAP PM: particulate matter
an environmental history may Jennifer S. Kim, MD, FAAP SHS: secondhand smoke
be obtained to evaluate the key Todd A. Mahr, MD, FAAP, Immediate Past Chair
indoor environmental exposures Michael Pistiner, MD, FAAP
that are known to trigger asthma Julie Wang, MD, FAAP
symptoms and exacerbations,
FORMER EXECUTIVE COMMITTEE MEMBERS REFERENCES
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