Steps families take to minimize asthma triggers in the home are either wrong or ignored

Parents of children who suffer with asthma are making many efforts to clear their homes of substances that could trigger their child's symptoms, but the steps they take aren't always the ones that could do the most good, a new University of Michigan study finds. And many don't take other steps that are known to help.

In fact, only half of the 1,788 asthma-proofing steps taken by parents of 896 asthmatic children in the study were likely to work. The other half were unproven, unlikely to be helpful against the child's individual triggers, or, in a few cases, potentially harmful.

This follows Swedish research released this week that found a clear co-variation between allergic symptoms in children and the concentration of softening agents in their homes.

Asthma is one of the most common chronic diseases in children, affecting at least 4.8 million in the United States. Although physical activity is an essential ingredient for healthy development, it can trigger asthma attacks in susceptible children. The researchers suggested that future study focus on why such a large percentage of asthmatic children were unprepared on the playing fields.

The study's authors say their findings indicate a tremendous need for doctors and other health care providers to educate parents about what might be triggering their child's asthma symptoms and attacks, and about the most effective steps they can take to reduce their child's exposure to those substances.

The research results, based on in-depth interviews, are published in the August issue of the Journal of Allergy and Clinical Immunology by a team from the U-M Health System, C.S. Mott Children's Hospital, and the U-M School of Public Health.

Most often, parents reported taking steps to control their child's exposure to dust, dust mites and animals, and many said they were using special filters on ventilation systems and vacuum cleaners. All are generally recommended steps under national asthma guidelines, but many parents took steps that wouldn't necessarily work for their child while overlooking others that would.

For instance, parents reported buying a mattress cover for a child whose asthma is triggered by plant pollen, but not shutting windows to keep pollen out of the house.

Even worse, one-quarter of the parents reported that someone in the same household as the asthmatic child smoked, but didn't report that there had been any effort to address this issue. Tobacco smoke is a major trigger for asthma attacks, and contributes to the chronic airway inflammation that characterizes asthma, a breathing disorder that affects 6 million children nationwide.

"Eighty percent of parents in this study knew at least one specific factor that triggered their child's asthma symptoms, and 82 percent of those had devoted some effort to help their children avoid these triggers," says lead author and U-M pediatrician Michael Cabana, M.D., M.P.H, M.A. "But we also found that a lot of parents were pursuing strategies that haven't been endorsed by national guidelines or aren't likely to be helpful given their child's particular triggers."

His co-author, U-M pediatric pulmonologist Toby Lewis, M.D., M.P.H., notes that this discrepancy between what parents were doing and what experts recommend probably stems from a combination of factors.

"The first level of education for parents is to learn that much of asthma occurs as a reaction to triggers in the environment, and that everyone's triggers are different. One of the first steps in getting asthma under control is figuring out a child's triggers," says Lewis, an assistant professor of pediatrics in the U-M Medical School. This is often done by allergy tests and symptom tracking.

"Once you have a child's triggers figured out, then parents need education on what to do," says Lewis. "There's a lack of good information out there about what works, and even when we know what works, it can be hard to do -- such as reducing smoke in a child's environment or quitting smoking. Even when parents know in their head it's the right thing to do, translating that into change is hard. Parents may need a lot of support to be able to follow through on recommendations."

A third factor, Lewis continues, is the constant bombardment of commercial messages about products purported to help reduce asthma symptoms. "Parents hear 'Sprinkle this on your carpet' or 'Clean out your air ducts' or 'Buy this air ionizer' and parents who are desperate to help their kids can get misled into spending money on things of questionable value," she says. "The bottom line is, talk to your doctor before you spend a lot of money, and do the cheap, easy things first."

Asthma education appears to have some effect, the study shows. Parents who had received some asthma education or whose children had seen a doctor regularly were more likely to have taken steps to protect their children from asthma triggers -- though not always the most appropriate ones.

And the study proves that every parent deserves educational outreach, the authors say. There were no differences in rates of taking appropriate anti-asthma action among parents of different races, ethnicities or educational and socioeconomic backgrounds.

"It's impossible to predict which parents are more likely or less likely to take a preventive action, so physicians shouldn't pre-judge who they think will follow advice and who won't," says Cabana, an associate professor of general pediatrics at the U-M Medical School.

The results published today come from the baseline parent interviews of the U-M's Physician Asthma Care Education (PACE) project, which is designed to improve asthma education for physicians, and consequently the health of their young patients who have asthma. The PACE project is led by U-M School of Public Health Dean Noreen Clark, Ph.D., and funded by the Robert Wood Johnson Foundation. Clark is senior author on the new paper.

PACE is part of the U-M Asthma Research Collaborative, a multidisciplinary network of professionals from around the University of Michigan and across partner institutions who share an interest in asthma. Asthma research at the University of Michigan also includes the integration of social, behavioral, environmental, and clinical aspects of asthma and the evaluation of interventions in community and clinical settings

As they compiled the PACE parent interview results, the researchers noticed a mismatch between what parents said their children's asthma triggers were, and what the parents were doing in their homes to reduce the presence of triggering substances.

Only a handful of the actions they were taking were potentially harmful, such as the use of a humidifier in the room of a child whose triggers include house dust mites. (House dust mites thrive in humid environments, and using a dehumidifer is a more appropriate strategy.) But many other strategies described by parents weren't likely to be useful against a child's particular trigger -- or helpful for any child with asthma.

"Physicians need to help parents match the intervention to the trigger, and to talk about what's proven to work and what's less likely to work," says Cabana. "For those who publish national guidelines, it's important to distinguish strategies that are proven from those that are less-proven, or less likely to be useful." The last national guidelines on effective measures for reducing asthma triggers in a child's environment came out in 1997, and while the sections of the guidelines focusing on medicines were updated and clarified in 2002, there have not been major additions to the guidelines.

Recently, studies have shown that there's little or no evidence to support the use of air ionizers, acupuncture, homeopathy or manual therapy for asthma, and that more study is needed on psychotherapy-related measures, dietary supplements, breathing exercises and biofeedback.

Lewis recommends that families with one or more asthmatic children talk with their doctor about asthma-proofing their home and helping reduce exposure to triggers -- and that if major lifestyle changes are needed that they figure out ways to make those work for them.

For example, while a parent works to quit smoking, perhaps by tapering back on the number of cigarettes per day, they should make sure to smoke outside, not just in another room or the garage. And they should realize that it may take weeks for a child's lungs to adjust to the lack of smoke, but that eventually their symptoms will get better.

Gradual progress can also help a child who is allergic to dust mites, the tiny bugs that live in soft materials like bedding, mattresses, upholstery and stuffed animals. "There are so many places that dust mites can hide, it's often hard to know where to start," says Lewis. "A good first step is to work on areas of the house where the child spends the most time, which for many children is their bedroom. Children spend many hours a night snuggled in bed, so covering the pillow and mattress in allergen-proof covers, taking stuffed animals out of the bed, and washing bedding regularly in hot water can make a big difference."

If necessary, parents may want to seek advice from a specialized doctor such as an allergist or a pulmonologist. These specialists emphasize self-management of asthma and prevention of symptoms through the help of nurse managers who take time to explain trigger-reduction methods that are right for each patient.