To the Editor—Severe complications occur every year in children with influenza, including acute necrotising encephalopathy.1 We have previously reported local data on influenza-related childhood mortality and morbidity.2 3

In January 2020, in the midst of the COVID-19 epidemic and annual influenza and avian influenza seasons, we successfully managed a boy who presented with high fever, four episodes of seizures, and fluctuating consciousness level. Nasopharyngeal aspirate test confirmed influenza A H1. The patient was treated with anticonvulsants and oseltamivir. Cerebral oedema was quickly relieved by hypertonic saline and mannitol infusion. Electroencephalogram showed non-specific slow-wave activities. The patient’s complete blood counts, C-reactive protein, liver function, and renal function results were within normal limits. The patient became stable after 48 hours of paediatric intensive care. His mother also reported fever and coughing with yellow sputum production but insisted visitation to the intensive care unit despite escalated isolation measures during the COVID-19 epidemic. Neither the mother nor the child had received the seasonal influenza vaccination.

Severe influenza complications occur annually, primarily in unvaccinated children, and caused one to three deaths among Hong Kong children.2 We have sufficient Hong Kong literature to reassure members of the public that influenza complications are uncommon in our city, and that influenza vaccination is recommended for prophylaxis. Despite potential serious sequelae, influenza encephalopathy can be successfully treated if prompt critical care management is instituted.4

The author drafted the manuscript, had full access to the data, contributed to the study, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author disclosed no conflicts of interest.

The patient was treated in accordance with the Declaration of Helsinki. Patient consent was obtained for all investigations and procedures.

1. Lam KF, Wu SW. Two cases of acute necrotising encephalopathy: same disease, different outcomes. HK J Paediatr (New Series) 2019;25:85-9.

2. Hon KL, Tang JW. Low mortality and severe complications despite high influenza burden among Hong Kong children. Hong Kong Med J 2019;25:497-8. Crossref

3. Hon KL, Leung TF, Cheung KL, Ng PC, Chan PK. Influenza and parainfluenza associated pediatric ICU morbidity. Indian J Pediatr 2010;77:1097-101. Crossref

4. Hon KL, Tsang YC, Chan LC, et al. Outcome of encephalitis in pediatric intensive care unit. Indian J Pediatr 2016;83:1098-103. Crossref

To the Editor—We would like to provide a condensed update on febrile seizures in children.

Febrile seizures are the most common type of provoked seizure in children. The cumulative risk varies in different cohorts but is generally reported from 2% to 5%.1 The typical febrile seizure is a generalised short seizure provoked by a febrile episode in children aged 6 months to 6 years. The duration is shorter than 15 minutes and usually does not recur in the same episode. There are typically no focal neurological deficits or signs of central nervous system (CNS) infection.2 Acute management of convulsive seizures, such as resuscitation and first-aid measures, should follow the local prevailing guideline provided by the Hospital Authority intranet.

Diagnosing typical febrile seizure is clinically important and can follow a simple management pathway (Fig). The chance of CNS infection and long-term neurodevelopmental sequelae is low. There is no significant difference in academic performance and behaviour at age 10 years for children who had a typical or atypical febrile seizure compared with control.3 Further tests are necessary for fever rather than the seizures themselves.

Lumbar puncture to exclude CNS infection is unnecessary even in infants aged <1 year with simple febrile seizures. It should be considered in complex febrile seizures, prolonged seizures, or presence of red flag signs such as meningism, bulging fontanelle, or focal neurological deficit.

Urgent neuroimaging, such as computer tomography or magnetic resonance imaging, should be considered only in prolonged seizures, presence of focal neurological deficits, or prolonged encephalopathic state.

Electroencephalography is of limited value even in complex febrile seizures. It might be considered in focal seizures, presence of focal deficit, persistent alteration of consciousness after seizure (to rule out subclinical or electrographic status epilepticus), or developmental delay.

Counselling is the most important aspect in managing febrile seizures:

1. Prognosis: excellent prognosis for typical febrile seizure; no significant increase in future epilepsy or other neurodevelopmental sequelae for typical febrile seizure even if recurrent; higher risk of sequelae in the presence of atypical features.4
2. Recurrence risk: on average 30% before 6 years old, higher if first attack at a younger age or in the presence of atypical features.
3. Antipyretics are not recommended for febrile seizure prophylaxis.
4. Long-term or intermittent anticonvulsants are useful to reduce recurrence but in general not recommended because of their side-effects.
5. Rescue medication, eg, rectal diazepam should be considered for prolonged febrile seizure, febrile status epilepticus, or patients with limited medical access.
6. Intermittent oral benzodiazepines could be considered for recurrent febrile seizures which are likely predictable, ie, seizures occurred after detection of fever.
7. Caregivers should be taught to manage acute seizures.

All authors have made substantial contributions to the concept of this study, acquisition and analysis of data, drafting of the article, and critical revision for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Chan KK, Cherk SW, Chan CH, Ng DK, Ho JC. A retrospective review of first febrile convulsion and its risk factors for recurrence in Hong Kong children. HK J Paediatr 2007;12:181-7.

2. Wong V, Ho MH, Rosman NP, et al. Clinical guideline on management of febrile convulsion. HK J Paediatr 2002;7:143-51.

3. Verity CM, Greenwood R, Golding J. Long-term intellectual and behavioral outcomes of children with febrile convulsions. N Engl J Med 1998;338:1723-8. Crossref

4. Leung AK, Hon KL, Leung TN. Febrile seizures: an overview. Drugs Context 2018;7:212536. Crossref

To the Editor—Every winter, the Hong Kong Hospital Authority appeals to the public for understanding amid overcrowding at the city’s public hospitals as influenza cases spike. The Centre for Health Protection (CHP) has been reporting the annual influenza burden and confirms that, in Hong Kong, there has been no significant increase in mortality among patients with influenza aged <18 years. Among paediatric patients, there are few severe cases and few deaths each year, usually among unimmunised children, in a population of around 1.5 million children and youths.1 2 3 4 5

The burden on public hospitals may be due, in part, to the low immunisation rate among children. Paediatric patients with severe influenza may require in-patient stays of 1 to 2 days. Paediatric patients who require urgent care must be prioritised and should not have to wait for >8 hours pending assessment or admission. Yet this may be inevitable if the department becomes overcrowded with too many competing demands on staff time. Ideally, patients should be seen initially by their family doctors and stay home to recover if their admission is not necessary or urgent.

Excessive and exaggerated media publicity over the relatively few annual influenza-related deaths and severe cases may contribute to public panic, with increased admissions, some of which may be unnecessary, leading to higher workloads for medical staff—all of which may serve to delay the assessment of severe cases. The media may constructively spend their energy in lobbying for immunisation in the local healthcare system to help to relieve the pressure on an already over-burdened and under-funded hospital healthcare system.

Seasonal influenza continues to cause significant morbidity, but not mortality or intensive care admissions among children and young persons in Hong Kong. Influenza-related morbidity in terms of severe cases in patients aged <18 years has increased but the total number is still low Table 6).

Immunisation rates can be enhanced using targeted strategies for healthcare practices and providers. Sufficient vaccine supply should be secured annually. School vaccination teams provide excellent timely delivery of vaccines to schoolchildren. Private medical practitioners are also generally willing to be involved and their involvement would help to relieve the intense manpower needed for influenza vaccination prior to (and sometimes during) the annual influenza season.

Influenza is a serious public health concern globally. Public misunderstandings, unfounded fears, and various myths surrounding influenza, influenza vaccines, and other essential childhood immunisations must be addressed. Prevention and prompt diagnosis and treatment of influenza reduces morbidity.7 Physicians, school teachers, parents, and policy makers should cooperate to effectively coordinate and deliver the annual seasonal influenza immunisation programme, as well as the management of acute influenza infections that present to our healthcare services. Children with infectious diseases who are nevertheless still relatively well should try to recover at home and avoid school, nurseries, or other public places, to prevent the spread of infectious diseases such as influenza.

All authors have contributed to the concept, acquisition of data, analysis of data, drafting of the article, and critical revision for important intellectual content. All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors declared no conflicts of interest.

This report received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Chan PK, Tam WW, Lee TC, et al. Hospitalization incidence, mortality, and seasonality of common respiratory viruses over a period of 15 years in a developed subtropical city. Medicine (Baltimore) 2015;94:e2024. Crossref

2. Hon KL, Luk MP, Fung WM, et al. Mortality, length of stay, bloodstream and respiratory viral infections in a pediatric intensive care unit. J Crit Care 2017;38:57-61. Crossref

3. Hon KL, Leung TF, Cheung KL, Ng PC, Chan PK. Influenza and parainfluenza associated pediatric ICU morbidity. Indian J Pediatr 2010;77:1097-101. Crossref

4. Hon KL, Leung E, Tang J, et al. Premorbid factors and outcome associated with respiratory virus infections in a pediatric intensive care unit. Pediatr Pulmonol 2008;43:275-80. Crossref

5. Chiu SS, Kwan MY, Feng S, et al. Influenza vaccine effectiveness against influenza A (H3N2) hospitalizations in children in Hong Kong in a prolonged season, 2016/17. J Infect Dis 2018;217:1365-71. Crossref

6. Cheung E. Girl, 3, becomes first child fatality winter flu season in Hong Kong. South China Morning Post 2018 Jan 15. Available from: https://www.scmp.com/news/hong-kong/health-environment/article/2128294/girl-3-becomes-first-child-fatality-winter-flu. Accessed 28 May 2019.

7. Muthuri SG, Venkatesan S, Myles PR, et al. Effectiveness of neuraminidase inhibitors in reducing mortality in patients admitted to hospital with influenza A H1N1pdm09 virus infection: a meta-analysis of individual participant data. Lancet Respir Med 2014;2:395-404. Crossref

To the Editor—In February 2019, local news in Hong Kong reported a 12-year-old boy died 3 days after choking on a beef ball.1 The boy bought some food after school and choked on a piece of beef ball he was eating while walking home. Reportedly, he could not breathe nor cry for help, but a security guard saw him clutching at his neck. She called the police as the boy collapsed. He was transferred to an intensive care unit, where he later died from hypoxic brain damage which led to multi-organ failure.

There were two similar incidents in 2018 in Hong Kong. In January, an 8-year-old girl choked on a cuttlefish ball bought at a school kiosk during recess and died after 26 days in hospital. In March, a 2-year-old girl died after choking on a grape at home. Reportedly, the girl could not breath and fell into a coma. Her father had slapped her back but failed to dislodge the object.

Ingestion-associated adverse events can arise from many different scenarios and may result in mortality and high morbidity.2 3 4 5 We have previously reported that these children are usually healthy, and that all age-groups can be affected.2 3 Solids are usually associated with symptoms from local obstruction or suffocation, whereas fluids may be associated with systemic manifestations and anaphylaxis. Presentations are generally acute, dramatic, and unmistakable. The majority of patients made a prompt and uneventful recovery and had only a short stay in an intensive care unit, especially if emergency care was promptly provided.

The tragic cases unfortunately often occur in previously healthy children. Although prevention is feasible (not eating while talking and walking), choking and suffocation are eminently treatable by a simple manoeuvre. People who see the unmistakable neck-clutching sign of choking can help by performing the Heimlich manoeuvre. To perform this, stand behind the individual in distress, make a fist, position it over the stomach of the individual, and pull sharply inward and upward on the abdomen until the object is ejected. The 2019 case illustrates that this simple life-saving procedure was not available in a timely manner. There is a lot of room for public education.

Effective strategies in the prevention of choking should include cultivating/developing the habit of not eating while talking and walking at individual, family, and public health levels. Studies have shown that children aged <3 years remain at greatest risk of food injury and death. Hard, round foods with high elasticity or lubricity properties, or both, pose a significant level of risk.6 7 Awareness of the key characteristics of the most hazardous foods may greatly decrease risks of airway obstruction injuries. Food safety education can help paediatricians and parents select, process, and supervise appropriate foods for children aged <3 years.

The possibility of engaging the public, especially those with jobs that bring them into contact with the public, such as security personnel, public transport workers, restaurant staff, school teachers, as well as parents and senior high school students, to learn basic first aid, external cardiac message, use of automated external defibrillator, and the Heimlich manoeuvre should be promoted. After all, the Heimlich manoeuvre is a simple life-saving procedure that is easy to master.8

All authors contributed to the concept, drafting of the article, and critical revision for important intellectual content.

All authors declared no conflicts of interest.

1. Boy, 12, dies three days after choking on beef ball. The Standard 2019 Feb 25. Available from: http://www.thestandard.com.hk/section-news.php?id=205303. Accessed 25 Feb 2019.

2. Hon KL, Leung TF, Hung CW, Cheung KL, Leung AK. Ingestion-associated adverse events necessitating pediatric ICU admissions. Indian J Pediatr 2009;76:283-6. Crossref

3. Hon KL, Leung TF, Cheung KL, et al. Severe childhood injuries and poisoning in a densely populated city: where do they occur and what type? J Crit Care 2010;25:175. e7-12. Crossref

4. Hon KL, Leung AK. Childhood accidents: injuries and poisoning. Adv Pediatr 2010;57:33-62. Crossref

5. Hon KL, Chu WC, Sung JK. Retropharyngeal abscess in a young child due to ingestion of eel vertebrae. Pediatr Emerg Care 2010;26:439-41. Crossref

6. Wu X, Wu L, Chen Z, Zhou Y. Fatal choking in infants and children treated in a pediatric intensive care unit: a 7-year experience. Int J Pediatr Otorhinolaryngol 2018;110:67-9. Crossref

7. Altkorn R, Chen X, Milkovich S, et al. Fatal and nonfatal food injuries among children (aged 0-14 years). Int J Pediatr Otorhinolaryngol 2008;72:1041-6. Crossref

8. Ekberg O, Feinberg M. Clinical and demographic data in 75 patients with near-fatal choking episodes. Dysphagia 1992;7:205-8. Crossref

To the Editor—I deeply appreciate the timely publication of the Consensus Statement on Chronic Idiopathic Constipation in the current issue of the Hong Kong Medical Journal (April 2019).1 It addressed many important issues, including advising caution on the popular use of fibre-rich supplements and lactulose. These compounds are indigestible for humans and serve as osmotic bulk expanders to facilitate faecal transit and expulsion. They are fermented by intestinal bacteria, often but not always favouring beneficial bacteria such as bifidobacteria over unfavourable bacteria such as clostridia and bacteroides. For decades, health food advocates focused on their value and seldom cautioned against any risks.2 However, the survival advantage might change, and allow opportunistic pathogens to thrive.3 Streptococcus gallolyticus is an example of such an opportunist. First, it is capable of digesting a wide range of plant cellulose and disaccharides, including lactulose. Second, it creates a highly acidic local environment deleterious to many other organisms but not to itself, having developed various pathways to survive such acidity. Third, it attains virulence with Pil-3 and other molecules, which enable it to infect intestinal mucosal cells, to evade host innate immunity, and to enter the bloodstream, whereupon it readily attaches to collagen-rich tissues such as heart valves resulting in endocarditis.4 For a patient with chronic constipation, the long-term intake of a high-fibre diet and lactulose has been found associated with Streptococcus gallolyticus endocarditis.5

The author had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

The author has no conflicts of interest to disclose.

This letter received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Wu JC, Chan AO, Cheung TK, et al. Consensus statement on diagnosis and management of chronic idiopathic constipation in adults in Hong Kong. Hong Kong Med J 2019;25:142-8. Crossref

2. Simpson HL, Campbell BJ. Review article: dietary fibre-microbiota interactions. Aliment Pharmacol Ther 2015;42:158-79. Crossref

3. Montagne L, Pluske JR, Hampston DJ. A review of interactions between dietary fibre and the intestinal mucosa, and their consequences on digestive health in young, non-ruminant animals. Anim Feed Sci Technol 2003;108:95-117. Crossref

4. Hensler ME. Streptococcus gallolyticus, infective endocarditis, and colon carcinoma: new light on an intriguing coincidence. J Infect Dis 2011;203:1040-2. Crossref

5. Rusniok C, Couvé E, Da Cunha V, et al. Genome sequence of Streptococcus gallolyticus: insights into its adaptation to the bovine rumen and its ability to cause endocarditis. J Bacteriol 2010;192:2266-76. Crossref