Risk factors for severe hand foot mouth disease in Singapore: a case control study.

BACKGROUND: Hand foot mouth disease (HFMD) is a common childhood infection that can potentially lead to serious complications. The aim of this study is to identify risk factors of acquiring severe HFMD in our population. METHODS: We performed a case control study using patients admitted to our hospital from August 2004 to July 2014. Cases were patients with severe HFMD disease while controls were age-matched patients obtained from the same year, in a 2:1 ratio. Data comprising demographic characteristics, clinical symptoms and signs, and lab findings were collected. Conditional univariable logistic regression was performed to determine risk factors for severe disease. RESULTS: A total of 24 cases of severe HFMD were identified and matched with 48 controls. Seventeen (70.8%) cases had central nervous system complications. Seven (29.2%) had cardiovascular complications without evidence of myocarditis. One patient died of encephalitis. The overall mortality of severe disease is 4%. Evidence of hypoperfusion, seizure, altered mentation, meningeal irritation, tachycardia, tachypnea, raised absolute neutrophil count and EV-A71 (Enterovirus A71) positivity were significantly associated with a severe course of HFMD. CONCLUSION: In managing children with HFMD, physicians should consider these factors to help identify patients at risk for severe disease.

Is prophylactic atropine necessary during ketamine sedation in children?

AIM: To quantify clinically significant hypersalivation and other adverse events requiring intervention, with and without the use of atropine during ketamine use, using a consensus-based, standardised terminology. METHODS: This was a retrospective study based on paediatric patients who received ketamine for procedures done at the children's emergency department from July 2010 to September 2010. Patients who were given atropine were compared with patients who were not given atropine with regard to clinically significant hypersalivation. All other side effects of ketamine (airway, respiratory, cardiovascular, neurological and gastrointestinal side effects) were documented. RESULTS: Two out of the 164 (1.2%) patients who received atropine and 1 out of the 119 (0.8%) patients who did not receive atropine had desaturation (odds ratio (OR) 1.5; 95% CI 0.1-16.3). These three patients were all under 5 years old (P = 0.3) and had airway malalignment requiring repositioning. None had hypersalivation requiring intervention. Two out of 164 (1.2%) who received atropine and 3 out of 119 (2.5%) who did not receive atropine had vomiting (OR 0.5; CI 0.1-2.9). One patient who vomited did not receive atropine and was given ondansetron. The others had delayed discharges following a longer period of observation in the unit. CONCLUSIONS: There was no clinically significant hypersalivation in children given ketamine sedation, with or without the coadministration of atropine. Ketamine is a relatively safe drug for use in children with few intervention-based side effects.

Unplanned reattendances at the paediatric emergency department within 72 hours: a one-year experience in KKH.

INTRODUCTION: Unscheduled reattendances at the paediatric emergency department may contribute to overcrowding, which may increase financial burdens. The objectives of this study were to determine the rate of reattendances and characterise factors influencing these reattendances and hospital admission during the return visits. METHODS: Medical records of all patients who attended the emergency department at KK Women's and Children's Hospital, Singapore, from 1 June 2013 to 31 May 2014 were retrospectively reviewed. We collected data on patient demographics, attendance data and clinical characteristics. Planned reattendances, recalled cases, reattendances for unrelated complaints and patients who left without being seen were excluded. A multivariate analysis was conducted to determine the odds ratio of variables associated with hospital admission for reattendances. RESULTS: Of 162,566 children, 6,968 (4.3%) returned within 72 hours, and 2,925 (42.0% of reattendance group) were admitted on their return visits. Children more likely to reattend were under three years of age, Chinese, triaged as Priority 2 at the first visit, and were initially diagnosed with respiratory or gastrointestinal conditions. However, children more likely to be admitted on their return visits were over 12 years of age, Malay, had a higher triage acuity or were uptriaged, had the presence of a comorbidity, and were diagnosed with gastrointestinal conditions. CONCLUSION: We identified certain subgroups in the population who were more likely to be admitted if they reattended. These findings would help in implementing further research and directing strategies to reduce potentially avoidable reattendances and admissions.

Extracorporeal life support for cardiac arrest in a paediatric emergency department.

The initiation of extracorporeal membrane oxygenation (ECMO) in the emergency department (ED) is a rare event. Herein, we report a case of acute fulminant myocarditis in a nine-year-old girl who was successfully resuscitated by early initiation of ECMO support in the paediatric ED of KK Women's and Children's Hospital, Singapore. The patient had rapidly progressed into a witnessed pulseless ventricular tachycardia on presentation, and ECMO was started in the ED following the failure of standard resuscitation measures to establish spontaneous circulation. ECMO was continued for nine days. The patient recovered well with normal neurocognitive function. The initiation of ECMO in the ED is potentially life-saving in the resuscitation of children with witnessed in-hospital cardiac arrest due to a reversible cause.