Dr Louise Fleming
Honorary consultant in paediatric respiratory medicine, Royal Brompton Hospital, London
29 May 2020
I work with a team that looks after a large number of children with severe asthma, including those on a biologic such as omalizumab (Xolair) and mepolizumab (Nucala). Over the last few months some themes have evolved in my clinical practice that I wanted to share because they may reassure parents of children with asthma as schools re-open and the ‘new normal’ becomes our reality.
As the first surge recedes, we’ve had the opportunity to reflect on the impact on children. Three key elements have emerged:
- Firstly, in the majority of cases, COVID-19 is a milder disease in children than adults
- Secondly, for the small number of children who have had severe COVID, asthma does not seem to be a risk factor
- Thirdly, we’ve seen a drop in asthma-related hospital admissions in children.
There are a number of plausible explanations for these observations, although we remain a long way from fully understanding them. The pattern of children generally having a less severe illness has been replicated across countries. Data from China demonstrated very few admissions among children with asthma. We have heard about more children with asthma being admitted in Europe, but in most cases the illness has been distinct from an asthma attack (i.e., their asthma hasn’t been affected by the illness). Unlike many viral infections SARS-CoV-2, the virus that causes COVID-19, doesn’t seem to cause wheezing. It attacks the air sacs (alveoli) rather than the airways which are affected by asthma.
There could be a few reasons why COVID-19 is milder in children and doesn’t seem to affect their asthma. Some interesting early research suggests it could be because certain human proteins (such as ACE2) that SARS-CoV-2 uses to enter cells and cause infection are found in lower numbers in children with allergic asthma. This may offer an explanation as to why children with asthma don’t seem to be at high risk. Interestingly, some early data from an adult study suggests that inhaled steroids may also reduce ACE2 expression. However, we need to be cautious over this. Furthermore, this doesn’t mean that children with asthma are immune (in fact they are just as likely to become infected as adults) or cannot become unwell with COVID-19, and we still don’t really know why some children are more affected by COVID-19 than others.
Why the drop in asthma related admissions in children?
During the lockdown we’ve seen fewer asthma admissions in children. Initially we were worried that the fall in asthma admissions was because people didn’t want to come into hospital. However, many of the children and their families we’ve spoken to tell us they feel their asthma control is better. This may be because shielding and social distancing have led to less contact with other viruses that we know can cause attacks. The reduction in air travel and car journeys has also led to a decrease in pollution and improvement in air quality. It also seems that children are taking their medications more regularly, possibly as a result of having fewer other time pressures.
However, we need to be mindful that for some children, the lockdown has increased their exposure to home environmental allergens such as house dust mites and irritants such as cigarette smoke. For some vulnerable children, spending more time with their family increases their risk of both physical and emotional abuse, leading to increased anxiety and depression which we know can sometimes exacerbate asthma. The removal of the safety net at school puts them at greater risk of harm. We need to remain vigilant, not only in ensuring safe environments to protect against COVID but also to safeguard children and ensure that for those with asthma it’s optimally managed.
The future and the ‘new normal’
Many parents have asked me whether it will be safe to send children with asthma or their siblings back to school. For the most part the considerations should be the same as for the general population of children. For any child going back to school it’s important that the social distancing advice can be followed, and the school is satisfied that it’s safe for children to return. A small number of children with severe asthma, particularly those taking regular oral steroids (prednisolone) may need to be shielded for longer, and this should be discussed with the specialist team looking after the child.
When children do return to school it’s absolutely vital that we continue to do all we can to monitor children with asthma, using objective measures whenever possible, and ensure optimal control. This includes taking medications regularly, as prescribed, having regular reviews (at least six monthly), which can be carried out remotely, and all children having an up to date Personal Asthma Action Plan. There’s more advice for parents on Asthma UK’s Back to School page.
We need to carry on adapting the ways we work as the ‘new normal’ continues to change and the pandemic enters new and uncharted waters. Above all, for those of us working with children with asthma, we must ensure their basic asthma care needs are met. Unless we do, it’s likely that more children will suffer uncontrolled asthma symptoms and even asthma attacks in the UK over the course of the pandemic, potentially coming to more harm from their asthma than they will from COVID-19.