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Managing childhood allergies and immunodeficiencies: An EACCI statement

In light of the COVID-19 pandemic, the European Academy of Allergy and Clinical Immunology (EAACI) has provided six recommendations for the management of childhood allergies and immunodeficiencies.

The statement notes how allergic diseases such as asthma are among the most prevalent conditions in children, necessitating a guideline for the health professionals who are providing care for these patients. The statement provides six recommendations for the management of childhood allergies and immunodeficiencies based on current facts and existing evidence. The statement itself reviews the current available evidence on the use of allergy treatments in children.

Are children different to adults?
While everyone is potentially liable to infection with COVID-19 although older age is a major risk factor, the statement notes how it appears that the infection is often less severe in children and mortality rates are lower than for adults although precisely why this might be the case is unclear.

COVID-19 and allergies
The current statement does notes that while patients with asthma are listed among those who are at a high risk of infection, pre-existing allergies are not currently considered to be a risk factor. Nevertheless, whether asthma treatments affect an individual’s susceptibility to COVID-19 is also unclear. The statement discusses how much attention has been directed at oral corticosteroids and how these drugs may have immune modifying effects and thus increase the risk of infection. Nevertheless, the statement directs readers to national and international asthma societies which currently do not advocate stopping oral corticosteroids. The statement acknowledges that much less is known about the effects of inhaled corticosteroids but based on the available evidence, suggests that inhaled corticosteroids are unlikely to pose an increased risk of either acquiring COVID-19 or of causing a more severe infection.

Patients with immunodeficiencies
The statement suggests that because primary immunodeficiencies (PID) are congenital disorders, those with PID may constitute an at-risk group and advises that this patient group should be carefully followed-up during the COVID-19 pandemic. Although COVID-19 may pose a risk for children prescribed immunosuppressive treatments, the statement still recommends that these treatments are continued despite the paucity of data on the immune effects of COVID-19.

The statement finishes with a series of six facts and recommendations based on these facts.

Facts and recommendations

  1. Children are at a lower risk of infection with COVID-19 and have less severe disease.

Recommendation one
Because children are at a lower risk, paediatric allergists are advised to gain control of a child’s current allergy symptoms and to ensure that patients follow the current recommendations for hygiene and social distancing to minimise the risk of infection.

2. Whenever possible, diminish or remove risk factors

Recommendation two
While not all asthma is allergic in nature, during a time when seasonal allergies are likely to become more common, it is especially important to ensure that patients gain control of their asthma because uncontrolled asthma represents a risk for more severe disease with COVID-19 infection.

3. Initial symptoms of seasonal allergy may be confused with mild flu-like infection

Recommendation three
The statements suggest that seasonal allergy symptoms can initially resemble flu, the common cold or even COVID-19. It therefore advises allergists remain vigilant to this fact and although they should not be over-suspicious, it is important not to miss COVID-19 in an allergic patient.

4. Treat allergic rhinitis patients according to usual guidelines

Recommendation four
In the absence of specific evidence that allergy treatments increase the risk of infection with COVID-19 or that there is a greater likelihood of more severe disease if infected, allergy specialists are advised to continue to treat their patients following usual care guidelines. One exception noted in the statement is that treatment with biologics should be withheld because this class of drugs lower immunity and thus increases the risk of infection with COVID-19. It is also noted that adequate control of allergic diseases would indirectly reduce the risk of COVID-19 infection because patients are less likely to visit their physician.

The statement cites the Global Initiative for Asthma which recommends continuation of all asthma therapies with the exception of nebulisers. This advice is based on the fact that during an acute attack, the use of a nebuliser increases the risk of disseminating COVID-19 to both other patients and health professionals. It is suggested that patients use metered-dose inhalers with a spacer if they suffer a severe attack.

5. Current knowledge might evolve and guidelines change

Recommendation five
Given that COVID-19 is rapidly spreading across the globe, the position paper recognises that an increasing number of people, including children with allergies are likely to become infected. Although there is currently no evidence to suggest that children with allergic airway diseases receiving AIT are at a higher risk of infection, new information may change this advice and allergists should remain flexible and keep abreast of any changes to recommendations.

6. Patients with immunodeficiency have an increased risk for infections with respiratory viruses

Recommendation six
Those who are immunodeficient are deemed to be in an at-risk category and are therefore advised to follow any national recommendations to reduce their risk of infection. In an effort to avoid disease exacerbations, patients should continue with their regular treatments and remain in contact with their allergy physician or team (via video or telemedicine) to ensure that any clinical symptoms can be quickly assessed and investigated.

The position paper suggests that clinical immunologists follow all advances in the science of COVID-19 as this may allow them to tailor their advice and treatment recommendations to patients in the near future.

Brough HA et al. Managing childhood allergies and immunodeficiencies during the respiratory virus epidemics – the 2020 COVID-19 pandemic. Pediatr Allergy Immunol 2020; Apr 22. doi: 10.1111/pai.13262. Online ahead of print.

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