Trends in Childhood Anaphylaxis in Singapore: 2015-2022.

BACKGROUND: There has been limited data regarding the incidence of anaphylaxis in Asia. We aim to describe patterns in patient characteristics, triggers and clinical presentation of childhood anaphylaxis in Singapore. METHODS: This was a retrospective review of emergency electronic medical records of children with anaphylaxis. Patients with the allergy-related diagnoses of anaphylaxis, angioedema, allergy and urticaria based on ICD-9 codes were screened. Cases fulfilling the World Allergy Organization criteria for anaphylaxis were included. RESULTS: A total of 1188 cases of anaphylaxis were identified with a median age of 6.3 years. Extrapolating data from the study sites, from 2015 to 2022, the incidence rate of childhood anaphylaxis emergency visits in Singapore doubled from 18.9 to 38.8 per 100,000 person-years, with an incidence rate ratio (IRR) of 2.06 (95% confidence interval [CI] 1.70-2.49). In 2022, the incidence rate of food anaphylaxis was 30.1 per 100,000 person-years, IRR 2.39 (95% CI 1.90-3.01) and drug anaphylaxis was 4.6 per 100,000 person-years, IRR 1.89 (95% CI 1.11-3.25). The incidence rate in children aged 0-4 years quadrupled during the study period. Common triggers were egg (10.4%), peanut (9.3%), tree nut (8.8%), milk (8%), shellfish (7.8%) and non-steroidal anti-inflammatory drug (4.4%). The majority (88.6%) of patients were treated with intramuscular adrenaline. Total number of allergy-related visits did not increase over time between 2015 and 2019. Rates of severe anaphylaxis, namely anaphylactic shock and admission to high-dependency and intensive care, did not increase over time, with a mean incidence of 1.6, IRR 0.85 (95% CI 0.40-1.83) and 0.7, IRR 1.77 (95% CI 0.54-5.76) per 100,000 person-years, respectively. CONCLUSION: While the number of emergency visits due to childhood anaphylaxis has increased, the number of cases of allergy-related visits, anaphylactic shock and anaphylaxis requiring high-dependency and intensive care did not rise.

Impact of COVID-19 on pediatric emergencies and hospitalizations in Singapore.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has impacted the provision of health services in all specialties. We aim to study the impact of COVID-19 on the utilization of pediatric hospital services including emergency department (ED) attendances, hospitalizations, diagnostic categories and resource utilization in Singapore. METHODS: We performed a retrospective review of ED attendances and hospital admissions among children < 18 years old from January 1st to August 8th 2020 in a major pediatric hospital in Singapore. Data were analyzed in the following time periods: Pre-lockdown (divided by the change in Disease Outbreak Response System Condition (DORSCON) level), during-lockdown and post-lockdown. We presented the data using proportions and percentage change in mean counts per day with the corresponding 95% confidence intervals (CIs). RESULTS: We attended to 58,367 children with a mean age of 5.1 years (standard deviation, SD 4.6). The mean ED attendance decreased by 331 children/day during lockdown compared to baseline (p < 0.001), attributed largely to a drop in respiratory (% change - 87.9, 95% CI - 89.3 to - 86.3, p < 0.001) and gastrointestinal infections (% change - 72.4, 95%CI - 75.9 to - 68.4, p < 0.001). Trauma-related diagnoses decreased at a slower rate across the same periods (% change - 40.0, 95%CI - 44.3 to - 35.3, p < 0.001). We saw 226 children with child abuse, with a greater proportion of total attendance seen post-lockdown (79, 0.6%) compared to baseline (36, 0.2%) (p < 0.001). In terms of ED resource utilization, there was a decrease in the overall mean number of procedures performed per day during the lockdown compared to baseline, driven largely by a reduction in blood investigations (% change - 73.9, 95%CI - 75.9 to - 71.7, p < 0.001). CONCLUSIONS: We highlighted a significant decrease in infection-related presentations likely attributed to the lockdown and showed that the relative proportion of trauma-related attendances increased. By describing the impact of COVID-19 on health services, we report important trends that may provide guidance when planning resources for future pandemics.

Dynamic adaptation to COVID-19 in a Singapore paediatric emergency department.

Singapore was one of the earliest countries affected by the coronavirus disease 2019 (COVID-19) pandemic, with more laboratory-confirmed COVID-19 cases in early February 2020 than any other country outside China. This short report is a narrative review of our tertiary paediatric emergency department (ED) perspective and experience managing the evolving outbreak situation. Logistic considerations included the segregation of the ED into physically separate high-risk, intermediate-risk and low-risk areas, with risk-adapted use of personal protective equipment (PPE) for healthcare personnel in each ED area. Workflow considerations included the progressive introduction of outpatient COVID-19 testing in the ED for enhanced surveillance; adapting the admissions process particularly for high-risk and intermediate-risk cases; and the management of unwell accompanying adult caregivers. Manpower considerations included the reorganisation of medical manpower into modular teams to mitigate the risk of hospital transmission of COVID-19. Future plans for a tiered isolation facility should include structural modifications for the permanent isolation facility such as anterooms for PPE donning/doffing; replication of key ED functions in the tent facility such as a separate resuscitation room and portable X-ray room; and refresher PPE training. Dynamic reassessment of ED workflow processes, in conjunction with the hospital and national public health response, may help in managing this novel disease entity.

Utility of Spatial Point-Pattern Analysis Using Residential and Workplace Geospatial Information to Localize Potential Outbreak Sources.

Identifying the source of an outbreak facilitates its control. Spatial methods are not optimally used in outbreak investigation, due to a mix of the complexities involved (e.g., methods requiring additional parameter selection), imperfect performance, and lack of confidence in existing options. We simulated 30 mock outbreaks and compared 5 simple methods that do not require parameter selection but could select between mock cases' residential and workplace addresses to localize the source. Each category of site had a unique spatial distribution; residential and workplace address were visually and statistically clustered around the residential neighborhood and city center sites respectively, suggesting that the value of workplace addresses is tied to the location where an outbreak might originate. A modification to centrographic statistics that we propose-the center of minimum geometric distance with address selection-was able to localize the mock outbreak source to within a 500 m radius in almost all instances when using workplace in combination with residential addresses. In the sensitivity analysis, when given sufficient workplace data, the method performed well in various scenarios with only 10 cases. It was also successful when applied to past outbreaks, except for a multisite outbreak from a common food supplier.

A review of stroller-related and pram-related injuries to children in Singapore.

Prams and strollers are commonly used in daily childcare. We aim to study the type and severity of injuries associated with prams and strollers in an Asian population. We performed a retrospective review of children below the age of 6 who presented to a tertiary paediatric hospital in Singapore, from January 2012 to June 2015, with such injuries. There were 248 pram-related and stroller-related injuries. The median age was 12.5 months old. 69 (27.8%) sustained open wounds, 17 (6.9%) suffered fractures or dislocations and 2 children had significant head injuries. 29 patients (11.7%) sustained injuries while on stairs or escalators. Most of the injuries (197 cases, 79.4%) occurred despite adult supervision. The need for intervention was associated with older age and entrapment injuries (p<0.001). Only appropriately sized prams and strollers without exposed hinges should be used. These should not be deployed on stairs and escalators.

Paediatric emergency department attendances during COVID-19 and SARS in Singapore.

INTRODUCTION: We evaluated the impact of public health measures on paediatric emergency department attendances during the COVID-19 and severe acute respiratory syndrome (SARS) outbreaks in Singapore. METHODS: Between 1 January 2020 and 31 July 2020, we retrospectively reviewed paediatric emergency department attendances and admissions in a tertiary paediatric hospital in Singapore before and after a national lockdown to combat the spread of COVID-19 in Singapore. Hospital attendances and admissions were compared with data from a corresponding period in 2019 (1 January 2019 to 31 July 2019), as well as during and after the SARS outbreak (1 January 2003 to 31 December 2004). RESULTS: Compared with a corresponding non-outbreak period, emergency department attendances decreased in line with nationwide public health measures during the COVID-19 and SARS outbreaks (2020 and 2003 respectively), before increasing gradually following lifting of restrictions, albeit not to recorded levels before these outbreaks. During the COVID-19 outbreak, mean daily attendances decreased by 40%, from 458 per day in January-July 2019, to 274 per day in January-July 2020. The absolute number of hospital inpatient admissions decreased by 37% from January-July 2019 (19,629) to January-July 2020 (12,304). The proportion of emergency department attendances requiring admission remained similar: 20% in January-July 2019 and 21% in January-July 2020. CONCLUSION: Nationwide public health measures in Singapore have had an impact on paediatric emergency department attendances and hospital inpatient admissions. Data from this study could inform planning and resource allocation for emergency departments in Singapore and internationally.

Parental knowledge and beliefs on the use of child car restraints in Singapore: a qualitative study.

INTRODUCTION: Road traffic injuries and fatalities represent a significant public health problem. In Singapore, compliance with appropriate child car restraints (CCRs) is poor. We aimed to understand parental knowledge, beliefs and barriers regarding the use of CCRs. METHODS: In this qualitative study, we conducted five focus group discussions with parents who drive with their children in private cars. Participants were recruited using the KK Women's and Children's Hospital's social media page. Guiding questions were derived by consensus following literature review and adaptation to the Singapore context, exploring parental perceptions of CCR use. Focus group interviews were then transcribed and analysed. RESULTS: 33 participants were recruited, with an age range of 28‒46 (mean age 35.5) years. They had a total of 46 children with ages ranging from 2.5 months to 14 years (mean age 4.2 years). Three key themes were identified: parental knowledge regarding CCRs, barriers to CCR use, and suggestions to increase CCR compliance. Barriers to compliance included lack of knowledge, difficult child behaviour and cultural norms. A multipronged approach was proposed to increase CCR use, including educating the public, reinforcing positive behaviour, legal enforcement as a deterrent to non-compliance, increasing CCR installation services, providing CCRs for taxi users and offering financial incentives. CONCLUSION: Non-compliance to CCR use is multidimensional, including multiple potentially modifiable factors. This study could inform ongoing collaborative injury prevention efforts among healthcare professionals, industry partners and the traffic police, using public education and outreach to reduce the burden of road traffic injuries.

Road traffic injuries among children and adolescents in Singapore - Who is at greatest risk?

INTRODUCTION: Pediatric road traffic injuries remain a significant cause of death and disability in many countries in Asia, despite the implementation of road traffic safety laws. We aim to describe the injuries, the use of restraints among road users, and risk factors associated with severe injuries for children in Singapore. METHODS: We performed a retrospective chart review of road traffic injuries presenting to the only two pediatric tertiary care hospitals in Singapore, from January 2012 to April 2016. We included children <16years old presenting to the emergency departments within 24h after injury (pedestrian, bicycle, motorcycle, motor vehicle). We calculated the frequencies for specific injury mechanisms, injury severity scores (ISS), and in-hospital outcomes of severe injuries (death, urgent resuscitation and emergent surgery). We performed a multivariate logistic regression to determine risk factors associated with severe injury. RESULTS: There were 2468 patients during the study period. The mean age was 7.9 years (SD 4.7); 60.1% of road injuries involved motor vehicle occupants (1483/2468). Most bicyclist/motorcyclists were not wearing helmets (70.0%, 245/350) and 51.1% of motor vehicle passengers (758/1483) were not restrained. Compared to motor vehicle passengers, pedestrians (adjusted OR 2.38, 95% CI 1.41-3.99), bicyclists (adjusted OR 2.12, 95% CI 1.04-4.32) and motorcyclists (adjusted OR 6.09, 95% CI 2.04-18.24) were more likely to sustain severe injuries. CONCLUSION: Child pedestrians, bicyclists and motorcyclists are especially vulnerable for severe injures. Further injury prevention efforts must focus on the enforcement of legislation to protect these high-risk groups.