Key points
- Heat can worsen asthma symptoms. Encourage children and teens with asthma to check the HeatRisk forecast daily during warm months.
- There are several ways to stay healthy when it's hot outside. Create a Heat Action Plan with your patients and caregivers of children and teens.
- Provide guidance to children and teens with asthma on the signs of overheating, such as difficulty breathing and more fatigue than usual with exercise.
- Ask patients and caregivers of children and teens with asthma to check the air quality index (AQI) every day and to take protective action when the AQI is >100, since hot days can also worsen air quality. Breathing air with unhealthy ozone levels for as little as one day can trigger asthma attacks.
- Review medications taken by children and teens with asthma for their potential to increase heat sensitivity. Make a plan to avoid medication complications during hot days, including keeping asthma inhalers out of hot cars and other hot places, since they can burst from high heat.
Background
Balancing outdoor time with staying safe from the heat
Being outside can provide many benefits to children's health. Hot weather, however, can create conditions that can harm children's health, especially because children have unique sensitivities to heat exposure. While this heat guidance is for children with asthma and their caregivers, all children have unique sensitivities to heat exposure. Children's developing minds and bodies may be more sensitive to higher temperatures than adults. Children may spend more time outdoors, have less control over their physical environments, less knowledge about the health effects of heat, and less ability to remove themselves from harm. Heat exposure can impair learning and physical development, compromise mental health, and worsen asthma comorbidities in children.
This guidance document is intended to help support your conversations with your pediatric and teen patients and their caregivers on the impact of heat on asthma. The information provided can empower them to take protective actions on hot days. While not every child or caregiver may be able to take all actions, each action can help children or teens with asthma stay healthy during hot days.
Risk factors
Heat, air quality, and asthma
Hot days can directly and indirectly increase risk to asthma patients.
Hot days may contribute directly to asthma attacks through dehydration. Dehydration, and associated lactic acidosis and electrolyte imbalance, can result in more severe asthma symptoms.
Hot weather can also increase levels of air pollutants, including ozone, fine particulate matter, and sulfur dioxide. These pollutants can trigger asthma attacks and increase the need for medical care. For example, heat fuels the creation of ground level ozone, or smog, formation. In addition, hot days can be humid, and humidity can worsen lung function.
Pollen is another common trigger for asthma. Over the past several decades, the pollen season has lengthened by several weeks in many regions of the United States.
Hot and dry weather can increase the risk of wildfires. Wildfire smoke pollutants provoke asthma symptoms. During the heat season, multiple environmental hazards can co-occur, including wildfire smoke, flooding which can lead to mold, and pollen. These concurrent hazards can result in children facing several simultaneous asthma triggers.
Children with asthma and special health care needs, including children with compromised lung function and other co-morbidities, such as obesity, may be more susceptible to harm from heat exposure and air pollution. For these children, a discussion about chronic condition management should include guidance on managing heat and air pollution risks while still achieving physical activity recommendations.
Children and teens with asthma can outline steps to reduce heat and poor air quality exposure in both their Heat Action Plan and their Asthma Action Plan.
Heat, medications, and asthma
Medications that treat asthma and heat can interact, leading to potentially severe side effects. Many medications, including over the counter medications, can impair heat tolerance and the body's ability to regulate its temperature. This can predispose people to heat illness during hot days. Heat-induced poor air quality may increase medication needs in children with asthma.
Medications should be carefully reviewed with attention to those that may affect heat tolerance or fluid balance. Review any necessary medication changes to maintain asthma control on hot days with your patients, and work with your patient to document them in their Heat Action Plan and Asthma Action Plan.
Patient management
These 5 steps can help patients and/or caregivers of children and teens with asthma stay safe on hot days. Help your patients and their caregivers document action steps in a Heat Action Plan .
- Assess heat- and air quality-related risk factors that may worsen your patient’s asthma control.
- Review your patient’s baseline control of asthma since children with poorly controlled asthma may be more sensitive to heat and poor air quality.
- Use the HEAT questionnaire to assess risk factors related to
- Housing and Indoor Environment
- Emergency Preparedness
- Awareness of Health Risks
- Temperature and Outdoor Environment
- Based on risk factor screening, refer your patient to needed services or engage social work support in your clinic as appropriate.
- Educate your patients on how to stay cool during hot days.
- Review the HeatRisk Tool and how it works with your patients or caregivers of children and teens. The tool assigns colors to each level of risk and recommends protective actions by color level.
- Ask your patients to monitor their asthma symptoms at HeatRisk yellow and orange and determine which level applies to them. Their Heat Action Plan should reflect the applicable HeatRisk level.
- Most children and teens with asthma can take action when the HeatRisk is orange.
- Some will be more sensitive to heat and will need to take action when HeatRisk is yellow.
- In addition to the recommended actions to take when outside for each level of HeatRisk, all children and teens with asthma and/or their caregivers can
- Wear light-colored, loose-fitting clothing that covers arms and legs, a hat with a brim that shades the face, ears, and back of the neck, and sunglasses.
- Apply broad spectrum sunscreen that filters out UVA and UVB rays. The sunscreen should have an SPF of 30 or higher.
- Schedule outdoor activities during the coolest time of the day or evening, if possible.
- Review heat-related symptoms with your patients and their caregivers.
- Review signs of worsening asthma and help them understand signs and symptoms that their asthma control may be worsened by heat (for example, more shortness of breath or more exertional fatigue than usual for them).
- Review symptoms of heat-related illness including heavy sweating, muscle cramps, weakness, lightheadedness, headache, nausea, and vomiting.
- Help your patients and their caregivers understand the difference between heat exhaustion and heat stroke.
- Review which symptoms constitute an emergency and what actions to take in an emergency setting.
- Talk to your patients and/or caregivers of children and teens about how to stay cool indoors. They can
- Use an air conditioner if they have one or find a location that does. Even a few hours in a cool location can lower the health risk from heat.
- Use fans if indoor temperatures are less than 90°F. In temperatures above 90°F, a fan can increase body temperature.
- Cool their bodies with a cool shower, a damp cool cloth, or a spray bottle of cool water.
- Direct your patients and their caregivers to information about public resources such as cooling centers, pools, and splash pads. The nearest cooling center locations can be located by calling 2-1-1, checking public resources, or contacting your local health department and/or emergency management agency.
- Refer patients who need assistance with home energy costs to the Low-Income Heat Energy Assistance Program (LIHEAP).
- Review the HeatRisk Tool and how it works with your patients or caregivers of children and teens. The tool assigns colors to each level of risk and recommends protective actions by color level.
- Educate your patient on how to stay hydrated.
- Review signs and symptoms of dehydration, which include:
Cold, clammy skin
Dizziness or feeling lightheaded
Rapid heart rate
Excessive sweating or an inability to sweat
Fatigue
Headache
Muscle cramps or spasms
Nausea
Abdominal cramping
Swelling in extremities
Darker color urine
Infrequent urination
Thirst
- Emphasize the importance of regular and consistent fluid and food intake throughout the day.
- Advise patients and their caregivers to try to limit beverages higher in sugars, sodium, and caffeine, which may lead to dehydration. See Guideline 4 of the dietary guidelines.
- Advise patients and their caregivers that water is usually the best choice, although sports drinks containing electrolytes may be necessary if sweating for several hours.
- Children and teens with asthma and with nausea, vomiting, and diarrhea will need particular attention to avoiding dehydration and fluid and electrolyte imbalance, which heat exposure can compound.
- To avoid sunburn, which can promote dehydration, see # 2 above, “How to Stay Cool”.
- Educate your patients on air quality. Heat can worsen air quality, which can worsen asthma control and lead to additional health harms.
- Review the Air Quality Index (AQI) with your patients and caregivers of children and teens at the HeatRisk Dashboard, the phone’s weather app, or at gov. Ensure they know how to access, understand, and use the information including which actions they can take at specific air quality levels.
- Review Steps to Take for Good Indoor Air Quality.
- Remind your patients and their caregivers that indoor air can be as polluted as outdoor air.
- Educate patients that cigarette and e-cigarette smoke, candles, and air fresheners are indoor sources of air pollution.
- If possible, bring outdoor air in when cooking indoors.
- Encourage patients to allow clean indoor air inside when the AQI is less than 100 (or <50 for individuals sensitive to poor air quality).
- Review Information on Air Filters
- Discuss air purifiers, also known as air sanitizers, air cleaners, and/or air filters used in HVAC systems. While these devices cannot remove all air pollutants, they can improve indoor air quality for many pollutants when used properly. A list of portable cleaners can be found here.
- Some homes have HVAC systems with replaceable filters. These filters have MERV (Minimum Efficiency Reporting Values) ratings or are designated as HEPA (high efficiency particulate air) filters. To effectively remove indoor air pollution, HEPA filters or filters with MERV of 13 or higher can be used.
- Air filters should be replaced regularly. Replacement frequency depends on how much air pollution is present but can be done every 60-90 days.
- Do-it-yourself (DIY) air cleaners may be a more affordable and accessible alternative to commercial versions to filter out smoke particles and can be constructed using a box fan and a high-efficiency home air filter.
- Make a plan with your patients for medication management on HeatRisk orange, red, and magenta days.
- Review the Heat and Medications page to familiarize yourself with how medications interact with heat, which medications are most likely to do so, and an approach to medication management during hot days.
- Ensure your pediatric patients and their caregivers know to not abruptly stop medications and to take all medications as directed unless otherwise guided by you or another clinician.
- Review your patient’s medication list with them, highlighting medications that may need to be adjusted because of interactions with heat. Document with your patient any medication adjustments during hotter weather and when to resume their normal medication schedule.
- Provide guidance on proper storage of medications, including for medications that individuals may carry with them, such as inhalers, which can malfunction or burst from high heat. Counsel patients and their caregivers not to leave medications in a car or other places that can get excessively hot and help your patients develop a medication storage plan in the event of a heat-related power outage.
- Counsel your patients and/or caregivers of children and teens to limit sun exposure if they take a medication that can cause sensitivity to the sun, such as certain antibiotics.
- Encourage your patients to reflect heat and medication information discussed with you in the medication section of their Health Action Plan and in their Asthma Action Plans.