Asthma presents hospitalization risks for children with COVID-19, but not worse outcomes

Researchers identified asthma as a risk factor for hospitalization among children who had COVID-19, but not for worse COVID-19 outcomes, according to a nested case-control study published in Pediatric Allergy and Immunology.

The researchers also found that SARS-CoV-2 did not seem to be a strong trigger for pediatric asthma exacerbations, nor did asthma severity correlate with higher risk for COVID-19.

“As the pandemic started, spread and eventually reached Allegheny County, [Pennsylvania] in March 2020, there were many unanswered questions about how the virus affected children, and particularly those with underlying chronic conditions,” study author Erick Forno, MD, MPH, ATSF, associate professor of pediatrics at University of Pittsburgh School of Medicine, told Healio.

A multidisciplinary group of physicians and nurse practitioners at University of Pittsburgh Medical Center (UPMC) Children’s Hospital of Pittsburgh and Children’s Community Pediatrics in Pittsburgh then launched the Pediatric COVID-19 Registry to guide conversations with patients and families so providers would not need to rely on anecdotal memory.

Erick Forno

“The registry helped us understand how the pandemic affected children locally, and asthma was one of the diseases we focused on,” said Forno, who also is director of the UPMC Children’s Hospital of Pittsburgh’s Pediatric Asthma Center.

Further, there has been conflicting evidence on whether COVID-19 affects people with asthma worse than other people, Forno said. Whereas most data have come from studies of adults, he continued, this new study was one of the first to focus on children.

The study included 142 children with COVID-19 and underlying asthma (A+C; mean age, 14.6 years; 55.6% boys), 1,110 children with COVID-19 but no underlying disease (C+ controls; mean age, 12 years; 50.5% boys) and 140 children with asthma but no COVID-19 (A+ controls; mean age, 10.2 years; 62.1% boys).

The A+C patients were more likely than the C+ controls to endorse recent travel; present with dyspnea, wheezing, chest pain and loss of taste (P < .01 for all); and to be hospitalized (4.9% vs. 1.7%; P = .01). They also were more likely to receive pharmacologic treatment such as albuterol (17.6% vs. 0.7%) and systemic steroids (8.5% vs. 0.8%; P < .001 for both).

Among the A+C patients, a greater proportion of those presenting with acute asthma symptoms were hospitalized than those without acute asthma symptoms (14.3% vs. 2.5%; P = .04).

An adjusted analysis revealed that the A+C patients were nearly four times more likely to be hospitalized than the C+ controls (adjusted OR = 3.95; 95% CI, 1.4-10.9) as well, though the length of stay and respiratory support level did not differ between the groups.

Additionally, 8.5% of the A+C cases presented with an asthma exacerbation, while another 6.3% developed acute exacerbation symptoms shortly after testing positive for SARS-CoV-2. The A+C cases had less severe asthma, were less likely to be on controller medications and had better symptom control than historic A+ controls (all P < .01).

“We were surprised to find that children with asthma presenting with COVID-19 were much more likely to be admitted to the hospital,” Forno said. “However, we found no other indications of COVID-19 being more severe, so the explanations could be that the virus triggered significant asthma exacerbations that required hospitalization, or that physicians were admitting children with asthma as a precautionary measure.”

The extra caution on these physicians’ part makes sense, Forno said, because not much was known about the effect of SARS-CoV-2 on asthma or vice versa at the start of the pandemic, so it was reasonable to expect that children with an underlying respiratory condition might get sicker.

“This is not typical,” Forno added. “Because asthma is a highly prevalent disease, we are very familiar with how to manage acute exacerbations.”

For example, Forno said, national guidelines and hospital protocols cover asthma exacerbations that range from mild to severe.

“The main concern with COVID-19 was that we simply did not know how things would turn out, if children with asthma would have a more severe or prolonged course, or if they would respond to the usual asthma treatments,” he said.

Children with asthma do not fare worse when they have COVID-19 on average, Forno said, although it is still important for these patients to control their asthma, including taking daily medications and attending regular doctor appointments.

“It is also important to seek care if a child with asthma and COVID-19 starts to develop concerning symptoms like difficulty breathing. While most will do well, they should be promptly evaluated and treated if sick, and with adequate treatment and support, most of them will recover quickly,” Forno said.

The researchers have continued to build the Pediatric COVID-19 Registry to continue to inform conversations with their patients, and Forno cited the team effort behind its success, including doctors from UPMC’s pulmonary medicine, infectious diseases, hospital medicine and critical care medicine departments as well as from Children’s Community Pediatrics.

The researchers are now focused on examining whether the latest wave driven by the delta variant will lead to a different course or severity in children, Forno said.

“We are certainly seeing many more pediatric cases and hospitalizations, but are these patients different than the ones we saw the first year? Are they taking any longer to recover?” Forno said. “We do not have much data in children to answer those questions so far.”

For more information:

Erick Forno, MD, MPH, ATSF, can be reached at erick.forno@chp.edu.