Environmental Control Measures for Allergies in Pediatric Patients

Educational Objectives

The goal of this program is to improve use of environmental control measures (ECMs) in patients with allergies. After hearing and assimilating this program, the clinician will be better able to:

1. Recommend effective measures to reduce exposure to common allergens.
2. Analyze the impacts of ECMs on allergen exposure in patients with asthma.

Summary

Environmental control measures (ECMs): identify patients with aeroallergens amenable vs nonamenable to ECMs; animal dander and house dust mites (HDMs) are most amenable to ECMs; effectively communicate ECMs to patients and their families; common aeroallergens that can be managed through ECMs are pollens, mold spores, animal dander, and HDMs; patients with immunoglobulin E (IgE)- mediated disease exacerbated by exposure to aeroallergens (ie, allergic rhinitis [AR], allergic asthma, atopic dermatitis [AD]) benefit most from ECMs; though ≈67% of children with AD have no known allergies, exposure to allergens in patients with allergy and AD may exacerbate AD; physical and airborne allergens can exacerbate AD

Allergy to pollens (in, eg, grasses, weeds, trees): removing the plant associated with allergy from the backyard may not reduce symptoms, as pollens travel for ≤40 mi through the air; rather than keep children inside the house during times of high pollen counts, parents should treat the allergy with medications and allow children to go outside

Allergy to mold: like pollens, individuals do not have much control over outdoor mold spore exposure; a report released in 2004 by the Institute of Medicine noted difficulty in discerning adverse health effects from exposure to mold spores vs dampness, because molds require moisture to grow and other organisms contributing to symptoms also grow in damp environments; some evidence demonstrates that sufficiently large exposure to mold fumes can irritate the respiratory tract, even in individuals without mold allergy; many people live with mold exposure without ill effects; the fact that mold produces a toxin is not proof that it causes disease, and evidence of mold toxins causing illnesses in indoor environments is weak; the Centers for Disease Control and Prevention (CDC) deem the term “toxic mold” inaccurate; though certain molds may produce toxins, the molds themselves are nontoxic; the CDC recommends against routine sampling for molds; sampling and culturing are unreliable for determining personal health risk, and standards for judging what is an acceptable, tolerable, normal quantity of mold have not been established; the speaker does not ask about dampness and mold unless skin allergy testing is positive; if symptoms and indoor mold coexist, alleviate the source and clean up the mold

Allergy to animal dander: small allergen particles from animals remain indefinitely airborne; even households without pets have measurable amounts of dog and cat allergens; it takes months for pet allergens to clear from a home; a correlation exists between the number of students with a cat at home and the quantity of cat allergens in that classroom; no hypoallergenic dogs exist; Nicholas et al (2011) demonstrated an equal concentration of dog allergens in the homes of people with hypoallergenic vs nonhypoallergenic dogs; any furry animal may cause allergy; advise families to exclude the animal from rooms occupied by the patient with the allergy, and use a high-efficiency particulate air (HEPA) filter to remove animal dander; Canis familiaris allergen 5 (Can f 5) is unique to male dogs; ≈70% of patients who are allergic to dogs make IgE against Can f 5, and ≈50% of those patients only develop IgE against Can f 5 (Basagaña et al [2017]), suggesting these patients may not be allergic to female dogs; thus, advise families to consider keeping female dogs if allergy testing only reveals positivity for Can f 5

Allergy to HDMs: allergens associated with HDMs are found in their body, excreta, and body parts; HDMs are universally present, regardless of cleanliness; they prefer to live in humid places and feed on shed skin; killing HDMs does not prevent allergic reactions, as dead and live HDMs cause allergy; HDMs are heavy and settle from the air; sampling the air in an inactive room with HDMs yields negative results; HDM allergen presence is higher in areas with high humidity; running air conditioning reduces the indoor humidity and may control HDM exposure; washing bedding in hot water kills HDMs; feather pillows contain less HDM allergens than synthetic pillows; stuffed animals contain considerable HDMs; run a dehumidifier or air conditioner to reduce indoor humidity; encase mattresses and pillows, and use a mattress pad or protector; remove HDMs with a vacuum cleaner (preferably with a HEPA filter)

Efficacy of ECMs: Evans et al (1999) demonstrated a larger reduction in allergen exposure among patients in households implementing ECMs, compared with homes without ECMs; statistically significant improvement in asthma symptoms (eg, days of wheezing, days of inactivity, nighttime awakening) was noted with use vs nonuse of ECMs

Readings

Basagaña M, Luengo O, Labrador M, et al. Component-resolved diagnosis of dog allergy. J Investig Allergol Clin Immunol. 2017;27(3):185-187. doi:10.18176/jiaci.0150; Eggleston PA. Methods and effectiveness of indoor environmental control. Ann Allergy Asthma Immunol. 2001;87(6 Suppl 3):44-7. doi:10.1016/ s1081-1206(10)62340-x; Evans R 3rd, Gergen PJ, Mitchell H, et al. A randomized clinical trial to reduce asthma morbidity among inner-city children: results of the National Cooperative Inner-City Asthma Study. J Pediatr. 1999;135(3):332-338. doi:10.1016/s0022- 3476(99)70130-7; Nicholas CE, Wegienka GR, Havstad SL, et al. Dog allergen levels in homes with hypoallergenic compared with nonhypoallergenic dogs. Am J Rhinol Allergy. 2011;25(4):252-6. doi:10.2500/ajra.2011.25.3606; Rudert A, Portnoy J. Mold allergy: is it real and what do we do about it? Expert Rev Clin Immunol. 2017;13(8):823-835. doi:10.1080/1744666X.2017.1324298; Zuiani C, Custovic A. Update on house dust mite allergen avoidance measures for asthma. Curr Allergy Asthma Rep. 2020;20(9):50. doi:10.1007/ s11882-020-00948-y.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Kelso was recorded at Pediatrics in the Islands: Clinical Pearls 2024, held October 28, 2024, in Waikoloa, HI, and presented by the Children’s Hospital Los Angeles Medical Group. For information on future CME activities from this presenter, please visit https://www.chla.org/chla-medical-group/cme-conferences. Audio Digest thanks Dr. Kelso and Children’s Hospital Los Angeles Medical Group for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

OT580202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.