Pediatrician advises against automatic asthma diagnosis for teen athletes

Teenage athletes reporting breathing difficulties during sports should not be automatically diagnosed with asthma, a pediatrician advised medical colleagues at the American Academy of Pediatrics 2026 National Conference. Suzanne McNulty, MD, of Aliso Viejo, California, stated during a presentation that long COVID operates as a systemic disease requiring clinicians to investigate the specific physiological mechanisms driving post-COVID breathing symptoms rather than relying on traditional assumptions about exercise-induced conditions.

Assessing Dyspnea Beyond Traditional Asthma Assumptions

Young athletes experiencing long COVID can struggle with breathlessness due to factors other than standard asthma or exercise-induced laryngeal obstruction. McNulty emphasized that treatment plans must look beyond merely helping a teenager survive a single workout. Clinicians need to understand patient physiology thoroughly enough to ensure athletes can exercise, recover, and return to competitive sports safely.

McNulty Outlines Safety Assessments and Diagnostic Testing for Athletes

McNulty outlined immediate safety assessments and extensive diagnostic testing protocols for evaluating adolescent athletes. Before proceeding further, practitioners must screen for red flags like fainting during exercise, low blood oxygen levels that remain low, worsening shortness of breath while at rest, spitting up blood or bloody phlegm, exertion-induced chest pain, abnormal heart signs, ongoing fever or systemic swelling, anaphylaxis at rest, and noisy breathing. Recommended diagnostic steps include pulse oximetry, cardiac and pulmonary exams, electrocardiograms, spirometry with bronchodilator responses, and complete blood counts paired with ferritin or complete iron studies and vitamin B12 testing.

Pulmonary testing alone cannot rule out underlying issues. McNulty highlighted a 2024 systematic review and meta-analysis examining 386 children post-COVID, which demonstrated that spirometry was generally normal even when some patients experience dyspnea, fatigue, and cough.

Differentiating Symptoms Across Diverse Physiological Triggers

Gathering detailed descriptions of what an athlete feels helps narrow down complex differential diagnoses. McNulty noted that distinct sensations point toward different conditions, explaining that I can’t get a satisfying breath differs from chest pain, while a blocked throat differs from a racing heart combined with breathlessness. Mast cell activation syndrome can present with air hunger, whereas iron deficiency or deconditioning related to long COVID can manifest as exertional dyspnea.

The differential diagnosis for post-COVID adolescent athletes encompasses several specific physiological pathways:

• Dysautonomia, marked by orthostatic or exertional tachycardia and heat intolerance.
• Mast cell activation syndrome, involving flares affecting the skin, respiratory, gastrointestinal, neurologic, autonomic, and genitourinary systems.
• Nutritional deficiencies, including low iron or vitamin B12 levels.
• Deconditioning.
• Post-exertional malaise, where multi-system deterioration appears later in the day and the next day after physical activity.

Targeting Sequential Treatment Plans

Managing these patients requires a step-by-step approach focused on targeting physiology. McNulty advised clinicians to track patient responses, reassess remaining symptoms, and evaluate whether specific interventions improve particular domains while leaving others unresolved. Speaking in a separate interview, Laura A. Malone, MD, PhD—who serves as an associate professor at the Johns Hopkins University School of Medicine and heads the Pediatric Post-COVID-19 Rehabilitation Clinic at the Kennedy Krieger Institute in Baltimore—verified that her facility encounters comparable presentations among both competitive athletes and younger kids.

Malone noted that symptom onset varies widely among adolescents. Some individuals develop long COVID symptoms immediately following acute infections, while others experience a recovery window lasting several weeks or 1-2 months before manifestations emerge.

Children and adolescents frequently have mild COVID-19 illnesses and may not always be tested to identify a cause. We know that some patients will have symptoms that start during or immediately following their COVID-19 acute symptoms, whereas others might have a recovery for a few weeks or 1-2 months before developing symptoms. Both these patterns can be seen in long COVID.

Laura A. Malone, MD, PhD