During the COVID-19 pandemic, most kids with asthma have unexpectedly done great. What can we learn?

When COVID-19 broke out, many parents of children with asthma were deeply worried — terrified might not be too strong of a word to describe it. In COVID-19, we had a lung-targeting virus with no treatment, no vaccine and no one with natural immunity. It seemed like the virus would find an easy target in children with asthma — a unpredictable lung condition that can cause severe breathing difficulty.

Going into the pandemic, the Centers for Disease Control and Prevention (CDC) estimated that asthma affected 5.7 million American children. In 2019, the Asthma and Allergy Foundation of America reported that 44.3% of all American children with asthma had experienced at least one attack that year.

Against that backdrop, the COVID-19 virus started its sprint across the globe in late 2019 and early 2020. “When we first started to hear about COVID-19, we thought it was going to be really bad for children with asthma,” says childhood asthma expert Manuel Arteta, M.D., a pediatric pulmonologist at Mayo Clinic Children’s Center in Rochester, Minnesota. “The reason is that viral illnesses are the most common trigger for asthma attacks.”

What is asthma?

• Asthma is a noncommunicable lung condition that is treatable but not curable.
• During an attack, lung airways contract, swell and produce a surplus of mucus.
• Symptoms of an asthma attack include wheezing, breathlessness and coughing.
• Common triggers include allergens, viruses and exercise.
• Many children with asthma and their parents experience anxiety, as the condition is unpredictable and needs daily vigilance.

Treating asthma typically features the use of two types of medications: long-acting inhaled anti-inflammatory medications for everyday use to prevent symptoms, and quick-acting inhaled bronchodilators for use during an attack. Treatment may be supplemented by injectables, nebulizers and medications that need to be swallowed.

On the frontline

As the COVID-19 infections started surfacing in the United States, Dr. Arteta answered many messages and calls from anxious parents.

“At the beginning, we didn’t know much about how COVID-19 would affect children with asthma,” he says. “We could provide some reassurance to families within the framework of ongoing care, but without all the facts, it was hard to be fully reassuring. So, what we did was follow the CDC guidelines and communicate what was known at any given time.”

Despite the very justified concern, the bad stuff never happened. In fact, there were less kids seeking medical attention for asthma problems than before the pandemic. With hindsight, Dr. Arteta now suspects that as social distancing, masking, hand-washing and remote learning became the new normal, children with asthma were less exposed to viral illnesses, and they probably stuck to their treatment plans at a level never done before.

“Families might have gotten scared from the news about the risks for people with underlying conditions and from not knowing what may happen to their kids,” Dr. Arteta says. “That may have helped quite a bit with adherence to their prescribed medications.”

The surprise benefits of social distancing

It seems social distancing may have had extra benefits beyond lowering the risk of COVID-19 infection, as Dr. Arteta saw in the example of a family he treated across the pandemic, whose child has asthma.

“As with many kids with asthma,” Dr. Arteta explains, “their child’s asthma attacks are mainly triggered by viral illnesses. In a recent conversation, a mother shared with me how well her kid had done during the pandemic. For two years, her kid was not seen in the emergency room, didn’t require steroids and performed much better. Hearing this, the question was why? And the answer is the things we’ve done to protect patients from getting COVID-19 have worked well to protect them from all other viruses too.”

That has been the biggest learning point, Dr. Arteta continues.  “It was a confirmation of something that we already knew, which is that viruses are the primary cause of asthma attacks, particularly in children whose asthma is not controlled at the time they get a viral illness. And anything and everything you can do to reduce the chances of that are going to decrease that outcome, including vaccination, masking, social distancing and hand-washing. All of these measures that we did to help address the pandemic also helped enormously with childhood asthma.”

Proving his hunch, the same child, who had no asthma emergencies for the first two years of the pandemic, has had four major attacks since September 2021, following the relaxing of social distancing requirements.

“What happened is kids are sharing viruses again,” Dr. Arteta explains. “But to address that: Do you mask? Keep the kids separated? That would be good for asthma. It would not be good for anything else.”

The mystery of allergens under lockdown

Going into the pandemic, Dr. Arteta had concerns about children with asthma growing up in homes with poor air quality, in homes near smog-drenched traffic routes, and in homes with allergens such as pet dander, traffic pollution and cigarette smoke — all of which are common asthma exacerbating factors.

“These factors are often a major discussion point with families,” Dr. Arteta says. “Imagine as the pandemic came on, a patient who is challenged by asthma in that kind of home environment and exposed to all these triggers, is suddenly under lockdown, doing remote schooling, at home, with no way out. That was something that really worried me. But such scenarios turned out not as bad as I feared. We don’t have full data from research on this yet, but the connection is important. The fact this wasn’t a calamity for kids with asthma is something that is intriguing and needs to be further investigated.”

Post-COVID-19

Dr. Arteta did not personally have any patients with asthma hospitalized with COVID-19. Still, seeing that adults with chronic health conditions such as chronic obstructive pulmonary disease (COPD), obesity, high blood pressure (hypertension) and heart disease fare badly with the virus, he continues to advise parents with children who have asthma to make sure their children are vaccinated and follow their asthma treatment plan.

“If they stick to their prescribed regimen, making sure their asthma is well controlled — and they’re vaccinated — kids with asthma should be fine,” says Dr. Arteta.

Despite the global trauma of the pandemic, Dr. Arteta has witnessed surprising medical learning regarding asthma.

“What happened with COVID-19 and asthma in children and asthma across the general population helps us understand better certain aspects of asthma,” he says. “COVID-19 emphasized the role of viruses in asthma. Having this so widely confirmed was huge for this field. We wouldn’t have had the chance to look at this aspect of asthma in such a large scale if not for this unfortunate pandemic.”

In the end, with the worst of COVID-19 hopefully behind us, Dr. Arteta sees no way to prescribe ongoing social distancing to children with asthma, but he is optimistic that their families may take other steps learned from the pandemic, such as following medication regimens more closely, washing hands and, while the pandemic is still with us, selective masking in settings such as a busy indoor mall, a packed cinema or a sell-out concert.

“The way to go if you want to limit asthma attacks is to follow what we learned from the pandemic. It’s up to each family how they go about doing that.”