Recent advances in environmental controls outside the home setting

Effective Ways to Prevent Allergic Diseases: Where Do We Stand?

Since allergic diseases are of great public health relevance, effective primary prevention strategies are urgently needed. This chapter gives an overview of existing primary prevention programs on environmental exposures and dietary strategies based on epidemiological studies which have defined risk- and protective factors for the development of allergic diseases.The allergy protective effect mediated by growing up on a traditional farm environment is well studied. But the exact underlying mechanisms have still not been fully clarified and have not yet led to concrete prevention strategies. The beneficial effect of avoiding cigarette smoke exposure, indoor moisture and molds in pregnancy and childhood on the development of asthma is well documented. Whereas the avoidance of house dust mite exposure is not recommended to prevent eczema or allergy. Dietary supplementation with vitamins, pre- and probiotics in pregnant woman and their offspring is not harmful but evidence for the prevention of allergic diseases is still lacking. Fish oil consumption was shown to be asthma protective. The early introduction of peanuts and egg protein to prevent peanut and egg allergy in children with atopic dermatitis is promising. Further studies are needed to increase the overall evidence in allergy prevention. Most studies lack methodological standards such as randomization and blinding. More evidence is in demand on the potential beneficial impact of multifaceted interventional studies. The future of allergy prevention strategies might be based on individual risk assessment. Therefore, research in the immunological and molecular basis of allergic diseases needs to be promoted.

The Role of Environmental Controls in Managing Asthma in Lower-Income Urban Communities

Children living in lower-income urban communities are at much greater risk of developing asthma, going to the emergency department for an asthma attack and being hospitalized for asthma than children living in upper- and middle-income communities. For many asthmatic children living in urban communities, especially those with greater morbidity, the allergic pathway is important in the etiology of the disease. The stages of developing allergic disease can be divided into the onset of allergic sensitization, development of allergic disease and subsequent exacerbations, and it is useful to consider the relevance of interventions at each of these stages. Indoor allergens and environmental exposures are a major contributor to allergic disease, particularly among lower socioeconomic status, urban, minority communities. These exposures include allergens, environmental tobacco smoke, combustion by-products, and mold, all of which can play an important role in asthma progression as well as morbidity. These exposures are often not found in isolation and thus these concomitant exposures need to be considered when conducting environmental interventions. There have been numerous studies looking at both primary and tertiary prevention strategies and the impact on allergic sensitization and asthma with varied results. While the outcomes of these studies have been mixed, what has emerged is the need for tertiary interventions to be targeted to the individual and to reduce all relevant exposures to which an asthmatic child is exposed and sensitized. In addition, effective intervention strategies must also consider other social determinants of asthma morbidity impacting low socioeconomic, urban communities.

Update in Pediatric Asthma: Selected Issues

Asthma is a complex condition that affects 14% of the world's children and the approach to management includes both pharmacologic as well as non-pharmacologic strategies including attention to complex socioeconomic status phenomena. After an historical consideration of asthma, allergic and immunologic aspects of asthma in children and adolescents are presented. Concepts of socioeconomic aspects of asthma are considered along with environmental features and complications of asthma disparities. Also reviewed are links of asthma with mental health disorders, sleep disturbances and other comorbidities. A stepwise approach to asthma management is discussed that includes pharmacologic and non-pharmacologic strategies in the pediatric population. The role of immunotherapy and use of various immunomodulators are considered as well.

School Environmental Intervention Programs

Exposure to indoor allergens and pollutants plays a significant part in the development of asthma and its associated morbidity. Inner-city children with asthma are disproportionately affected by these exposures with increased asthma morbidity. Although years of previous research have linked exposures in the urban home environment with significant childhood asthma disease, many of these allergens are also present in inner-city school environments. Therefore, evaluation of the school environment of patients with asthma is also essential. School-based environmental interventions may offer benefit for this problem and has the potential to help many children with asthma at once in a cost-effective manner. It is important that environmental health researchers continue to assess which interventions are most practical and result in the greatest measurable improvements.

A Review of the Field on Children's Exposure to Environmental Contaminants: A Risk Assessment Approach

Background: Children must be recognized as a sensitive population based on having biological systems and organs in various stages of development. The processes of absorption, distribution, metabolism and elimination of environmental contaminants within a child's body are considered less advanced than those of adults, making them more susceptible to disease outcomes following even small doses. Children's unique activities of crawling and practicing increased hand-to-mouth ingestion also make them vulnerable to greater exposures by certain contaminants within specific environments. Approach: There is a need to review the field of children's environmental exposures in order to understand trends and identify gaps in research, which may lead to better protection of this vulnerable and sensitive population. Therefore, explored here are previously published contemporary works in the broad area of children's environmental exposures and potential impact on health from around the world. A discussion of children's exposure to environmental contaminants is best organized under the last four steps of a risk assessment approach: hazard identification, dose-response assessment, exposure assessment (including children's activity patterns) and risk characterization. We first consider the many exposure hazards that exist in the indoor and outdoor environments, and emerging contaminants of concern that may help guide the risk assessment process in identifying focus areas for children. A section on special diseases of concern is also included. Conclusions: The field of children's exposures to environmental contaminants is broad. Although there are some well-studied areas offering much insight into children exposures, research is still needed to further our understanding of exposures to newer compounds, growing disease trends and the role of gene-environment interactions that modify adverse health outcomes. It is clear that behaviors of adults and children play a role in reducing or increasing a child's exposure, where strategies to better communicate and implement risk modifying behaviors are needed, and can be more effective than implementing   changes in the physical environment.