COVID-19 and preschool wheeze care: lessons learned
Authors: Heidi Makrinioti, Mando Watson, Andrew Bush, Dougal Hargreaves
Journal: The Lancet Respiratory Medicine (2020)

The pattern of increasing visits to the emergency department by children younger than 5 years with preschool wheeze and other respiratory conditions has been disrupted by the COVID-19 pandemic. Since March, 2020, presentations to the emergency department have decreased among children of all age groups, especially infants and preschool children who are the most frequent attenders. This notable change in asthma exacerbations in children has raised research interest into how the COVID-19 pandemic has contributed to this change, and what lessons can be learned. Risks of harm due to delayed medical assessment or treatment were flagged early in the pandemic but are still unclear; empirical UK data to date have been conflicting, with one prospective multicentre study suggesting that the number of "inappropriately delayed hospital presentations" was low, but another survey of paediatricians reported more widespread evidence of delay. The sudden changes to health-care seeking behaviour and health-care delivery offers a rare opportunity to redesign and improve health care for children with preschool wheeze to allow for better outcomes in the future. We have previously argued the need for a joined-up strategy to improve outcomes of children with preschool wheeze and this need is reinforced by lessons from the COVID-19. Three important areas to consider include measures to reduce the incidence of wheeze attacks (viral triggers, environmental pollution, direct and second-hand smoke); improved accessibility of health-care pathways; and the provision of the right advice at the right time, enhancing parental knowledge and confidence to manage the condition successfully. 80–90% of preschool wheeze attacks are triggered by respiratory viruses. Most epidemiological studies report coronaviruses as co-infections rather than sole infective agents. The reduced number of wheeze attacks triggered by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could be partially explained by low expression of ACE2 receptor in atopic asthmatic children, as described in the Urban Environment and Childhood Asthma cohort. However, atopic children represent a small group of preschool children with wheeze. Other factors could be driving the decrease in wheeze presentations to the emergency department. Tobacco smoking and exposure to second-hand smoke are considered as causative factors for childhood asthma, affecting millions of children around the world. Exposure to prenatal or postnatal passive smoke has been associated with a 30–70% increased risk of incidence of wheezing and a 21–85% increase in incidence of asthma. Increases in allergen levels associated with indoor tobacco exposure could potentially trigger airway hyper-reactivity underlying a wheeze attack. During the COVID-19 pandemic, the public health message was to avoid smoking because it was considered a risk factor for severe COVID-19 disease. A suspected decrease in smoking could have positively contributed to the decreased incidence of wheeze attacks. Although the data are inconclusive, recent evidence suggests a small increase in the use of an anti-smoking app in the UK since 2019. A favourable effect of lockdown measures on reduction of environmental pollution could be another factor contributing to the lower incidence of wheeze attacks. In the medium term, a focus on reducing exposure to wheeze triggers could have huge impact. Options range from stricter air pollution laws, more handwashing in schools, more vaccination against respiratory viruses associated with wheeze attacks in children, more antivirals in the management of virus-induced wheeze attacks, and a better understanding of how we can use respiratory virus testing in the clinical care pathway (to estimate the risk of recurrent wheeze attacks). Telemedicine has been an effective tool for health-care delivery during the pandemic, offering caregivers the chance to receive care for their children in the comfort of their own home. Although digital tools have been available for years, they have rarely been used in routine care in the UK. The urgent need for establishment of remote patient care led to the rapid commissioning of these tools. The question is how adoption of these tools in clinical care might change outcomes in preschool wheeze. If telemedicine is to be the future of health-care service provision for preschool children with recurrent wheeze, then this must be a safe and equally accessible tool. Accessibility to professional advice is often easier through digital pathways, but it is not clear yet what is the level of technological literacy of the wider population of caregivers. Since 2016, UNESCO has placed digital platforms at the heart of education throughout the world. However, many groups do not have access due to insufficient skills or internet access, for example. These groups must not be deprived of health-care access and relevant medical knowledge. Furthermore, health-care professionals who provide virtual care and give advice on acute management need to be technologically skilled. Assessing the severity of an acute wheeze attack might not be safely performed through a screen. During the COVID-19 pandemic, there was scepticism around the use of existing scores (eg, Roth Score) to assess severity of dyspnoea in adults during primary care consultations. COVID-19-associated hypoxaemia during acute presentation was considered to be out of proportion to dyspnoea, complicating remote acute assessment of patients. Any acute assessment of wheeze severity, when performed remotely, needs to be followed by safety-netting advice and education of caregivers' in how to recognise signs of deterioration. These strategies have been shown to reduce risk but rely on the caregivers' ability to make an assessment for which they are often unprepared, at a time when they feel frightened for their child's safety. Tools, such as smartphone apps could help provide more accurate assessment of vital signs by caregivers. We believe that to make telemedicine a safe and accessible future for health-care service delivery in recurrent preschool wheeze, a renewed focus on parental education and partnership working between caregivers and physicians is needed. One tool that can enhance such partnerships is a patient reported outcome measure (PROM) that provides the caregivers' perspective of how well preschool wheeze is controlled and the impact of the condition on family quality of life. These tools, when available in digital form, can assess response to preventive treatment and can identify those preschool children with wheeze who need to be reviewed earlier or require further interventions. Crucially they encourage parents to assess their child's symptoms regularly when the child is well, providing opportunities to build and practice the skills that are needed when the child has a wheeze attack. PROMS can also encourage an integrated approach to care by supporting earlier identification in primary care of children who would benefit from specialist review; in turn, following specialist review, PROMS can support primary care physicians to continue to take a lead role in the care of the child. Without specific tools, such as PROMS, telemedicine might otherwise restrain discussion between physicians and caregivers about important factors other than clinical symptoms. Key topics addressed in PROMS include understanding care plans, navigation of the new digital health-care system, and discussion of concerns around returning to school. PROMs can, therefore, help ensure gaps in communication during virtual clinic appointments are mitigated. Furthermore, PROMS can help to identify and address barriers to optimal use of preventive medication by caregivers, to allow for understanding of the importance of regular use of control medication and effective administration of inhalers to their children. A prospective study showed that caregivers' adherence to prescribed inhaled steroids as a regular medication is low. One possible reason for fewer children attending hospital with preschool wheeze during lockdown is that caregivers are spending more time at home, enabling increased support for their children. Additionally, caregivers might have maintained strict adherence to medication during lockdown because hospital visits were discouraged unless essential, leading to a reduction in wheeze attacks. In one study, caregivers stressed their need to be educated around safely assessing their child's severity of presentation. Alongside PROMS, patient reported experience measures (PREMS) can assess and improve quality of care. Routinely asking caregivers of preschool children with wheeze to feedback about the care their children receive will help clinicians understand whether digital preschool management works for all and to identify areas for improvement in delivery of care. The COVID-19 pandemic experience highlights that large reductions in hospital activity for preschool wheeze are possible. The transition to delivering more remote care for children with preschool wheeze offers opportunities for rapid, convenient care. Potential risks have been identified, particularly in acute assessment and management of sick children, but these risks can be mitigated through a greater focus on education and partnership working with caregivers when their children are well. PROMS and PREMS have a key part in building these partnerships with parents, grounded in greater focus on their needs, which could transform outcomes as well as safety, efficiency, and experience of services in the future. We declare no competing interests. DH is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration North West London. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health and Social Care.