Prevalence, risk factors and parental perceptions of gastroesophageal reflux disease in Asian infants in Singapore

INTRODUCTION@#Infant gastroesophageal reflux disease (GERD) is a significant cause of concern to parents. This study seeks to describe GERD prevalence in infants, evaluate possible risk factors and assess common beliefs influencing management of GERD among Asian parents.@*METHODS@#Mother-infant dyads in the Singapore PREconception Study of long-Term maternal and child Outcomes (S-PRESTO) cohort were prospectively followed from preconception to 12 months post-delivery. GERD diagnosis was ascertained through the revised Infant Gastroesophageal Reflux Questionnaire (I-GERQ-R) administered at 4 time points during infancy. Data on parental perceptions and lifestyle modifications were also collected.@*RESULTS@#The prevalence of infant GERD peaked at 26.5% at age 6 weeks, decreasing to 1.1% by 12 months. Infants exclusively breastfed at 3 weeks of life had reduced odds of GERD by 1 year (adjusted odds ratio 0.43, 95% confidence interval 0.19-0.97, P=0.04). Elimination of "cold or heaty food" and "gas producing" vegetables, massaging the infant's abdomen and application of medicated oil to the infant's abdomen were quoted as major lifestyle modifications in response to GERD symptoms.@*CONCLUSION@#Prevalence of GERD in infants is highest in the first 3 months of life, and the majority outgrow it by 1 year of age. Infants exclusively breastfed at 3 weeks had reduced odds of GERD. Cultural-based changes such as elimination of "heaty or cold" food influence parental perceptions in GERD, which are unique to the Asian population. Understanding the cultural basis for parental perceptions and health-seeking behaviours is crucial in tailoring patient education appropriately for optimal management of infant GERD.

Economic value of using partially hydrolysed infant formula for risk reduction of atopic dermatitis in high-risk, not exclusively breastfed infants in Singapore

<p><b>INTRODUCTION</b>Previous trials have demonstrated reductions in atopic dermatitis (AD) incidence when healthy, high-risk, non-exclusively breastfed infants were fed until four months of age with 100% whey-based partially hydrolysed formula (PHF-W) versus standard cow's milk formula (CMF). We assessed the cost-effectiveness of this intervention in Singapore.</p><p><b>METHODS</b>Modelling techniques were used to simulate, from birth to Month 30, the incidence and clinical/economic burden of AD in high-risk, non-exclusively breastfed infants fed with PHF-W or CMF for up to four months. Epidemiologic and clinical data were from a local comparative trial. Expert opinion informed AD treatment patterns and outcomes. Outcomes included reduction in AD risk, time spent with AD, days without AD flare, quality-adjusted life years (QALYs) and direct/indirect costs. Multivariate probabilistic sensitivity analysis was used to assess model parameter uncertainty.</p><p><b>RESULTS</b>Over 30 months, with the use of PHF-W instead of CMF, the proportion of children who developed AD and the time spent with AD decreased by 16.0% (28.3% vs. 44.3%) and 6.4 months, respectively, while time without AD flare and QALYs increased by 14.9 days and 0.021 QALYs per patient, respectively. Estimated AD-related discounted costs per child for PHF-W and CMF were SGD 771 and SGD 1,309, respectively (net savings: SGD 538). PHF-W was less expensive and more effective than CMF for 73%, and cost less than SGD 50,000 per QALY for 87% of all multivariate simulations.</p><p><b>CONCLUSION</b>Early short-term nutritional intervention with PHF-W instead of CMF may reduce AD incidence and costs for healthy, high-risk, non-exclusively breastfed infants in Singapore.</p>

Clinical characteristics and outcomes of patients undergoing drug provocation tests (DPTs)

<p><b>INTRODUCTION</b>Patients who have an adverse drug reaction are frequently labelled drug allergic without undergoing proper evaluation and confirmatory testing. These drug allergy labels may be inaccurate, leading to unnecessary lifelong avoidance. The aim of this study was to review the patients that underwent drug provocation tests (DPTs) in our centre and examine the usefulness of DPTs in confirming or rejecting a diagnosis of drug hypersensitivity.</p><p><b>MATERIALS AND METHODS</b>The study design was a retrospective chart review of all adult patients who underwent drug provocation in the allergy unit at the National University Hospital, Singapore, for single or multiple suspected drug allergies from the period January 2009 to June 2011.</p><p><b>RESULTS</b>Eighty-seven patients underwent 123 DPTs (median age 41; interquartile range 28 to 50). Twenty-one patients underwent multiple DPTs. The most common culprit drugs reported were antibiotics (43.9%) of which beta-lactams were implicated in 75.9% of the cases. This was followed by non-steroidal anti-inflammatory drugs (NSAIDS) in 15.4%, paracetamol in 7.3% and both NSAIDs and paracetamol in 3.3%. Rash was the most commonly reported symptom (41.5%), followed by angioedema (32.5%), anaphylaxis (9.8%), and other symptoms including respiratory (2.4%), gastrointestinal (0.8%) and others (13.0%). The majority of DPTs were performed to antibiotics (43.9%), NSAIDs (19.5%) and paracetamol (6.5%). DPTs were negative in 93.5% of subjects and positive in 6.5%. Of the 8 positive DPTs, none had a serious reaction, with 5 patients requiring rescue therapy, which comprised solely of oral antihistamines.</p><p><b>CONCLUSION</b>Suspected drug hypersensitivity is common but true drug allergy is rare. DPTs remain the gold standard and should be included as part of an investigative protocol. DPTs are a safe and valuable diagnostic tool in the hands of the experienced clinician.</p>

Childhood food allergy: a Singaporean perspective

Food allergy is defined as reaction to a food which has an immunologic mechanism. Its prevalence is increasing in children globally and is therefore of increasing clinical importance. A useful clinical approach is to distinguish food allergic reactions by the timing of clinical reaction in relation to food exposure and classified as immediate (generally IgE-mediated) and delayed (generally non-IgE-mediated), with the exception of eczema and eosinophilic gastrointestinal disease, which, when associated with food allergy may be associated with either mechanism. This review is aimed at providing the clinician with a Singaporean perspective on the clinical approach and management of these disorders.

Food-dependent exercise-induced anaphylaxis - a review of 5 cases

<p><b>INTRODUCTION</b>Food-dependent exercise-induced anaphylaxis (FDEIA) is an uncommon and under-recognised syndrome that clinicians may not consider in a patient presenting with anaphylaxis.</p><p><b>CLINICAL PICTURE</b>We describe here 5 patients aged 9 to 20 years old who presented at a local tertiary hospital over a 2-year period from August 2006 to July 2008. All presented with urticaria, 4 were hypotensive, 2 had angioedema and another 2 had dyspnoea. The symptoms occurred between 15 and 150 minutes (mean, 81) after exercising and consuming various food. All had consumed shellfish. All patients were admitted with the diagnosis of anaphylaxis of undefined aetiology. Diagnosis of FDEIA was only reached upon referral to an allergist.</p><p><b>TREATMENT AND OUTCOME</b>Patients were treated with standard medicines for anaphylaxis including adrenaline, antihistamines, steroids and fluid flushes. Symptoms resolved in 2 to 3 days with no further episodes. At discharge, patients were prescribed epinephrine auto-injectors and given written anaphylaxis management plans.</p><p><b>CONCLUSIONS</b>More public awareness and strategies to ensure accurate diagnosis and management of this condition are necessary.</p>