Fewer children hospitalized with asthma exacerbations during early days of COVID-19
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Fewer children with asthma were hospitalized for exacerbations during the first few months of the COVID-19 pandemic compared with the previous year, although they presented with more severe symptoms, according to a recent study.
Nada Alabdulkarim, MBBS, a pediatric resident at Children’s National Hospital in Washington, D.C., and colleagues examined 50 cases between April 1 and Sept. 30, 2020, as well as 243 controls from the same period in 2019, in the study published in Annals of Allergy, Asthma & Immunology.
The children in the pandemic cases were significantly older compared with those in the control cases (9.8 ± 4.3 years vs. 6.7 ± 3.8 years; P < .0001). There also was a trend toward fewer Hispanic children among the pandemic cases compared with the controls.
The control cases had a greater proportion of children with eczema (32.1% vs. 16%; P = .02) and food allergies (18.5% vs. 6%; P = .03), although the researchers did not find any significant differences in the prevalence of other comorbidities.
Considering its use an objective measure of increased severity of asthma exacerbations at presentation, the researchers said that intravenous magnesium sulfate was more frequently administered during the pandemic compared with the control period (84% vs. 63%; P = .001).
In fact, there was a 16% higher likelihood of patients receiving magnesium sulfate with each year increase in age. African American and Hispanic patients had higher odds of receiving magnesium sulfate in the ED as well.
However, use was independent of sex or comorbidities such as obstructive sleep apnea, eczema, food allergies, obesity, baseline asthma management regimens and reported compliance with preventive regimens.
More of the pandemic cases did not comply with controller medications compared with the control cases (46% vs. 24.7%; P = .0023), and a smaller proportion of them received inhaled corticosteroids during their hospital stay (30% vs. 58.8%; P = .0002).
Yet the researchers also noted that non-compliance was not an independent predictor of whether magnesium would be needed. Plus, fewer children began or restarted controller therapy during the pandemic compared with the control period.
This lower compliance may have contributed to the visit, the researchers continued, but it did not influence the need for magnesium, indicating that other clinical differences such as a lower prevalence of atopy between cases and controls may influence asthma severity during presentation.
These lower rates of atopy among children who were hospitalized line up with previous studies finding a protective effect of atopy among patients who had been infected with SARS-CoV-2, the researchers said, possibly due to the use of inhaled corticosteroids.
The researchers further speculated that parents and caregivers may have been afraid to visit the ED for mild asthma symptoms during the pandemic and treated them at home instead, leading to the greater proportion of more severe cases.
The financial and transportation difficulties experienced by many families may have prevented them from refilling controller medications or attending routine asthma care visits, also leading to the greater severities in asthma exacerbations, the researchers said.
Perspective
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The results are not surprising as many studies have shown that early in the pandemic, health care utilization for non-COVID-19 diagnoses, including pediatric asthma exacerbations, decreased. However, this research goes a step further and adds a valuable contribution to our knowledge by comparing the characteristics of children hospitalized for asthma exacerbations before and during the COVID-19 pandemic.
The study found that those children hospitalized for asthma during the early phase of the pandemic were older and less allergic. Using administration of magnesium sulfate as a marker of severe exacerbation, the authors also found that children presenting to the ED for asthma were more likely to have a severe presentation early in the pandemic compared with pre-pandemic.
Additionally, these children reported noncompliance with asthma medications. A limitation of this study, however, is that the authors do not define how they determined this noncompliance.
These characteristics, while important, may be too subtle to reliably appreciate in individual practice, which is why a study like this one lends valuable information.
Anecdotally, early in the pandemic, it did seem that children presenting to hospital for asthma exacerbations were generally more severely ill and had difficulties with controller medications. In a study from our institution, we too found that children with COVID-19 and asthma were older and less atopic compared with children with asthma pre-COVID-19.
Now, the “fear” of COVID-19 has greatly waned. People are far less hesitant to seek non-COVID-19 medical care than they were early in the pandemic. This is due to a multitude of factors including improved COVID-19 prevention strategies (masking, vaccines), better detection/treatment options (home testing, novel therapies), the ubiquity of COVID-19 and the longevity of the pandemic (“pandemic fatigue”). Were this study repeated using cases from 2022 rather than 2020, I would expect fewer, if any, differences in cases compared with the 2019 controls.
The authors’ findings, namely that children hospitalized for an asthma exacerbation in the early months of the pandemic were more likely to report difficulties with controller medications compared with those hospitalized for an asthma exacerbation prior to the pandemic, highlight how existing vulnerabilities may have been amplified during the pandemic.
As the authors point out, some of the controller medication difficulties may have been due to pandemic-related financial strain, such as the ability to refill medications, attend routine appointments and access transportation.
Further research is needed to determine the possible association between COVID-19 and severity of asthma exacerbations in nonallergic children with asthma.
Reference:
Gaietto K, et al. Pediatr Allergy Immunol. 2022;doi:10.1111/pai.13696.
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