Dr Liew is a pediatrician who practices at the SBCC Baby & Child Clinic, Gleneagles Hospital Singapore and is also a visiting consultant to KK Hospital. He subspecialises in allergy, immunology and rheumatology. He was also awarded several research grants to pursue clinical research in paediatric anaphylaxis, drug allergy, primary immunodeficiencies and Kawasaki disease.
This was an original four posts of Friday Q&A, combined into one more informative post. MarcieMom contacted Dr Liew on setting up an eczema fund in Singapore and subsequently collaborated on this Q&A.
Childcare for Allergy Kids
MarcieMom: Suppose a child who has an allergy has to have alternative care-giver, say at child care centre.
What would you recommend a parent to share with the childcare?
Dr Liew: Your allergist should be able to advice what the caregivers be taught. Written action plans for eczema are useful for daily skin care instructions, whilst food allergy/anaphylaxis action plans provide information on treatment in emergencies. There is continued public education regarding allergic conditions via hospitals and societies like AAA.
Food Allergy in Childcare
How should a parent besides obviously telling the teachers/ care-givers of the allergy, help to make it easier for the school to prevent contact with the food?
For instance, is there a need to warrant 0% contact, for instance, the whole school shouldn’t even bring the food in?
Dr Liew: After a diagnosis of food allergy, it would be important to relay the importance of food avoidance and emergency care plans with the care-givers. Written food allergy/anaphylaxis plans are useful. The degree of strict avoidance varies accordingly to the food allergen and severity of allergic reaction. It would be better to discuss specific advice with your allergist.
What are the common non-food allergens?
And if it’s dust mite, how can a parent tell the school to keep the dust mite level low since house dust mite is something that can’t be totally eliminated? And if it’s dog droppings allergy, should a parent not even sign up a child care centre where teachers or even classmates have dogs at home? For common skin allergen like soaps and detergents, should a parent go as far as to monitor what detergent the child care centre or caregiver is using? (And the bigger question is – how can a child care centre with 70+ kids cope with so ‘many requests’ of a parent?)
Dr Liew: The most common environmental allergen is house dust mites in Singapore. House dust mite avoidance measures are useful to reduce the levels of protein, but results variable. I would not recommend schools to implement house dust mite avoidance measures as they are time-consuming and difficult to implement in the long term. Dog sensitisation is usually to the hair epithelia, rather than poo, and is not common in Singapore. Irritants like harsh soaps and detergents should be avoided in children with eczema and dry skin. It may be helpful to provide the school with your child’s soap substitute and moisturisers, and get the teachers assistance for application.
Allergic Reactions in Kids
How can a parent recognize an allergic reaction and more importantly, which are the symptoms that are signs of serious reaction such as anaphylaxis?
Mild to moderate allergic reaction include:
• Swelling of lips, face, eyes
• Hives or welts
• Tingling mouth
• Abdominal pain, vomiting
Antihistamines usually suffice.
Severe allergic reaction (anaphylaxis) include:
• Difficult/noisy breathing
• Swelling of tongue
• Swelling/tightness in throat
• Difficulty talking and/or hoarse voice
• Wheeze or persistent cough
• Persistent dizziness or collapse
• Pale and floppy (young children)
Epi-pens at Childcare
When should a parent prepare an epi-pen and how can the parent teach the child and the alternative care-giver on when an epi-pen is to be used?
Epipen should be administered for severe reactions. A written anaphylaxis plan should be provided with pictorial reminders on how to administer an epipen.
What are some common outdoor allergens in Singapore?
For instance, to certain type of trees or to certain pollen? Pollen counts are usually higher in the morning and on a warm, windy day versus just after a rain. Many places in Singapore are air-conditioned, is this better or worse off for a child with dust mite, pollen or certain allergy?
Dr Liew: Outdoor aeroallergens include tree pollen (Oil palm tree pollen is commonest), grass pollen are common in temperate countries with seasons, but is uncommon in Singapore. Air-conditioning is better tolerated for eczema patients but can worsen an allergic rhinitis. The impact on specific allergens are not great except moulds, as they may grow in poorly maintained air-conditioning units.
Air-conditioning is better tolerated for eczema patients but can worsen an allergic rhinitis.
Mold & Indoor Allergens
MarcieMom: Mold is another allergen and lots seem to be growing in my home!
If a child is allergic to mold, what steps should a parent take?
Also, for allergies like cockroach droppings, does it mean that the parent must diligently hunt for all droppings in corners of the home and remove them?
Dr Liew: Steps to reduce mould in the environment include a well-ventilated room, and if air-conditioning is used, frequent maintenance of the AC unit. Pest control measures are best for cockcroach sensitisation, as cockroaches often “roam” around and leave traces of protein.
Vaccines and Allergy
MarcieMom: On vaccines, there is so much discussion out there where even doctors are coming out to say that vaccines are unnecessary and pharmaceutical companies are coming up with more and more vaccines that are unnecessary and even harmful for our children. Some parents may be opting their child out of vaccines due to egg protein included in some of the vaccines.
What’s your recommendation on this and when should a parent seriously questions a vaccine before letting his/her child have it?
Dr Liew: Vaccines are the one of the proven public health measures to reduce mortality from infectious diseases. Vaccines are produced for significant infectious diseases. There is no link between vaccination and allergies. Traces of egg proteins can be found in influenza vaccines and specialised vaccines like yellow fever. Egg allergic patients should discuss the risk benefit ratios of receiving these vaccines. MMR vaccines are safe for egg allergic patients.
MarcieMom: On antibiotics, I’ve read online that antibiotics are mostly unnecessary since they are only effective against bacteria yet it is so common for general practitioners to prescribe antibiotics! (in fact, I always have to refuse the prescription because it’s just a common flu!) Antibiotics are also known to cause allergic reaction, what would be your recommendation?
Dr Liew: Antibiotics should only be prescribed for bacterial infections.
MarcieMom: On cross-reaction, it’s commonly heard of when a child is allergic to birch pollen, he/she is also allergic to apple. Or a child who is allergic to latex is also allergic to kiwi.
Can such allergy be identified by allergy tests?
Also, what are some of the common allergies that you can point our parents to, so that they are aware if their child is allergic to one thing, they should probably avoid something else.
Dr Liew: Cross-reactive allergens occur due to the similarity of one protein to another, usually within the same botany taxonomy. They can be easily tested by skin prick test or blood IgE testing. A good example would be most cow’s milk allergic patients are allergic to goat’s milk as there is an approximately 95% similarity between the two.
MarcieMom: Thank you Dr Liew, it’s such a great pleasure to have you explaining all these allergy questions that many parents have, we are all so grateful!