An independent association of prenatal depression with wheezing and anxiety with rhinitis in infancy.

BACKGROUND: Different maternal psychological states during pregnancy have been associated with wheeze-rhinitis-eczema symptoms in children. However, previous studies were limited and it was unclear whether the type of prenatal psychological state was associated with a particular symptom. We examined the association of maternal depression and anxiety during pregnancy with wheeze-rhinitis-eczema symptoms in infancy. METHODS: In a longitudinal birth cohort (GUSTO) of 1152 mother-child pairs, wheeze-rhinitis-eczema symptoms in the infants during the first year of life were collected by parental report. Maternal depressive and anxiety symptoms were assessed at 26 weeks of gestation using the Edinburgh Postnatal Depression Scale (EPDS) and State Trait Anxiety Inventory (STAI). Logistic regression analyses were performed with adjustment for potential confounders. RESULTS: An increased risk of wheezing was found in infants of pregnant women with probable depression (EPDS ≥ 15) [odds ratio (OR) = 1.85 (95% confidence interval (CI) 1.10-3.12)], and an increased risk of rhinitis was associated with maternal anxiety [STAI state ≥ 41: OR = 1.42 (95% CI 1.04-1.93); STAI trait ≥ 43: OR = 1.38 (95% CI 1.01-1.88)]. After adjusting for known risk factors for the development of allergic disease, these associations remained significant [EPDS ≥ 15: adjusted OR = 2.09 (95% CI 1.05-4.19); STAI state ≥ 41: adjusted OR = 1.82 (95% CI 1.17-2.82); STAI trait ≥ 43: adjusted OR = 1.70 (95% CI 1.10-2.61)]. However, maternal psychological states were not associated with infantile eczema. CONCLUSION: This study suggests that there may be an independent effect of prenatal depression on wheezing and anxiety on rhinitis in infancy.

Breastfeeding Practices and Postpartum Weight Retention in an Asian Cohort.

This study examines relationships between breastfeeding practices and postpartum weight retention (PPWR) at 6 and 12 months postpartum among 379 first-time mothers participating in a clinical trial in Singapore. We categorized feeding modes at 6 months into exclusive breastfeeding, mixed feeding, and exclusive formula feeding. Participants were analyzed in two groups based on their PPWR assessment at 6 and 12 months postpartum, with complete datasets available for each assessment. We calculated PPWR by subtracting pre-pregnancy weight from self-reported weight at 6 and 12 months postpartum, defining substantial PPWR as ≥5 kg retention. Modified Poisson regression models adjusted for potential confounders were performed. At 6 and 12 months, 35% (n = 132/379) and 31% (n = 109/347) of women experienced substantial PPWR, respectively. Compared to exclusive breastfeeding, mixed feeding (risk ratio 1.85; 95% confidence interval 1.15, 2.99) and exclusive formula feeding (2.11; 1.32, 3.28) were associated with a higher risk of substantial PPWR at 6 months. These associations were slightly attenuated at 12 months and appeared stronger in women with pre-pregnancy overweight or obesity. This study suggests that breastfeeding by 6 months postpartum may help mitigate PPWR, particularly with exclusive breastfeeding. It also draws attention to targeted interventions to promote breastfeeding among women with overweight or obesity.

Impact of family and caregiver factors on development and behaviours in maltreated young children.

Introduction: This study aimed to evaluate the prevalence of developmental and emotional/ behavioural concerns in maltreated children and to examine the impact of adverse family/caregiver risk factors on these outcomes. Method: We analysed family demographic and baseline data of 132 maltreated children and their caregivers from a family support programme in Singapore. We examined the associations of 3 main risk factors (i.e., caregiver mental health, educational attainment, and family socio-economic status [SES]) with developmental/behavioural outcomes using multivariable logistic regression, controlling for caregiver relationship to the child. Caregiver mental health was assessed using the Patient Health Questionnaire 9 (PHQ-9) and General Anxiety Disorder 7 (GAD-7) tools. Developmental/behavioural outcomes were assessed using the Ages and Stages Questionnaires (ASQ-3), ASQ-Social-Emotional (ASQ-SE), and the Child Behaviour Checklist (CBCL). Results: The children ranged in age, from 2 months to 3 years 11 months (median age 1.7 years, interquartile range [IQR] 0.9-2.6). Among caregivers, 86 (65.2%) were biological mothers, 11 (8.3%) were biological fathers, and 35 (26.5%) were foster parents or extended family members. Low family SES was associated with communication concerns on the ASQ-3 (adjusted odds ratio [AOR] 3.04, 95% CI 1.08-8.57, P=0.04). Caregiver mental health concerns were associated with increased behavioural concerns on the CBCL (AOR 6.54, 95% CI 1.83-23.33, P=0.004) and higher scores on the ASQ-SE (AOR 7.78, 95% CI 2.38-25.38, P=0.001). Conclusion: Maltreated children with caregivers experiencing mental health issues are more likely to have heightened emotional and behavioural concerns. Those from low SES families are also at increased risk of language delay, affecting their communication.

Profile of hospitalised maltreated children aged 0 to 3 years and their families.

INTRODUCTION: Maltreatment adversely affects children's health and development. Knowledge of child maltreatment in early childhood is limited. We studied the demographic factors and health issues in children aged 0-3 years who were hospitalised for maltreatment. METHODS: In this retrospective cohort study, health and demographic information was extracted from the electronic medical records of children hospitalised in KK Women's and Children's Hospital between January 2018 and June 2019. High-risk groups were children with developmental delay (DD), missed vaccination (MV), low outpatient attendance, high dependency unit (HDU) or intensive care unit (ICU) admission and Child Protection Service (CPS) referral. Chi-square or Fisher's exact test was used for categorical variables. Mann-Whitney U test was used for skewed quantitative variables. RESULTS: Among the 101 children included in the study, the most common type of abuse and alleged perpetrator were physical abuse and parents, respectively. In addition, 35.6% of the children had pre-existing health conditions before hospitalisation, 58.4% had new health conditions diagnosed during hospitalisation requiring follow-up and 26.7% had maltreatment-related injuries. One-fifth of the children had DDs and another one-fifth had MVs. About 20% of them had defaulted all outpatient appointments. High-risk children mostly lived in rented housing. Their mothers mostly had primary education or lower. Most children admitted to ICU or HDU were <6 months old (8/12 [66.7%] vs. 6-24 months 3/12 [25%] vs. 24-47 months 1/12 [8.3%], P = 0.001). A higher number of children with DD were referred to CPS (63.2%, P = 0.049) than to other agencies. CONCLUSION: Maltreated children have significant health needs that are not fully met through routine surveillance practices. They are at risk of defaulting their hospital appointment. It is imperative that families at risk of child maltreatment are identified early and their needs holistically evaluated, with care coordinated within the hospital-community support system.

Utility of overnight oximetry indices in the evaluation of children with snoring and suspected obstructive sleep apnea.

STUDY OBJECTIVES: Optimal cutoff values of oximetry indices that differentiate obstructive sleep apnea (OSA) from primary snoring (PS) is not well established. Our study aimed to assess the utility of overnight oximetry indices in differentiating PS from OSA and assessing OSA severity, compared to polysomnography (PSG), in children with suspected OSA. METHODS: This was a retrospective study of children (1-18 years) with snoring who underwent PSG. Patients with Down syndrome, craniofacial anomalies, known genetic syndromes, neuromuscular conditions and central apnea index ≥ 5 were excluded. Demographic data, PSG variables and oximetry indices (e.g. oxygen desaturation index [ODI3, defined as number of ≥ 3% desaturation episodes/hour of artifact free recording time and SpO2 nadir]) were collected. RESULTS: Of 1,203 children (mean age 9.1±3.9 years, 67.7% males), 91.8% (847/923) ≤ 12 years and 84.3% (236/280) > 12 years had OSA. Optimal cutoff of ODI3 for differentiating PS from OSA was 2.4 [Se: 78.8% (75.9%-81.6%), Sp: 80.5% (69.9%-88.7%)] in ≤ 12 years and 3.6 [Se: 71.1% (64.8%-76.8%), Sp: 91.1% (78.8%-97.5%)] in > 12 years. The optimal cutoff of ODI3 for differentiating PS from mild, moderate and severe OSA categories were 2.0 [Se: 70.1% (65.3%-74.5%), Sp: 70.1% (58.6%-80.0%)]; 3.7 [Se: 82.3% (76.6%-87.1%), Sp: 94.8% (87.2%-98.6%)] and 4.3 [Se: 99.1% (96.8%-99.9%), Sp: 98.7% (93.0%-100.0%)] in ≤ 12 years; and 1.9 [Se: 78.8% (75.9%-81.6%), Sp: 80.5% (69.9%-88.7%)]; 4.1 [Se: 85.4% (72.2%-93.9%), Sp: 91.1% (78.8%-97.5%)] and 6.9 [Se: 98.4% (91.2%-100.0%), Sp: 97.8% (88.2%-99.9%)] in > 12 years, respectively. CONCLUSIONS: This study provides optimal cutoff values for ODI3 in differentiating PS from OSA and assessing OSA severity in children. As oximetry is cheaper and widely available, ODI3 has the potential to be incorporated into cost-effective clinical decision-making algorithms, especially in resource limited settings.

A Community-enabled Readiness for first 1000 Days Learning Ecosystem (CRADLE) for first-time families: study protocol of a three-arm randomised controlled trial.

BACKGROUND: Enhanced parenting self-efficacy (PSE) contributes to positive parenting and future parental-child health. First-time parents, in particular, are in need of support since the pregnancy until post-delivery to strengthen their early PSE. However, there is a lack of effective and sustainable relevant programmes in the community. The Community-enabled Readiness for first 1000 Days Learning Ecosystem (CRADLE) aims to develop a self-learning eco-community throughout the pregnancy and early childhood to promote PSE among first-time parents. We apply choice architecture strategy using behavioural nudges and midwife-led continuity care during the first 1000 days, and test their effects on PSE and mother-child health for first-time families in Singapore. METHODS: This three-arm randomised controlled trial will recruit up to 750 pregnant women from the KK Women's and Children's Hospital, Singapore. Participants will be randomly assigned to receive: (1) standard routine care; (2) behavioural nudges (text messages) along with the use of a social media platform; or (3) midwife-led continuity care involving individualised teleconferencing sessions, during pregnancy and post-delivery. Using web-based questionnaires, participants will be assessed for baseline socio-demography and health status in the first visit, with follow-up assessments in the third trimester, at birth, 6-week (primary end-point), 6-, 12-, 18- and 24-month post-delivery. The primary outcome is PSE. Secondary outcomes include health and birth experience, mental wellness, feeding practice, maternal and child nutritional status. Intention-to-treat and per-protocol analyses will be performed using general linear models to test the effects of interventions across three arms. Recruitment has begun in June 2020 and is estimated to complete in September 2022. DISCUSSION: This study may identify a sustainable effective strategy in the community by helping first-time parents to have a positive experience during the pregnancy, childbirth and parenthood, leading to an enhanced PSE and health outcomes for both mother and child. Findings from this study will provide insight into the implementation of early parenting and mother-child care programmes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04275765 . Registered on 19 February 2020.

Hypersensitivity to paracetamol in Asian children with early onset of nonsteroidal anti-inflammatory drug allergy.

BACKGROUND: The published incidence of paracetamol cross-reactivity in adults and adolescents with nonsteroidal anti-inflammatory drug (NSAID) reactions is low and all data on such reactions in young children is sparse. The study aim was to characterize the clinical presentation and cross-reactivity with paracetamol in patients with a reported onset of NSAID hypersensitivity before 6 years of age. METHODS: A retrospective case review was done of patients with cross-reactive hypersensitivity reactions to antipyretic/analgesic medications from the pediatric allergy clinic of the Kendang Kerbau Hospital, Singapore. Included patients reported the onset of such reactions before 6 years of age. Hypersensitivity was established through a detailed history of recurrent reactions to NSAIDs or an oral provocation test. RESULTS: Eighteen patients fulfilled the diagnostic criteria within the study period. Eighty-three percent had cross-reactive reactions with paracetamol. When compared to the group of children with later onset of NSAID hypersensitivity, children with onset before 6 years of age had a significantly increased likelihood of reacting to paracetamol (odds ratio 9.6, 95% confidence interval 1.6-58.0, p < 0.05). CONCLUSION: Paracetamol seems to be a major eliciting drug in this group of children.

Is the childhood asthma questionnaire a good measure of health-related quality of life of asthmatic children in Asia?: validation among paediatric patients with asthma in Singapore.

BACKGROUND: Health-related quality of life (HR-QOL) is an important outcome in the treatment of chronic childhood diseases such as asthma. However, this measure is rarely used in young children in Asia because of the difficulty of obtaining valid, reliable instruments that are developmentally and culturally suitable. OBJECTIVES: To select, culturally adapt and validate a disease-specific HR-QOL questionnaire (Childhood Asthma Questionnaire [CAQ]-B) for asthmatic children aged 7-11 years in Singapore, and to understand the relationship between patient-reported HR-QOL domains and physician- or caregiver-rated severity. METHODS: A literature review was conducted to shortlist questionnaires based on pre-specified criteria. A pre-test was conducted to assess suitability and relevance of the questionnaires in Singapore. The selected questionnaire (CAQ-B) was then adapted to more closely reflect the local culture, climate, school system and terminology. Cross-sectional validation was conducted. All asthmatic patients aged 7-11 years attending the respiratory clinic in a paediatric hospital, and without co-morbidities that could significantly affect their HR-QOL, were invited to participate. Patients and their parents or caregivers were asked to complete the relevant sections of the questionnaire before their medical consultation. The child's severity of asthma was rated by the attending physician according to guidelines from the Singapore Ministry of Health. Correlations between the child-reported CAQ-B outcomes and clinical ratings of severity by both parents and physicians were investigated. Internal reliability was tested with Cronbach's alpha, and the overall questionnaire structure was explored using principal axis analysis with oblimin rotation and extraction for factors with Eigen values >1.0. RESULTS: The adapted CAQ-B was validated in 96 patients (40 girls and 56 boys) with a mean age of 8.7 +/- 1.1 years (range 7-11). Most children had no difficulty understanding and completing the questionnaire. The median time taken to complete a questionnaire was 10 minutes. Internal consistency of the various scales ranged from 0.29 to 0.76 (Cronbach's alpha) when items were analysed according to the UK or Australian scale structure. This increased to 0.57-0.76 after item reduction. Physician-rated severity only correlated significantly with the Active Quality of Living (AQOL) domain (r = -0.29, p = 0.02). However, parent/caregiver-rated severity correlated with three of four patient-reported domains: AQOL (r = -0.359, p = 0.001), Passive Quality Of Living (PQOL) [r = -0.271, p < 0.01] and severity (r = 0.367, p < 0.001). The AQOL domain was significantly correlated with the PQOL domain (r = 0.513, p = 0.005). CONCLUSIONS: The children and parents/caregivers in this study found CAQ-B to be a simple and acceptable questionnaire with some evidence of content validity. While two of the domains did not meet internal consistency standards expected of HR-QOL instruments for adults (Cronbach's alpha = 0.70), they were acceptable for children of this age. The patterns of correlation also suggest that parent/caregivers' perception of the severity of a young child's asthma may be a better indicator of a child's HR-QOL than clinical diagnosis of severity. However, further investigation is recommended to improve and validate the internal structure of the scale.

Concordance between bronchial hyperresponsiveness, fractional exhaled nitric oxide, and asthma control in children.

BACKGROUND: Previous studies on association between level of asthma control, markers of airway inflammation and the degree of bronchial hyperresponsiveness (BHR) have yielded conflicting results. Our aim was to determine the presence and severity of BHR and the concordance between BHR, asthma control, and fractional exhaled nitric oxide (FeNO) in children with asthma on therapy. METHODS: In this cross-sectional observational study, children (aged 6-18 years) with asthma on British Thoracic Society (BTS) treatment steps 2 or 3, underwent comprehensive assessment of their asthma control (clinical assessment, spirometry, asthma control test [ACT], Pediatric Asthma Quality of Life Questionnaire [PAQLQ]), measurement of FeNO and BHR (using mannitol dry powder bronchial challenge test [MCT], Aridol™, Pharmaxis, Australia). RESULTS: Fifty-seven children (63% male) were studied. Twenty-seven children were on BTS treatment step 2 and 30 were on step 3. Overall, 25 out of 57 (43.8%) children had positive MCT. Of note, 9 out of 27 (33.3%) children with clinically controlled asthma had positive MCT. Analyses of pair-wise agreement between MCT (positive or negative), FeNO (>25 or ≤25 ppb) and clinical assessment of asthma control (controlled or partially controlled/uncontrolled) showed poor agreement between these measures. CONCLUSIONS: A substantial proportion of children with asthma have persistent BHR despite good clinical control. The concordance between clinical assessment of asthma control, BHR and FeNO was observed to be poor. Our findings raise concerns in the context of emerging evidence for the role of bronchoconstriction in inducing epithelial stress that may drive airway remodeling in asthma. Pediatr Pulmonol. 2016;51:1004-1009. © 2016 Wiley Periodicals, Inc.

Pilot study of the use of Yin Qiao San in children with conventional antipyretic hypersensitivity.

BACKGROUND: Children with a diagnosis of cross-reactive hypersensitivity to both paracetamol and nonsteroidal anti-inflammatory drugs are limited in their choice of antipyretics. OBJECTIVE: The aim of this pilot study is to evaluate the feasibility of using a Chinese proprietary medicine, Yin Qiao San (YQS), for fever relief. METHODS: A single centre, open label, prospective clinical trial exploring the tolerability and feasibility of using YQS for fever relief in children who are unable to use conventional antipyretic medications. Children between 1-18 years of age with hypersensitivity to multiple antipyretics were recruited. Eligible participants underwent an oral provocation test with YQS. Children who passed the oral provocation test were instructed to take a prescribed dose of YQS when the temperature was >38.0℃ and continued till the fever settled. Time taken for fever resolution and any adverse events were collected. RESULTS: A total of 21 children, mean age 10.7 years, had a diagnosis of paracetamol and ibuprofen hypersensitivity. All except one patient successfully tolerated an oral challenge of YQS. Of the 88 doses of YQS taken for fever over 38.0℃, 16 (18%) had documented temperature reduction 2 hours after ingestion and 30 (34%) had documented temperature reduction 4 hours after ingestion. There were 2 reports of urticaria after YQS use which were attributed to flare of recurrent spontaneous urticaria during the illness. None of the patients developed symptoms of circulatory compromise or respiratory distress. CONCLUSION: YQS is generally well tolerated in patients with paracetamol and ibuprofen hypersensitivity.

Compliance with noninvasive home ventilation in children with obstructive sleep apnoea.

INTRODUCTION: This study aimed to determine compliance with noninvasive home ventilation in children with obstructive sleep apnoea and the factors affecting this compliance. METHODS: We retrospectively reviewed 51 children who were prescribed noninvasive home ventilation for the management of obstructive sleep apnoea from 1 January 2000 until 31 May 2008. Noninvasive ventilation was started based on positive polysomnogram, i.e. obstructive apnoea hypopnea index ≥ 1/hr. Compliance was defined as the use of noninvasive ventilation ≥ 4 days/week. RESULTS: Noninvasive home ventilation was started at a median age of 11.5 years. In all, 21 (41.2 %) children were reported to be compliant with treatment. Univariate analysis revealed that the female gender (p = 0.017), presence of asthma (p = 0.023), presence of genetic syndromes (p = 0.023), use of bi-level ventilation versus continuous positive airway pressure (p = 0.027), and funding from the social work department (p = 0.049) were associated with compliance with noninvasive home ventilation. Logistic regression revealed the presence of asthma (p = 0.008) and female gender (p = 0.047) to be significantly associated with compliance with treatment. However, factors such as counselling prior to initiation of treatment, severity of obstructive sleep apnoea before initiation of treatment, obesity, use of humidification, and polysomnogram indices were not found to be associated with treatment compliance. CONCLUSION: Only 41.2% of the children in this study were reported to be compliant with noninvasive home ventilation. The female gender and the presence of asthma were associated with treatment compliance. Future research focusing on effective methods to improve compliance with noninvasive home ventilation in children should be undertaken.

Paediatric anaphylaxis in a Singaporean children cohort: changing food allergy triggers over time.

BACKGROUND: We have noticed changes in paediatric anaphylaxis triggers locally in Singapore. OBJECTIVE: We aimed to describe the demographic characteristics, clinical features, causative agents and management of children presenting with anaphylaxis. METHODS: This is a retrospective study of Singaporean children presenting with anaphylaxis between January 2005 and December 2009 to a tertiary paediatric hospital. RESULTS: One hundred and eight cases of anaphylaxis in 98 children were included. Food was the commonest trigger (63%), followed by drugs (30%), whilst 7% were idiopathic. Peanut was the top food trigger (19%), followed by egg (12%), shellfish (10%) and bird's nest (10%). Ibuprofen was the commonest cause of drug induced anaphylaxis (50%), followed by paracetamol (15%) and other nonsteroidal anti-inflammatory drugs (NSAIDs, 12%). The median age of presentation for all anaphylaxis cases was 7.9 years old (interquartile range 3.6 to 10.8 years), but food triggers occurred significantly earlier compared to drugs (median 4.9 years vs. 10.5 years, p < 0.05). Mucocutaneous (91%) and respiratory features (88%) were the principal presenting symptoms. Drug anaphylaxis was more likely to result in hypotension compared to food anaphylaxis (21.9% vs. 2.7%, Fisher's exact probability < 0.01). There were 4 reported cases (3.6%) of biphasic reaction occurring within 24 h of anaphylaxis. CONCLUSION: Food anaphylaxis patterns have changed over time in our study cohort of Singaporean children. Peanuts allergy, almost absent a decade ago, is currently the top food trigger, whilst seafood and bird's nest continue to be an important cause of food anaphylaxis locally. NSAIDs and paracetamol hypersensitivity are unique causes of drug induced anaphylaxis locally.

Allergic rhinitis and non-allergic rhinitis in children in the tropics: prevalence and risk associations.

BACKGROUND: The age-related comparative prevalence of allergic rhinitis (AR) and non-allergic rhinitis (NAR) in children is poorly defined. We aimed to characterize AR and NAR in children. METHODS: This study enrolled children with chronic rhinitis who presented to a tertiary paediatric center for a diagnostic skin prick test (SPT). Parents completed a medical history questionnaire for their child, including disease activity for asthma and rhinitis. Sociodemographic data was obtained and all participants underwent a common inhalant SPT panel. A positive SPT indicated AR. RESULTS: From March 2001 to March 2009, 6,660 children (64% male) were enrolled (aged 6 months to 19 years, mean 7.82 years). Only 3.7% (249) of the children were <2 years old, and almost 30% of these had AR. Most children with AR (73%) presented after age 6. Males were more likely to have AR (vs. NAR) (OR 1.5; CI 1.39-1.77). Antihistamine and salbutamol use did not differ between children with AR and NAR. Children with AR were more likely to require adjunct therapy with inhaled corticosteroids (51.2% vs. 43.2%, P < 0.001), have drug hypersensitivity (especially antipyretic drugs) (2.5% vs. 1.3%, P = 0.384) or an asthma admission (9.1% vs. 6.0%, P < 0.001). CONCLUSIONS: AR is more common in male children, is relatively rare below the age of 2 years, and accounts for two-thirds of all childhood chronic rhinitis and 73.3% of all chronic rhinitis in school-aged children (≥6 years old). Children with AR have more severe rhinitis symptoms and more often suffer from asthma-related events and admissions.

Pediatric Flexible Bronchoscopy in Singapore: A 10-year Experience.

AIM: To determine the results of children who underwent flexible bronchoscopy and bronchoalveolar lavage (BAL) in the Respiratory Medicine Service of Kandang Kerbau Women's and Children's Hospital from 1996 to 2005. METHOD: This was a retrospective study of all patients who underwent flexible bronchoscopy. Patients were traced from the hospital records. RESULTS: Two hundred and eight records were reviewed over a 10-year period. Of these, 63.5% were for male patients. The mean age of the patients was 4.1 years (range: 0.01 to 26 y). Sixty-six percent of the patients were below the age of 5 years. The main indications for bronchoscopy were abnormalities on chest x-ray (56.7%) followed by stridor (23.1%). An abnormality was detected in 77.7% of patients who underwent bronchoscopy. Twenty-three percent (n=45) of the bronchoscopes with BAL were performed on immunocompromised children for identification of microorganisms, of which 20% (n=9) yielded a positive microbiologic result. A positive yield was better if no earlier antimicrobials (26.3%) or only 1 antimicrobial was prescribed (42.8%) as compared with a 10% yield rate on treatment with 2 or more antimicrobials. The most common pathologic microorganisms identified were Candida albicans (18.5%) and Cytomegalovirus (18.5%). Complications from the bronchoscopy occurred in 16.6% of the patients. The main complication was hypoxia, which occurred in 28 children (13.4%). Other complications included cardiac arrhythmias (n=1, 0.5%) and laryngospasm (n=4, 1.9%). There were no fatalities experienced in our center. CONCLUSIONS: Flexible bronchoscopy was well tolerated with no serious adverse events being experienced. It is a useful tool in the investigation of stridor and persistent wheezing in children. For microbiologic identification, the BAL should be performed before initiating antimicrobials for better results.

Influenza vaccine concurrently administered with a combination measles, mumps, and rubella vaccine to young children.

Children aged 11 to <24 months received 2 intranasal doses of live attenuated influenza vaccine (LAIV) or placebo, 35+/-7 days apart. Dose 1 was administered concomitantly with a combined measles, mumps, and rubella vaccine (Priorix). Seroresponses to measles and mumps were similar between groups. Compared with placebo, response rates to rubella in LAIV+Priorix recipients were statistically lower at a 15 IU/mL threshold (83.9% vs 78.0%) and the prespecified noninferiority criteria were not met. In a post hoc analysis using an alternate widely accepted threshold of 10 IU/mL, the noninferiority criteria were met (93.4% vs 89.8%). Concomitant administration with Priorix did not affect the overall influenza protection rate of LAIV (78.4% and 63.8% against antigenically similar influenza strains and any strain, respectively).

Early presentation with angioedema and urticaria in cross-reactive hypersensitivity to nonsteroidal antiinflammatory drugs among young, Asian, atopic children.

OBJECTIVE: Nonsteroidal antiinflammatory drugs (NSAIDs), mainly ibuprofen, are used extensively among children as analgesic and antipyretic agents. Our initial survey in the Kendang Kerbau Children's Hospital in Singapore showed NSAIDs to be the second most common adverse drug reaction-causing medications among children of Asian descent. We attempted to characterize the clinical and epidemiologic profile of NSAID reactions in this group of patients. METHODS: A retrospective case series from a hospital-based pediatric drug allergy clinic was studied. A diagnosis of NSAID hypersensitivity was made with a modified oral provocation test. Atopy was evaluated clinically and tested with a standard panel of skin-prick tests. We excluded from analysis patients with any unprovoked episodes of urticaria and/or angioedema, patients < 1 year of age, and patients who refused a diagnostic challenge test. RESULTS: Between March 1, 2003, and February 28, 2004, 24 patients, including 14 male patients (58%) and 18 Chinese patients (75%), with a mean age of 7.4 years (range: 1.4-14.4 years), were diagnosed as having cross-reactive NSAID hypersensitivity. A family history consistent with NSAID hypersensitivity was elicited for 17% of patients. None of the patients reported any episodes of angioedema/urticaria unrelated to NSAIDs. The median cumulative reaction-eliciting dose was 7.1 mg/kg. Facial angioedema developed for all patients (100%) and generalized urticaria for 38% of challenged patients, irrespective of age. There was no circulatory compromise, but respiratory symptoms of tachypnea, wheezing, and/or cough were documented for 42% of patients. A cross-reactive hypersensitivity response to acetaminophen was documented for 46% of our patients through their history and for 25% through diagnostic challenge. Compared with patients with suspected adverse drug reactions to antibiotics, patients in the NSAID group were older (7.4 vs 4.8 years) and more likely to have a diagnosis of asthma (odds ratio: 7.5; 95% confidence interval: 3.1-19). CONCLUSIONS: Early presentations of facial angioedema and urticaria are key features of dose- and potency-dependent, cross-reactive reactions to NSAIDs in a subpopulation of young, Asian, atopic children. Significant overlap with acetaminophen hypersensitivity, especially among very young patients, for whom the use of a cyclooxygenase-2-specific medication may not be feasible, severely limits options for medical antipyretic treatment.

Bimodal skin reactivity to histamine in atopic children in Singapore: influence of specific sensitizations.

Histamine skin prick test (SPT) is used as the 'golden standard' for positive control in in vivo immediate type hypersensitivity testing. The skin reactivity to histamine can, however, be modulated by a bevy of extraneous factors. We aimed to define whether histamine skin reactivity in atopic children in Singapore is influenced by age, ethnic origin, gender, environmental exposure or specific sensitization patterns. A retrospective analysis of children, with specific aeroallergen sensitization (as measured by at least one allergen-specific SPT with a wheal size > 3 mm compared with the negative control) from the outpatient speciality clinic of the KK Children's Hospital, during 06/2002-06/2003. A total of 315 patients were included, 235 (75%) were males, 252 (80%) were Chinese, age mean was 7.7 yr (range: 2-15). Patients were referred to the SPT with a diagnosis of one or more of: allergic rhinitis 287 (91%), asthma 112 (36%) or atopic dermatitis 60 (19%). The mean histamine response showed a bimodal distribution, independent of age, ethnic origin, gender or phenotypical expression of allergic disease. Histamine skin reactivity was higher in atopic patients with polysensitization (mean 5.0 mm vs. 2.9 mm in monosensitized patients, p < 0.001), and in patients with mould sensitization (mean 5.1 mm vs. 3.3 mm in patient not sensitized to moulds, p < 0.001). The presence of passive smoking increased the likelihood of a diminished histamine skin response. Histamine skin response data strongly suggested the presence of two heterogeneous subpopulations. Children with polysensitization and mould sensitization were more likely to show a large significant histamine response, whereas children with passive smoke exposure, showed a diminished skin reactivity to histamine.