Abstract: Anaphylaxis in the operating room although infrequent can be potentially fatal.1 The diagnosis of perioperative anaphylaxis is complex due to a multitude of factors. Firstly, patients under anesthesia cannot verbalize their complaints, the anesthetic agents themselves can alter vital parameters (e.g. heart rate and blood pressure) and cutaneous signs in a completely draped patient may be missed.2 Secondly, the differential diagnosis of intraoperative anaphylaxis is wide. Conditions such as asthma exacerbation, arrhythmia, hemorrhage, angioedema, mastocytosis, acute myocardial infarction, drug overdose, pericardial tamponade, pulmonary edema, pulmonary embolus, sepsis, tension pneumothorax, vasovagal reaction, venous air embolism, laryngospasm, blood transfusion reaction and malignant hyperthermia need to be considered.3 Thirdly, the diagnostic workup is challenging due to the multiple medications administered and other exposures encountered such as latex and chlorhexidene. However, through a timely allergy consultation and a systematic approach, identification of the culprit agent and safe alternatives can be established to prevent future occurrences as illustrated in the case below.
Anaphylaxis

Asthma ; drug therapy ; epidemiology ; physiopathology ; prevention & control ; Humans ; Pediatrics ; Singapore ; epidemiology

INTRODUCTIONFood-dependent exercise-induced anaphylaxis (FDEIA) is an uncommon and under-recognised syndrome that clinicians may not consider in a patient presenting with anaphylaxis.

CLINICAL PICTUREWe 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.

TREATMENT AND OUTCOMEPatients 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.

CONCLUSIONSMore public awareness and strategies to ensure accurate diagnosis and management of this condition are necessary.

Adolescent ; Anaphylaxis ; drug therapy ; etiology ; Angioedema ; etiology ; Animals ; Bronchodilator Agents ; therapeutic use ; Child ; Dyspnea ; etiology ; Epinephrine ; therapeutic use ; Exercise ; Female ; Food Hypersensitivity ; diagnosis ; drug therapy ; etiology ; Humans ; Male ; Retrospective Studies ; Seafood ; adverse effects ; toxicity ; Syndrome ; Urticaria ; etiology ; Vasoconstrictor Agents ; therapeutic use ; Young Adult

BACKGROUND: The Pink peppercorn belongs to the same Anacardiaceae family as cashew and pistachio. However, the cross-reactivity of pink peppercorn with cashew and pistachio has yet to be studied. To date, there has been a single case report of anaphylaxis to pink peppercorn in a cashew and pistachio allergic individual. OBJECTIVE: We aim to demonstrate cross-sensitization to pink peppercorn in cashew and/or pistachio allergic children. METHODS: A small descriptive cohort study looking at cross-sensitization of pink peppercorn in cashew and/or pistachio allergic children was conducted. Children with a history of reaction to pistachio and/or cashew nut underwent skin prick tests to the pink peppercorn species Schinus terebinthifolius to determine cross-sensitization. RESULTS: Out of the 21 cashew and/or pistachio allergic subjects, 16 (76.2%) demonstrated cross-sensitization to pink peppercorn. None of the subjects had any knowledge of previous exposure or allergic reactions to pink peppercorn. DISCUSSION: This study demonstrates potential cross-reactivity between pink peppercorn and cashew and pistachio. While an oral food challenge to pink peppercorn would have been important in demonstrating clinical cross-reactivity, this was not performed due to ethical constraints. We hope to increase the awareness of pink peppercorn as a potential and hidden source of allergen and encourage further studies to demonstrate the clinical cross-reactivity and to better delineate the major allergen involved.
Anacardiaceae ; Anacardium ; Anaphylaxis ; Child ; Cohort Studies ; Cross Reactions ; Food Hypersensitivity ; Hope ; Humans ; Hypersensitivity ; Nuts ; Pistacia ; Skin

Food allergies and atopic diseases are on the rise worldwide. There have been several published practice guidelines on the primary prevention of these diseases. One aspect of these guidelines is the recommendations on infant nutrition, as food allergen exposure and other nutritional factors may influence allergen sensitization. This article aims to review the current international recommendations on infant diet and weaning practices in the primary allergy prevention of infants. The conclusions drawn are as follows: (1) Breastfeeding is considered the gold standard for infant nutrition, especially since exclusive breastfeeding confers some protection against the development of allergic diseases. However, large cohort studies have not been carried out in Asian populations. (2) Maternal avoidance of allergenic food substances during pregnancy and lactation has not been proven to reduce the risk of allergies and is not recommended as a primary prevention strategy. (3) Hydrolyzed formulas have not been shown to have an advantage over breastfeeding, although they have some protective value against atopic eczema in at risk infants when compared to regular cows milk based infant formula. (4) Soy formula is also not recommended for prevention of atopic diseases. (5) Weaning to semisolids should be undertaken between the ages of 4 to 6 months as weaning before the age of 4 months is associated with increased of allergy symptoms. (6) The age for introduction of certain highly allergenic foods have been arrived at empirically and included in some guidelines. These comprise the initiation of dairy products at 12 months, eggs at 24 months, and peanuts, nuts and fish at 36 months.
Arachis ; Asian Continental Ancestry Group ; Breast Feeding ; Cohort Studies ; Dairy Products ; Dermatitis, Atopic ; Diet ; Eggs ; Female ; Food Hypersensitivity ; Humans ; Hypersensitivity ; Imidazoles ; Infant ; Infant Formula ; Lactation ; Milk ; Nitro Compounds ; Nuts ; Ovum ; Pregnancy ; Primary Prevention ; Weaning

With the exception of shellfish, the overall food allergy rates in Singapore have not reached the epidemic proportions of the West. The rates of egg, milk and fish allergies remain low. However, the patterns of some food allergies in Singapore have changed over the last decade. For example, peanut allergy, once rare in Singapore, is now the most common cause of anaphylaxis in children. Studies analysing lifestyle practices, particularly with respect to prevention of food allergy, are necessary in order for practitioners to understand global differences and maintain this low prevalence.
Anaphylaxis ; diagnosis ; Child ; Child, Preschool ; Egg Hypersensitivity ; Fish Products ; Food Hypersensitivity ; diagnosis ; epidemiology ; prevention & control ; Humans ; Infant ; Infant, Newborn ; Milk Hypersensitivity ; Peanut Hypersensitivity ; Singapore ; epidemiology ; Surveys and Questionnaires

Paediatric rheumatology is an exciting field exploding with new knowledge of autoimmune and autoinflammatory conditions and how to treat them. It is, however, a relatively new subspecialisation in Asia. There is thus a great need to educate the public and medical community about paediatric rheumatic diseases so that children with such conditions are given the highest possibility of achieving normal function in their daily lives.
Adolescent ; Arthritis, Juvenile ; diagnosis ; therapy ; Autoimmune Diseases ; diagnosis ; therapy ; Child ; Child, Preschool ; Humans ; Inflammation ; diagnosis ; therapy ; Pediatrics ; methods ; Rheumatic Diseases ; diagnosis ; therapy ; Rheumatology ; methods ; Singapore ; Treatment Outcome

Rhinitis is a disease of the upper airway characterized by runny and/or blocked nose and/or sneezing. Though not viewed as a life threatening condition, it is also recognized to impose significant burden to the quality of life of sufferers and their caretakers and imposes an economic cost to society. Through a PubMed online search of the literature from 2006 to September 2011, this paper aims to review the published literature on rhinitis in young children below the age of 6 years. It is apparent from epidemiology studies that rhinitis in this age group is a relatively common problem. The condition has a heterogenous etiology with classification into allergic and non-allergic rhinitis. Respiratory viral infections may play a role in the pathogenesis of long standing rhinitis, but definitive studies are still lacking. Treatment guidelines for management are lacking for this age group, and is a significant unmet need. Although the consensus is that co-morbidities including otitis media with effusion, adenoidal hypertrophy and asthma, are important considerations of management of these children. Pharmacotherapy is limited for young children especially for those below the age of 2 years. This review underscores the lack of understanding of rhinitis in early childhood and therefore the need for further research in this area.
Adenoids ; Asthma ; Child ; Classification ; Consensus ; Drug Therapy ; Epidemiology ; Humans ; Hypertrophy ; Nose ; Otitis Media with Effusion ; Prevalence ; Quality of Life ; Rhinitis ; Risk Factors ; Sneezing

In the original publication, we created a mistake in typing the name. Thus it was spelled as Antony Hadjojo when submitted to the publisher. We request for a correction of the author name into Antony Hardjojo.
Child ; Humans ; Publications ; Rhinitis

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.
Breast Feeding ; Child ; Child, Preschool ; Eczema ; diagnosis ; immunology ; Food Hypersensitivity ; diagnosis ; prevention & control ; Humans ; Hypersensitivity, Delayed ; diagnosis ; prevention & control ; Immunoglobulin E ; blood ; Infant ; Infant, Newborn ; Skin Test End-Point Titration