Results of a home-based environmental intervention among urban children with asthma. Reduction in Asthma Morbidity in Children as a Result of Home Remediation Aimed at Moisture Sources Is respiratory viral infection really an important trigger of asthma exacerbations in children? Differential effects of outdoor versus indoor fungal spores on asthma morbidity in inner-city children. Household Levels of Nitrogen Dioxide and Pediatric Asthma Severity Effect of mattress and pillow encasings on children with asthma and house dust mite allergy. The respiratory health effects of nitrogen dioxide in children with asthma Effects of improved home heating on asthma in community dwelling children: randomised controlled trial The effects of exclusion of dietary egg and milk in the management of asthmatic children: a pilot study Environmental intervention for house dust mite control in childhood bronchial asthma Randomized controlled trial of unflued gas heater replacement on respiratory health of asthmatic schoolchildren. Does a multifaceted environmental intervention alter the impact of asthma on inner-city children? Mechanical ventilation and high-efficiency vacuum cleaning: A combined strategy of mite and mite allergen reduction in the control of mite-sensitive asthma. Association between gas cooking and respiratory disease in children.
BACKGROUND Children with asthma who live in the inner city are exposed to multiple indoor allergens and environmental tobacco smoke in their homes . Reductions in these triggers of asthma have been difficult to achieve and have seldom been associated with decreased morbidity from asthma . The objective of this study was to determine whether an environmental intervention tailored to each child 's allergic sensitization and environmental risk factors could improve asthma-related outcomes . METHODS We enrolled 937 children with atopic asthma ( age , 5 to 11 years ) in seven major U.S. cities in a r and omized , controlled trial of an environmental intervention that lasted one year ( intervention year ) and included education and remediation for exposure to both allergens and environmental tobacco smoke . Home environmental exposures were assessed every six months , and asthma-related complications were assessed every two months during the intervention and for one year after the intervention . RESULTS For every 2-week period , the intervention group had fewer days with symptoms than did the control group both during the intervention year ( 3.39 vs. 4.20 days , P<0.001 ) and the year afterward ( 2.62 vs. 3.21 days , P<0.001 ) , as well as greater declines in the levels of allergens at home , such as Dermatophagoides farinae ( Der f1 ) allergen in the bed ( P<0.001 ) and on the bedroom floor ( P=0.004 ) , D. pteronyssinus in the bed ( P=0.007 ) , and cockroach allergen on the bedroom floor ( P<0.001 ) . Reductions in the levels of cockroach allergen and dust-mite allergen ( Der f1 ) on the bedroom floor were significantly correlated with reduced complications of asthma ( P<0.001 ) . CONCLUSIONS Among inner-city children with atopic asthma , an individualized , home-based , comprehensive environmental intervention decreases exposure to indoor allergens , including cockroach and dust-mite allergens , result ing in reduced asthma-associated morbidity Objective Home dampness and the presence of mold and allergens have been associated with  asthma morbidity . We examined changes in  asthma morbidity in children as a result of home remediation aim ed at moisture sources . Design In this prospect i ve , r and omized controlled trial , symptomatic , asthmatic children ( n = 62 ) , 2–17 years of age , living in a home with indoor mold , received an asthma intervention including an action plan , education , and individualized problem solving . The remediation group also received household repairs , including reduction of water infiltration , removal of water-damaged building material s , and heating/ventilation/air-conditioning alterations . The control group received only home cleaning information . We measured children ’s total and allergen-specific serum immuno-globulin E , peripheral blood eosinophil counts , and urinary cotinine . Environmental dust sample s were analyzed for dust mite , cockroach , rodent urinary protein , endotoxin , and fungi . The follow-up period was 1 year . Results Children in both groups showed improvement in asthma symptomatic days during the preremediation portion of the study . The remediation group had a significant decrease in symptom days ( p = 0.003 , as r and omized ; p = 0.004 , intent to treat ) after remodeling , whereas these parameters in the control group did not significantly change . In the postremediation period , the remediation group had a lower rate of exacerbations compared with control asthmatics ( as treated : 1 of 29 vs. 11 of 33 , respectively , p = 0 . 003 ; intent to treat : 28.1 % and 10.0 % , respectively , p = 0.11 ) . Conclusion Construction remediation aim ed at the root cause of moisture sources and combined with a medical/behavioral intervention significantly reduces symptom days and health care use for asthmatic children who live in homes with a documented mold problem We performed a prospect i ve cohort study from September 2003 to December 2004 to delineate attributing the effect of different respiratory viral infections including newly discovered ones to asthma exacerbations in children in Hong Kong . One hundred and fourteen children aged 6–14 years with chronic stable asthma and on regular inhaled steroid were monitored for  respiratory symptoms  over a full calendar year from recruitment . They would attend the study clinic if peak expiratory flow rate decreased to below 80 % of their baselines , if they met a predefined symptom score , or if parents subjectively felt them developing a cold . Virological diagnosis using virus culture , antigen detection , and polymerase chain reaction methods on nasal swab specimens would be attempted for all these visits irrespective of triggers . Physician diagnosed outcome of each episode was documented . Three hundred and five episodes of respiratory illnesses were captured in the cohort . Nasal specimens were available in 166 episodes , 92 of which were diagnosed as asthma exacerbations , and 74 non-asthma related episodes . Respiratory viruses were detected in 61 of 166 episodes ( 36.7 % ) . There was no significant difference in virus detection rate between asthma exacerbations ( 32 out of 97 episodes , 34.8 % ) and non-asthma respiratory illnesses ( 29 out of 79 episodes , 39.2 % ) . Although newly discovered respiratory viruses were identified in these episodes , rhinovirus was the commonest organism associated with both asthma exacerbations and non-asthma related episodes . Plausible explanations for much lower virus detection rate than previously reported include improved personal hygiene and pre caution ary measures taken during respiratory tract infections in the immediate post-severe acute respiratory syndrome period together with a significant contribution of other adverse factors like environmental air pollution . We conclude that not all viral infections in children with asthma lead to an asthma exacerbation and the attributing effect of different triggers of asthma exacerbations in children vary across different time periods and across different localities BACKGROUND Although sensitization to fungal allergens is prevalent in inner-city children with asthma , the relationship between fungal exposure and morbidity is poorly understood . OBJECTIVE We examined relationships between fungal sensitization , exposure , and asthma morbidity in inner-city children . METHODS Participants were 5 to 11 years old and enrolled in the Inner-City Asthma Study . This report includes the subset of children with at least 1 positive skin test ( PST ) response to a fungal allergen extract ;  for these children , indoor and outdoor airborne culturable fungi levels were measured at baseline and throughout the 2-year study . Asthma morbidity measures were collected prospect ively . The primary outcome was symptom days per 2 weeks . RESULTS At baseline , children with a PST response to a fungal allergen extract had significantly more symptom days compared with those without a PST response to any fungal allergen extract ( 6.3 vs 5.7 days per 2 weeks , P = .04 ) . During the study , increases in total fungal exposure and indoor Penicillium species exposure were associated with increases in symptom days and asthma-related unscheduled visits . Indoor exposures to total fungi and to Penicillium species were associated with significant increases in unscheduled visits , even after controlling for outdoor fungal levels . Adverse effects associated with exposure to a specific fungus were stronger among children with PST responses to that fungal allergen extract compared with those seen in children with negative skin test responses . CONCLUSION Outdoor fungal exposure is primarily associated with increased asthma symptoms and increased risk of exacerbations in this population Background : Adverse respiratory effects in children with asthma are associated with exposures to nitrogen dioxide ( NO2 ) . Levels indoors can be much higher than outdoors . Primary indoor sources of NO2 are gas stoves , which are used for cooking by one-third of U.S. households . We investigated the effects of indoor NO2 exposure on asthma severity among an ethnically and economically diverse sample of children , controlling for season and indoor allergen exposure . Methods : Children 5–10 years of age with active asthma ( n = 1,342 ) were recruited through schools in urban and suburban Connecticut and Massachusetts ( 2006–2009 ) for a prospect i ve , year-long study with seasonal measurements of NO2 and asthma severity . Exposure to NO2 was measured passively for four , month-long , periods with Palmes tubes . Asthma morbidity was concurrently measured by a severity score and frequency of wheeze , night symptoms , and use of rescue medication . We used adjusted , hierarchical ordered logistic regression models to examine associations between household NO2 exposure and health outcomes . Results : Every 5-fold increase in NO2 exposure above a threshold of 6 ppb was associated with a dose-dependent increase in risk of higher asthma severity score ( odds ratio = 1.37 [ 95 % confidence interval = 1.01–1.89 ] ) , wheeze ( 1.49 [ 1.09–2.03 ] ) , night symptoms ( 1.52 [ 1.16–2.00 ] ) , and rescue medication use ( 1.78 [ 1.33–2.38 ] ) . Conclusions : Asthmatic children exposed to NO2 indoors , at levels well below the U.S. Environmental Protection Agency outdoor st and ard ( 53 ppb ) , are at risk for increased asthma morbidity . Risks are not confined to inner city children , but occur at NO2 concentrations common in urban and suburban homes BACKGROUND House dust mite ( HDM ) allergy is a frequent cause of allergic asthma in children . Reduction of exposure seems to be the most logical way to treat these patients . OBJECTIVE Our aim was to investigate whether mattress and pillow encasings result ed in an effective long-term control of HDM allergen levels , thereby reducing the need for asthma medication in children with asthma and HDM allergy . METHODS In a prospect i ve , double-blind , placebo-controlled study 60 children ( age range , 6 - 15 years ) with asthma and HDM allergy were r and omized to active ( allergy control ) or placebo mattress and pillow encasings . After a 2-week baseline period , follow-up was performed every 3 months for 1 year . During the entire study period , the dose of inhaled steroids was tapered off to the lowest effective dose according to well-defined criteria . RESULTS Fifty-two patients completed the trial , and 5 were excluded , leaving data from 47 children ( 26 in the active treatment group and 21 in the placebo group ) for analysis . A significant perennial reduction in HDM allergen concentrations was seen only for the active treatment group . Also , a significant decrease in the dose of inhaled steroids ( mean , 408 to 227 microg/d ; P < .001 ) was found for the active treatment group only , with significant differences between groups after 9 and 12 months . After 1 year , the dose of inhaled steroids was reduced by at least 50 % in significantly more children in the active treatment group than in the placebo group ( 73 % vs 24 % , P < .01 ) . CONCLUSION Encasing of mattresses and pillows result ed in a significant long-term reduction in HDM allergen concentrations in mattresses and in the need for inhaled steroids in children with asthma and HDM allergy There is growing evidence that asthma symptoms can be aggravated or events triggered by exposure to indoor nitrogen dioxide ( NO2 ) emitted from unflued gas heating . The impact of NO2 on the respiratory health of children with asthma was explored as a secondary analysis of a r and omised community trial , involving 409 households during the winter period in 2006 ( June to September ) . Geometric mean indoor NO2 levels were 11.4 μg·m−3 , while outdoor NO2 levels were 7.4 μg·m−3 . Higher indoor NO2 levels ( per logged unit increase ) were associated with greater daily reports of lower ( mean ratio 14 , 95 % CI 1.12–1.16 ) and upper respiratory tract symptoms ( mean ratio 1.03 , 95 % CI 1.00–1.05 ) , more frequent cough and wheeze , and more frequent reliever use during the day , but had no effect on preventer use . Higher indoor NO2 levels ( per logged unit increase ) were associated with a decrease in morning ( -17.25 mL , 95 % CI -27.63– -6.68 ) and evening ( -13.21 , 95 % CI -26.03– -0.38 ) forced expiratory volume in 1 s readings . Outdoor NO2 was not associated with respiratory tract symptoms , asthma symptoms , medication use or lung function measurements . These findings indicate that reducing NO2 exposure indoors is important in improving the respiratory health of children with asthma Objective To assess whether non-polluting , more effective home heating ( heat pump , wood pellet burner , flued gas ) has a positive effect on the health of children with asthma . Design R and omised controlled trial . Setting Households in five communities in New Zeal and . Participants 409 children aged 6 - 12 years with doctor diagnosed asthma . Interventions Installation of a non-polluting , more effective home heater before winter . The control group received a replacement heater at the end of the trial . Main outcome measures The primary outcome was change in lung function ( peak expiratory flow rate and forced expiratory volume in one second , FEV1 ) . Secondary outcomes were child reported respiratory tract symptoms and daily use of preventer and reliever drugs . At the end of winter 2005 ( baseline ) and winter 2006 ( follow-up ) parents reported their child ’s general health , use of health services , overall respiratory health , and housing conditions . Nitrogen dioxide levels were measured monthly for four months and temperatures in the living room and child ’s bedroom were recorded hourly . Results Improvements in lung function were not significant ( difference in mean FEV1 130.7 ml , 95 % confidence interval −20.3 to 281.7 ) . Compared with children in the control group , however , children in the intervention group had 1.80 fewer days off school ( 95 % confidence interval 0.11 to 3.13 ) , 0.40 fewer visits to a doctor for asthma ( 0.11 to 0.62 ) , and 0.25 fewer visits to a pharmacist for asthma ( 0.09 to 0.32 ) . Children in the intervention group also had fewer reports of poor health ( adjusted odds ratio 0.48 , 95 % confidence interval 0.31 to 0.74 ) , less sleep disturbed by wheezing ( 0.55 , 0.35 to 0.85 ) , less dry cough at night ( 0.52 , 0.32 to 0.83 ) , and reduced scores for lower respiratory tract symptoms ( 0.77 , 0.73 to 0.81 ) than children in the control group . The intervention was associated with a mean temperature rise in the living room of 1.10 ° C ( 95 % confidence interval 0.54 ° C to 1.64 ° C ) and in the child ’s bedroom of 0.57 ° C ( 0.05 ° C to 1.08 ° C ) . Lower levels of nitrogen dioxide were measured in the living rooms of the intervention households than in those of the control households ( geometric mean 8.5 μg/m3 v 15.7 μg/m3 , P<0.001 ) . A similar effect was found in the children ’s bedrooms ( 7.3 μg/m3 v 10.9 μg/m3 , P<0.001 ) . Conclusion Installing non-polluting , more effective heating in the homes of children with asthma did not significantly improve lung function but did significantly reduce symptoms of asthma , days off school , healthcare utilisation , and visits to a pharmacist . Trial registration Clinical Trials NCT00489762 Current underst and ing of the use of exclusion diets in the management of  asthma in children is limited and controversial . The aim of this study was to examine the effects of excluding eggs and milk on the occurrence of symptoms in children with asthma and involved 22 children aged between three and 14 years clinical ly diagnosed as having mild to moderate disease . The investigation was single blind and prospect i ve , and parents were given the option of volunteering to join the ‘ experiment ’ group , avoiding eggs , milk and their products for eight weeks , or the ‘ control ’ group , who consumed their customary food . Thirteen children were recruited to the experimental group and nine to the control group . A trained paediatrician at the beginning and end of the study period assessed the children . A seven-day assessment of food intake was made before , during and immediately after the period of dietary intervention in both groups . A blood sample was taken from each child for determination of food specific antibodies and in those children who could do so , the peak expiratory flow rate ( PEFR ) was measured . Based on the recommended nutrient intake ( RNI ) , the mean percentage energy intake of the children in the experimental group was significantly lower ( p<0.05 ) in the experimental group . After the eight-week study period and compared with baseline values , the mean serum anti-ovalbumin IgG and anti-beta lactoglobulin IgG concentrations were statistically significantly reduced ( p<0.05 ) for both in the experimental group . In contrast , the values for anti-ovalbumin IgG in the control group were significantly increased and those for anti-beta lactoglobulin IgG were practically unchanged . The total IgE values were unchanged in both groups . Over the study period , the PEFR in those children in the experimental group able to perform the test was significantly increased , but no such change was noted in the children in the control group who could do the test . These results suggest that even over the short time period of eight weeks , an egg- and milk-free diet can reduce atopic symptoms and improve lung function in asthmatic children Objectives This study was carried out to determine the effectiveness of physical and chemical environmental control measures for house dust mites ( HDM ) in controlling bronchial asthma in children . Methods A total of 160 asthmatic children who were sensitized to HDM underwent clinical and environmental assessment .  The children were r and omly allocated into one of four groups according to the intervention ( chemical , physical , both chemical and physical , none ) and the effectiveness of the intervention was assessed at 8 and 16 weeks . Results The group for which physical control measures were used showed significant improvement in all outcome measures , including mean differences of forced expiratory volume after 1 s ( FEV1 ) and peak expiratory flow rate ( PEFR ) , which were 2.05 % and 4.65 l/min , respectively , at the 8-week follow-up evaluation . The percentage of severe asthma decreased from 45 to 22 % . Similar results were obtained for the group with both chemical ( tannic acid ) and physical interventions ( p < 0.05 for all measures ) . In the group where tannic acid was used as a chemical measure , the number of children with moderate and severe asthma decreased from 15 in each category to 11 and 7 , respectively . In the control group , only the mean difference of PEFR ( 1.62 l/min ) was significant after 16 weeks . Despite these promising findings , only the FEV1 was significantly different ( p = 0.014 ) when the four groups were compared . Conclusions Based on these results , we conclude that simple physical control measures have the potential to contribute to the control of asthma symptoms in asthmatic children sensitized to HDM allergen BACKGROUND Previous studies do not provide a clear picture of the relationship between nitrogen dioxide ( NO(2 ) ) exposure and asthma . METHODS Eighteen schools using unflued gas heating in winter were r and omly allocated to either retain their heaters ( 10 control schools ) or to have replacement flued gas or electric heaters installed at the beginning of winter  ( 8 intervention schools ) . Fortnightly telephone interviews were used to record daily individual asthma symptoms that occurred over 12 weeks ( including winter ) . Lung function and histamine challenge tests were performed at baseline and the end of the study . NO(2 ) was measured in each school classroom on 9 days and in each household on 3 days spread over the study period . RESULTS From 199 primary school children that met the eligibility criteria , 45 intervention and 73 control children agreed to participate . Baseline characteristics were similar between groups . Difficulty breathing during the day ( Relative Risk [ RR ] = 0.41 ; 95 % CI : 0.07 , 0.98 ) and night ( RR = 0.32 ; 95 % CI : 0.14 , 0.69 ) , chest tightness during the day ( RR = 0.45 ; 95 % CI : 0.25 , 0.81 ) , and daytime asthma attacks ( RR = 0.39 ; 95 % CI : 0.17 , 0.93 ) were significantly reduced in the intervention group . Percentage predicted forced expiratory volume in one second ( FEV(1 ) ) , the concentration of histamine inducing a 20 % fall in FEV(1 ) ( PD(20 ) ) , and the dose-response slope ( DRS ) were similar between groups at follow-up . Mean ( st and ard deviation ) NO(2 ) levels were 15.5 ( 6.6 ) parts per billion ( ppb ) and 47.0 ( 26.8 ) ppb in the intervention and control schools respectively ( P < 0.001 ) . CONCLUSIONS Asthma symptoms were reduced following a replacement intervention that removed high exposure to NO(2 ) . Such replacement should be considered a public health priority for schools using unflued gas heating during winter OBJECTIVE To evaluate the impact of a multifaceted environmental and educational intervention on the indoor environment and health in 5 - 12-year-old children with asthma living in urban environments . DESIGN Changes in indoor allergen levels and asthma severity measurements were compared between children who were r and omized to intervention and delayed intervention groups in a 14-month prospect i ve field trial . Intervention group households received dust mite covers , a professional house cleaning , and had roach bait and trays placed in their houses . RESULTS Of 981 eligible children , 410 ( 42 % ) were enrolled ; 161 ( 40 % ) completed baseline activities and were r and omized : 84 to intervention and 77 to delayed intervention groups . At the study 's end , dust mite levels were 163 % higher than at baseline for the delayed intervention group . Overall asthma severity scores did not change . However , the median functional severity score ( FSS ) component of the severity score improved more in the intervention group ( 33 % vs. 20 % ) than in the delayed intervention group . At the study 's end , the median FSSs for the intervention group improved 25 % compared with the delayed intervention group , ( p<0.01 ) . Differences between groups for medication use , emergency department ( ED ) visits or hospitalization were not significant . CONCLUSIONS Despite low retention , the intervention result ed in decreased dust mite allergen levels and increased FSSs among the intervention group . The interventions probably contributed to the improvements , especially among the more severely affected children . This study highlights the complexities of design ing and assessing the outcomes from a multifaceted asthma intervention BACKGROUND The relationship between exposure to house dust mite ( HDM ) allergens and prevalence of sensitization to these allergens in patients with asthma has been confirmed in many studies . Mite population growth is regulated by humidity . Reducing humidity and removing allergen by efficient vacuuming should control mite allergen and reduce symptoms . OBJECTIVE We sought to investigate the effect of mechanical ventilation and high-efficiency vacuuming on HDM numbers and Der p 1 concentrations in the homes of mite-sensitive asthmatic subjects and to evaluate the effect of any reductions on symptoms . METHODS The homes of 40 HDM-sensitive asthmatic subjects were r and omized to receive ( 1 ) mechanical ventilation and a high-efficiency vacuum cleaner ( HEVC ) ; ( 2 ) mechanical ventilation alone ; ( 3 ) an HEVC alone ; and ( 4 ) no intervention . Homes and patients were monitored for 12 months . Change in absolute humidity , mite numbers , Der p 1 concentrations , lung function , bronchial hyperresponsiveness , and symptom scores were analyzed . RESULTS Homes with mechanical ventilation achieved significantly lower humidity levels than those without ( P < .001 ) , with an associated reduction of mite numbers ( P < .05 ) and Der p 1 concentrations ( P < .001 ¿ in nanograms per gram , P = .006 ¿ in milligrams per square meter ) in bedroom carpets and some other mite sources in the ventilated areas of the homes . The addition of a vacuum cleaner enhanced this effect . There was a trend for an improvement in histamine PC(20 ) ( P = .085 ) in the patients whose homes were ventilated . CONCLUSION The use of a mechanical ventilation system in suitable homes result ed in some reduction in numbers of HDM and Der p 1 concentrations . The addition of an HEVC slightly enhanced the effect but not sufficiently to see an improvement in symptoms A four-year longitudinal study of the prevalence of respiratory symptoms and disease in schoolchildren and related environmental and socio-economic factors is in progress . We report results for the first year of this study ( 1973 ) . A total of 5758 children aged 6 to 11 years from 28 r and omly selected areas of Engl and and Scotl and were examined . In an analysis of the effects on health of possible indoor pollutants , boys and girls from homes in which gas was used for cooking were found to have more cough , " colds going to the chest " , and bronchitis than children from homes where electricity was used . The girls also had more wheeze if their families used gas for cooking . This " cooking effect " appeared to be independent of the effects of age , social class , latitude , population density , family size , overcrowding , outdoor levels of smoke and sulphur dioxide and types of fuel used for heating . It was concluded that elevated levels of oxides of nitrogen arising from the combustion of gas might be the cause of the increased respiratory illness
OBJECTIVE To complete a systematic review of the literature describing associations between all environmental exposures and  asthma symptoms and exacerbations in children up to mean age of 9 years .