COVID-19 and Asthma in Children: What Parents Need to Know

By John M. Robertson, M.D.

Moderate to severe asthma is a possible risk factor for severe COVID-19 disease according to the Centers for Disease Control and Prevention. But a COVID-19 infection can cause a flare up of even mild asthma. COVID-19 is a respiratory virus and contracting an infection with any respiratory virus can trigger an asthma flare-up. In fact, the most common cause of an asthma flare-up in children is a viral respiratory infection.

What does my child with asthma need to do to stay healthy during COVID-19?

The single most important thing a child with asthma can do to stay healthy during COVID-19 is to control their asthma. Here is a list of some important ways to keep your child with asthma healthy:

1. Control their asthma.
2. Wash hands frequently with soap and warm water for 20 seconds, especially before eating or drinking or touching any part of their face.
3. Avoid being around people who are sick.
4. Maintain a social distance of 6 feet outside the home.
5. Wear a face mask in public (if the child is older than 2 years of age and is able to remove the mask by themselves).
6. Absolutely no smoking or vaping inside or around a child with asthma. Now is a great time to try quitting by calling 1-800-QUITNOW!

In addition, make sure to track when the asthma medications need to be refilled so the child does not run out, as this can trigger an asthma flare-up. And keep an extra supply of the child’s quick relief medication (usually albuterol or levalbuterol) at home in addition to the one they are using.

What is “asthma control”?

Children with controlled asthma are less likely to develop an asthma flare-up when they are exposed to one of their triggers, like a viral respiratory infection. Asthma control also means almost no day-to-day asthma symptoms. The symptoms of asthma are wheezing, coughing, chest tightness and shortness of breath. Asthma is UNCONTROLLED if any of those asthma symptoms are:

1. present during the day more than just two days per week
2. OR cause any night waking
3. OR cause any physical activity limitation
4. OR require more than to quick-relief treatments per week
5. OR require systemic steroids (like oral prednisolone or prednisone) more than once in the last 12 months

The best way to control asthma is to avoid or minimize exposure to asthma triggers and take daily maintenance asthma medication (typically an inhaled steroid) as prescribed. Asthma maintenance medication should almost always be taken every day, even when the child with asthma “feels fine.” Not all children with asthma need daily maintenance medications. But, if a child’s asthma symptoms are uncontrolled, they might benefit from daily asthma maintenance medication. Now is a great time to assess your child's asthma symptoms to determine if the current plan is controlling their asthma. If the asthma isn’t controlled, call your asthma doctor to review the plan and adjust if needed.

What if my child with asthma says they “can’t breathe” or is scared while wearing the face mask?

Wearing a face mask is important for everyone going out in public at this time and is especially important for children with asthma. Many young children can be resistant to wearing them at first but with persistence and patience, this can usually be overcome. Here are a few ideas to help make masks seem less scary from the American Academy of Pediatrics:

1. Look in the mirror with the face coverings on and talk about it.
2. Put a cloth face covering on a favorite stuffed animal.
3. Decorate them so they're more personalized and fun.
4. Show your child pictures of other children wearing them.
5. Draw one on their favorite book character.
6. Practice wearing the face covering at home to help your child get used to it.

Regarding a child with asthma saying that they “can’t breathe” while wearing a face mask, it is important to make a distinction between the feeling of being short of breath and a true difficulty breathing causing a drop in the oxygen level in the blood. Only patients with very severe lung disease or who have very weak breathing muscles would have their blood oxygen levels decreased simply by wearing a face mask. If needed, this could be tested with a pulse oximeter at most physician offices. If the feeling of being short of breath is present but their blood oxygen level is normal, then it is safe for them to wear a face mask.

For more information on children and face masks from the American Academy of Pediatrics

Are steroids safe to give to treat asthma during the pandemic?

Inhaled steroids have been the daily asthma maintenance medication of choice for decades now and continue to be very safe, very effective, and very necessary for patients with persistent asthma during in the COVID-19 pandemic. A child with asthma should NEVER stop their daily inhaled steroids unless instructed to by their asthma doctor.

Systemic steroids are related to inhaled steroids but instead are much stronger and given by mouth (or injection) for short periods of time (less than 10 days) to treat asthma flare-ups. Systemic steroids can be safely given for asthma flare-up, if needed, even if that flare-up is triggered by a COVID-19 infection.

Are nebulizers safe during the pandemic?

COVID-19 (like all respiratory viruses) spreads by aerosols created when an infected person coughs or sneezes. An aerosol is a super-fine mist that floats in the air. Another person can then catch COVID-19 by breathing in these infectious aerosols. COVID-19 can also be spread if these aerosols settle on surfaces that are then touched by someone else who then touches their face. In addition to coughing or sneezing, anything that generates aerosols can spread a virus. This includes laughing, singing, loud talking and nebulization.

Nebulizers are devices for administering certain kinds of asthma medication. Nebulizers work by turning a liquid medication into an aerosol that is then breathed in by the patient. If a person infected with COVID-19 (even if they have no symptoms) uses a nebulizer, the virus can become aerosolized and pose a risk of infection to anyone nearby. Fortunately, most nebulized asthma medications can be changed to medication given by inhalers. Inhalers can be used with a mask attached to a tube (such as a spacer or valved holding chamber) in even the youngest asthmatics and cannot create infectious aerosols the way a nebulizer does. Discuss with your asthma doctor if changing from nebulizers to inhalers is right for your child.

How do I tell the difference between COVID-19 and asthma?

COVID-19 symptoms can appear two to 14 days after someone comes into contact with an infected person. COVID-19 symptoms can include fever, chills, cough, shortness of breath, trouble breathing, feeling tired and weak, muscle or body aches, headache, new loss of taste or smell, sore throat, stuffy or runny nose, diarrhea, nausea or vomiting, pinkeye, painful blue or purple lesions on toes and even hives or rashes. Many of these symptoms overlap with those of asthma, allergies, the flu or other viral respiratory infections (“colds”). Because of this overlap, being tested is the only way to know for certain if a child’s symptoms are due to COVID-19.

For more information, The Asthma and Allergy Network has a helpful chart comparing the symptoms of COVID-19, the cold, flu, allergies and asthma

What do I do if my child gets sick with asthma during the COVID-19 pandemic?

The possibility that a child with asthma’s active symptoms could be due COVID-19 infection does not change the initial treatment. I tell my patients that an asthma flare-up due to COVID-19 is still an asthma flare-up. If a child has asthma and develops any coughing, any wheezing, any shortness of breathing, any trouble breathing or any chest tightness, they should start their asthma action plan immediately.

The most common first step in an asthma plan is to treat these symptoms with their quick relief medication (usually albuterol or levalbuterol). If these symptoms do not respond or get worse, the child’s asthma doctor should be consulted immediately for additional guidance.

 When should I take my child with asthma to the doctor?

Most asthma flare-ups can be safely and effectively managed at home by following your asthma action plan and consulting your child’s asthma doctor by phone if needed. But, if the plan is not working or symptoms worsen, a change in the treatment plan or closer monitoring might be needed. Call your child’s asthma doctor if any of the following symptoms occur:

• worsening cough or wheeze
• new chest pain or back pain
• decreased ability to do usual physical activities​
• symptoms not responding to albuterol plan (but otherwise not in distress)
• needing albuterol more frequently than every 4 hours (but otherwise not in distress)
• not improving significantly after 2-3 days of increasing albuterol

Asthma flare-ups can become a life threatening emergency. If your child shows any of the following warning signs, their asthma flare-up has become a life threatening emergency. Start the emergency plan part their asthma action plan (often called “the red zone”) and call 911 or go to the nearest emergency room immediately if your child:

• can't catch their breath,
• can’t speak in full sentences
• can’t walk because of breathing difficulties
• sucking in (retractions) under the ribs or at base of neck
• abnormal movement of the belly while breathing (belly breathing)
• turning a bluish or grayish color around their mouth or fingernails
• making grunting noises
• head bobbing with each breath
• not responding to albuterol treatments
• feeling drowsy or confused

When should I take my child with asthma get tested for COVID-19?

The CDC website has a Coronavirus Self-Checker – an excellent and easy to use assessment tool to you decide if a child (older than 2 years) or adult needs to seek testing or medical care due to COVID-19. The online and mobile-friendly tool asks a series of questions, and based on your responses, provides recommended actions and resources.

If my child with asthma gets sick, when can we be around other people again?

If a child has an asthma flare-up during the COVID-19 pandemic, it is important to stay home and away from other people. Staying away from others helps stop the spread of COVID-19. You can be around others after 10 days since symptoms first appeared and at least 24 hours with no fever without the use of fever-reducing medications

For more information about COVID-19 and children with asthma from the American Academy of Pediatrics, click here.

https://www.healthychildren.org/English/health-issues/conditions/COVID-19/Pages/Caring-for-Children-with-Asthma-During-COVID-19.aspx

For more information about COVID-19: cdc.gov

References

** Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2020. Ginaasthma.org

*** https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html