key: cord-0894822-3o1ihr9b authors: Rabha, Anna Clara; Fernandes, Fátima Rodrigues; Solé, Dirceu; Bacharier, Leonard Benjamin; Wandalsen, Gustavo Falbo title: Asthma is associated with lower respiratory tract involvement and worse clinical score in children with COVID‐19 date: 2021-05-29 journal: Pediatr Allergy Immunol DOI: 10.1111/pai.13536 sha: b34b573b752359e00508213506778f4e7861cbb2 doc_id: 894822 cord_uid: 3o1ihr9b During the SARS-CoV-2 pandemic, most clinical reports about COVID-19 manifestations and risk factors have been focused on adults, while data on children are relatively limited. COVID-19 mortality in children is considerably lower than in adults and children are considered at lower-risk for severe respiratory manifestations of the disease. Asthma is one of the most prevalent chronic conditions in children and is also a frequently reported comorbidity among children with COVID-19. 2, 3 Despite that, the relationship between asthma and COVID-19 in children is not fully understood, as data regarding this relationship are mainly from adults. 4 The objectives of this study were to describe the involvement of the lower respiratory tract (LRT) in children and adolescents with COVID-19 and to examine the relationship between asthma and the manifestations and severity of COVID-19. This is a cross-sectional, retrospective, and observational study. Clinical data were collected from medical records of children and adolescents (0 to <18 years) seen in the emergency room (ER) of Sabará Hospital Infantil (São Paulo, Brazil) between March 2020 and January 2021 who had a diagnosis of COVID-19. Cases were defined by a clinical diagnosis of COVID-19 supported by a positive RT-qPCR test for SARS-CoV-2. The severity of cases (maximal level of the illness) was classified into mild, moderate, severe, or critical (Table 1 of the Supplementary Appendix S1). 5 The presence of comorbidities was recorded according to family information. Younger children (≤5 years) with recurrent wheezing were considered as asthmatic children for the analysis. LRT involvement was defined by the presence of any of the following: dyspnea; wheezing; respiratory distress; SpO 2 <93%; SABA (short-acting beta-2 agonist); or oxygen (O 2 ) use. The study was approved by the Research Ethics Committee of the institution. In total, 607 children and adolescents were diagnosed clinically with COVID-19, but 19 were excluded from the study due to the diagnosis being established only by serology or having incomplete data. Among the 588 included children, 56.0% were boys. The median age was three years (IQR = 1-8 years). Eight-five (14.5%) children were hospitalized, 28 (4.8%) in ICU. A relevant comorbidity was reported in 157 (26.7%) cases, including asthma (12.2%), other allergic diseases (7.0%), neurological disease (6.5%), and prematurity (3.9%). Fever (67.5%) and nasal discharge/congestion (55.4%) were the most frequently reported symptoms, and LRT involvement was observed in 14.3% of the cases. Regarding illness severity, 88.2% of the children were classified as mild. There were no deaths. Asthmatic children were older than non-asthmatic children (5 [3] [4] [5] [6] [7] [8] [9] [10] years vs 3 [1] [2] [3] [4] [5] [6] [7] [8] years, p < .001). Some demographic and clinical data of asthmatic and non-asthmatic children are shown in Table 2 of the Supplementary Appendix S1. LRT involvement, dyspnea, wheezing, respiratory distress, SABA use, and SpO 2 <93% were each significantly more common among asthmatic children (Table 1) . Abnormal chest radiography was found in 17.1% (7 in 41) of children with asthma and in 16.2% (27 in 167) of those without asthma (p = .87). Asthma was significantly associated with COVID-19 severity score (Table 1) . In multivariate analysis, LRT involvement was significantly associated with prematurity and asthma, whereas a more severe COVID-19 score was associated with asthma, prematurity, neurological disease, and age <2 years of age. Age <2 years, prematurity, and neurological disease were significantly associated with hospitalization ( Table 2 ). Our results show that the morbidity of COVID-19 in children attending an ER should not be overlooked. Although most cases were mild, 14% of children in our study required hospitalization, including 5% in the ICU. LRT involvement is considered a sign of severity during COVID-19 infection, 4 and it was observed in 14% of our cases. The relative infrequency in which wheezing was observed (4.8%) is noteworthy, even among children with asthma (19.4%). Several hospitals have reported a significant decrease in cases of wheezing and/or exacerbation of asthma during the pandemic. 6, 7 This reduction may be mainly due to the suspension of face-to-face school classes and social distancing measures, resulting in lower rates of viral infections. Even so, this relatively low tendency to induce viral wheezing by SARS-CoV-2 may have contributed to this scenario. As observed in other respiratory viral infections, LRT involvement during COVID-19 was more common among children with asthma. Additionally, children with asthma had worse COVID-19 severity scores indicating that asthma may be a risk factor for more severe forms of COVID-19 among children seeking ER care. Nevertheless, we found no higher risk of hospitalization for COVID-19 among children with asthma. Insufficient sample size could be an explanation for this absence of association, since hospitalization was infrequent among children with COVID-19. In adults, asthma is not associated with higher COVID-19 severity or worse outcomes (death, intubation, or mechanical ventilation). 8 Note: Variables in the equations: infant or not (age <2 years of age); sex; prematurity (gestational age <37 weeks); asthma; obesity; any neurological disease; allergic diseases (other than asthma). in which medical care was sought in another hospital. The presence of a medical diagnosis of asthma was recorded according to family information, and there may be inaccuracies. In addition, the diagnosis of asthma in young children is difficult to establish accurately and 51% of the children with asthma or recurrent wheezing in our study were ≤5 years of age. Thus, the interpretation of the findings should consider this limitation. In conclusion, we have found that LRT involvement occurs in approximately 1/7 of children with COVID-19 presenting to the ER, but wheezing was infrequently observed. Asthma/recurrent wheezing and prematurity were associated with LRT involvement and worse COVID-19 severity scores among children seeking ER care. This study was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES). The peer review history for this article is available at https://publo ns.com/publo n/10.1111/pai.13536. Clinical characteristics of COVID-19 in children compared with adults in Shandong Province Clinical Characteristics and outcomes of hospitalized and critically ill children and adolescents with coronavirus disease 2019 at a tertiary care medical center COVID-19 in children and adolescents in Europe: a multinational, multicenter cohort study Pediatric asthma and COVID-19: the known, the unknown and the controversial World Health Organization. COVID-19 Clinical management: living guidance Impact of COVID-19 on pediatric emergencies and hospitalizations in Singapore COVID-19 is not a driver of clinically significant viral wheeze and asthma Prevalence of comorbid asthma and related outcomes in COVID-19: a systematic review and meta-analysis Asthma and COVID-19 in children: a systematic review and call for data Impact of the COVID-19 pandemic in children with allergic asthma COVID-19 in children with underlying chronic respiratory diseases: survey results from 174 centres Risk factors for severe COVID-19 in children