Epidemiological trends and outcomes of children with aural foreign bodies in Singapore

INTRODUCTION@#Aural foreign bodies (FBs) are a common presenting complaint in emergency departments (EDs) worldwide. This study aims to describe trends and outcomes of aural FBs in the paediatric population, presenting to a tertiary hospital in Singapore.@*METHODS@#A retrospective review of medical records was conducted of all children 0-16 years old with aural FBs who presented to KK Women's and Children's Hospital ED from 2013 to 2017. Clinical data that were collected include patient demographics, type of FB, ear compartment and laterality of FB, symptoms, duration of impaction, mode of removal, outcome in ED, and final disposition.@*RESULTS@#There were a total of 1,003 cases. The largest age group consisted of 53.7% preschool children of 0-6 years. Males (61.7%) were more common than females (38.3%). FBs were predominantly organic materials (25.6%), followed by beads and stones (15.2%). Most FBs were found in the right ear (56.6%). The majority of patients were asymptomatic (62%). Symptoms observed included ear pain (20.1%), itch (4.8%) and bleeding (3.2%). FBs were removed by instruments (36.6%), suctioning (15.4%), syringing (8.2%), or a combination of methods (13.7%). In the ED, 73.9% of patients had an attempt at removal, among which 78.4% of FBs were successfully removed, 5.9% required specialist review, and 15.7% were unsuccessful.@*CONCLUSION@#The majority of paediatric aural FBs can be successfully removed in the ED. Emergency physicians should be trained and equipped with the relevant skills to remove aural FBs.

A review of child sexual abuse cases presenting to a paediatric emergency department

INTRODUCTION@#Child sexual abuse (CSA) adversely affects a child's growth and well-being. This study aimed to describe the profile of children presenting to a tertiary paediatric emergency department(ED) with CSA.@*METHODS@#Children 0-16 years old presenting to KK Women's and Children's Hospital ED from June 2016 to August 2020 with sexual abuse were retrospectively reviewed. We performed a secondary analysis on girls and stratified them by age <13 and ≥13 years old.@*RESULTS@#There were 790 patients who made 833 visits for CSA. Victims were predominantly girls (747, 94.8%) and perpetrators were predominantly men (763, 96.6%). The abuse first occurred before the age of 13 years in 315 victims (39.9%). For 468 (59.2%), more than one incident occurred before presentation. Compared to girls ≥13 years old, girls <13 years old were more frequently abused by a family member (47.7% versus 8.0%, @*CONCLUSION@#The findings highlight common characteristics of CSA cases, and can aid the future identification and protection of vulnerable children. The fact that most children presented after more than one incident suggests the need to more closely monitor and protect potentially at-risk children.

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.

A retrospective review of trampoline-related injuries presenting to a paediatric emergency department in Singapore

INTRODUCTION@#Trampolining is a popular activity. However, to our knowledge, no studies on paediatric trampoline-related injuries (TRIs) have been conducted in Asia. We aimed to provide an Asian perspective on paediatric TRIs and evaluate current safety measures.@*METHODS@#Patients aged under 16 years who presented to the emergency department at KK Women's and Children's Hospital, Singapore, from March 2012 to June 2016 with a TRI were identified from the National Trauma Registry. Data was collated retrospectively focusing on age, location of the trampoline, mechanism and location of injury, treatment, disposition, and follow-up treatment.@*RESULTS@#137 children were seen for a TRI during this period. There was even representation across age groups (< 6 years, 6-11 years and 11-16 years). 60.6% of these injuries occurred in a public trampoline park, and a smaller proportion involved home and school trampolines. 61.3% of injuries occurred on the trampoline and 25.5% involved a fall off it, while the remaining were incurred by hitting the trampoline frame. The most common injury was soft tissue injury, followed by fractures and dislocations, of which 16.7% required surgical intervention. Most patients were discharged to an outpatient clinic. 14.6% of all patients required admission and 9.5% eventually required surgical intervention. There were three stable head injuries and no cervical spine injuries or deaths.@*CONCLUSION@#The existence of trampoline parks has contributed to a rise in TRIs. We recommend measures such as general education, changes in the setup around the trampoline, increasing the age limit for trampolining, adult supervision and discouraging double bouncing.

Bicycle injuries among the paediatric population at an emergency department in Singapore

INTRODUCTION@#Bicycles injuries are the leading cause of emergency department visits among all recreational activities and have been established as a significant worldwide public health burden. The purpose of this retrospective study was to describe the epidemiology and patterns of paediatric bicycle-related injuries in Singapore.@*METHODS@#This was a single-centre retrospective study based on data collected from a trauma registry between 2011 and 2016.@*RESULTS@#A total of 760 patients presented to the emergency department during this period, of whom 68.2% were male and 39.7% were aged 10-16 years. 50.1% of the patients were Chinese and 25.9% were Malay. The cyclist was the person most commonly injured (65.7%) during the bicycle accident. From 2011 to 2015, the number of bicycle injuries showed a persistent upward trend. Superficial injuries such as abrasions and bruises were the most common injuries sustained (46.1%), followed by fractures. The majority of the patients were discharged from the emergency department. There were no bicycle accident deaths recorded during the study period.@*CONCLUSION@#Our study demonstrated an increasing number of bicycle injuries among paediatric cyclists in the local setting. Parents, teachers, coaches and other caregivers should be educated regarding the need to use protective equipment and to seek medical care promptly in the case of trauma resulting from bicycle injuries.

The Singapore Paediatric Triage Scale Validation Study

<p><b>INTRODUCTION</b>This study aimed to determine the usefulness and validity of the triaging scale used in our emergency department (ED) by analysing its association with surrogate clinical outcome measures of severity consisting of hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalisation.</p><p><b>METHODS</b>A retrospective observational study was conducted of the performance markers of the Singapore Paediatric Triage Scale (SPTS) to identify children who needed immediate and greater care. All children triaged and attended to at the paediatric ED at KK Women's and Children's Hospital, Singapore, from 1 January 2014 to 31 December 2014 were included. Data was retrieved from the Online Paediatric Emergency Care system, which is used for patients' care from initial triaging to final disposition.</p><p><b>RESULTS</b>Among 172,933 ED attendances, acuity levels 1, 2 plus, 2 and 3 were seen in 2.3%, 26.4%, 13.5% and 57.8% of patients, respectively. For admissions, triage acuity level 1 had a strong positive predictive value (79.5%), while triage acuity level 3 had a strong negative predictive value (93.7%). Fewer patients with triage acuity level 3 (6.3%) were admitted as compared to those with triage acuity level 1 (79.5%) (p < 0.001). There was a correlation between triage level and length of ED stay.</p><p><b>CONCLUSION</b>The SPTS is a valid tool for use in the paediatric emergency setting. This was supported by strong performance in important patient outcomes, such as admission to hospital, ICU admissions and length of ED stay.</p>

Road traffic accidents in children: the 'what', 'how' and 'why'

<p><b>INTRODUCTION</b>Road traffic accidents (RTAs) in Singapore involving children were evaluated, with particular focus on the epidemiology, surrounding circumstances and outcomes of these accidents. Key factors associated with worse prognosis were identified. We proposed some measures that may be implemented to reduce the frequency and severity of such accidents.</p><p><b>METHODS</b>This was a retrospective study of RTAs involving children aged 0-16 years who presented to the Children's Emergency at KK Women's and Children's Hospital, Singapore, from January 2011 to June 2014. Data was obtained from the National Trauma Registry and analysed in tiers based on the Injury Severity Score (ISS).</p><p><b>RESULTS</b>A total of 1,243 accidents were reviewed. RTA victims included motor vehicle passengers (60.4%), pedestrians (28.5%), cyclists (9.9%) and motorcycle pillion riders (1.2%). The disposition of emergency department (ED) patients was consistent with RTA severity. For serious RTAs, pedestrians accounted for 63.6% and 57.7% of Tier 1 (ISS > 15) and Tier 2 (ISS 9-15) presentations, respectively. Overall use of restraints was worryingly low (36.7%). Not restraining increased the risk of serious RTAs by 8.4 times. Young age, high ISS and low Glasgow Coma Scale score predicted a longer duration of intensive care unit stay.</p><p><b>CONCLUSION</b>The importance of restraints for motor vehicle passengers or helmets for motorcycle pillion riders and cyclists in reducing morbidity requires emphasis. Suggestions for future prevention and intervention include road safety education, regulation of protective restraints, use of speed enforcement devices and creation of transport policies that minimise kerbside parking.</p>

Epidemiology of paediatric poisoning presenting to a children's emergency department in Singapore over a five-year period

<p><b>INTRODUCTION</b>Paediatric poisoning accounts for 1% of daily emergency department presentations. The aim of this study was to review the characteristics and outcomes of paediatric patients who presented with drug overdose over a five-year period.</p><p><b>METHODS</b>We performed a retrospective review of paediatric poisoning cases at KK Women's and Children's Hospital (KKH), the largest children's public hospital in Singapore, from 1 January 2009 to 31 December 2013.</p><p><b>RESULTS</b>A total of 1,208 cases of poisoning were seen in KKH's Department of Children's Emergency during the study period. The gender distribution was about equal, with a slight male predominance. The majority of the poisoning cases were accidental. Slightly more than half of the intentional ingestions were of paracetamol and the majority were female patients belonging to the 12-16 year age group. The bulk of poisonings occurred in children aged 1-4 via the oral route, slightly more than half of the oral ingestions consisted of oral medications and a sizeable portion were of household liquids. Mothballs and silica gels accounted for almost a quarter of the solid household products ingested. Slightly less than half of the patients required admission and only a small portion of the admitted patients required intensive or high dependency care.</p><p><b>CONCLUSION</b>The prognosis of paediatric patients who presented with poisoning in our study was good, with a short median length of stay for those admitted and no fatalities being reported across the span of five years.</p>

Five-Year Review of Patients Presenting with Non-Accidental Injury to a Children's Emergency Unit in Singapore

INTRODUCTION@#There is an increasing trend of physical child abuse cases reported in Singapore. Children presenting to the Emergency Department with injuries require a high index of suspicion for clinicians to distinguish those that are abusive in nature.@*MATERIALS AND METHODS@#A retrospective study of children with diagnosis of NAI presenting to KK Women's and Children's Hospital (KKH) from June 2011 to May 2016 was conducted.@*RESULTS@#There were 1917 cases reported from 1730 subjects, of  which: 8.8% of subjects had repeat visits; 55.2% of cases were male; and mean age was 7.69 years. Racial demographics were: Chinese 45.5%, Malay 33.4%, Indian 15.4% and Others 5.9%. The most frequent injuries sustained were head and neck (50.8%), limbs (32.2%), and chest (5.7%). Of the type of injuries, 55% had contusions, 21% had cane marks, 16% had lacerations, 4.4% had burn marks and 1% sustained fractures. Males were more likely to be caned ( <0.001); 54.9% of cases were admitted and 38.9% were discharged. Cases that presented without a parent ( <0.001), were known to Child Protective Service ( <0.001), or had a history of  parental substance abuse ( = 0.038), mental illness in caregiver ( = 0.021), or domestic violence ( <0.001) were more likely to require admission.@*CONCLUSION@#Analysing these factors provide a better understanding of  the presentation of  NAI cases, including 'red flags' and vulnerable groups who should have better protection.

Singapore Paediatric Resuscitation Guidelines 2016

We present the revised 2016 Singapore paediatric resuscitation guidelines. The International Liaison Committee on Resuscitation's Pediatric Taskforce Consensus Statements on Science and Treatment Recommendations, as well as the updated resuscitation guidelines from the American Heart Association and European Resuscitation Council released in October 2015, were debated and discussed by the workgroup. The final recommendations for the Singapore Paediatric Resuscitation Guidelines 2016 were derived after carefully reviewing the current available evidence in the literature and balancing it with local clinical practice.

Anaphylaxis in Children: Experience of 485 Episodes in 1,272,482 Patient Attendances at a Tertiary Paediatric Emergency Department from 2007 to 2014

: Anaphylaxis is a predominantly childhood disease. Most of the literature on anaphylaxis has emerged from Western countries. This study aimed to describe the incidence, triggers and clinical presentation of anaphylaxis among children in Singapore, look for predictors for anaphylaxis with severe outcomes, and study the incidence of biphasic reactions.: We retrospectively reviewed records of children presenting with anaphylaxis to our paediatric emergency department from 1 January 2007 to 31 December 2014.: We identified 485 cases of anaphylaxis in 445 patients. Cutaneous symptoms (urticarial/angio-oedema) were the most common across all age groups (481 cases, 99%), followed by respiratory (412, 85%), gastrointestinal (118, 24%) and cardiovascular (35, 7.2%) symptoms. Central nervous system symptoms (drowsiness/ irritability) were rare across all age groups (11, 2.2%). Food was identified as the most common trigger across all age groups (45% to 63%). Seafood was the most common food trigger (57, 25%). A total of 420 (86.6%) children were treated with adrenaline, 451 (93%) received steroids and 411 (85%) received antihistamines. Sixty-three (13%) children fulfilled the criteria of severe anaphylaxis. There was no statistically significant association between severe anaphylaxis and the type of trigger (= 0.851), nor an overall past history of atopy (= 0.428). The only independent predictor for severe anaphylaxis was a previous drug allergy (= 0.016). A very low prevalence of biphasic reactions (0.6% of study population) was noted in our study.: We described the presentation and management of anaphylaxis in the Singapore population. A history of drug allergy is associated with severe presentation. Biphasic reactions are rare in our population.

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

<p><b>INTRODUCTION</b>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.</p><p><b>METHODS</b>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.</p><p><b>RESULTS</b>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.</p><p><b>CONCLUSION</b>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.</p>