Children with asthma not at increased risk for SARS-CoV-2 infection, study finds

 From the start of the COVID 19 pandemic, a real ongoing concern was identifying children and adolescents who could be high risk for poor outcomes with COVID 19 infections.  Asthma was presumed to be one of these conditions.  However, although mucosal respiratory viruses all have the potential to trigger asthma exacerbations, high quality data consistent fails to show any increased risk of COVID 19 related complications.  However, another Scottish study from last year reported higher risk for hospitalization due to asthma exacerbations after a COVID 19 infection if asthma was NOT well controlled.  To put it simply, if your child has asthma make sure it is controlled.

In a new study published in Pediatrics, researchers concluded that children with asthma have similar risk for for SARS-CoV-2 infection compared with children without asthma.

“We found no evidence that children with asthma are at higher risk of COVID-19 or of developing severe illness from COVID-19,” Matthew Kelly, MD, MPH, associate professor of pediatrics and global health, associate program director of the Pediatric Infectious Diseases Fellowship and associate director of physician-scientist development in the Office of Pediatric Education at Duke University School of Medicine in Durham, North Carolina, told Healio.

Kelly and colleagues conducted a retrospective cohort study that included 46,900 children aged 5 to 17 years in the Duke University Health System with a Durham County, North Carolina, residential address. Children with asthma were classified using previously validated electronic health record-based definitions, and SARS-CoV-2 infections were identified via positive polymerase chain reaction testing of samples collected from March 2020 to September 2021. Children with asthma were matched to those without asthma.

“Because severe asthma exacerbations are often associated with respiratory virus infections, there has been concern that children with asthma who acquire SARS-CoV-2 might be at high risk for severe illness,” Kelly told Healio. “However, we and others had seen relatively few children with SARS-CoV-2 infections hospitalized with asthma exacerbations; moreover, there were some data to suggest that asthma, or the inhaled corticosteroids commonly prescribed to children with asthma, might lower the risk of acquiring SARS-CoV-2.”

Read article here.

Read study here.

Long COVID in Children - What is it?

 COVID 19 infections in children and adolescent or rarely associated with a severe respiratory illness.  However, persistent respiratory symptoms have been reported in children after a COVID 19 infection.  With increased awareness about "long COVID" in adults, the question could be asked does such a disease exist in children.  This study attempted to answer this question by studying adolescents after COVID infection who had persistent respiratory symptoms like cough and shortness of breath.   The most common conditions identified in this small cohort of children included asthma features, paradoxical vocal fold motion, deconditioning and dysautonomia.

Abstract

Rationale

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes long-term pulmonary sequelae in adults, but little is known about pulmonary outcomes in pediatrics.

Objective(s)

The aim of this study was to describe long-term subjective and objective pulmonary abnormalities after SARS-CoV-2 infection in pediatric populations.

Methods

Single-center, retrospective cohort of patients seen in post-coronavirus disease 2019 (COVID-19) pulmonary clinic in 2021. Subjects evaluated had persistent pulmonary symptoms 4 weeks or more after initial infection. Clinical testing included a 6-min walk test (6MWT), chest X-ray, pre- and postbronchodilator spirometry, plethysmography, and diffusion capacity. Patients were followed 2-to-3-months after the initial visit with repeat testing. The primary outcome was the presence of abnormal pulmonary function testing. Secondary measures included variables associated with pulmonary outcomes.

Results

Eighty-two adolescents were seen at a median of 3.5 months postinfection, with approximately 80% reporting two or more symptoms at clinic presentation (cough, chest pain, dyspnea at rest, and exertional dyspnea). At follow-up (~6.5 months) exertional dyspnea persisted for most (67%). Spirometry was normal in 77% of patients, but 31% had a positive bronchodilator response. No abnormalities were noted on plethysmography or diffusion capacity. Clinical phenotypes identified included inhaled corticosteroid responsiveness, paradoxical vocal fold motion disorder, deconditioning, and dysautonomia. Multivariable modeling demonstrated that obesity, anxiety, and resting dyspnea were associated with reduced 6MWT, while female sex and resting dyspnea were associated with higher Borg Dyspnea and Fatigues scores.

Conclusions

This is the largest study to date of pediatric patients with long-term pulmonary sequelae post-COVID-19. Identified clinical phenotypes and risk factors warrant further study and treatment.

Read article here.

FDA approves dupilumab for children aged 6 to 11 with moderate to severe asthma

Now that another biologic therapy is available for pediatric severe asthma, it is important to look at the indications for add on biologic therapy for asthma.  In general, there are 2 broad categories of asthma that may warrant adding an injectable biologic therapy:

1) Children and adolescents with severe asthma, poorly controlled despite compliance with high dose asthma therapy.  Here, poorly controlled may indicate frequent hospitalization, ER, or urgent care visits.  In addition, systemic steroid use and symptoms that affect quality of life (school, exercise, etc) are important considerations.

2) Children and adolescents with severe asthma that is controlled, but requires high dose asthma controller medication.  This is an important consideration because high dose inhaled glucocorticoids have been associated with a numbers of risks including reduced growth velocity, obesity, adrenal insufficiency, and ocular side effects like cataracts.

The FDA has approved dupilumab as an add-on maintenance treatment for children aged 6 to 11 years with moderate to severe asthma characterized by an eosinophilic phenotype or with oral corticosteroid-dependent asthma.
The expanded approval of dupilumab (Dupixent, Regeneron/Sanofi) to children aged 6 to 11 was based on data from the phase 3, double-blind, placebo-controlled LIBERTY ASTHMA VOYAGE trial that evaluated efficacy and safety of dupilumab compared with standard care in children with uncontrolled moderate to severe asthma. More than 90% of children in the trial had at least one concurrent type 2 inflammatory condition, according to a company press release.
“I was impressed that dupilumab met not only its primary endpoint of reduction in asthma exacerbations, but also all key secondary endpoints in the pediatric ASTHMA VOYAGE trial,” Leonard B. Bacharier, MD, professor of pediatrics at Monroe Carell Jr. Children’s Hospital at Vanderbilt University Medical Center and principal investigator of the ASTHMA LIBERTY VOYAGE trial, told Healio. “I anticipate that clinicians will begin to include dupilumab in their discussions with families of children with uncontrolled moderate-severe asthma. Many children in this age group continue to experience repeated asthma exacerbations, and experience side effects from frequent courses of systemic corticosteroids. Dupilumab’s demonstrated efficacy in significantly reducing exacerbations will allow such children greater disease control.” 

Read article here.

It's Here! Home Monitoring For Asthma

 During a period where office visits are reduced when possible and safe, and when some lung function testing maneuvers are avoided (spirometry) because of increased risk for asymptomatic infection spread, it is a great advantage to have quality home monitoring options.  The Capmedic device does this and provides the additional benefit of coaching asthma patients through proper lung function and allowing your asthma doctor to monitor compliance.  Dr. Susarla

CapMedic Measures Lung Function, Makes Sure Inhalers Used Correctly

The FDA has cleared the CapMedic device that helps to make sure that metered dose inhalers (MDIs) are properly used, even by young patients.

MDIs are most commonly employed to deliver asthma medications deep into the lungs, but to work effectively they have to be used correctly and on a consistent schedule.

The CapMedic snaps onto the top of many inhalers and, using built-in lights and a tiny speaker, it works to nudge users to inhale the medication correctly and at the right time. When a person is ready, the device talks them through all the steps, like shaking the inhaler, properly squeezing it while keeping it upright, and timing the inhalation just right.

The same device can snap onto an accompanying plastic adapter to turn it into an accurate at-home spirometer for lung function measurement. It can now measure FEV1, the maximum amount of air that the patient can push in a second, and PEF, the maximum flow one can generate at a steady rate.

Readings about usage and spirometer data are stored on an accompanying smartphone, helping patients, parents, and caretakers, make sure that the inhaled medication regimen is adhered to.

“Decades of studies have shown that almost 90% of patients are unable to use MDIs correctly – a result of their complex, multi-step usage requirements. The Cognita team has conducted drug deposition studies showing a tenfold improvement in the delivery of medication from just 4-5% to 45% when inhalers are used correctly,” said Rajoshi Biswas, Ph.D., Chief Scientific Officer and co-founder at Cognita Labs, in the announcement. “Getting an effective daily dose means patients are more likely to avoid costly, life-threatening hospitalizations.”

Read article here.

Clinic Update During COVID 19 Pandemic

We have stepped up to protect our patients, our staff and the community during the coronavirus (COVID-19) pandemic.  Houston Specialty Clinic has CHANGED almost all clinic office visits to telemedicine, effective immediately due to the urgent need for all of us to reduce the risk of infection. 

   We will still be OPEN for the following patient visit types: 

• Patients requiring regular injections for asthma management  
• Urgent visits

Fortunately, the State of Texas has issued an emergency declaration waiving many restrictions on telemedicine.  Therefore, our providers are available during office hours for telemedicine consultation for both new AND existing patients. 

Please see the following links for useful resources infection prevention: 

https://www.cdc.gov/coronavirus/2019-nCoV/index.html 

https://www.thoracic.org/patients/patient-resources/resources/coronavirus-patient.pdf