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Melanie Cole (Host): There's no handbook for your child's health, but we do have a podcast featuring world-class clinical and research physicians covering everything from your child's allergies to zinc levels. Welcome to Kids Health Cast by Weill Cornell Medicine.

I'm Melanie Cole, and I invite you to listen as we discuss Healthy Lung Month. And my guests in this round table thought-leader conversation are Dr. Perdita Permaul, she's the Director of Pediatric Research and the Director of Pediatric Allergy and Immunology at New York Presbyterian Queens, and an Assistant Professor of Pediatrics at Weill Cornell Medicine; Dr. Kalli Tsirilakis, she's the Director of Pediatric Pulmonary and Asthma at New York Presbyterian Queens and an assistant professor of clinical pediatrics at Weill Cornell Medicine; and Dr. Jenny Ono, she's the Medical Director for Inpatient Pediatrics and the Asthma Program at Weill Cornell Medicine and the Komansky Children's Hospital at New York Presbyterian Hospital, Weill Cornell Medical Center. She's also an Assistant Professor of Clinical Pediatrics at Weill Cornell Medicine.

Doctors, I'm so glad to have you join us today. This is such an interesting topic and we have so much to cover. And Dr. Ono, I'd like to start with you. Have you seen an uptick in RSV and other respiratory illnesses as we saw this curve with COVID go down a bit and people were getting vaccinated and more outside activity, and then the masks kind of went away? Have you seen as school started and throughout the summer an uptick in some of these respiratory illnesses?

DR Jennie Ono: Thank you, Melanie. So it's interesting because typically right around when school starts up again, we typically see respiratory viruses. So viruses like RSV or rhinovirus are two very common viruses that we see, essentially around school time and in the winter. When the pandemic happened or it's still ongoing, but when everybody was staying indoors and schools were mostly remote, we were really not seeing RSV and rhinovirus in the same way.

In fact, what we would normally expect, especially on the inpatient unit, we would normally expect a lot of children coming in with difficulty breathing sometimes with these viruses and, in the pediatrician's offices, a lot of stuffy noses, coughs and colds. But with the pandemic, we actually saw that this really decreased.

And so now that schools are reopening, that children are getting back to their normal activities, they're going to school, they're seeing their friends, we are starting to see an uptick in what is normally our regular viral seasons, so our RSV and our rhinovirus both in the pediatrician's office and also in the hospital where some children have a harder time with those viruses and need a little extra support.

Melanie Cole (Host): Well, certainly. At the juncture of all of these things, Dr. Ono, at this time of the year, you know, we concern ourselves with flu and then we've got this pandemic and now we're talking about asthma and seasonal allergies and RSV and all of these things. Can you tell parents about the coinfection aspect of all of these respiratory viruses? And if you can give us some brief way to tell the difference if a parent is wondering if this is just a seasonal allergy or if the kid caught COVID at school or, you know, God forbid, the flu or any of these things. Can you tell us how we can tell the difference at all?

DR Jennie Ono: This is a really good question and actually one that I find myself asking with my own children. So the fact is that a lot of these viruses have symptoms that you can't tell the difference. In fact, we don't always have to test. If we have a child with nasal congestion or cough or sneezing, we don't necessarily in the pediatrician's office will ever test for these viruses.

However, that's of course a little different now that we're around in our COVID age. Because now the question really becomes, "Do you have a regular cold or do you have COVID?" And oftentimes, it's very difficult to tell the difference between RSV rhinovirus and now the novel coronavirus.

For the novel coronavirus, we know actually that many children are actually asymptomatic and so may not display the typical signs and symptoms of an upper respiratory infection. Some do, but some will not or will present with other kinds of symptoms such as diarrhea or abdominal pain. But RSV and rhinovirus typically will have nasal congestion and cough, sneezing, really sort of that bad sort of head cold symptoms. And it's really not possible to distinguish without a doctor's test between these viruses.

And we are seeing a lot more testing for the novel coronavirus now because schools are requiring it to come back in some cases or parents just want to know, because they want to protect everybody else around them. So it's not easy to distinguish at all just by clinical symptoms. And this is making a lot of parents have a lot of questions when it comes to what do they do when their child has a cold or they have a cold? Is it just a regular old virus that all kids get when they sort of go back to school? Or is this the coronavirus that they have to be more careful of? So in this situation, we always say, "Just reach out to your pediatrician to get guidance on what the next steps are if you're concerned that your child has a cold."

Dr Perdita Permaul: What I would also add to Dr. Ono is that, while the three illnesses do share some symptoms, there are also signs and symptoms that are specific to one or the other. For instance, loss of taste and smell is sometimes the hallmark symptom of COVID-19 and also RSV is more likely to produce wheezing than COVID-19 or the flu. You can still get wheezing with COVID-19 or the flu, but you tend to get it more with RSV. And also RSV seems to be most common in children under the age of two. So those are some of the differentiating signs and symptoms that you can look for, but it is difficult now when we have all three of these things floating around at the same time.

Melanie Cole (Host): Well, thank you for that explanation. This is such a great topic. And Dr. Permaul, are kids with allergies or asthma more likely to suffer more serious symptoms of some of these things that we're seeing?

Dr Perdita Permaul: So some studies are showing that allergies might be protective against COVID-19, but these are hypothesis-generating studies. We know that research to date suggests that asthma may not be a major risk factor for getting COVID-19 disease or experiencing severe COVID-19 symptoms. But I do believe that children with asthma should absolutely receive the COVID-19 vaccine if they are eligible for it, to protect themselves from viral infection and to lower the risk of severe symptoms if they do become infected.

DR Jennie Ono: I just wanted to also add that you had also brought up the flu in a previous question and the COVID vaccine and the flu vaccine for those patients that are able to get it, especially in those patients with asthma is really, really important. The flu vaccines aren't for all children, especially when, as you mentioned with a co-infection, with multiple viruses, but certainly in asthma patients, we're really recommending that parents seek out the the COVID vaccine when they're eligible. And hopefully for children under 12 years old, that will be in the next up and coming.

Dr Kalli Tsirilakis: And I would also add, this is Dr. Tsirilakis, that because of the lack of viruses that we saw last season, so especially last flu season, there was very little flu virus that was around, the natural immunity that we all have against flu virus is actually decreased this year, so that it is even more important that the general population, including especially those patients with respiratory diseases and allergies and other chronic illnesses, do get their flu vaccine this year because we are not going to have even that baseline immunity built up from last year's flu, because people weren't getting it last year. So when the flu does come back this year, it has potential to make a lot more people sick.

Melanie Cole (Host): This is such an interesting conversation, and I love that we're talking about it in this panel. So Dr. Tsirilakis, you all represent three specialties here. And you're all focused on treating these children with asthma and allergies. Can you please tell us about your combined efforts, why it's relevant and why a multidisciplinary approach is so important for these kids? I think it's so cool that you guys are doing this all together. And what are you finding are the largest benefits, both for yourselves as physicians, but also for the families of these children?

Dr Kalli Tsirilakis: Absolutely. The care of patients and children with asthma and their families has always been a collaborative effort between pulmonologists, allergists and, of course, general pediatricians. The reason for that is that general pediatricians are of course the front lines. The majority of children who have asthma, which in New York city, where we are based, is over 10% of the pediatric population in New York city has asthma. Those children are being seen by their pediatricians. So it's really important that the subspecialist partner with the pediatricians to make sure that those children that are coming in so frequently with asthma exacerbations and really to identify those children who have asthma, that these pediatricians are comfortable with what the asthma management guidelines are that are out there on the national level and the international level, as well as being able to know when they can reach out to other specialists such as pulmonologists or allergists who care for patients with asthma so that they can have a little bit more assistance with how they manage those patients.

We have worked very, very closely at New York Presbyterian Hospital as well as at Weill Cornell between New York Presbyterian Queens and our other regional hospitals, such as Brooklyn Methodist Hospital, New York Presbyterian at Weill Cornell, as well as New York Presbyterian Columbia to really align our practices for our asthma patients and to align our asthma programs across our institution. And this is generally the case in many institutions around the United States, because we all know that it really takes a village to care for these children.

From the pulmonary perspective, we bring the perspective of how we manage our asthma patients with the medicines that are available to us. We are able to monitor patients with pulmonary function testing and really make sure that they are not having any functional limitations from their asthma.

In addition from the allergy perspective, we are able to incorporate in environmental testing and environmental remediation practices. And again, we're aligning ourselves with the general pediatricians to make sure that we are looking at the children as the whole picture of that child and that family so that we are really providing the best care that we can for them.

Our program has worked very hard to develop asthma self-management education program under the offices of the New York State Department of Health Breathe New York Program, which is really designed to help, educate, providers and families on how best to take care of their asthma in their own home, so that they are not needing to seek emergency care for their asthma and so that they are able to keep their asthma under the best control possible.

Dr Perdita Permaul: And from an allergy perspective, I will say that allergens can definitely trigger asthma as well. And in fact, about 80% of children with asthma have allergy triggers compared to 50% of adults. And so if you inhale something that you are allergic to, you may experience asthma symptoms, so it's best to avoid or limit contact with those known allergens to decrease these asthma episodes. And so that's where the allergists would come in to perform skin testing and to fully tell you what exactly your child might be allergic to.

DR Jennie Ono: And if I could add also to this, I think, you know, we have been working collaboratively for several years at this point on all fronts here. So both the clinical front, so between the pulmonologists and the allergists and our inpatient doctors, our ER doctors, our general pediatricians in the outpatient setting. Part of why we think it's so important to work together is because the communication around all of asthma care is complex and we want to do as best we can to not confuse our families to give consistent recommendations amongst all of us, because we are all working in different settings and in different places. But we really strive to make sure that what we are able to offer our families and our patients is as consistent, is evidence-based, and with the most recent asthma guidelines and that we're all able to help our patients with asthma self-management skills so that also the parents can feel empowered, the patient can feel empowered to also understand their asthma.

We also work collaboratively on research initiatives between our campuses at Cornell and Queens, and also Brooklyn Methodist. We have a large research initiative going on because we think it's also incredibly important to understand the basis of asthma. Why do kids get sick with asthma? How does asthma work? And how can we answer some of these questions that we simply don't have enough information to address. And so that's part of your asking about why we think it's important for us, because there's a direct impact on the families, but really understanding why asthma happens and how we can make it better is just as important as being able to deliver the care and deliver it effectively as well.

Melanie Cole (Host): What great points you are all making. And I'd like to give you each a chance to kind of give your best advice to parents. So Dr. Permaul, I'd like you to speak about home and lifestyle things that we can try, because there's a lot on the market when someone has allergies or they're having an asthma. You know, we're going to talk about asthma attack, but when they're having allergies, we hear about neti pots and any parent that's ever tried to do that to their kids, I'm telling you what, that is not easy to do, nasal lavage, but windows and air filters and their pillow cases. We hear about all these things. Can you give us your best advice for home and lifestyle things that we can try and when you feel it's important that a parent look to an allergist/immunologist for some medicational help with their children that have seasonal allergies?

Dr Perdita Permaul: I think that if your symptoms are mild and you're well-controlled on over-the-counter medications, and that's under the guidance of a pediatrician, I think you're fine. However, if you want to know exactly what your child is allergic to and you want to make environmental changes to the home environment, let's say, then I think seeing an allergist would be a good thing.

So you come to the allergist, we do skin testing. We might do some blood work and, well, I'll find out exactly what you're allergic to, whether it's pollens, molds, dust mites, pets, cockroach, rodents. Once we know exactly what you're allergic to, then we can make better recommendations regarding your home and lifestyle changes.

And so, for instance, we are now in fall pollen season. Ragweed is surfacing now as well as mold. And so for pollens in general, we usually recommend keeping your house and your car windows closed, running the air conditioner, avoiding lawnmowing if you have grass or weed pollen allergies; showering, washing your hair, changing clothes if you've been outside for a period of time, especially in high pollen count days.

We do recommend nasal rinses. You brought up neti pots. I do actually like neti pots and I will sometimes show a video to parents on how to appropriately administer the neti pot nasal rinses. I'd like to recommend them doing it while in the shower and then using their intranasal allergy medication sprays afterwards. And believe it or not, we also will sometimes, recommend face masks if it's a high pollen count day and you're going to be outside.

For mold allergies, we usually decreased humidity in the home with air conditioner or a dehumidifier. I'll oftentimes tell my parents to go to the local home improvement store and get a humidity gauge that they can put on the wall, and humidity level less than 40% is what we aspire for. Using diluted bleach to eliminate any visible mold or mildew in the bathrooms. Ventilating the bathrooms and cooking areas are some of the measures that we would recommend.

Dust mites, that's a big one in children and it is also dust mite season now in the Northeast. Dust mites are dying since the air is now dryer, maybe the heat is on and dust mites are a little microscopic insects that need humidity to survive. They can be found in pillows and mattresses and blankets and carpets and other soft materials. And so we will usually recommend allergy encasements for the mattress and pillows and box springs, which is very tightly woven material so that no dust mite particles can seep through. Washing your blankets and your comforters and your sheets and pillowcases in hot water every two weeks. Removing stuffed toys from the bedroom, et cetera.

Pet allergy, that's a big one. So we have patients who come in who have pets, and unfortunately they are allergic to them. I have a really severe cat allergy for instance. And so unfortunately, the number one measure that we do recommend is removal of the pet. Now, oftentimes that's not as easy to do. And so if the family is not wanting to remove their pet, we will ask them to keep the pet outside or at a minimum out of the bedroom and opening windows actually to allow for air exchange might be helpful, but realize you might not be able to do that during the pollen season.

And lastly, in the colder winter months, if the windows are closed, you can use a HEPA air cleaner. That has been shown to help with airborne allergens, such as pet allergies. And those are some of the mitigation measures that we would recommend.

Melanie Cole (Host): Wow. That was great advice from a pediatric allergist and immunologist. Listeners, I hope you took that down or you can always listen again. And Dr. Tsirilakis, your last word here. If a child's diagnosed with asthma by a pediatrician, when do they take them to the pulmonologist? I'd like your best advice. There are so many children that suffer from allergies and asthma specifically. Speak to those parents whose children have asthma. What you want them to know about working with the schools? Do they give those rescue inhalers to the school nurse? Are masks helping children with asthma? We've heard that around. Whether it's good or bad, give us your take on this particular topic.

Dr Kalli Tsirilakis: So really the best time to see a pulmonologist is any time that you have more questions. The recommendations from the national guidelines state that any child who is diagnosed with mild persistent asthma, it is recommended that their pediatrician refer them to an asthma specialist, whether it's a pulmonologist or an allergist for evaluation. Any child who has more severe asthma, so either moderate, persistent, or severe persistent asthma, absolutely should be seen by a specialist. But patients even with intermittent asthma or mild persistent asthma could benefit from evaluation by a specialist because we are able to monitor patients with specialized testing, such as pulmonary function testing, which we can perform in children as young as the age of five. Some tests can be done in children down to the age of three even. And of course, allergy testing is also an important procedure, which specialists are able to provide.

The other questions that you had asked about, so I would also encourage patients to seek out specialist's advice about their child's asthma anytime that they have questions or that they feel like they would like to learn more about their child's asthma.

We are asthma specialists because this is what we do all day. We educate our patients on how to manage their asthma on their own. In most cases, pediatricians do not have the time to spend with their families and with their patients to really get down to the nitty-gritty details of what they should be doing in that situation when their child gets sick, because we all know that asthma is the type of disease that can change in a moment. And so one minute your child might be fine and then the next minute they might be struggling to breathe, which can be very frightening for parents. We absolutely want to empower patients and their parents to be able to manage those exacerbations and to keep them at home without having to run to the emergency room and also to keep their asthma under good control by staying on the controller medications that have been prescribed to them by their physicians.

The most important thing with asthma control is really by listening to your physician and working with your physician so that you are describing to them what symptoms you are still experiencing, what limitations you are having in your day-to-day activities, how often your child is getting sick and how often they're really needing to use their rescue medication is incredibly important. And something that the specialists will be able to help you with in particular.

One important thing that we do know is incredibly important for children who have asthma as well as it is for other children, so it's important for all children, but especially for children who have asthma, is that they do wear masks when they are indoors even if they are vaccinated. We have learned throughout the COVID pandemic that, in addition to preventing children from getting COVID, that mask wearing has significantly decreased the communicability and the passage of other viruses as well. And the number one trigger for asthma exacerbations are viruses, so that we are strongly recommending that all children with asthma, who are indoors with other children, that they should be wearing masks at all times.

It is also incredibly important that children are encouraged to return to school, and that they are encouraged to return to activity levels of pre-pandemic. One of the other problems we have seen throughout this pandemic is that there has been an epidemic of weight gain and obesity, not just in adults, but also in our pediatric population, which has confounded and made much worse our patients with asthma symptoms and their ability to participate in exercise and to get back to normal living. So we are strongly encouraging all families to get their children back to school, to a healthy lifestyle, to encourage exercise, to encourage socialization with their friends, and to really help them with psychological support as well as physical support for their illnesses from a mental health perspective as well as the physical health perspective.

Melanie Cole (Host): This is such an informative episode. And I have to say it, I do love that we're all ladies. Such professionals and experts you all are. And Dr. Ono, as we started with you, we will then wrap it up with you. Can you please tell us, everybody's been talking about asthma and allergies and all of these things and giving us great advice and even said it if our children are vaccinated, they can still wear masks at school. We're talking Healthy Lung Month, what would you like parents to know about your combined clinic, about this program, how you work together to help these families, how you help the families and how you work with them, so they can mitigate some of the triggers of all of these things we're discussing today?

DR Jennie Ono: I think that's a great question. And one of the main goals of our program is really the coordination of the care that we provide families and patients and the communication amongst the providers. And especially when it comes to children with asthma or sometimes we'll see children who wheeze due to viral illnesses that may not be necessarily asthma, but are still struggling with the effect of these viral illnesses on their lungs. One of the pieces of advice that always give patients is just ask questions. And if you don't know what questions to ask, even ask your doctor, "What should I know about my child's condition?"

It's our responsibility to make sure that we arm families and patients with the information that we think will be helpful and really tailor that to your parent's and family's specific situations. So Dr. Permaul had mentioned about pet allergies and that can be very difficult, because we know pets can be part of the family. And so how do we address that particular trigger, knowing what an important part that pet is in the family? And so oftentimes, the advice related to keeping kids healthy, keeping their asthma under control, keeping their allergies under control really has to be very individualized. And I think that's where we really try to focus for our program is that we really take a family and patient-centered approach to how we make recommendations, the kind of education that we provide and the kind of resources that we provide our families and patients.

It's incredibly important to make sure that whatever the medical recommendations that are provided fit in with the life of the family, because we can write a prescription. But if someone doesn't know how to administer their medication, doesn't know if they're doing it correctly or when to even give it, then it doesn't really matter if we write the prescription. The education around how that prescription and that medication translates into the life of that patient is incredibly important.

So that's why I really feel like our program really focuses on how do we empower that family to be able to proceed with the recommendations that their medical team is giving. And then to make sure that those medical providers are talking to each other, because we all know it's very difficult and challenging when you see multiple doctors to make sure everybody's on the same page. And so that's another real significant goal of ours, is to make sure that we are all communicating. And I think that's a real benefit of all of us working together across different campuses, because if a patient comes into the inpatient unit for us here and lives nearby, where Dr. Permaul and Dr. Tsirilakis are practicing, then it makes more sense for us to connect them with services that are closer to home that relieves some of the burden of them on their followup. And we can do that because of our program and our network of collaboration. And so these are all important parts of just making sure that kids are staying healthy in the environment that they're in.

So at Weill Cornell, really our goal has been to create a unified program so that we can provide the best care for our children. And if you come see a pediatrician at Weill Cornell, especially with a child with asthma, we have a team of asthma educators and nurses and physicians, allergy physicians, asthma specialists, pulmonologists, that are able to provide coordinated health and communicate amongst each other so that we can provide highest level of care that we possibly can.

And the goal is always to keep children out of the emergency room and out of the inpatient units. But if they do end up having to seek escalation of care, do you know that, because of our system in place, we were able to coordinate our care amongst all of our clinical sites. Therefore, we think this is the best way to approach asthma care in our children.

Melanie Cole (Host): What an informative episode this was, and you all work together so well, thank you so much for joining us today and sharing your expertise for parents and families. For more information, please visit weillcornell.org and search pediatric pulmonology. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Kids Health Cast. We'd like to invite our audience to download, subscribe, rate, and review Kids Health Cast on Apple Podcasts, Spotify and Google Podcast. For more health tips, you can also go to weillcornell.org and search podcasts. We have so many interesting podcasts in our library, and don't forget to check out Back To Health. I'm Melanie Cole. Thanks so much for joining us today.

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