key: cord-0975546-kau9e0e3
authors: Golan‐Tripto, Inbal; Arwas, Noga; Maimon, Michal S.; Bari, Romi; Aviram, Micha; Gatt, Dvir; Goldbart, Aviv
title: The effect of the COVID‐19 lockdown on children with asthma‐related symptoms: A tertiary care center experience
date: 2021-06-14
journal: Pediatr Pulmonol
DOI: 10.1002/ppul.25505
sha: 2753e434cfadaa674745a98068c5cc923fd0431c
doc_id: 975546
cord_uid: kau9e0e3

BACKGROUND: Acute asthma exacerbations are a common cause for emergency department (ED) visits and hospitalizations in children. Since the outbreak of coronavirus disease 2019 (COVID‐19) and the education system closure/total lockdown in Israel on March 2020, we have noticed a decrease in pediatric ED visits and an increase in hospitalizations of asthma exacerbations. OBJECTIVE: to examine the patterns of ED visits for asthma exacerbations during COVID‐19 outbreak, in comparison to the previous year. METHODS: A retrospective study comparing asthma related ED visits and hospitalizations among children aged 2–18 years at a tertiary center in southern Israel. Three time periods were selected: 2020 A (prelockdown, 2/1/20 to 3/14/20), 2020 B (lockdown, 3/15/20 to 5/15/20) and 2020 C (postlockdown, 5/16/20 to 6/30/20) and compared to the three parallel time periods in 2019. Data regarding demographics, number of ED visits and clinical severity parameters were collected and analyzed. RESULTS: Five hundred and twelve children visited the ED for asthma exacerbation: 273 children during 2019 and 239 children during 2020. Lockdown period in 2020 revealed significantly fewer ED visits per day compared to the parallel calendar period in 2019 (1.8 vs. 1.43, p < .001). Significantly higher hospitalization rate (47.1% vs. 33.7%, p = .05) and longer length of stay (3.15 vs. 1.9 days, p = .03) were observed during the lockdown. CONCLUSION: Lockdown is associated with fewer ED visits for asthma exacerbation, probably due to; reduced exposure to viral infections and environmental allergens, decreased availability of primary physicians and families' reluctance to arrive to the ED. ED visits during lockdown were characterized by higher hospitalization rate and longer LOS.

The coronavirus disease 2019 (COVID-19) outbreak has led, since the beginning of 2020, to the implementation of "social distancing" practices including school closures in many countries, to reduce the transmission of the disease. 1 When we analyze the "lockdown approach" during influenza pandemic, a mean reduction of 29.6% in the peak of the epidemic after school closure was reported by a systematic review of 31 studies. 2 Another review presented a substantial reduction of up to 50% in the transmission of disease among children after school closure during influenza outbreak. 3, 4 To date, children appear to represent a low proportion out of total confirmed COVID-19 cases and are usually asymptomatic or present with mild symptoms. 5 Asthma is the most common pediatric chronic respiratory disease. Acute exacerbations continue to be a major health concern among children worldwide and a common reason for emergency department (ED) visits and hospitalizations in the pediatric age. In a study examining asthma-related ED visits and hospital admissions in the United State between 2010 and 2015, acute asthma exacerbations accounted for 3% of ED visits and 6% of hospital admissions among children aged 5-17 years. 6 Respiratory tract infections and allergen exposure have been recognized as the most common triggers for asthma exacerbations in children, with suggested synergistic interactions between these factors. 7 The seasonal pattern of asthma exacerbations is well established. 8 A typical peak is in September, when children return to school after the summer break. In schoolaged children, another peak has been viewed during the spring months, that can be attributed to the spread of pollen allergens, also known as a trigger for asthma exacerbation in this age group. 9 There is scarcely any data on whether childhood asthma constitutes a risk factor for COVID-19 severity. 10 Recent data suggests blood eosinophil counts may have a prognostic value in COVID-19, with eosinopenia indicating a severe disease. 11, 12 Since the introduction of the COVID-19 outbreak and education system closure in Israel on March 

Pediatric patients aged 2-18 years that presented to the ED during one of the selected time periods for asthma related symptoms (e.g., shortness of breath, wheezing, tachypnea), and were treated during the visit with anti-asthmatic medications, were included in the study.

Using electronic health record data, we collected the parameters for each patient, including relevant medical history and medications.

Data collected included: demographic data, chronic diagnoses, medications prescribed, vital signs on admission, radiological findings, treatment at the ED, triage acuity during presentation according to Canadian Triage assessment score, 14 

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OSA, Upper airway obstruction

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.326 Table 3 ). access to health care in some of the settlements. 16 In those areas, social distancing is more difficult to achieve and the exposure to outdoor allergens was probably not significantly reduced, even during the lockdown. The mildly lower heart rate and respiratory rate noticed in 2020 is clinically insignificant and could stem from the difference in patients age between 2019 and 2020, with an average of 1.5 years older in 2020. Since asthma severity parameters (hospitalization rate and LOS) were higher during 2020 B, we can assume that this change in vital signs did not reflect milder cases, but probably proportionate to an older age. Treatment in the ED was similar between all time periods except for a significant drop in the use of NACL 0.9% inhalations during 2020 B and 2020 C. Since the COVID-19 outbreak, in accordance with the Israeli pediatric pulmonology society guidelines, there has been a shift from using smallvolume nebulizers to metered-dose inhalers with valved-holding chambers for beta-agonist and anticholinergic inhalations to reduce the viral infection transmission by reducing the spread of aerosol mass by small-volume nebulizers. 17, 18 The accumulating evidence on the impact of COVID-19 pandemic on ED visits patterns, show a substantial decrease in the volume of patients presenting to the ED during the pandemic, throughout various disciplines and countries. 19 Abbreviations: BP, blood pressure; ED, emergency department; HR, heart rate; RR, respiratory rate; SAT, oxygen saturation.

| 2829 questionnaires studies, along with an increase in children's psychological and behavioral symptoms and elevated screen-time. [31] [32] [33] Socioaffective complications and insufficient physical activity were underscored as two of the main concerns, particularly among socioeconomic deprived children. 34 As a result, a reduction in physical activities reduces the number of asthma exacerbations related to exercise induced bronchospasm and exercise induced asthma. The fewer ED visits during lockdown can also result from better asthma control while the parents are at home, providing better adherence to anti asthmatic controllers therapy. 35 Although, this issue is most probably of limited effect, since most of the parents that participated in a telephone visit during lockdown, stated they stopped the preventive therapy as their child was feeling well. Another issue that should be discussed is the avoidance of approaching for medical care After lockdown, we demonstrated significant rise in number of ED visits, even in comparison to same time period during the previous year. In Israel, children younger than 12 years of age returned back to school after lockdown, while adolescences (aged 12-18 years) attended home school program. When we looked at the subgroup of children aged 12-18 years, the visit's numbers were similar between different study periods. That fact actually correlates with our hypothesis that everyday exposure to classmates is one of the major triggers for asthma exacerbation, and because this age group was in home schooling program during 2020 C, it was not affected by lockdown opening. We speculate that post lockdown rise represents the return to routine activity with everyday exposure to classmates, outdoor pollen exposure, rise in air pollution and physical activity, especially in the younger sub-group, aged 2-12 years. This may resemble "September pandemic," when children returning to school after summer vacations with significant rise in asthma exacerbations. 8 Alongside with a significant reduction in ED visits for asthma exacerbations during lockdown, higher hospitalization rates and longer LOS were observed, that may indicate more severe exacerbations predominate this period. This observation could be attributed to delay in presentation both due to reduced availability of community medical services during lockdown and transition towards telemedicine-based practice as well as the hesitation to come to the ED due to the fear to contract COVID-19. Our data indicated that hospitalization rate was 1.5 times higher during lockdown period compared to the previous year, in contrary to other publications that reported a reduction in the number of hospitalizations in the pediatric population during this period. 25, 36 We believe this fact is related to different demographics between countries, with majority of Bedouin Arab population in our region. Another possible explanation for the higher admission rate and longer LOS seen during lockdown could be a lower threshold for admission at the ER and higher threshold for discharging the patient from the wards, in light of the reduced availability of community health care services and the concern of lack of proper follow-up in the community.

Our study has a few limitations. This is a single tertiary center experience, and therefore can be influenced, as mentioned, by the unique demographics in the region. Another limitation is the retrospective nature of our study, with all data drawn from electronic files. We did not capture data regarding viral PCR in nasal swabs, which could emphasize the role of viral infections as a trigger for exacerbation during different study periods. Some of the data that was documented in a hard copy, in extremely acute patients treated in the resuscitation room, may be missing in the electronic files (e.g., intravenous Magnesium Sulfate).

In conclusion, we report a new pattern of ED visits and hospital stay of children with asthma related symptoms, associated with the COVID-19 pandemic, that perhaps is not only confined to asthma.

Pediatricians should be aware to this phenomenon at the community and hospital levels.

The authors declare that there are no conflict of interests.

Inbal Golan-Tripto completed conceptualization (lead); investigation (lead); methodology (lead); project administration (lead); writing original draft (lead); writing review and editing (lead). Noga* Arwas completed conceptualization (equal); investigation (equal); writing original draft (equal); writing review and editing (lead). Michal Maimon and Micha Aviram completed methodology (equal); supervision (equal); writing review and editing (equal). Romi Bari completed data curation (lead); formal analysis (lead); methodology (equal); writing review and editing (equal). Dvir Gatt completed investigation (equal); methodology (equal); writing review and editing (equal).

The data that support the findings of this study are available from the corresponding author upon reasonable request. 

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):e0243694. How to cite this article: Golan-Tripto I, Arwas N, Maimon MS, et al. The effect of the COVID-19 lockdown on children with asthma-related symptoms: A tertiary care center experience