Bird Droppings and Lung Infections in Children on Long-Term ICS for Asthma
Children with asthma on long-term inhaled corticosteroids are theoretically at increased risk for opportunistic infections from bird droppings, but this risk is minimal at recommended low-to-medium ICS doses and does not warrant discontinuation of essential asthma therapy.
Understanding the Infection Risk
Bird droppings can transmit several pulmonary infections through inhalation of infectious agents:
- Ornithosis (psittacosis), histoplasmosis, and cryptococcosis develop from inhalation of organisms present in infected bird droppings 1
- These infections can cause severe pulmonary disease in exposed individuals 1
- Pigeon-breeder's lung represents a hypersensitivity pneumonitis rather than infection, caused by allergic reaction to avian proteins 1
ICS Effects on Immune Function
The immunosuppressive concern with ICS in children is dose-dependent and clinically minimal at recommended doses:
- Low-to-medium dose ICS (the preferred treatment for persistent asthma in children) have no clinically significant effects on hypothalamic-pituitary-adrenal (HPA) axis function in most children 2
- Rare individuals may show increased susceptibility even at conventional doses, but this represents exceptional cases 2
- Adrenal insufficiency is rare and confined to children receiving high doses of ICS 3, 4
- Sensitive laboratory measures may show statistically significant changes in adrenal function, but these do not predict clinically meaningful immunosuppression 3
Risk-Benefit Analysis for Continuing ICS
The benefits of ICS therapy far outweigh theoretical infection risks:
- ICS remain the preferred first-line therapy for persistent asthma in children of all ages, with strong evidence for improved outcomes including reduced exacerbations and hospitalizations 2, 5
- For children 5 years and older with mild persistent asthma, low-dose ICS are the preferred therapy 2, 5
- For children younger than 5 years, low-dose ICS via nebulizer, DPI, or MDI with holding chamber are recommended 2, 5
- Uncontrolled asthma poses greater risks to morbidity and mortality than the minimal immunosuppression from appropriate-dose ICS 3, 4
Practical Management Approach
Continue ICS therapy at the lowest effective dose while implementing environmental precautions:
- Do not discontinue or reduce ICS based solely on bird exposure concerns, as this would compromise asthma control 3, 6
- Titrate ICS to the minimum effective dose required to maintain asthma control, which minimizes any systemic effects 7, 3
- Implement strict avoidance of direct contact with birds, bird cages, and areas contaminated with bird droppings 1
- Ensure proper inhaler technique to minimize swallowed drug and systemic absorption 3
- Consider mouth rinsing after ICS administration to reduce local and systemic effects 8
When to Heighten Concern
Specific scenarios warrant increased vigilance:
- Children receiving high-dose ICS (>medium dose range) have dose-related increased risk of systemic effects 2, 3, 4
- Children on multiple forms of topical corticosteroids for concomitant allergic conditions face compounded risk 3
- Direct, repeated exposure to bird droppings in enclosed spaces (e.g., cleaning bird cages, pigeon coops) represents higher-risk scenarios 1
Common Pitfalls to Avoid
- Do not stop ICS therapy due to theoretical infection concerns without considering the proven mortality and morbidity risks of uncontrolled asthma 3, 6
- Do not use high-dose ICS when low-to-medium doses provide adequate control 8, 3
- Do not ignore environmental control measures—avoidance of bird exposure is the primary intervention for ornithopulmonary disease prevention 1