Tolerance development in cow's milk-allergic children receiving amino acid-based formula with synbiotics: 36-Months follow-up of a randomized controlled trial (PRESTO Study).

The objective of the present study is to assess the rates of acquired tolerance to cow's milk (CM) after 36 months in subjects who consumed amino acid-based formula with synbiotics (AAF-S) or amino acid-based formula without synbiotics (AAF) during a 1-year intervention period in early life as part of the PRESTO study (Netherlands Trial Register number NTR3725). Differences in CM tolerance development between groups were analysed using a logistic regression model. Results show that the proportion of subjects (mean [±SD] age, 3.8 ± 0.27 years) who developed CM tolerance after 36 months was similar in the group receiving AAF-S (47/60 [78%]) and in the group receiving AAF (49/66 [74%]) (p = 0.253), that is, figures comparable to natural outgrowth of CM allergy. Our data suggest that the consumption of AAF and absence of exposure to CM peptides do not slow down CM tolerance acquisition.

Tolerance development in cow's milk-allergic infants receiving amino acid-based formula: A randomized controlled trial.

BACKGROUND: Tolerance development is an important clinical outcome for infants with cow's milk allergy. OBJECTIVE: This multicenter, prospective, randomized, double-blind, controlled clinical study (NTR3725) evaluated tolerance development to cow's milk (CM) and safety of an amino acid-based formula (AAF) including synbiotics (AAF-S) comprising prebiotic oligosaccharides (oligofructose, inulin) and probiotic Bifidobacterium breve M-16V in infants with confirmed IgE-mediated CM allergy. METHODS: Subjects aged ≤13 months with IgE-mediated CM allergy were randomized to receive AAF-S (n = 80) or AAF (n = 89) for 12 months. Stratification was based on CM skin prick test wheal size and study site. After 12 and 24 months, CM tolerance was evaluated by double-blind, placebo-controlled food challenge. A logistic regression model used the all-subjects randomized data set. RESULTS: At baseline, mean ± SD age was 9.36 ± 2.53 months. At 12 and 24 months, respectively, 49% and 62% of subjects were CM tolerant (AAF-S 45% and 64%; AAF 52% and 59%), and not differ significantly between groups. During the 12-month intervention, the number of subjects reporting at least 1 adverse event did not significantly differ between groups; however, fewer subjects required hospitalization due to serious adverse events categorized as infections in the AAF-S versus AAF group (9% vs 20%; P = .036). CONCLUSIONS: After 12 and 24 months, CM tolerance was not different between groups and was in line with natural outgrowth. Results suggest that during the intervention, fewer subjects receiving AAF-S required hospitalization due to infections.

Safety of House Dust Mite Subcutaneous Immunotherapy with a rush and cluster combination protocol in the build-up phase.

BACKGROUND: Conventional and cluster subcutaneous immunotherapy (SCIT) are effective but may be time-consuming. Rush SCIT may offer a more convenient treatment option to patients and be of shorter duration; however, it is also associated with a higher incidence of systemic adverse reactions. Therefore, a combination of protocols between rush and cluster SCIT could have a superior risk-benefit ratio. OBJECTIVE: To determine the safety of the combination of rush and cluster HDM-SCIT and to identify the risk factors for local and systemic adverse reactions. METHODS: We retrospectively reviewed the charts of patients who received HDM-SCIT, with rush and cluster combination protocols, at a tertiary care hospital between January 2009 and December 2020. Data were collected at the initial visit (demographic data; underlying allergic disease; current medication; and laboratory investigation results including skin prick test, serum specific IgE (sIgE) levels to aeroallergen, total IgE, and eosinophil count) and follow-up visits (rate and severity of local and systemic adverse reactions). RESULTS: In total, 698 injections (28 patients) were reviewed. Overall, 13 patients developed systemic adverse reactions, at 3% (21/698) per injection visit. All reactions occurred within 60 minutes. In total, 6 patients experienced large local reactions, at 1.1% (8/698) per injection visit. A high level of sIgE to D. pteronyssinus was significantly associated with systemic adverse reactions (HR = 1.02; P = 0.009). CONCLUSIONS: HDM-SCIT with a combination of rush and cluster schedules in the build-up phase could be used as an alternative protocol, given its acceptable systemic adverse reaction rate and shortened duration.

Coexisting Iron Deficiency Anemia and Thalassemia Traits in Infants: Implication for an Anemia Screening Program.

OBJECTIVES: To study the prevalence of anemia among healthy infants, and outcomes of giving a therapeutic trial of iron to anemic infants in thalassemia-endemic area. METHODS: A cross sectional study was conducted in 6-9-month-old, full-term healthy infants who attended the well child clinics at 2 tertiary care centers in southern Thailand. Complete blood count and serum ferritin were performed in every infant, and hemoglobin typing was performed only in anemic cases. All anemic infants were given a therapeutic trial of iron and categorized into either; iron responder (hemoglobin increased ≥ 1 g/dL) or iron non-responder (hemoglobin increased <1 g/dL) groups after one month of the therapeutic trial. Mean levels of hematological parameters, including the Mentzer index, were compared within the groups. RESULTS: A total of 620 infants were included in the study. From this, 230 infants (37%) were anemic for which iron deficiency contributed for 80% of the etiology. The iron responder group showed significant improvement in hematological parameters after a trial of iron, while there was no improvement in the iron non-responder group. Among iron responders, there were 31 out of 186 infants (16.6%) who had coexisting abnormal hemoglobin typing, and their post-treatment complete blood count still showed a mean corpuscular volume < 70, with a Mentzer index < 13. CONCLUSION: Iron deficiency remains a major cause of anemia among infants, and a therapeutic trial of iron is beneficial in this age group, even though thalassemia trait/hemoglobinopathy can co-exist.

Risk factors of uncontrolled symptoms using the standard dose of second-generation H1 -antihistamines in chronic spontaneous urticaria children.

BACKGROUND: A standard dose of second-generation H1 -antihistamines is recommended as the first-line treatment of chronic spontaneous urticaria (CSU), previous studies have found that approximately 20-50% of CSU children fail to control their symptoms and required step-up treatments. OBJECTIVE: To evaluate the predictors of uncontrolled symptoms with first-line medication and describe the treatment outcomes of CSU children in the southern region of Thailand. METHODS: This retrospective chart review of CSU patients, aged 2-18 years, who were initially treated with the standard dose of second-generation H1 -antihistamine at the Pediatric Allergy Clinic, Songkhlanagarind Hospital, from January 2008 to July 2018. The data were collected at the initial visit (demographic data, onset of rash, frequency of urticaria, presence of angioedema, previous resolved CU, laboratory investigation results) and follow-up visits (treatment outcome, time to controlled urticaria). RESULTS: The medical records of 192 CSU children were reviewed; their median age were 8.5 years and the mean frequency of rash was 4 days/week. Forty-seven children (24.4%) fail to controlled symptoms with a standard dose of second -generation H1 -antihistamines and a factor significantly associated was frequency of rash for more than 4 days per week (OR = 4.36, P < 0.001). The median time to controlled urticaria was 1.28 months. CONCLUSIONS: Most of CSU children in the southern region of Thailand experienced controlled symptoms with a standard dose of second-generation H1 -antihistamines, and the frequency of urticaria for more than 4 days per week was a factor associated with uncontrolled symptoms that regimen.

Characteristics and Contributing Factors Related to Nonsteroidal Anti-Inflammatory Drugs Hypersensitivity.

INTRODUCTION: Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) is reported to be the most common drug hypersensitivity. The aim of this study was to evaluate the characteristics of self-reported NSAID hypersensitivity and identify patients at high risk of NSAID hypersensitivity. METHODS: Patients who presented at a single tertiary care hospital between January-December 2017 with reported NSAID hypersensitivity were evaluated. Clinical information obtained from a review of medical records was further supplemented with data gained from a telephone-administered questionnaire. RESULTS: From a total of 535 patients with reported NSAID hypersensitivity, 301 were included in the study. The mean age of onset of NSAID hypersensitivity reaction was 30.3 ± 14.9 years old. A total of 84 patients (27.9%) were hypersensitive to 2 or more chemically unrelated NSAIDs. The leading NSAID hypersensitivity was to propionic acid derivatives (73%) followed by acetic acid derivatives (28.9%). Immediate reaction (≤1 h) was identified in 171 patients (57.8%), and angioedema was the most frequently reported symptom (179 patients, 59.5%), followed by urticaria and anaphylaxis in 85 (28.2%) and 62 (20.6%) patients, respectively. A drug provocation test was performed on 53 patients, and NSAID hypersensitivity was confirmed in 38 patients (71.6%). The independent factors identified, which could predict NSAID hypersensitivity, were personal history of allergic rhinitis/chronic rhinosinusitis (AR/CRS), onset of NSAID hypersensitivity over 15 years old, and immediate reaction. CONCLUSION: Angioedema was the most typical symptom, and propionic acid derivatives were the most frequently reported culprit drugs. The significant risk factors predicting NSAID hypersensitivity were personal history of AR/CRS, onset of NSAID hypersensitivity reaction over 15 years old, and immediate reaction.

Risk factors of food sensitization in young children with atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common chronic and relapsing skin disease in children and food allergies have been well documented in one-third of children. However, there are limit data about the risk factors of food sensitization in children with AD. OBJECTIVE: The aim of this study was to evaluate the risk factors associated with food sensitization, among AD children. METHODS: A cross-sectional study, from the electronic medical records of 119 AD patients, aged from 2 to 5 years were reviewed. The demographic data, onset and severity of AD, family history of atopy, age of first antibiotic usage, age of first applying and frequency of moisturizer used, age of introduction to allergenic foods and food specific IgE levels were recorded. RESULTS: The prevalence of food sensitization was; 60%. The most common food allergens were egg white (56.8%), cow's milk (40%) and wheat (34.7%). The significant factors associated with overall food sensitization were; history of parent-reported food allergies (OR = 4.4, P = 0.001), severe AD (OR = 4.5, P = 0.03) and breast feeding > 6 months (OR = 3.5, P = 0.002). Factors associated with egg white allergies were the history of parent-reported food allergies (OR = 3.8, P = 0.02), and severe AD (OR = 4.2, P = 0.04). There were also significant factors associated with cow's milk allergies this being; severe AD (OR = 6, P = 0.03) and a maternal history of asthma (OR = 10.9, P = 0.01). CONCLUSIONS: Severe AD was a factor associated with all food sensitization, egg allergy and cow's milk allergy. Maternal asthma was also significantly associated with cow's milk allergy.

Clinical practice guidelines for the diagnosis and management of atopic dermatitis.

Atopic dermatitis (AD), a chronic, relapsing dermatitis, is characterized by dry and pruritus skin in patients with a personal or family history of atopy. It affects up to 20% of children and 1-3% of adults in most countries worldwide, and leads to significant treatment costs and morbidity. These guidelines are developed in accordance with evidence-based publications and expert opinions. Following simple algorithms, the guidelines aim to assist adult and pediatric physicians in the better care of patients with AD. As with other diseases, there have been several diagnosis criteria proposed over time. Nonetheless, the classical Hanifin and Rajka criterion with no pathognomonic laboratory biomarkers is still the most widely used worldwide for the diagnosis of AD. The management of AD must be considered case by case to provide suitable care for each patient. Basic therapy is focused on avoiding specific/unspecific provoking factors and hydrating skin. Topical anti-inflammatory treatments such as glucocorticoids and calcineurin inhibitors are suggested for disease flare, and proactive therapy is best for long-term control. Other therapies, including antimicrobial agents, systemic antihistamines, systemic anti-inflammatory agents, immunotherapy, phototherapy, and psychotherapy, are reviewed in these guidelines. Crisaborole, a new topical phosphodiesterase 4 inhibitor, can be used twice daily in AD patients over three months old. Dupilumab, a biological drug for patients with moderate-to-severe AD, may be considered in patients with no improvement from other systemic treatments.

Determinants of Lung Function at Age 8.5 Years in a Birth Cohort of Thai Children.

BACKGROUND AND AIMS: Early life factors have reported the associations with impaired lung function in later life. In the present study, the birth cohort was followed up longitudinally to investigate the determinants of lung function in Thai children. METHODS: Cohort subjects were recruited from children born in Songkhla Province in southern Thailand. Data collections were obtained starting from antenatal, at birth, and at 1, 5 and 8.5 years of age. Spirometry was assessed at age 8.5 years. The variables investigated included birth weight, smoke exposure, respiratory diseases during the newborn period and during the first year of life, and asthma diagnosed at age 5 or 8.5 years. RESULTS: Of 1056 subjects, 892 (84.5%) subjects completed the spirometric measurements. The presence of asthma was the only factor that was significantly associated with a lower forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio, forced expiratory flow at 25-75% vital capacity (FEF25-75%VC) and peak expiratory flow rate (PEFR). The regression analysis found that asthma was significantly associated with a lower FEV1/FVC ratio, FEF25-75%VC, and PEFR value with estimated coefficients ± standard error of -1.27 ± 0.55%, p = 0.02; -131.8 ± 48.2 ml/s, p = 0.006; and -166.2 ± 65.0 ml/s, p = 0.01, respectively. Asthma diagnosed at age 5 or 8.5 years was more likely among children who had lower respiratory tract illness during the first year of life. The odds ratio for the association was 4.81 (95% confidence interval 2.14-10.83, p < 0.001). CONCLUSION: The main factor associated with lower lung function in Thai cohort subjects was the present of asthma by age 5 or 8.5 years and early respiratory illness was the risk factor for asthma in childhood period.

Quality of life among caregivers and growth in children with parent-reported food allergy.

BACKGROUND: Some caregivers who believe their children have food allergy avoid feeding certain foods to their children without proper allergy tests. Such actions made without a proper diagnosis can negatively impact the child's health and impose an unnecessary burden on the caregivers. OBJECTIVE: This study aimed to evaluate the caregiver quality of life (QoL) and growth in children with a parent-reported food allergy. METHODS: An observational cross-sectional study was performed in 200 children younger than five years who had a parent-reported food allergy. The caregivers' QoL was evaluated by two questionnaires: the Food Allergy Quality of Life -Parental Burden and the Scale of Psychosocial Factors in Food Allergy. Growth of the children was evaluated by their weight-for-age and length/height-for-age percentiles. RESULTS: Among the caregivers, 50% expressed worry that their children might be allergic to some foods and 30% were concerned about leaving their children in the care of others. According to the QoL scores, caregivers whose children underwent an oral food challenge (OFC) test were significantly less stressed, while caregivers whose children had multiple food allergies and had experienced at least one anaphylactic reaction were significantly more stressed. The distributions of both weight-for-age and length/height-for-age percentiles were 50th comparable to the general population. CONCLUSIONS: Parent-reported food allergy could put caregivers under high stress, but the OFC test could reduce stress among anxious, over-parenting caregivers. Parent-reported food allergy had no impact on a child's growth in our study.

Component-resolved diagnostics in Thai children with cow's milk and egg allergy.

BACKGROUND AND OBJECTIVE: Component-resolved diagnostics (CRD) have garnered a lot of attention in recent years in the diagnosis of food allergies. We aimed to investigate sensitization against cow's milk and egg white components, and to study the clinical usefulness of serum food-specific immunoglobulin E (sIgE) to cow's milk and egg white components in Thai children with cow's milk and egg allergies. METHOD: Children with IgE-mediated cow's milk and/or egg allergy were enrolled. Clinical reactions were determined. Specific IgE against cow's milk, egg white, alpha-lactalbumin (ALA), beta-lactoglobulin (BLG), casein, ovomucoid, ovalbumin and conalbumin were measured. RESULTS: Thirteen cow's milk allergic subjects and 32 egg allergic subjects were identified. The sensitization rate to BLG and casein was 91.7%, followed by ALA (66.7%) for cow's milk, and the sensitization rate to ovalbumin was 93.8%, followed by ovomucoid (81.3%) and conalbumin (37.5%) for egg. Patients in the urticaria group had a higher level of casein sIgE than the atopic dermatitis (AD) group but this difference was not significant (9.8 kUA/L vs. 0.9 kUA/L, p = 0.11). The level of ovomucoid sIgE was significantly higher in the non-AD group than in the AD group (3.8 kUA/L vs. 1.3 kUA/L, p = 0.048). CONCLUSIONS: BLG and casein for cow's milk and ovomucoid and ovalbumin for egg were the common components causing sensitization in cow's milk and egg allergic patients. Among the patients with cow's milk allergy, the level of casein sIgE in the urticaria group tended to be higher than the AD group, and in egg allergic patients, the non-AD group had a significantly higher ovomucoid sIgE level compared with the AD group.

Elective cesarean delivery as a predisposing factor of respiratory syncytial virus bronchiolitis in children.

OBJECTIVE: To investigate the effect of cesarean delivery and other predisposing factors of respiratory syncytial virus (RSV)-positive acute bronchiolitis in children. MATERIAL AND METHOD: The case-control study was conducted in three main tertiary hospitals in Kunming, China between September 2012 and July 2013. Children with first episode of wheezing diagnosed as bronchiolitis and testedfor RSV were included RSV was detected by real-time reverse transcription polymerase chain reaction. Mode ofdelivery and characteristics of children, parents, and household were interviewed and analyzed with RSV-positive status by multiple logistic regression. RESULTS: Of 265 children, RSV-positive was found in 75.5%, and the majority of children (83.3%) were younger than 12 months. Compared to vaginal delivery, the odds of RSV-positive detection were double in children born by elective cesarean delivery (adjusted odds ratio 2.32; 95% confidence interval 1.19-4.52). Children aged less than 6 months, born in the rainy season, having maternal history of asthma and living in family that smoked more than 20 cigarettes per day were more likely to be RSV-positive. CONCLUSION: Children born by elective cesarean delivery increased the risk of RSV-positive acute bronchiolitis after adjusting for age, birth season, maternal asthma, and family smoking status.

Intradermal Fractional ChAdOx1 nCoV-19 Booster Vaccine Induces Memory T Cells: A Follow-Up Study.

The administration of viral vector and mRNA vaccine booster effectively induces humoral and cellular immune responses. Effector T cell responses after fractional intradermal (ID) vaccination are comparable to those after intramuscular (IM) boosters. Here, we quantified T cell responses after booster vaccination. ChAdOx1 nCoV-19 vaccination induced higher numbers of S1-specific CD8+ memory T cells, consistent with the antibody responses. Effector memory T cell phenotypes elicited by mRNA vaccination showed a similar trend to those elicited by the viral vector vaccine booster. Three months post-vaccination, cytokine responses remained detectable, confirming effector T cell responses induced by both vaccines. The ID fractional dose of ChAdOx1 nCoV-19 elicited higher effector CD8+ T cell responses than IM vaccination. This study confirmed that an ID dose-reduction vaccination strategy effectively stimulates effector memory T cell responses. ID injection could be an improved approach for effective vaccination programs.

Cranial ultrasound performance assessment tool: development and validation.

AIM: A standard assessment tool for direct evaluation of procedural skills to ensure proficiency of trainees is necessary for cranial ultrasound (US) in clinical practice. This study created and validated an assessment tool for cranial US performance by radiologists. MATERIAL AND METHODS: An initial evaluation tool for cranial US using criteria was developed based on existing literature. The assessment form was modified using a three-round Delphi process by an expert panel, conducted between January 2021 and April 2021. Rubric scales for grading were added once consensus regarding generated items was reached. Experts confirmed the final assessment tool using a rubric scale. Two raters evaluated cranial US performance of 27 residents in video clips using the tool. Reliability and percent agreement were assessed. RESULTS: Seventeen pediatric radiologists working in different settings participated in the expert panel. The content validation of the proposed evaluation tool was enabled by expert pediatric radiologists. Following three rounds of the Delphi process, the initial 14-item assessment form became a final 15-item form. A three-part rubric scale was used in the final form (preparation, US machine operation, and cranial US performance). Interrater reliability was evaluated with Cohen's Kappa. The Kappa value and percent interrater agreement for most items was moderate to almost perfect (0.42-0.93 and 77.8-100%, respectively). The Cronbach's alpha values for both raters were 0.856 and 0.891. CONCLUSIONS: This study produced the first validated cranial US assessment tool using a modified Delphi method. The final assessment form is a simple and reliable tool.

Recent 5-year trends of asthma severity and allergen sensitization among children in southern Thailand.

BACKGROUND: Asthma is a major public health issue that affects morbidity. The greater severity of asthma requires more health care resource utilization. OBJECTIVE: To investigate the possible changes in disease severity and allergen sensitization of children with asthma in an interim period of 5 years. METHODS: We retrospectively reviewed the charts of 200 patients with established asthma in the pediatric allergy clinic. The data were collected in different time periods with 100 consecutive cases in each group starting in January of 2004 and in January of 2009. All patients underwent a skin prick test (SPT) to common allergens, with positive and negative controls. SPTs with a mean wheal diameter 3 mm greater than a negative control were considered test-positive. RESULTS: The mean ages of patients in the 2004 and 2009 groups were 7.54 and 7.73 years. Compared with patients in the 2004 group, the 2009 group had more severe asthma (p = 0.006). The distribution of asthma severity was mild (intermittent and mild persistent) 98.0% in 2004 and 87.9% in 2009, and moderate to severe persistent 2.0% in 2004 and 12.1% in 2009. The prevalence of patients sensitized to both house dust (HD) and house dust mites (HDM) increased from 21.2% in 2004 to 34.3% in 2009 (p =0.007). Sensitization to allergens of HD, HDM and cockroach increased to 14.1% in 2009 from 9.1% in 2004 (p =0.021). CONCLUSIONS: During the years between 2004 and 2009, asthma severity increased with increasing sensitization to HD, HDM and cockroach. Awareness of these changes and further studies are required.

Allergic family history as a protective determinant to helminthic infection.

OBJECTIVE: Investigate the resistance to helminths in children with an allergic family history. MATERIAL AND METHOD: The study was undertaken as part of the Prospective Cohort Study of Thai Children (PCTC) that followed all births in the year 2001 from rural districts in Thailand. The family histories of allergic diseases were validated by the physicians'diagnoses and medical record reviews. Fresh stool examinations were carried out at 18 to 36 months of age. RESULTS: Of 1,076 live births in the cohort, 659 children had complete information. A family history of allergy presented in 5.4% of the children. The prevalence of any helminthic infection, Ascaris lumbricoides, Trichuris trichiura, and hookworm were 25.0%, 18.2%, 9.2%, and 5.3%, respectively. The adjusted odds ratio of a family history of allergy for helminthic infection was 0.28 (95% CI, 0.08-0.95). CONCLUSION: A family history of allergic diseases independently increases resistance to helminthic infection.

Effects of dragon fruit oligosaccharides on immunity, gut microbiome, and their metabolites in healthy adults - A randomized double-blind placebo controlled study.

Healthy food has wide popularity and relates positively to health. Our previous studies have shown that dragon fruit oligosaccharides (DFO) have prebiotic activities, balancing the gut microbiota in a simulated human colon system, and are safe and stimulate the immune system in rats. The effects of DFO on immune stimulation gut microbe modulation and the correlation of gut microbiota and nutrients were investigated in a human trial. This clinical study was a randomized, double-blinded, placebo-controlled trial. The participants were 107 healthy adults, divided into 3 groups that received DFO in drinking waterdoses of 4 and 8 g/day, compared to the placebo group for 4 consecutive weeks. DFO consumption at 4 g/day increased IgA level (11.31 mg/dL or 10.95% from baseline) and 8 g/day outstandingly promoted the growth of Bifidobacterium spp. (8.41%) and Faecalibacterium (1.99%) and decreased harmful bacteria, especially, Escherichia coli (8.44%). The relationship between gut microbes and nutrient intake was explored and significant (p < 0.05) correlations between specific microbial groups and intakes of specific macro- and micronutrients were observed. The potential dose of DFO for healthy adults was established as 4 g/day for improving IgA level and 8 g/day for promoting beneficial gut microbiota.

A population-based study of fish allergy in the Philippines, Singapore and Thailand.

BACKGROUND: Fish allergy is the third most common food allergy after milk and egg in parts of Europe, but there is little data about prevalence in South East Asia where it is an important part of regular diets. OBJECTIVE: We aimed to obtain an estimate of the population prevalence of fish allergy among older children in the Philippines, Singapore and Thailand. METHODS: The population prevalence of fish allergy in 14- to 16-year-old children in the 3 countries was evaluated using a structured written questionnaire which was distributed to students of randomly selected secondary schools. An extended questionnaire to determine convincing fish allergy on the basis of typical clinical manifestations within 2 h of ingestion was administered to those with positive responses. RESULTS: From a cohort of 25,842 students, responses were 81.1% in the Philippines (n = 11,434), 67.9% in Singapore (n = 6,498) and 80.2% (n = 2,034) in Thailand. Using criteria for convincing food allergy, fish allergy was much higher in the Philippines [2.29%, 95% confidence interval (CI) 2.02-2.56] than in Singapore (0.26%, 95% CI 0.14-0.79) and Thailand (0.29%, 95% CI 0.06-0.52). Weighted multiple logistic regression analyses showed that compared to the Philippines, prevalence rates were lower in Singapore [odds ratio (OR) 0.40, 95% CI 0.27-0.60, p < 0.0001] and Thailand (OR 0.13, 95% CI 0.05-0.33, p < 0.0001). Females were more likely to have fish allergy compared to males for all children combined (OR 1.32, 95% CI 1.11-1.58, p = 0.002). Most allergies appeared mild, as only 28% of cases sought medical consultation at the time of the reaction and 31.2% of cases reported continued exposure despite allergic symptoms. CONCLUSION: Fish allergy in late childhood is more common in the Philippines compared to Singapore and Thailand. Differences in food processing, dietary habits and other cultural practices might be important risk factors for the development of fish allergy in these populations.

Revisiting current "barefoot doctors" in border areas of China: system of services, financial issue and clinical practice prior to introducing integrated management of childhood illness (IMCI).

BACKGROUND: Under-5-years child mortality remains high in rural China. Integrated management of childhood illness (IMCI) was introduced to China in 1998, but only a few rural areas have been included. This study aimed at assessing the current situation of the health system of rural health care and evaluating the clinical competency of village doctors in management of childhood illnesses prior to implementing IMCI programme in remote border rural areas. METHODS: The study was carried out in the border areas of Puer prefecture of Yunnan province. There were 182 village doctors in the list of the health bureau in these border areas. Of these, 154 (84.6%) were recruited into the study. The local health system components were investigated using a qualitative approach and analyzed with triangulation of information from different sources. The clinical component was assessed objectively and quantitatively presented using descriptive statistics. RESULTS: The study found that the New Rural Cooperative Medical Scheme (NRCMS) coordinated the health insurance system and the provider service through 3 tiers: village doctor, township and county hospitals. The 30 RMB per person per year premium did not cover the referral cost, and thereby decreased the number of referrals. In contrast to available treatment facilities and drug supply, the level of basic medical education of village doctors and township doctors was low. Discontent among village doctors was common, especially concerning low rates of return from the service, exceptions being procedures such as injections, which in fact may create moral hazards to the patients. Direct observation on the assessment and management of paediatric patients by village doctors revealed inadequate history taking and physical examination, inability to detect potentially serious complications, overprescription of injection and antibiotics, and underprescription of oral rehydration salts and poor quality of counseling. CONCLUSION: There is a need to improve health finance and clinical competency of the village doctors in the study area.

Comparison of skin test reactivity to histamine on back and forearm in young children.

RATIONALE: Skin responses to standardized positive and negative controls are important in the interpretation of a skin prick tests (SPT). However, this information in young children is lacking. We aimed to determine skin reactivity and compare the skin responses to these controls on the upper back and forearm in young children. METHODS: SPTs for histamine hydrochloride 1 mg/ml (positive control) and 50% glycerol-saline (negative control) were performed on the upper back and forearm of children aged 6-25 months who came to the well-child clinic at Songklanagarind Hospital. SPTs to common allergens (cow's milk, soybean, egg white and house dust mite) were also evaluated. RESULTS: A total of 133 children with a mean age of 12.4 months were enrolled in the study. Seventy-five children (56.4%) were male. The results from the upper back and the forearm of the histamine-induced mean wheal diameter + standard deviation (SD) were 4.74+1.37 mm and 3.86+1.82mm (p < 0.0001). The mean flare responses to histamine on the upper back and the forearm were 18.47 +/- 4.28 mm and 16.37 +/- 5.50 mm (p < 0.0001). The SPT results from the negative control on the upper back and forearm also had significant differences among the sizes of the wheal (0.57+1.17 vs. 0.34+0.89 mm, p = 0.007) and flare (4.57 +/- 3.04 mm vs. 3.34 +/- 1.91 mm, p < 0.0001). CONCLUSIONS: Our study showed regional differences in wheal and flare responses to standardized positive and negative controls in young children. The upper back is more reactive than the forearm and is the preferred SPT site in young-aged children.