Reviews and feature article
Environmental determinants of allergy and asthma in early life

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Allergic disease prevalence has increased significantly in recent decades. Primary prevention efforts are being guided by study of the exposome (or collective environmental exposures beginning during the prenatal period) to identify modifiable factors that affect allergic disease risk. In this review we explore the evidence supporting a relationship between key components of the external exposome in the prenatal and early-life periods and their effect on atopy development focused on microbial, allergen, and air pollution exposures. The abundance and diversity of microbial exposures during the first months and years of life have been linked with risk of allergic sensitization and disease. Indoor environmental allergen exposure during early life can also affect disease development, depending on the allergen type, dose, and timing of exposure. Recent evidence supports the role of ambient air pollution in allergic disease inception. The lack of clarity in the literature surrounding the relationship between environment and atopy reflects the complex interplay between cumulative environmental factors and genetic susceptibility, such that no one factor dictates disease development in all subjects. Understanding the effect of the summation of environmental exposures throughout a child's development is needed to identify cost-effective interventions that reduce atopy risk in children.

Section snippets

Microbial exposure

The increase in the prevalence of allergic disease, particularly in the Western world, has coincided with significant environmental changes that have reduced microbial exposure in early life, such as improved sanitation and increased rates of immunization. Many have proposed that among genetically susceptible subjects, these changes in environmental conditions might alter normal development of the immune system and thus affect susceptibility to allergic disease, the basis of the hygiene

Indoor allergen exposure

The indoor environmental allergen milieu is of particular interest in the study of the determinants of allergic disease because of constant exposure during early childhood and the potential for intervention. In samples taken from 831 homes across the United States, at least 6 detectable allergens were found in more than 50% of homes.50 Allergens from house dust mite (HDM), furred pets (cats and dogs), mice, cockroaches, and fungi comprise the most common indoor allergens implicated in patients

Ambient air pollution exposure

Great strides have been made in understanding the effects of environmental air pollutants on population health, which has affected environmental health policy and consequently improved public health. However, despite overall improvements in air quality, indoor and outdoor air pollutants continue to cause adverse health effects and have been shown recently to promote the onset of atopic disease.

The World Health Organization reported in 2016 that 92% of the world's population lives in places

Conclusions and future directions

The effect of microbial, allergen, and air pollutant exposures has been artificially subdivided in this review; in reality, these exposures and many others interact simultaneously with each other to promote or prevent allergic disease (Fig 1). For example, air pollution and climate change can promote oxidative stress in pollen-producing plants, increasing both the amounts and allergenicity of pollen grains.150 Individual factors identified in this review as protective for or promoting the

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    A.J.B. is supported by grant 2T32GM086330. D.B.P. is supported by grants R01ES023349 and P30ES010126. M.L.H. is supported by the AAAAI ARTrust Gail G. Shapiro Clinical Faculty Development Award.

    These authors contributed equally to this work.

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