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Children and Allergies

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Slide 1 :

Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers James R. Roberts MD, MPH Medical University of South Carolina robertsj@musc.edu

Slide 2 :

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

Slide 3 :

Variation in Asthma Severity by Race/Ethnicity African-American and Latino children worse asthma status than comparable white children1 African-American children as compared to white children2 >3 times as likely to be hospitalized >4 times as likely to die from asthma 1TA Lieu, P Lozano, et al. Pediatrics 2002; 109(5):857-865. 2LJ Akinbami, KC Schoendorf.Pediatrics 2002: 110; 315-322.

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Variation in Asthma Care by Race/Ethnicity African-American children less likely to have made office visit for asthma (OR 0.48) P Lozano, FA Connell, TD Koepsell. Use of health services by African-American children with asthma on Medicaid. JAMA 1995; 274 (6); pages. African-American and Latino children less likely to use inhaled corticosteroids (OR 0.69 and 0.58 respectively) TA Lieu, et al. Racial/Ethnic Variations in Asthma Status and Management Practices in Managed Medicaid. Pediatrics 2002; 109(5):857-865.

Slide 5 :

National Survey on Environmental Management of Asthma Assessed public’s knowledge of environmental asthma triggers and their actions to manage environmental triggers. People from low income, low education households are more likely to have asthma. Less than 30% of people with asthma are taking all the essential actions recommended to reduce their exposure to indoor environmental asthma triggers. People with written asthma management plans (AMP) are more likely to take actions to reduce exposure to environmental asthma triggers; however, only 30% of people with asthma have a written AMP. Children with asthma are just as likely to be exposed to ETS in their home as children in general. US Environmental Protection Agency 2003

Slide 6 :

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

Slide 7 :

Pediatric Asthma Care 1997 NAEPP Asthma Guidelines Stepwise approach to managing asthma Gaining control Maintaining control Classifying asthma severity Controller medication for persistent asthma Provide WRITTEN asthma action plan 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

Slide 8 :

National Asthma Education and Prevention Program Expert Panel Report-3: Guidelines for the Diagnosis and Management of Asthma

Slide 9 :

Monitoring Asthma Control New framework for measuring control: Impairment: current experience with symptoms, low lung function, or activity limitation Risk: likelihood of future exacerbations, progressive loss of lung function or, for children, lung growth, or medication side effects Both domains are important: Treatment may affect impairment or risk differently Patients may have low day-to-day impairment but high risk of frequent exacerbations

Slide 10 :

Control of Environmental Factors New recommendation: comprehensive approaches are necessary (single steps are not sufficient) Emphasis on avoidance of tobacco smoke New consideration of specific immunotherapy for selected allergic pts.

Slide 11 :

Childhood Asthma New distinction of 3 age groups to reflect new evidence on children 0-4 years 5-11 years 12 years and adult Children may respond differently to asthma medications (e.g. more children may do well on ICS alone rather than combination therapy)

Slide 12 :

Six Key Messages Inhaled corticosteroids are the most effective anti- inflammatory medication for long term management of persistent asthma All patients should receive: Written asthma action plan Initial assessment of asthma severity Review of the level of asthma control (impairment and risk) at all follow up visits Periodic, follow up visits (at least every 6 months) Assessment of exposure and sensitivity to [environmental] allergens and irritants and recommendation to reduce relevant exposures

Slide 13 :

Control of Allergens NHLBI guidelines includes allergens House dust mite Animal dander Cockroaches Pollen Other environmental triggers exist Relationship clearest for these indoor allergens

Slide 14 :

Clearing the Air Institute of Medicine Sufficient evidence of Causal Relationship Sufficient evidence of an Association Limited evidence of Association Committee on the Assessment of Asthma and Indoor Air; Division of Health Promotion and Disease Prevention; Institute of Medicine, 2000.

Slide 15 :

Dust Mite Control Rx group vinyl covers for pillows, mattresses, and laundered bedding every 2 weeks control no changes in child’s room 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.

Slide 16 :

Dust Mite Control 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 Children of Group 1 with reduced airway reactivity Enhert B, et al. Allergy Clin Immunology 1992;90:135-8

Slide 17 :

Dust Mite Control Danish study in children (n= 60) Allergen impermeable mattress covers Significant reduction in dust mite concentration for intervention group Significant decrease in effective dose of inhaled steroid Halken S, et al. J Allergy Clin Immunol 2003;111:169-176

Slide 18 :

Cats Stick with You 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 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

Slide 19 :

Control of Cat Ag 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 No effect on disease activity 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

Slide 20 :

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

Slide 21 :

Slide 22 :

Cockroach Ag Control Home extermination– 2 applications Abamectin, Avert Directed education on cockroach allergen removal 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 Gergen PJ et al. J allergy Clin Immunol 1999;103:501-6

Slide 23 :

Cockroach Ag Control Occupant education, professional cleaning Insecticide bait Substantial reductions in cockroach allergy levels achieved1 Second Study– Professional cleaning Bait traps with insecticide Bait traps without insecticide Significant reduction in cockroach allergen2 1Arbes SJ et al. J Allergy Clin Immunol 2003;112:339-45 2McConnell R et al. Ann Allergy Asthma Immunol 2003;91:546-52

Slide 24 :

Inner City Asthma Study Follows 937 urban children with asthma 1 year of intervention, 1 additional year of follow up Evaluation --questionnaire and skin testing Home sampling --dust, cockroach, cat and dog allergen 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

Slide 25 :

Inner City Asthma Study Results and Cost Effectiveness Fewer days with symptoms1 Greater decline in level of allergens at home2 Persisted through 2nd “follow up” year Dust and cockroach Ag correlated with fewer complications of asthma Cost Effectiveness analysis3 38 more symptom free days Under $30 per symptom free day 1,2Morgan WJ, et al. New Engl J Med 2004;351:1068-80 3Kattan M, et al. J allergy Clin Immunol 2005;116:1058-63

Slide 26 :

Who takes the Advice? Seen by Allergists v. Pediatricians 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 More knowledge about carpet removal (23% v. 11%) Stuffed animal removal (10% v. 2%) Made some changes in their home Use of mattresses encasements (38% v. 11%)-- 0.001 Use of pillow encasements (36% v. 16%)– 0.009 Carpet removal (26% v. 36%)-- NS Callahan KA, et al. Annals Aller Asthma Immunol 2003;90:302-7.

Slide 27 :

Environmental Management of Pediatric Asthma: Guidelines for Health Care Providers Founded upon NHLBI Guidelines Meant to complement its clinical and pharmacological components Developed for 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 http://www.neefusa.org/Health/asthma.htm

Slide 28 :

Overview of Asthma Guidelines Developed for children 0-18 years, already diagnosed with asthma 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

Slide 29 :

Endorsed by: Ambulatory Pediatric Association American Association of Colleges of Nursing Association of Faculties of Pediatric Nurse Practitioners Supported by: American Academy of Pediatrics National Association of Pediatric Nurse Practitioners Overview of Asthma Guidelines

Slide 30 :

Components of Asthma Guidelines Educational competencies Environmental history form Environmental intervention guidelines Sample Patient Flyers and References Supplemented by online list of resources with web-links http://www.neefusa.org/health/asthma/asthma_resources.htm Available in English and Spanish online, in hard copy, and on CD-ROM http://www.neefusa.org/health/asthma/asthmaguidelines.htm

Slide 31 :

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

Slide 32 :

Environmental History Form 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 Once identified as a problem, (i.e. dust mites) the intervention sheet provides additional questions http://www.neefusa.org/Health/asthmahistoryform.htm

Slide 33 :

Slide 34 :

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

Slide 35 :

Allergy Referral? In vitro testing for allergens can be considered, but false positives occur 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) Costly interventions should be done after you have referred for skin testing

Slide 36 :

Get Rid of the Dust Mites

Slide 37 :

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

Slide 38 :

Dust Mites Other Interventions For non-encased bedding (e.g. blankets and quilts) choose items that can withstand frequent hot water washing Remove or wash and dry stuffed toys weekly Vacuum with a HEPA vacuum cleaner Avoid humidifiers

Slide 39 :

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

Slide 40 :

Animal Allergens Additional Questions What type of pet and how many of each? Indoor v. Outdoor pet? Child sleep with pet? Was asthma improved when pet outside? Furry pet in child’s classroom? (p. 21)

Slide 41 :

Animal Allergens Effective Interventions Find a new home for indoor pets Keep pet outside 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 households1 1Wood RA et al. J Allergy Clin Immunol 1989;83:730-4

Slide 42 :

Animal Allergens Unlikely Interventions Bathing cats MAY be effective at reducing allergen (n = 8 cats) The reduction was not maintained by 1 week1 Therefore it had been recommended to bathe the cat twice a week… However, A more recent study of 12 cats suggests the decrease in dander after bathing lasts about 1 day2 1Avner DB et al. J Allergy Clin Immunol 1997;100:307-12 2Ownby D et al. J Allergy Clin Immunol 2006:118:521-2

Slide 43 :

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

Slide 44 :

Mold and Mildew Interventions 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)

Slide 45 :

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

Slide 46 :

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

Slide 47 :

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

Slide 48 :

Air Pollution Possible Outdoor Air Interventions 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) Red AQI of 151-199 (unhealthy for all) Contact health care provider if more albuterol is needed the day after AQI level is high http://www.airnow.gov

Slide 49 :

Summary Written asthma action plans Asthma that is at least mild-persistent should be treated with controller medication as per NHLBI guidelines Environmental management can and should supplement good medical care Ask about environmental exposures and seek ways to intervene Low cost interventions are effective in children Consider allergy referral to define exposure risk

Slide 50 :

Contact Information Leyla Erk McCurdy Senior Director, Health & Environment National Environmental Education Foundation Email: mccurdy@neefusa.org Phone: 202.261.6488 Environmental Management of Pediatric Asthma Guidelines for Health Care Providers Created by the National Environmental Education Foundation through the Pediatric Asthma Initiative http://www.neefusa.org/health.htm

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