By: Franziska Rosser MD, MPH, FAAP & Sylvia Owusu-Ansah MD, MPH, FAAP
If your child has asthma, you may worry whether they are at greater risk from
respiratory viruses such as COVID-19, influenza (flu) and respiratory syncytial virus (RSV). Here are some common questions and ways to help keep children with asthma healthy while respiratory viruses are spreading.
Does having asthma put my child at higher risk of getting sick from COVID-19, the flu or RSV?
moderate-to-severe or uncontrolled asthma may be more likely to be hospitalized from COVID-19. Having asthma also raises the risk of
complications from flu, and flu can trigger asthma attacks. Similarly, RSV can worsen asthma symptoms. And there is evidence that children who had RSV may be at higher risk of developing asthma.
How important is it that my child's asthma is well-controlled with respiratory viruses going around?
It is always important to have well controlled asthma. With respiratory viruses like flu, RSV and COVID-19 surging, this is especially important. We want to prevent children from needing emergency department care when possible.
Having uncontrolled asthma is a risk factor for asthma attacks, so control is the goal. However, if your child is having an asthma emergency, don't delay seeking immediate medical care.
How do I know if my child's asthma is well-controlled?
If you're not sure your child's asthma is well controlled, the first step would be to call your pediatrician or other asthma care provider. Well controlled asthma usually means your child is:
coughing on no more than 2 days per week
waking up at night from coughing no more than once per month (or no more than 2 nighttime awakenings for children 12 years and older)
needing 2 or less rescue treatments per week (this does not include pre-treating before exercise)
having no more than 1 course of oral steroids such as prednisone in the last 12 months
able to fully participate in regular activity without breathing limitations
This would be a good time to review your child's asthma control and management plan with the doctor. Your pediatrician and other asthma providers want to know about your child's asthma concerns, so don't be shy about contacting them!
What if my child has an asthma attack during respiratory illness surges?
For children with asthma, we recommend that parents, other caregivers and school or child care have an
asthma action plan. Your child's asthma action plan will tell you what to do every day for asthma care, as well as what to do if your child has asthma symptoms. It is important to manage asthma attacks the same way as usual during outbreaks. Don't worry about using oral steroids, for example, if that is part of your child's action plan.
Make sure you talk with your pediatrician if you have any questions or concerns about your child's asthma medicine or action plan.
When should I seek emergency care for my child with asthma?
Go to the emergency department immediately or call 911 if your child is having symptoms that include:
can't catch their breath, speak in full sentences (if developmentally appropriate), or walk or run because of breathing difficulties
movement of the muscles in between the ribs, abdomen (sometimes called
belly breathing) and/or in the neck
making grunting noises, head bobbing, not responding to albuterol treatments
older child complains of chest pain or chest tightness while having trouble breathing
feeling drowsy or confused
turning a bluish or grayish color around their mouth, middle of the face, or chest
Your child's asthma action plan can provide more details about when to seek immediate or emergency care.
Some children may not require emergency care, but need a change in treatment plan or closer monitoring. Call your pediatrician or asthma care provider if your child is having any of these symptoms:
increased coughing; chest pain, back pain
decreased ability to do usual activities
symptoms not responding to albuterol (but otherwise not in distress)
needing albuterol treatments more frequently than every 4 hours (but otherwise not in distress)
not getting better after 2-3 days of increasing albuterol
What is the best form of albuterol to give—an inhaler or nebulizer treatment?
Studies have shown that albuterol given through a nebulizer or metered-dose inhaler, when taken appropriately, are equally effective. There is some evidence that albuterol inhalers, when used with spacers, are more effective than albuterol through a nebulizer.
Whether you have an inhaler or nebulizer, it is important to make sure you are using the medications correctly.
Using a spacer or spacer/mask with an albuterol inhaler helps more medicine get into the airways, for example. For most metered-dose inhalers, we don't recommend using it without a spacer or spacer/mask. Once children are able to take a deep slow breath in through their mouth and hold it for 10 seconds, we recommend using a spacer. Most children are able to switch from a spacer/mask to a spacer around 5 or 6 years of age.
When using a nebulizer, children should use a face mask until they are at least 5-6 years old. They can use a mouthpiece once they are able to breath in through their mouth. Blow-by albuterol, or rather holding the nebulizer tube near the face, delivers very little albuterol to airways and is not recommended.
One thing to keep in mind: Using a nebulizer for albuterol treatments may increase the amount of virus in the air if the person has a respiratory virus like COVID-19. This could potentially spread the virus to others more easily, since the virus may stay in air droplets for up to several hours.
Talk with your child's asthma care provider about which delivery method is best for them. Shortages of albuterol inhalers have previously been reported in some areas, and some insurances have not covered spacers. Best practices are probably going to be different based on location and a child's individual needs.
How can I help prevent my child from having an asthma attack during viral season?
Help your child follow their asthma management plan and take their
controller medications as prescribed. Know when to step up care and when to call your pediatrician or asthma care provider. In addition, there are other steps you can take:
Get vaccinated. It is especially important for children and teens with asthma to be up-to-date on immunizations. Vaccines keep the immune system primed and ready when respiratory viruses spread. Currently, there is no vaccine available for RSV. But everyone ages 6 months and up should get vaccines for COVID-19 and the flu, along with other routine immunizations.
Use good hand hygiene & other basics. Handwashing is a simple but powerful way to help prevent the spread of germs. Wearing a face mask and avoiding crowded spaces, especially indoors, is also an effective way to reduce exposure to respiratory viruses.
Go smoke-free and vape-free. People with asthma should avoid asthma triggers such as tobacco smoke, marijuana smoke or e-cigarette/vape aerosol. If a parent or caregiver
smokes or vapes, it is important to do it outside. Smoking or vaping in another room does not prevent pollution from traveling to different areas of the home. Teenagers or pre-teens themselves should not smoke or vape as this will worsen asthma symptoms and lung disease. Tobacco smoke also increases the risk of developing certain cancers. The 1-800-QUITNOW is a free nationwide number that helps people stop smoking. Many states provide free supplies such as nicotine replacement patches.
Avoid allergy triggers. Try to reduce exposure to known allergy
triggers, which can also aggravate asthma. For example, if a child with asthma is allergic to ragweed pollen, you might want to keep windows closed during the Fall to reduce exposure. Cleaning is important to help reduce allergens, along with respiratory virus germs, but can be tricky for parents of children with asthma. If your child is sensitive to certain cleaning products, use them when your child is not in the room, turn on a fan, open a window or try switching to less irritating products.
Avoid indoor and outdoor air pollution: Air pollution can irritate airways and can trigger asthma symptoms. Some sources of indoor air pollution can include using a gas stove without venting outside, burning candles or incense, tobacco smoke/e-cig aerosols, and older wood stoves. If you use a chimney or wood stove and smell smoke in the house, consider having it checked by a professional.
air pollution such as particle pollution and ozone can worsen asthma and cause attacks. Particle pollution is generally higher near major roadways and during rush hour. Ozone pollution is generally higher in the afternoon on warm days. If your child has asthma, you can check the Air Quality Index (AQI) on Airnow.gov or the Airnow smartphone app. The Environmental Protection Agency (EPA) has great information about
indoor and outdoor air quality.
Reduce stress. Stress can be another trigger for asthma. Take time to relax as a family and use
positive parenting tips to help your child cope and build
resilience. Taking a walk
outside and keeping active can help to reduce stress.
Take care of all health needs. People with asthma should take extra care of their overall health. In addition to getting vaccinated, avoiding tobacco smoke, reducing stress and avoiding allergy triggers and air pollution, it's important to remember the basics: using good
hand hygiene, eating nutritious food and getting enough
physical activity and
Make sure you have enough asthma medicine on hand. It's a good idea for people with asthma to make sure they have asthma medicines at home and to call for refills when the inhaler is getting close to empty. Many pharmacies will deliver medicine through the mail at no extra charge.
Having an asthma action plan, knowing how to use it, and communicating with your asthma provider can give you more information and confidence to handle your child's asthma, including asthma attacks.
About Dr. Owusu-Ansah
Sylvia Owusu-Ansah, MD, MPH, FAAP, is a member of the American Academy of Pediatrics (AAP) Section on Emergency Medicine. She is an Assistant Professor of Pediatrics, University of Pittsburgh School of Medicine Department of Emergency Medicine. She also serves as EMS/ Prehospital Director for the UPMC Children's Hospital of Pittsburgh.
About Dr. Rosser
Franziska Rosser MD, MPH, FAAP, is an Assistant Professor of Pediatrics, Division of Pulmonary Medicine at the University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh. She is a member of AAP's Section on Tobacco Control.