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For comparison&#44; we reviewed presentations in the same calendar weeks in 2017&#8211;2019&#46; Our paediatric asthma nurses record every acute wheeze&#47;asthma attendance at St George&#39;s Hospital in South West London on a daily basis allowing direct comparison&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The figure shows the total number of emergency attendances for each week during the 12-week period for each year &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In 2020&#44; prior to the lockdown&#44; an average of 17 children &#40;range 16&#8211;19&#41; presented each week and was comparable to attendance rates in 2017&#8211;2019&#46; This fell to 2 acute presentations per week &#40;range 0&#8211;5&#41; in the eight weeks after the national lockdown&#46; In previous years&#44; although there were trends to lower admissions corresponding to the school spring vacation &#40;weeks 14&#8211;16&#41;&#44; the comparative numbers of attendances remained consistently higher&#46; Even though some families may have taken pre-emptive action prior to the government announcement&#44; the significant fall in attendances coincided at the point of the Government announcement&#46; Overall there has been a 90&#37; reduction in attendances over the 8 week lockdown period compared to 2017&#8211;2019&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">There are a number of potential factors which may have impacted on this observation&#46; Our initial concern was that patients&#47;parents were avoiding presentation to hospital due to concerns about the risk of exposure to COVID-19 in hospital and in response to the government instructions to &#8216;stay home&#8217;&#46; Against this&#44; our asthma nurses have not dealt with increased numbers of parents phoning for advice about acute management&#46; Furthermore&#44; those families contacted for routine asthma reviews report good health&#46; The numbers have also continued to fall through the lockdown and we haven&#8217;t seen children with more severe symptoms associated with delayed presentation&#46; Despite early concerns in the safety of using inhaled corticosteroids with SARS-CoV-2 infection&#44; there are anecdotal reports of improved adherence to controller medications&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A second positive benefit from the lockdown has been the potential improvement in air quality due to the enforced reduction in road and air travel&#46; Data from the European Environment Agency indicate generally lower NO<span class="elsevierStyleInf">2</span> and PM10 levels this year compared to the same time period in 2019&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However average daily levels of PM10 &#40;shown in figure&#41; and NO2 from monitors in our locality do not indicate a change in these pollutants in SW London potentially affected by other atypical atmospheric conditions&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The abrupt fall in attendances coincided with the wide scale closure in schools along with the implementation of social distancing&#46; In closing schools&#44; children may also have reduced exposure to pollution on the school run and have undertaken less formal exercise&#46; We propose the most likely impact is in the reduction of spread of other typical respiratory viruses&#46; A similar&#44; partial effect may be seen during school vacations but is amplified at present by the more pronounced isolation and hygiene messages associated with the pandemic&#46; Whilst this data does not show causation&#44; and recognising the effects are probably multifactorial&#44; it is important to reflect on the information gained during this unique time&#46; In the UK&#44; asthma&#47;wheeze remains one of the highest causes for school absence and hospital admissions with wider ramifications on society&#46; We should question what inadvertent harms are potentially caused by our systems&#46; Class sizes of 30 children or more in small&#44; overcrowded classrooms&#44; narrow corridors&#44; and lax personal hygiene practices may all likely contribute to high levels of viral spread within the school institution environment&#46; As the lockdown relaxes and schools restart&#44; it will be important to monitor how quickly acute asthma presentations increase&#46; With this information it may be prudent for government to review education strategies to improve the learning environment and reduce the risks of inadvertent harm&#46; Whilst children have been relatively spared the physical ravages of SARS-Cov-2 infection&#44; their lives will have been affected educationally&#44; emotionally and longer term financially by the pandemic&#46; It is important that we learn what lessons we can for their benefit and their future&#46;</p></span>"
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Letter to the Editor
The Indirect Impact of COVID-19 on Children With Asthma
El impacto indirecto de la covid-19 en los niños con asma
Richard Chavassea,
Corresponding author
rchavasse@nhs.net

Corresponding author.
, Andres Almariob, Anne Christopherb, Alexia Kapposb, Anu Shankarb
a St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London SW17 0QT, United Kingdom
b St George's University Hospitals NHS Foundation Trust, London, United Kingdom
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Asthma&#47;wheeze attendances to st Goerge&#39;s Hospital Paediatric Emergency Department before and after COVID-19 Lockdon 2020 in comparison to 2017&#8211;2019 attendances&#46; Bars indicate mean weekly atmospheric PM10 levels &#40;&#956;g&#47;m<span class="elsevierStyleSup">3</span>&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">One of the few positive features of the SARS-CoV-2 pandemic has been the significant reduction in paediatric hospital admissions and attendances to urgent care settings&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Early evidence from China and Italy indicated that children fared better than adults with lower SARS-CoV-2 infection rates&#44; a lower incidence of severe disease and minimal mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#8211;4</span></a> The reduction in attendances however includes other anticipated illnesses which would not have been predicted&#46; In our hospital we have noted a marked reduction in children and young people presenting with acute asthma&#47;wheeze&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We reviewed the numbers of acute hospital presentations with wheeze&#47;asthma in children aged 1&#8211;17 years of age over the four weeks prior to the UK national lockdown on March 23rd 2020 and the 8 weeks afterwards&#46; For comparison&#44; we reviewed presentations in the same calendar weeks in 2017&#8211;2019&#46; Our paediatric asthma nurses record every acute wheeze&#47;asthma attendance at St George&#39;s Hospital in South West London on a daily basis allowing direct comparison&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The figure shows the total number of emergency attendances for each week during the 12-week period for each year &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In 2020&#44; prior to the lockdown&#44; an average of 17 children &#40;range 16&#8211;19&#41; presented each week and was comparable to attendance rates in 2017&#8211;2019&#46; This fell to 2 acute presentations per week &#40;range 0&#8211;5&#41; in the eight weeks after the national lockdown&#46; In previous years&#44; although there were trends to lower admissions corresponding to the school spring vacation &#40;weeks 14&#8211;16&#41;&#44; the comparative numbers of attendances remained consistently higher&#46; Even though some families may have taken pre-emptive action prior to the government announcement&#44; the significant fall in attendances coincided at the point of the Government announcement&#46; Overall there has been a 90&#37; reduction in attendances over the 8 week lockdown period compared to 2017&#8211;2019&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">There are a number of potential factors which may have impacted on this observation&#46; Our initial concern was that patients&#47;parents were avoiding presentation to hospital due to concerns about the risk of exposure to COVID-19 in hospital and in response to the government instructions to &#8216;stay home&#8217;&#46; Against this&#44; our asthma nurses have not dealt with increased numbers of parents phoning for advice about acute management&#46; Furthermore&#44; those families contacted for routine asthma reviews report good health&#46; The numbers have also continued to fall through the lockdown and we haven&#8217;t seen children with more severe symptoms associated with delayed presentation&#46; Despite early concerns in the safety of using inhaled corticosteroids with SARS-CoV-2 infection&#44; there are anecdotal reports of improved adherence to controller medications&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A second positive benefit from the lockdown has been the potential improvement in air quality due to the enforced reduction in road and air travel&#46; Data from the European Environment Agency indicate generally lower NO<span class="elsevierStyleInf">2</span> and PM10 levels this year compared to the same time period in 2019&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However average daily levels of PM10 &#40;shown in figure&#41; and NO2 from monitors in our locality do not indicate a change in these pollutants in SW London potentially affected by other atypical atmospheric conditions&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The abrupt fall in attendances coincided with the wide scale closure in schools along with the implementation of social distancing&#46; In closing schools&#44; children may also have reduced exposure to pollution on the school run and have undertaken less formal exercise&#46; We propose the most likely impact is in the reduction of spread of other typical respiratory viruses&#46; A similar&#44; partial effect may be seen during school vacations but is amplified at present by the more pronounced isolation and hygiene messages associated with the pandemic&#46; Whilst this data does not show causation&#44; and recognising the effects are probably multifactorial&#44; it is important to reflect on the information gained during this unique time&#46; In the UK&#44; asthma&#47;wheeze remains one of the highest causes for school absence and hospital admissions with wider ramifications on society&#46; We should question what inadvertent harms are potentially caused by our systems&#46; Class sizes of 30 children or more in small&#44; overcrowded classrooms&#44; narrow corridors&#44; and lax personal hygiene practices may all likely contribute to high levels of viral spread within the school institution environment&#46; As the lockdown relaxes and schools restart&#44; it will be important to monitor how quickly acute asthma presentations increase&#46; With this information it may be prudent for government to review education strategies to improve the learning environment and reduce the risks of inadvertent harm&#46; Whilst children have been relatively spared the physical ravages of SARS-Cov-2 infection&#44; their lives will have been affected educationally&#44; emotionally and longer term financially by the pandemic&#46; It is important that we learn what lessons we can for their benefit and their future&#46;</p></span>"
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                          "autores" => array:6 [
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