key: cord-0937556-kekyqepf authors: Farzan, Sherry; Rai, Shipra; Cerise, Jane; Bernstein, Shari; Coscia, Gina; Hirsch, Jamie S.; Jeanty, Judith; Makaryus, Mary; McGeechan, Stacy; McInerney, Alissa; Quizon, Annabelle; Santiago, Maria Teresa title: Asthma and COVID‐19: An early inpatient and outpatient experience at a US children's hospital date: 2021-06-01 journal: Pediatr Pulmonol DOI: 10.1002/ppul.25514 sha: b33ff39cdf5836a779aa85453c2b4cca7b2f3c50 doc_id: 937556 cord_uid: kekyqepf BACKGROUND: Initially, persistent asthma was deemed a risk factor for severe COVID‐19 disease. However, data suggests that asthmatics do not have an increased risk of COVID‐19 infection or disease. There is a paucity of data describing pediatric asthmatics with COVID‐19. OBJECTIVE: The objectives of this study were to determine the prevalence of asthma among hospitalized children with acute symptomatic COVID‐19, compare demographic and clinical outcomes between asthmatics and nonasthmatics, and characterize behaviors of our outpatient pediatric population. METHODS: We conducted a single‐center retrospective study of pediatric patients admitted to the Cohen Children's Medical Center at Northwell Health with symptomatic COVID‐19 within 4 months of the surge beginning in March 2020 and a retrospective analysis of pediatric asthma outpatients seen in the previous 6 months. Baseline demographic variables and clinical outcomes for inpatients, and medication compliance, health behaviors, and asthma control for outpatients were collected. RESULTS: Thirty‐eight inpatients and 95 outpatients were included. The inpatient prevalence of asthma was 34.2%. Asthmatics were less likely to have abnormal chest x‐rays (CXRs), require oxygen support, and be treated with remdesivir. Among outpatients, 41% reported improved asthma control and decreased rescue medication use, with no COVID‐19 hospitalizations, despite six suspected infections. CONCLUSIONS: Among children hospitalized for acute symptomatic COVID‐19 at our institution, 34.2% had a diagnosis of asthma. Asthmatics did not have a more severe course and required a lower level of care. Outpatients had improved medication compliance and control and a low risk of hospitalization. Biological and behavioral factors may have mitigated against severe disease. (SARS-CoV2) was discovered in Wuhan, China. 1 Now known as COVID-19, it was declared a pandemic on March 11, 2020 , and a national emergency in the U.S. on March 13, 2020. 2 SARS-CoV2 is a beta coronavirus and a single strand positive-sense RNA virus that uses the ACE2 receptor to attach to the respiratory epithelial cells. 3 The clinical picture of COVID-19 includes fever, fatigue, sore throat, cough, chest pain, dyspnea, headache, and diarrhea. The infection can lead to pneumonia and a cytokine storm. 1 Patients with COVID-19 present with lymphopenia and elevated C reactive protein (CRP), procalcitonin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), D-Dimer. 4 Although cases continue to rise, research is still forthcoming about the impacts of COVID-19 on both adults and children. Initially, the Centers for Disease Control and Prevention (CDC) listed asthma as significant comorbidity for COVID-19. 5 However, in Wuhan, a retrospective analysis of the first 425 cases found that only 0.9% of the study population had asthma, which is lower than the adult asthma prevalence (4.5%). 6 In the USA, hospitalized adult COVID-19 patients had a lower prevalence of asthma and COPD as compared to obesity, hypertension, and diabetes. 7 A systematic review showed only 1.8% of patients had asthma in 18 studies that included 8690 patients. 8 Among pediatrics, asthma was not considered significant comorbidity. 9,10 Most children with asthma and COVID-19 did not require ICU admission and did not have a severe infection. 11, 12 Additionally, studies have shown decreased admission rates for asthmatics as compared to the same time period in previous years. 11, 12 A systematic review that evaluated 67 pediatric studies found no data on whether asthma constitutes an increased risk of COVID-19 infection or severity and called for more research. 13 Professional societies recommend limiting in-person visits and having asthmatics continue their controller medications. 2 In a survey of 91 pediatric asthma specialists from 27 countries, about 39% stopped physical appointments and 47% stopped seeing new patients. 14 Limiting in-person visits poses difficulties in management due to technological barriers and limited clinical information without spirometry. 15 Providers are also concerned about the impact of corticosteroid use on patients infected with COVID-19. Adult patients with SARS or MERS had higher viral loads, longer duration of viremia, and worse clinical outcomes with systemic steroid use. 16 However, specifically timed systemic steroid treatment in COVID-19 patients is now known to significantly decrease mortality and median hospital stay. [17] [18] [19] Given the paucity of data regarding COVID-19 among pediatric asthmatics, the current study aims to describe the characteristics of hospitalized pediatric asthmatics compared to nonasthmatics, as well as the experience of outpatient pediatric asthmatics during the beginning of the pandemic. This data may provide clinicians with a basis for recommendations for pediatric asthmatics and their families during the COVID-19 pandemic. We examined if there was a difference in COVID-19 outcomes between asthmatic and nonasthmatics. We also hypothesize that among outpatient pediatric asthmatics, their asthma control improved during the pandemic Given the limits on in-person visits, parents of asthma patients seen in our pediatric asthma, pulmonary and allergy clinics were contacted for telephone interviews to assess asthma control and compliance during the initial phase of the pandemic (April-June 2020 Kaplan-Meier treating the patient who was not discharged as censored, and asthmatics were compared to nonasthmatics, using Wilcoxon test. A p-value <.05 was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA). Medical records of eighty-nine pediatric patients admitted to CCMC during the study period were reviewed. Eleven had MISC-C/PIMS, 12 were asymptomatic, and 28 patients were under 2 years of age. Of the remaining 38 patients, 13 (34.2%, 95% exact CI: 19.6% to 51.4%) had asthma. Demographic characteristics of asthmatics and nonasthmatics are summarized in Table 1 . The nonasthmatics had significantly more women (18, 72 .0%) compared to asthmatics (4, 30.8%) (p < .02). No significant differences were found between nonasthmatics and asthmatics with respect to race, ethnicity, age distribution, distribution of BMI percentiles, COVID-19 exposure, or days of illness onset before ER presentation. Four asthmatics (30.8%) were on daily ICS, none were on ICS/LABA and one was on montelukast (7.7%). Ventilatory support, medical management, and outcomes are summarized in Table 1 . Significantly more nonasthmatics (n = 11, 44.0%) required oxygen support compared to asthmatics (n = 1, Length of stay was not significantly different between nonasthmatics (median 6.85, IQR: 3.05-15.00 days) and asthmatics (median 3.98, IQR: 2.00-6.75). There were no statistically significant differences in discharge disposition between nonasthmatics and asthmatics; most patients were discharged home. One nonasthmatic patient died and one nonasthmatic patient was transferred to inpatient rehabilitation, but for non-COVID-related reasons. Additionally, two (8.0%) nonasthmatics versus no asthmatics required oxygen at discharge. asthmatics are summarized in While the global SARS-CoV2 pandemic continues worldwide, the pediatric population has not experienced the level of morbidity and mortality faced by adults. Nevertheless, it is important to better understand risk factors for morbidity and mortality from COVID-19, especially among children. Since asthma is the most common chronic disease of childhood and SARS-CoV-2 primarily impacts the respiratory system, it is a valid concern that asthmatics would be at Nonasthmatics were more likely to have an abnormal CXR, be treated with remdesivir, and have oxygen requirements. Lab values such as WBC, ALC, ANC, initial ALT, and AST were not significantly different between the asthmatics and nonasthmatics, except for peak AST and ALT. The difference in peak liver enzymes between the two groups reflects that the nonasthmatics were likely a more medically complex population. The outpatient portion of this study demonstrated that pediatric asthmatics had the same or improved asthma control and compliance and that the majority had the same or less, level of exacerbations and rescue medication use during that time. There is only one other study examining behaviors of pediatric outpatient asthmatics, and it found that early in the pandemic, inperson asthma encounters and systemic steroid prescriptions decreased, consistent with our findings of improved control. 28 These findings suggest that patient behaviors agree with the recommendations from professional bodies regarding the management of asthma during this pandemic. 29 In our cohort, we did not find evidence that asthma elevates a child's risk for more severe disease or outcomes with COVID-19, and adds to the existing literature demonstrating the same. 9, 10, 14, 14, 21, 27, 30 This contrasts with the MMWR report in which the most common underlying condition was chronic lung disease, including asthma. 31 Nevertheless, our findings are reassuring given the fact that COVID-19 infects primarily through the respiratory epithelium. Allergic sensitization and atopic asthma are inversely associated with the expression of the ACE2 receptor, which is required for the entry of SARS-CoV2 into respiratory epithelial cells. 32 Most childhood asthma is atopic in nature and 80% of asthmatics have co-morbid allergic rhinitis. 33 have been demonstrated to have more severe disease. 12 As the pandemic is surging in all areas of our country, it is rea- We would like to thank the Northwell Health COVID-19 Research Consortium for supporting our research efforts. The authors have no conflicts of interest relevant to this article to disclose. Sherry Farzan helped with conceptualization (lead); investigation (lead); methodology (lead); project administration (lead); supervision (lead); writing original draft (lead); writing review and editing (lead). Shipra Rai helped with conceptualization (equal); data curation (lead); investigation (equal); methodology (equal); writing original draft (lead); writing review and editing (lead). Jane Cerise helped with formal analysis (lead); validation (equal); writing review & editing (equal). Shari Bernstein helped with data curation (supporting). Gina Coscia helped with conceptualization (supporting); data curation (equal); investigation (equal); writing review and editing (supporting). Jamie Hirsch helped with data curation (lead); software (lead). Judith Jeanty helped with data curation (equal). Mary Makaryus helped with data curation (equal). Alissa McInerney helped with data curation (equal). Annabelle Quizon helped with conceptualization (equal); data curation (equal); investigation (equal); writing review and editing (equal). Maria Santiago helped with conceptualization (lead); data curation (lead); investigation (lead); writing original draft (lead); writing review and editing (lead). The data that support the findings of this study are available from the corresponding author upon reasonable request. 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