Coronavirus Disease 2019 and Pediatric Asthma: Friend or foe?

Elissa M. Abrams


Curr Opin Allergy Clin Immunol. 2022;22(2):95-100. 

In This Article

The Role of Coronavirus Disease 2019 (or Lack Thereof) in Asthma Exacerbations

Historically, seasonal coronavirus infection is associated with asthma exacerbations in children.[17] However, previous coronavirus epidemics have not been associated with a risk of asthma exacerbations. For example, with SARS, also a novel coronavirus epidemic, the incidence in children was low and symptoms were predominantly mild with low morbidity and mortality.[18] SARS did not induce bronchial hyper-reactivity nor cause eosinophilic inflammation and was not associated with an increase in asthma exacerbations.[18]

In keeping with previous coronavirus epidemics, there is actually some basis to suggest that children with atopic asthma may be at reduced risk of asthma exacerbations during COVID-19. A retrospective review of 212 children with confirmed atopic asthma in Spain found that, compared with those children with asthma who did not develop COVID-19, those who did had no significant difference in asthma treatment, lung function, asthma severity or asthma control.[19] In fact, families did not report any worsening of symptoms compared with a similar time period in the previous year among the atopic children with asthma who developed COVID-19.[19] During the first 5 weeks of the lockdown in Slovenia, there was a 71–78% decrease in pediatric asthma admissions compared with the same time periods in the last 3 years.[20] At a large US tertiary care center during the spring of 2020, a 76% reduction in asthma emergency department (ED) visits was noted, with similar trends for children of all levels of acuity.[21] The percentage of children with asthma subsequently admitted to the hospital also decreased (from 31 to 22%). Electronic health records from Children's Hospital of Philadelphia found that, compared with the 5 previous years, in-person asthma encounters decreased by 87 (outpatient) and 84% (emergency and inpatient), and asthma-related systemic steroid prescriptions decreased.[22] A study of pediatric patients with asthma treated in the Children's Hospital of Orange County found 78, 90, 68% reductions in hospitalization, ED visits and asthma exacerbations, respectively, compared with pre-COVID-19 2020, and significant reductions in albuterol and inhaled corticosteroid use (P < 0.05).[23] A retrospective chart review of children utilizing the pediatric ED in the Bronx from March to June 2020 found a significant reduction in asthma-related ED visits (P < 0.0001).[24] While not specific to children, a cohort from a US database of healthcare claims for over 200 million privately insured patients found a significant decline in asthma exacerbations after the COVID-19 pandemic onset (P < 0.001).[25]

It is possible that public health measures resulting in masking, reduced viral transmission, reduced outdoor aeroallergen exposure, reduced traffic/industrial pollution, and improved air quality overall are contributing to the reduction in asthma exacerbations.[26] During the first spring of the pandemic in Slovenia, when a dramatic reduction in asthma exacerbations was noted, there was also a 51–58% decrease in admissions for acute respiratory tract infections and a 48–58% reduction in the air nitrogen dioxide level [although concentrations of particulate matter with a diameter of less than 10 micrometers (PM10) did not change substantially].[20] The Children's Hospital of Orange County study found a significant reduction in PM2.5 and influenza rates during the pandemic, as well as increased use of telehealth resources which may serve previously under-accessed populations (with greater use in the publicly insured group compared with the commercially insured group).[23] Other possibilities include that patients and their families are avoiding seeking care during the pandemic, and/or that the pandemic has led to improved compliance with asthma medications.[25]