Coronavirus disease (COVID-19), an acute respiratory infection caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), is presently affecting children and adults worldwide [1]. Asthma is a common respiratory disease in children and may be a co-morbidity in some affected children; we, herein, highlight a few related issues.

Moderate to severe, especially uncontrolled asthma, is considered as an increased risk for SARS-CoV-2 infection, though not reported initially as one of the co- morbidities amongst COVID- 19 patients [2]. However, the data from United States and United Kingdom shows asthma as one of the prevalent underlying conditions in patients with COVID-19 [3,4]. Nonetheless, the evidence is still evolving and is primarily from adults. Experimental studies have revealed that inhaled corticosteroid (ICS) and/or bronchodilator can suppress SARS-CoV-2 replication and cytokines synthesis [5], but its therapeutic implications are still unclear. In children, asthma flare up is usually due to viral infections, and clinically, it is difficult to differentiate these viral infections from SARS-CoV-2 infection [5]. At present, there is no evidence that asthma medications viz. bronchodilators, corticosteroid (inhaled, intranasal or oral) or antihistamine can lead to increase risk of severe disease from SARS-CoV-2 infection. Therefore, asthmatic children should continue their maintenance therapy in the same dose, as proper asthma control can prevent unnecessary hospital visits [6].

Spirometry and peak expiratory flow meter (PEFR) should be better avoided during the COVID-19 pandemic, due to the risk of transmission to healthcare staff or other children. If these are essential for some reason, then full infection control should be followed as per the standard guideline [6].

There is tremendous scope of telemedicine in the management of asthmatic children, particularly in follow-up patients. The compliance and technique of a child can be checked and corrected through video conference, and health education provided about the asthma action plan for the worsening of the symptoms, which can reduce non-urgent health care visits to a great extent [7].

Nebulization is considered as a potential risk for aerosol generation and transmission of SARS-CoV-2 infection. Thus, if a child presents with asthma exacerbation, it is recommended to use a pressurized meter dose inhaler (pMDI) with a spacer with a tightly fitted mask for rescue medication. Though there may be concern regarding the use of systemic steroids in the COVID-19 pandemic, Global Initiative for Asthma (GINA) 2020 guideline clearly stated that systemic steroids, if required, should be given in asthma exacerbation for a shorter duration [8].

Emphasizing general precautions to all asthma patients and their caregivers should, of course, continue during outpatient visits or telemedicine consults.

Funding: None; Competing interest: None stated.

REFERENCES

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2. Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM. Comorbidity and its impact on 1590 patients with Covid-19 in China: A Nationwide Analysis.Eur Respir J. 2020. Available from: http://erj.ersjournals.com:4040/cgi/pmidlookup?view=long&pmid =3221765.  Accessed May 2, 2020.

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6. Brough HA, Kalayci O, Sediva A, Untersmayr E, Munblit D, Rodriquez Del Rio P, et al. Managing childhood allergies and immunodeficiencies during respiratory virus epidemics - the 2020 COVID-19 pandemic. Pediatr AllergyImmunol. 2020 Apr 22. Available from: https://onlinelibrary.wiley. com/doi/abs/10.1111/pai.13262. Accessed April 29, 2020.

7. COVID-19 Rapid Guideline: Severe Asthma. Available form:https://www.nice.org.uk/guidance/ng166/resources/ covid19-rapid-guideline-severe-asthma-pdf-66141904108741. Accesed May 2, 2020.

8. Global Initiative for Asthma (GINA) 2020. Interim guidance on asthma management during the COVID-19 pandemic. Available from: https://ginasthma.org/gina-reports/. Accessed April 29, 2020.