Identifying preventable risk factors for hospitalised asthma in young Aboriginal children: a whole-population cohort study.

BACKGROUND: Australia has one of the highest rates of asthma worldwide. Indigenous children have a particularly high burden of risk determinants for asthma, yet little is known about the asthma risk profile in this population. AIM: To identify and quantify potentially preventable risk factors for hospitalised asthma in Australian Aboriginal children (1-4 years of age). METHODS: Birth, hospital and emergency data for all Aboriginal children born 2003-2012 in Western Australia were linked (n=32 333). Asthma was identified from hospitalisation codes. ORs and population attributable fractions were calculated for maternal age at birth, remoteness, area-level disadvantage, prematurity, low birth weight, maternal smoking in pregnancy, mode of delivery, maternal trauma and hospitalisations for acute respiratory tract infection (ARTI) in the first year of life. RESULTS: There were 705 (2.7%) children hospitalised at least once for asthma. Risk factors associated with asthma included: being hospitalised for an ARTI (OR 4.06, 95% CI 3.44 to 4.78), area-level disadvantage (OR 1.58, 95% CI 1.28 to 1.94), being born at <33 weeks' gestation (OR 3.30, 95% CI 2.52 to 4.32) or birth weight <1500 g (OR 2.35, 95% CI 1.39 to 3.99). The proportion of asthma attributable to an ARTI was 31%, area-level disadvantage 18%, maternal smoking 5%, and low gestational age and birth weight were 3%-7%. We did not observe a higher risk of asthma in those children who were from remote areas. CONCLUSION: Improving care for pregnant Aboriginal women as well as for Aboriginal infants with ARTI may help reduce the burden of asthma in the Indigenous population.

Dietary advice, dietary adherence and the acquisition of tolerance in egg-allergic children: a 5-yr follow-up.

IgE-mediated egg allergy is a common childhood food allergy affecting about 1-2% of 2-yr-old children. Egg avoidance is the mainstay of treatment for egg allergy; however, it is unclear what type of dietary advice parents of children with egg allergy receive and to what extent this dietary advice is adhered to. This study aimed to assess: (i) the type and source of dietary advice parents receive in a tertiary hospital setting, (ii) how closely parents adhere to advice given, (iii) what patient characteristics influenced adherence to diet and (iv) whether strict adherence to dietary advice was an identifiable factor in whether children outgrew their egg allergy. In 2006, a questionnaire was sent to 261 parents of children seen in a tertiary paediatric allergy clinic in 2003 and diagnosed with egg allergy which included 84 children who had undergone an in-hospital open oral egg challenge during this time period (2003-2006). Questions included demographic data, details of egg allergy, dietary avoidance and attainment of unrestricted egg ingestion. Of 199 questionnaires confirmed received, 167 were returned (84%). The mean age of the cohort was 6.6 yr with an average of 5.5 yr of follow-up since the first reaction. Sixty-eight percent of subjects reported avoidance of all food containing egg all the time. Forty-seven percent of the children had been accidentally exposed to egg. The severity of the initial reaction did not appear to influence adherence to an advised diet. Of the 84 children who underwent in-hospital open egg challenges, 57 children were able to ingest egg without clinical reaction and were classified as having outgrown their egg allergy. These children did not differ from those who were challenge positive to egg in terms of either the dietary advice they received or the degree to which they had undertaken strict avoidance of egg. In addition, children who had outgrown their egg allergy did not differ from those who remained egg-allergic on in-hospital challenge in terms of either the frequency of accidental ingestion or the severity of initial reaction. Strict avoidance of egg and accidental ingestion of egg did not appear to influence the acquisition of tolerance.

Parental perceptions in egg allergy: does egg challenge make a difference?

The aim of the study was to determine the effect of an oral egg challenge in egg sensitized children on parental perceptions relating to their child's allergy. A questionnaire was completed by parents for 167 children attending a tertiary paediatric clinic with egg sensitization. The questionnaires included 10 questions concerning parental perceptions of their child's egg allergy. Parental perceptions of those children who had not had an egg challenge (n = 83) were compared with those whose children had a positive (n = 27) and those with a negative (n = 57) egg challenge. A significant difference (p = < or =0.02) was observed between challenge positive(CP) and challenge negative (CN) subjects in reported changes to lifestyle and the fact that more parents in the CN group expected little or no future inconvenience for the child. The responses of parents whose child had undergone an egg challenge differed significantly (p = < or =0.005) from those not challenged with a significant reduction in the following parameters; the effect on out-of-home care arrangements, the perception of being more severe as compared to other common childhood illnesses, whether they found egg allergy to be moderately or very stressful, whether their lifestyle was changed, the expectation of little or no future discomfort for the child and whether others treated the child differently. The performance of an egg challenge was associated with reduced adverse parental concerns. For 6/10 parameters, expectations concerning egg allergy in children who had been challenged were significantly better than those who had never been challenged irrespective of the challenge outcome. The greater certainty provided by the performance of a food challenge may be a positive outcome in both CP and CN children.

Egg allergy: are all childhood food allergies the same?

Egg allergy is one of the most common food allergies in childhood affecting about 1-2% of preschool children and differs in a number of ways from other common childhood food allergies such as cows milk and peanut. Common egg allergens are altered both by heat and gastric enzymes. Compared with peanuts/tree nuts and milk, egg allergy appears less likely to cause severe life-threatening reactions or fatal anaphylaxis. Children are much more likely to outgrow egg allergy by school age as compared with peanut allergy. While the MMR vaccine is no longer contraindicated in egg allergy, influenza vaccine is contraindicated in children with anaphylaxis to egg. An understanding of the similarities and differences in these common food allergies of childhood is helpful in the management of these common and increasing problems.

Implementation and evaluation of a neonatal educational program in rural Nepal.

A needs assessment at Tansen Mission Hospital established gaps in knowledge, skills and attitudes of health professionals, contributing to the high neonatal mortality in Nepal. This study was designed to implement and evaluate the effectiveness of an educational program in Newborn Care, using best evidence teaching methods and content. Pre intervention, an audit of newborn care practices and documentation was performed using a structured checklist. Intervention consisted of four teaching sessions each involving short lectures and interactive skills stations. Post intervention, participant satisfaction, knowledge, competence and performance were evaluated. In 80 per cent of responses (n=30), participants evaluated the program as very good or excellent. Matched pair pre and post education MCQ scores compared knowledge, with significant improvement in all groups (nurses, doctors and community health workers). Competence was evaluated by an Objective Structured Clinical Examination with mean scores (+/-SD) ranging from 65 per cent (7.0) to 87 per cent (7.3). Performance was examined by pre and post-intervention audit of records. Significant changes in practice included a 100 per cent increase in measuring length and head circumference, charting percentiles and documentation of structured history and examination in the Newborn Care Notes. Administration of vitamin K at birth increased by 71 per cent, assessment of hypoglycaemia risk by 94 per cent and those at risk of hypoglycaemia having a blood sugar level measured increased by 58 per cent. These results led to consideration of appointment of a postgraduate educator. Even with limitations in educating and implementing change in a resource limited rural setting, a short, interactive education program can have positive educational outcomes and can change practice. Sustainability is dependent on staff employing continuing education.