• The Environmental History Form is available in the original guideline document and as a Word document on the Web (http://www.neetf.org/Health/asthmahistoryform.htm)
• This form is intended for use with children already diagnosed with asthma. Designed for ease of use, the Environmental History Form is obviously not comprehensive and is intended as an initial intake tool.
• It is recommended that a health care provider (physician, nurse, nurse practitioner, or physician's assistant) administer the questions rather than being given to the patient's caregiver to fill out.
• This form should also be used to elicit information on triggers commonly overlooked, such as weekly trips to a relative where a hobby or pet is located.

Environmental Intervention Guidelines

• These environmental intervention guidelines are to be used for children already diagnosed with asthma. A separate fact sheet is provided for each of the major environmental asthma triggers. The questions on these fact sheets are intended to supplement the questions listed in the environmental history form related to each trigger. Interventions that are thought to be the most crucial for each asthma trigger are listed first and in bold type.
• In addition to educating families on effective interventions, it is also important to explain why certain interventions are not recommended, particularly the use of ozone-generating air cleaners which may be harmful.
• Providers should give families affected by asthma: educational materials (an example of a patient handout is listed under each trigger); relevant website information; and information about allergy supplies, smoking cessation programs, and other community resources. A variety of these materials available from a number of organizations are listed at http://www.neetf.org/Health/asthma_resources.htm.
• The intervention guidelines assume a two-visit concept for the patient. The first visit includes taking an environmental history, possible allergy testing or referral, and a commitment by the parent to work on reducing exposures to known allergens or irritants. The second, follow-up visit involves counseling of the patient or patient's family on controlling the exposures that trigger the child's asthma. In addition to this two-visit concept, providers should work with the family to schedule appropriate follow-up visits to evaluate the patients' self-management skills. It is very important to ask about all environments in which a child with asthma may be spending significant amounts of time, including all residences where the child sleeps or spends time, such as schools, daycares, camps, and college dorms.
• Although primary care providers do not perform skin testing as an asthma specialist might, in vitro testing is an option that may be considered. However, any testing should be focused on allergens that are identified by the environmental history, and should not replace timely allergy referral. The health care provider should try to document sensitivity for each suspected allergen through allergy testing before making any major or costly recommendations related to environmental controls. However, some simple and low cost recommendations may be reasonable, particularly in areas where widespread exposure to cockroaches or dust mites is well known. Providers can assist families in implementing environmental interventions by helping them prioritize the changes they make in the home. For example, providers can encourage families to begin by creating a safe sleeping zone for the child.
• A separate fact sheet is not provided for outdoor pollens (from trees, grass, or weeds) and molds. To avoid exposures, children should be recommended to stay indoors with windows closed in an air conditioned environment — if possible — during the season in which they have problems with outdoor allergens, especially during the afternoon.
• Viral illnesses are not included in this list of environmental triggers, although their importance in triggering and exacerbating asthma is recognized. Primary care providers should remain aware that when a child with known asthma develops an upper respiratory infection, an asthma exacerbation is likely to follow.
• Environmental management is only one component of a comprehensive asthma management plan. It is recommended that these materials be used in conjunction with the National Asthma Education and Prevention Program's clinical and pharmacological guidelines.

Dust Mites and Asthma

Additional History Questions to Supplement the History Form

• Did you know that dust mite exposure can trigger asthma symptoms?
• What type of floor covering is in your child's bedroom?
• Do you have a vacuum cleaner with a high efficiency particulate air (HEPA) filter?
• What have you tried so far to reduce dust/dust mite exposure?
• How often do you wash your child's bed linens?
• Are you currently using a mattress or pillow covering on your child's bed?
• Do you use other ways to decrease dust mite exposure?

Possible Interventions

No matter how clean a home is, dust mites cannot be totally eliminated. The following suggestions can reduce exposure. Emphasis should be placed on reducing dust mite exposure where the child sleeps.

• Encase all pillows and mattresses of the beds that the child sleeps on using allergen impermeable encasings. (There are numerous sources for allergen impermeable encasings, and prices as well as quality may vary.)
• Wash bedding weekly to remove allergen. Wash in hot water (130˚ F) to kill mites
• Replace wool or feathered bedding with synthetic materials that will withstand repeated hot water washing
• Either remove from the bedroom or wash and thoroughly dry stuffed toys weekly
• Move stuffed toys away from the pillow the child sleeps on
• Vacuum once or twice weekly preferably using a vacuum cleaner with a HEPA filter or a double-layered microfilter bag (when the child is not around)
• Use a damp mop or rag to remove dust, not a dry cloth that just stirs up dust mite allergens
• Avoid use of humidifiers
• The following interventions are expensive and are only recommended after an allergist has identified your child as allergic to dust mites:
• Consider replacing draperies with blinds or other wipeable window covering
• Consider carpet removal in the child's bedroom
• Consider removing upholstered furniture
• Consider using portable air cleaner with HEPA filter for child's bedroom
• Avoid use of ozone generators and certain ionic air cleaners which can actually generate harmful ozone

Animal Allergens and Asthma

Additional History Questions to Supplement the History Form

• What type of furry pet(s) do you have (and how many of each)?
• Is it a strictly indoor pet? outdoor? indoor/outdoor?
• Does your child sleep with the pet?
• Has your child's asthma become worse since having the pet?
• If you moved your pet outdoors, did your child's asthma improve?
• If there is evidence of rodents in your home, how severe is the problem (mild, moderate, severe, very severe)
• Does your child's classroom (or other places he/she spends time) have a furry pet that he/she plays with?

Possible Interventions

Interventions with regard to pets should only be recommended if the child is allergic to the animal. Testing should therefore be done before making any recommendations. To reduce your child's exposure to animal allergens, the first two options below have been shown to be the most effective:

• Consider finding a new home for indoor cats, dogs, and pet rodents
• At a minimum, keep pets outside
• If neither of those are possible, the following may help reduce exposure:
  • Keep pets out of the child's bedroom
  • Encase mattresses and pillows
  • Remove carpets
  • Vacuum regularly using a cleaner with a HEPA filter or a double-layered microfilter bag (when the child is not around)
  • Use portable air cleaner with HEPA filter for child's bedroom
  • Keep pets off furniture and out of cars
  • Bathing cats and dogs has been shown to decrease these allergens, however, it must be done at least twice a week to be effective
• If rats or mice have been observed, use the least toxic extermination method, such as traps and baits
• Also use methods listed for cockroach control (See Cockroach Allergen and Asthma fact sheet below and on page 22 of the original guideline document)

Cockroach Allergen and Asthma

Additional History Questions to Supplement the History Form:

• Approximately how many cockroaches do you see in your home on a daily basis?
• Do you see evidence of cockroach droppings?
• How do you get rid of the cockroaches in your home?
• Does your child's school (or other places she/he spends time) have cockroaches?

Possible Interventions

Eradication can be very difficult, especially in apartment buildings, and it is often temporary. Roaches follow food and water sources in your house. In general, the least toxic methods of roach control should be employed first.

• Clean up all food items/crumbs/spills as soon as possible
• Store food and trash in closed containers
• Limit spread of food around house, especially bedrooms
• Fix water leaks under sinks
• Mop kitchen floor at least once a week
• Clean counter tops daily
• Take garbage out daily
• Check for and plug up crevices outside your house that cockroaches may enter
• Use the integrated pest management (IPM) approach for extermination — least toxic methods first
• Use boric acid powder under stoves and other appliances
• Use bait stations and gels. It is highly recommended to use a professional, licensed exterminator.
• If you choose to apply the pesticides yourself, read the product label and follow all directions carefully
• Avoid using liquid sprays inside the house, especially near places children crawl, play, or sleep
• Never attempt to use industrial strength pesticide sprays that require dilution

Mold/Mildew and Asthma

Additional History Questions to Supplement the History Form

• Do you see mold growth in any part of your home?
• How large an area is the mold growth? (i.e. greater than 3 ft. x 3 ft?)
• Does your child's school (or other places he/she spends time) have mold growth?
• Do you have problems with moisture or leaks in your home?
• Do you frequently have condensation on your windows?
• Have you tried using something to decrease the humidity in your home?

Possible Interventions

The emphasis should first be on controlling all sources of moisture in the house. Items that are too moldy to clean should be discarded. The size of the mold contamination in the house should determine how the mold gets cleaned up. Generally, an area of 3 feet x 3 feet or larger should be cleaned by a professional.

• Check faucets, pipes, and ductwork for leaks and repair as soon as possible
• Control indoor humidity
  • Use a dehumidifier or air conditioner (non-evaporative or water-filled type) to maintain indoor relative humidity below 50%
  • Clean the dehumidifier as instructed by the manufacturer
  • Do not use a humidifier
  • Vent bathrooms and clothes dryers to the outside
  • Install and use exhaust fans in the kitchen, baths and damp areas
  • Avoid carpet and wallpaper in rooms prone to dampness
  • For those who own a home with an evaporative cooler, control the humidity level with a dehumidifier
• When first turning on home or car air conditioners, have your child leave the room or drive with the windows open for several minutes to allow mold spores to disperse
• Remove decaying debris from the yard, roof, and gutters
• Your child should avoid raking leaves, mowing lawns, or working with peat, mulch, hay, or dead wood if he/she is allergic to mold spores
• If you choose to clean mold yourself, use chlorine solution diluted 1:10 with water but do not mix bleach with other cleaning solutions containing ammonia due to toxic fumes
• Quaternary ammonium compounds are effective fungicides when bleach cannot be used
• For extensive mold contamination, (greater than 9 square feet – 3 ft. x 3 ft.) professional removal is recommended.

Environmental Tobacco Smoke and Asthma

Additional History Questions to Supplement the History Form

• Who in the family smokes cigarettes?
• How many cigarettes per day?
• Does he/she (they) smoke in the house?
• Outside? Both inside and outside? In the car?
• Does anyone who spends time at your house smoke (friends, neighbors, relatives)?
• Have you established a smoking ban or no smoking policy in the household?
• Does anyone smoke in childcare settings where the child stays?
• Describe the circumstances when your child may be exposed to smoke?

Possible Interventions

• Keep your home and car smoke-free
• Seek support to quit smoking, consider aids such as nicotine gum, patch, and medication from your doctor to help you in quitting
• Choose smoke-free childcare and social settings
• Seek smoke-free environments in restaurants, theaters, and hotel rooms
• If you choose to smoke, do not smoke near your child

Air Pollution and Asthma

Additional History Questions to Supplement the History Form

Indoor Air Pollution Questions

• Do you live in a home that was built in the past 1 to 2 years?
• If you recently made changes to your house – installed new carpets, painted, or other changes – how long ago was that?
• Was there a change in your child's asthma symptoms after moving to a new house or having the work mentioned above done in your home?
• Do you ever notice a chemical smell in your home?
• If you have a wood burning fireplace or stove, how many times per month in the winter do you use it?
• Does anyone in your house use strong-smelling perfumes, scented candles, hairsprays, or other aerosol substances?

Outdoor Air Pollution Questions

• Do you live within 300 yards of a major roadway or highway? An area where trucks or other vehicles idle? A major industry with smokestacks?
• Is residential or agricultural burning a problem where you live?
• How do you hear about air quality alerts?

Possible Interventions

For indoor air pollution, the two best approaches to reducing indoor air pollution are source control and ventilation.

• Eliminate tobacco smoke
• Use good housekeeping practices to control particles
• Install an exhaust fan close to the source of contaminants, and vent it to the outside
• Properly ventilate the room where a fuel-burning appliance is being used
• Ensure that wood stove doors are tight-fitting
• Follow manufacturers' instructions when using an unvented kerosene or gas space heater
• Ensure that fireplaces are properly vented so smoke escapes through the chimney
• Never use a gas-cooking appliance as a heating source
• Open windows especially when indoor pollutant sources are in use (this option must be balanced against the concern of mold or other plant allergens and outdoor air pollution)
• Parents should change clothes prior to returning from work if they work around any strong smelling chemicals or paints or other toxic substances
• Avoid strong odors and minimize use of products and materials that emit irritants, such as smoke, strong perfumes, talcum powder, hair sprays, cleaning products, paint fumes, sawdust, chalk dust, air freshener sprays, and insect sprays

Outdoor air pollution, especially ozone and particulate matter can increase asthma symptoms.

• Monitor air quality index levels and reduce your child's outdoor activities when the Air Quality Index (AQI) is in the unhealthy range
• If your child's symptoms are worse or he/she requires more albuterol (rescue medicine) the day after AQI levels are in the unhealthy range, contact your health care provider
• Use HEPA filters in household vents
• Reduce use of candles, wood-burning stoves and fireplaces
• If particle pollution levels are high outdoors, do not vacuum the floor since this increases particle levels indoors
• Advise your child to stay away from the exhaust pipe of idling school buses and trucks
• Consider moving to a new location if this is possible

Electronic copies: Available in Portable Document Format (PDF) from the National Environmental Education and Training Foundation Web site.

Print copies: Available from The National Environmental Education & Training Foundation, 4301 Connecticut Avenue NW, Suite 160, Washington, DC 20008.

• Resources for environmental management of pediatric asthma. Washington (DC): National Environmental Education & Training Foundation (NEETF). Electronic copies: Available from the National Environmental Education and Training Foundation Web site.

The following are also available in the original guideline document:

• Set of competencies for the environmental management of asthma (Part 1)
• Environmental history form for pediatric asthma patient (Part 2)
• Asthma home environment checklist (Appendix)

Sample patient flyers and patient information sheets on environmental allergens are available in the original guideline document.

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