Pediatric asthma has many causes and can manifest differently in different children and at different times. Understanding the many factors related to the development and exacerbation of asthma is complicated by the complexity of the many environmental exposures related to asthma development and morbidity. Furthermore, the same environmental exposures that may cause increased symptoms at 1 point in time may be protective when the exposure occurs earlier or at high enough levels. We know that environmental exposures such as allergens, irritants, and pollutants are quite complex in their composition; further examination of this complexity may improve our understanding of this complex and highly prevalent disease. Pediatrics 2009;123:S160-S167 I N THE PAST 20 years, we have begun to understand that airway inflammation in asthma arises from maladaptation to environmental stresses. In studying this process, we have tended to focus on one mechanism or another (eg, immunoglobulin E [IgE]-mediated responses to biological materials or oxidative stress resulting from ozone or particulates) and have found evidence that each is important. Patients encounter these environmental stresses simultaneously, however, and this simultaneous exposure may enhance responses (ie, adjuvant or priming) or may decrease responses to one of the stressors. We have begun to address the issue of complex responses to simultaneous exposure to other bioactive materials in the hygiene hypothesis. 1,2 Originally, this hypothesis proposed that the increased prevalence of allergic diseases was related to a population shift in immune responsiveness because infectious illnesses were less prevalent. More recently, researchers found that children had less asthma and allergic disease when they were exposed early in life to endotoxin from Gram-negative bacteria, 2 a finding that seems to confirm the hygiene hypothesis. This finding, however, could also be an example of effect modification (ie, simultaneous exposure to endotoxin in airborne particulates decreased IgE-mediated sensitization to allergens).
ENVIRONMENTAL ALLERGENS ARE CARRIED ON PARTICLESOur understanding of environmental allergen exposure depends on continually developing technology that allows us to measure levels of allergenic proteins in the environment. Technological advances have made it possible to test the hypotheses that environmental allergen exposure is related to sensitization, asthma prevalence and severity, and asthma incidence rates. In addition, asthma prevalence and severity have clear dose-response relationships to allergen exposure. Indoor allergen levels measured both in settled household dust and in indoor air are more clearly related to asthma than are outdoor allergen levels 3 ; therefore, many of the data supporting a discussion of interactions between allergens and pollutants refer to indoor allergen exposure. An important corollary of those studies is the demonstration that allergens carried on airborne particles have clearly defined characteristics that are rel...