Pediatric Asthma and the Pandemic

A few days ago I saw a fascinating Twitter thread on pediatric asthma by Chris Carroll, a pediatric ICU doctor. It's not one of my usual topics, though I guess it ties in to some of them. Here goes:

Lately, I’ve been reflecting a lot of how much racism has affected our understanding of the pathophysiology of asthma in children. And how the pandemic has exposed just how wrong so many of the underlying assumptions were.

Some background. Asthma is the most common chronic disease in children, affecting 1 in 7 children at some point during childhood. Each year approximately 10,000 children/year are admitted to a peds ICU with severe asthma. Severe asthma exacerbations disproportionately affect BIPOC children, with higher rates of hospitalization, ICU admission and intubation.

For decades, we’ve thought that home environments were a significant contributor to severe exacerbations. Consciously or unconsciously families were shamed/judged for it. It was the dust mites, or the cockroaches, or your smoking that brought them to the ICU. Although this wasn’t said out loud, the judgmental implications were there in our questions to families about asthma triggers. If only you didn’t smoke, or kept your house clean, or lived in a nicer home, or weren’t so poor, then maybe your kid wouldn’t be here?

But then the pandemic hit. And we sent all those children with asthma home. And guess what? Severe asthma exacerbations WENT AWAY!

During quarter 2 of 2020, when there would typically be about 1400 kids in peds ICUs around the US, there were 241. And this trend persisted throughout the pandemic. We went an entire spring, summer and fall with barely ANY asthma in peds ICUs.

So it turns out it WASN’T the home environment that was triggering severe asthma exacerbations. And those assumptions are judgements were wrong.

So what was responsible for this decrease in severe asthma? Was it the mask-wearing or isolating, keeping kids from spreading infectious diseases? Was it increased particulate exposure in schools? Who knows?

But it is clear we need to rethink our understanding of asthma in children.

While there have been positive and negative effects on kids from the pandemic, one thing is clear: Measures taken to reduce spread of COVID markedly reduced respiratory illnesses. As my friend Janine said, we asked people to put masks on and suddenly kids could breathe again.

I’ve been seeing a lot of “unmask your kids” signs in my town lately. I wish we (as a society) were able to have rational discussions about which public health measures we should continue post-pandemic, but apparently that’s not possible.

But one thing we can do is reflect on how much of our understanding of asthma may have been wrong. And reflect on how racism may have affected our understanding of this common chronic disease. I have.

Some of the commenters remarked on how their home, with its controlled environment during the pandemic, exposed them to fewer environmental triggers (from cleansers, etc.), while others commented on the toxic daily stress of racism at school or the fact that masks could have been filtering out particulates from the air in general. Others suggested that not getting other respiratory infections meant there were fewer underlying infections to bring on asthma attacks.

All in all, pretty interesting.