PEDIATRIC ASTHMA AND COVID-19

Pediatric Asthma And Covid-19 – Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory.

I. DEFINITION Of ASTHMA

Asthma is the most prevalent chronic respiratory disease worldwide, affected people all ethnic groups throughout all ages. Asthma also the most common chronic disease in children. Asthma can’t go away, but it can be reduced to become more severe. But its still become significant public health problem. Furthermore, asthma disproportionately affects minorities and socioeconomically disadvantages children.²

II. EPIDEMIOLOGICAL AND PREVALENCE

From epidemiological and experimental studies shows that there is relationship between environmental factors and allergic r4espiratory disease such as rhinitis and asthma.³ Air pollution could be the reason of each asthma cases in the Asia Pacific especially in urban cities with rapid developing economics, increasing infrastructure, numbers of vehicles, and reduced green spaces. Fossil fuel and transportation are the main sources of air pollution (e.g., sulfur oxide and nitrous) released into the atmosphere leading to health problems. A global study that 9–23 million and 5–10 million annual asthma emergency room visits globally in 2015 could be attributable to O3 and particulate matter (PM) with a diameter of 2.5 μm or less (PM2.5), respectively, representing 8%–20% and 4%–9% of the annual number of global visits, respectively.³

The top 3 countries for both asthma incidence and prevalence in Asia were India, China, and Indonesia, driven largely by population size nearly half (48%) of estimated O3-attributable and over half (56%) of PM2.5-attributable asthma emergency room visits were estimated in Southeast Asia (includes India), and western Pacific regions (includes China). Of all countries globally, India and China had the most estimated asthma emergency room visits attributable to total air pollution concentrations, respectively contributing 23% and 10% of global asthma emergency room visits estimated to be associated with O3, 30% and 12% for PM2.5, and 15% and 17% for nitrogen dioxide (NO2). In this global study,16 million new pediatric asthma cases could occur globally each year due to anthropogenic PM2.5 concentrations, translating to 33% of global pediatric asthma incidence. The percentage of national pediatric asthma incidence that may be attributable to anthropogenic PM2.5 was estimated to be 57% in India, 51% in China, and over 70% in Bangladesh.³

Asthma affects 1 in 12 US children aged 0 through 17 years. After decades of increases, the prevalence of asthma in this group plateaued between 2010 and 2012, decreased in 2013 from 9.3% in 2012 to 8.3%, and remained stable through 2016. In contrast, pediatric asthma prevalence in black children increased between 2001 and 2009, leveling off by 2013. In 2016, asthma prevalence in black children rose sharply to 15.7% (a 2.3% increase from 2014 and 2015), twice that of white children. This rate surpassed that of Puerto Rican children, who previously had the highest prevalence of asthma of all US children. The prevalence of asthma in children in poverty did not decrease between 2001 and 2013 and remained high in 2016 (10.5%).²

Percentages asthma more higher  in the city than villagers

Asthma has become an issue of international development as its economic and social cost have been recognized. Asthma is one of the chronic respiratory diseases (CRDs), CRD’s ) including asthma cause 15% of world deaths. Strangely we still didn’t understand exactly what can cause number of asthma increasing each year.

III. RISK FACTORS ASTHMA IN CHILDHOOD

1. Microbial Exposure

Hygiene and environment have been suggested to become cause problem increasing the risk of asthma. Accordingly, children raised in modern environment with a scanty natural microbial burden may be prone to develop allergic diseases in view of an under stimulation of the immune system. Indeed, recent evidences showed that exposure to some microbes can protect from atopy, whereas others seem to promote allergic diseases. The timing of exposure to as well as the properties of the infectious agent, in addition to the genetic susceptibility of the host, may influence the future development of asthma.⁵

Data from the Copenhagen birth cohort first showed that infants carrying 3 major pathogenic bacteria in their nasopharynx (ie, Streptococcus pneumoniae, Moraxella catharralis, and Haemophilus influenzae) were more likely to develop asthma by the age of 6 years than those not carrying these microbes.⁶

2. Atopy

Word atopy originally from the Greek “atopos” meaning out of place.(William C. Shiel Jr., MD, FACP, FACR, Medical Definition of Atopy. Atopy is typically associated with heightened immune responses to common allergens, especially inhaled allergens and food allergens. ATOPY DEFINITION, American Academy of Allergy Asthma & Immunology). Data from epidemiological studies showed the strong link between asthma and atopy. Indeed, the family history of atopy is considered one of the most relevant risk factors for developing asthma.⁵Atopy refers to the genetic tendency to develop allergic diseases such as allergic rhinitis, asthma, atopic dermatitis (eczema) .

From a study showed that children who were sensitized to 1 or more aeroallergens by age 1 year had the highest rate of asthma at year 13. Children who were not sensitized at year 1 but sensitized to 1 or more aeroallergens by age 5 years had a 40% rate of asthma at age 13 years.⁷

3. Environmental Exposure

The increasing case of asthma in metropolitan areas was possibly because of their air pollution. An evidence from a study showed evidence that increased childhood exposure to PM_2,5 and black carbon was associated with increased risk of asthma at age 12 years.⁵ According to the WHO, nearly one million of the 3.7 million people who died from ambient air pollution in 2021 lived in South-East Asia. Several areas in Indonesia such as Sumatra and Borneo island resulted in spikes of increased pollution and health hazard by produced smoke haze.³ Several studies have linked the smoke and haze produced by the fires to chronic respiratory problems.

Living in an environment where the number of smokers are high mainly can cause lung damage eventually when it happens near of children area or even to a pregnancy. Several negative effects of nicotine exposure on structural and functional development of the fetal lung were established, such as alteration of the alveolar phase, damage of the epithelial cells of type I, inhibition of fibroblast proliferation, reduction of the small airways caliber, increase of the muscular tone, and reduction of lung compliance. Exposure during pregnancy may be responsible for permanent modifications of the respiratory tract that can persist into adulthood and might culminate in chronic obstructive pulmonary disease.⁷

IV. COVID-19 IN CHILDREN WITH ASTHMA

In fact, there is still no reported cases of asthma in pediatric can be the risk factor of covid-19. Children are less commonly symptomatic with coronavirus disease-2019 (COVID-19) than adults. Those who are symptomatic less commonly require hospitalization. Among 96% of cases where age was known, only 8,1% was among children less than 18 years of age. A report of 12.055 COVID-19 patients in Italy also supports a lower risk in children, although noting that COVID-19 can affect children of any age, including infants.⁸

Multiple international organizations including the CDC list asthma as a prognostic factor for COVID-19 outcomes such as morbidity and mortality. There is also a theoretical risk that COVID-19 could trigger viral-induced asthma exacerbations but still no data to support.   

The clinical course of COVID-19 in children is usually milder than in adults. A study stated that 23% of children with severe form of the disease have an underlying condition.⁹

• PEDIATRIC ASTHMA AND COVID-19 DIAGNOSIS

Diagnosis of pediatric asthma and covid -19 during COVID-19 Pandemic may be complicated by a similarity in symptoms between COVID-19 (dry cough, shortness of breath) and worsening asthma. As a result, even if cough history is consistent with asthma, screening protocols for COVID-19 should be applied to all children who have worsening cough or shortness of breath, and appropriate personal protective equipment worn.⁸

lung function test such as spirometry is specific test for diagnosing a asthma, but in terms of COVID-19 pandemic The North American guidance on passed resumption of allergy care during COVID-19 notes that for Phase 2 rollout (community infection risk declining/stable) “spirometry is still contraindicated in most scenarios because of the aerosolization risk, except in highly individualized situations in which it would be essential for immediate treatment decision that could not otherwise be made without such information and where it can be performed with appropriate precautions and room/equipment disinfection.⁸

• What is parents have to know if their kids develop an asthma during this Corona Virus pandemic?

Differentiating COVID-19 from worsening asthma, or an asthma exacerbation, is challenging. As a result, pediatricians and families have an essential role in ensuring that children with asthma maintain good asthma control during this time.¹⁰

Multiple international guidelines support children with asthma remaining on their maintenance asthma medications, such as inhaled corticosteroids or antileukotrienes, during COVID-19 if they are well controlled. A statement from the European Academy of Allergy Asthma and Clinical Immunology (EAACI) notes that “since asthma itself may be a risk factor for the severity of COVID‐19 disease and since the use of ICS does not pose an increased risk for pulmonary or systemic infections in children with asthma, their regular use is unlikely to increase the risk of acquiring the infection or increasing the severity of the present infection.⁸

Children and adolescents with asthma should remain on their current asthma medications and still practice social distancing and make sure to avoid aeroallergen also exposure to second-hand cigarette smoking¹⁰, because it can increase the expression of the ACE2 receptors in the lower respiratory tract, which is the coronavirus receptor. Which ACE2 as the receptor for Sars-CoV-2 means it will increase susceptibility to contract the COVID-19 infection and potentially to develop a more severe form.⁸

pediatric asthma and covid

REFERRENCES

1. GINA committees. POCKET GUIDE FOR ASTHMA MANAGEMENT AND PREVENTION for adults and children older than 5 years.2019. Access : https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf
2. Shilpa J. Patel, MD,MPH, Stephen J. Teach, MD, MPH. Asthma. Pediatrics in Review, An Official Journal of the American Academy of Pediatrics. Vol 40 No II November 2019. Division of Emergency Medicine, Children’s National Medical Center, Washington, DC. Access : http://pedsinreview.aappublications.org/
3. Ruby Pawankar, Jiu-Yao Wang, I-Jen Wang, Francis Thien. White Paper 2020 on Climate Change, Air Pollution, and Biodiversity in Asia-Pacific and Impact on Allergic Disease. Asia Pacific Association of Allergy, Asthma and Clinical Immunology. 2020. Jan;10(1):e11. Access :  https://doi.org/10.5415/apallergy.2020.10.e11
4. Kementerian Kesehatan RI. Hasil Utama RISKESDAS 2018. Penyakit Tidak Menular, Prevalensi Asma. Access : https://kesmas.kemkes.go.id/assets/upload/dir_519d41d8cd98f00/files/Hasil-riskesdas-2018_1274.pdf
5. Giuliana Ferrante and Stefania La Grutta. The Burden of Pediatric Asthma. Frontiers in Pediatric. June 2018. Volume 6. Article 186. Access : Frontiers | The Burden of Pediatric Asthma | Pediatrics (frontiersin.org)  
6. Fernando D. Martinez, MD. Childhood Asthma Inception and Progression Role of Microbial Exposures, Susceptibility to Viruses and Early Allergic Sensitization. Elsevier Ltd. Volume 39, Issue 2. 2019. P 141-150. Access : Childhood Asthma Inception and Progression: Role of Microbial Exposures, Susceptibility to Viruses and Early Allergic Sensitization – ScienceDirect
7. Frederick J. Rubner, MD, Daniel J. Jackson, MD, Michael D. Evans, MS. Early life rhinovirus wheezing, allergic sensitization, and asthma risk at adolescence. 2017. The Journal of Allergy and Clinical Immunology. Asthma and Lower Airway Disease. Volume 139, issue 2, P501-507. Early life rhinovirus wheezing, allergic sensitization, and asthma risk at adolescence – Journal of Allergy and Clinical Immunology (jacionline.org)
8. Elissa M.Abrams MD, FRCPC. Ian Sinha MBBS, FRCPCH, PhD. Pediatric Asthma and COVID-19: The known, the unknown, and the controversial. Wiley Periodicals LLC: Pediatric Pulmonology. 2020; 55:3573-3578. DOI: 10.1002/ppul.25117
9. M. Kamali Aghdam, M. Sadeghzadeh, S. Sadeghzadeh and K. Namakin. Challenges in A Child with Asthma and COVId-19. Elsevier Ltd. 2020. New Microbe and new Infections, Vol 37 Number C. Access : Challenges in a child with asthma and COVID-19 – ScienceDirect
10. Elissa M. Abrams, MD, MPH, and Stanley J. Szefler, MD. Managing Asthma during Coronavirus Disease-2019: An Example for Other Chronic Conditions in Children and Adolescents. The Journal of Pediatrics. Vol 222. July 2020. Access: https://www.jpeds.com/article/S0022-3476(20)30528-X/fulltext