Women and Infants Research Foundation

Subiaco, Australia

Women and Infants Research Foundation

Subiaco, Australia

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French N.,King Edward Hospital | French N.,Center for Neonatal Research and Education | Kelly R.,State Child Development Center | Reynolds V.,Princess Margaret Hospital | And 5 more authors.
Pediatrics | Year: 2013

Background and Objectives: Voice abnormality is a frequent finding in school age children born at <25 weeks' gestation in Western Australia. The objective of this study was to determine the frequency of voice abnormality, voice-related quality of life, and demographic and intubation factors in this population. Methods: Survivors <25 weeks' gestational age in Western Australia born from 1996 to 2004 were included. Voice assessments (auditory perceptual assessment scale and Pediatric Voice Handicap Index) were carried out by speech pathologists. Intubation history was obtained by retrospective chart review. Results: Of 251 NICU admissions, 154 (61%) survived. Exclusions were based on severe disability (11) or distant residence (13). Of 70 assessed, 67 completed assessments, 4 (6%) were in the normal range and 39 (58%) showed moderate-severe hoarseness. Simultaneous modeling of demographic and intubation characteristics showed an increased odds of moderate-severe voice disorder for children who had more than 5 intubations (odds ratio 6.96, 95% confidence interval 2.07-23.40, P = .002) and for girls relative to boys (odds ratio 3.46, 95% confidence interval 1.12-10.62, P = .030). Tube size and duration of intubation were not significant in the multivariable model. Median scores of parent-reported voice quality of life on the Pediatric Voice Handicap Index were markedly different for preterm (22) and term (3) groups, P < .001. Conclusions: Voice disorders in this population were much more frequent than expected. Further studies are required to assess voice across a broader range of gestational ages, and to investigate voiceprotective strategies in infants requiring multiple episodes of intubation. Copyright © 2013 by the American Academy of Pediatrics.


Russell T.,King Edward Memorial Hospital | Russell T.,Sir Charles Gairdner Hospital | Ng L.,King Edward Memorial Hospital | Nathan E.,Women and Infants Research Foundation | Debenham E.,King Edward Memorial Hospital
Anaesthesia | Year: 2014

The presence of a facemask leak significantly reduces the effectiveness of pre-oxygenation and increases the risk of post-induction hypoxia. We randomly assigned 24 healthy volunteers to a six-period crossover trial with and without a simulated facemask leak. Pre-oxygenation was performed using a standard anaesthesia machine circuit supplemented either by nasal prong oxygen or by anaesthesia machine flush oxygen. Each intervention was completed with both 3-min tidal breathing and 8 deep breath techniques: end-tidal oxygen fraction was used as the measure of preoxygenation effectiveness. The presence of a stimulated mask leak significantly reduced the effectiveness of preoxygenation regardless of the breathing method used. With a simulated facemask leak introduced, the mean (SD) end-tidal oxygen fraction with the 3-min tidal breath technique was 74.7 (9.3)% compared with 57.5 (6.2%) for the 8 deep breath technique with 3-min tidal breathing and a leak. End-tidal oxygen fractions increased by 11.0% (95% CI 7.8-14.3%) (p < 0.0001) with the addition of nasal prong oxygenation and 16.8% (13.6-20.0%) (p < 0.0001) with machine oxygen flush compared with standard pre-oxygenation. When a leak is present, 3-min tidal breathing with either nasal prong or anaesthesia machine flush oxygenation is an effective pre-oxygenation method, and preferable to the 8 deep breath method. © 2014 The Association of Anaesthetists of Great Britain and Ireland.


Miu M.,King Edward Memorial Hospital for Women | Paech M.J.,King Edward Memorial Hospital for Women | Paech M.J.,University of Western Australia | Nathan E.,Women and Infants Research Foundation
International Journal of Obstetric Anesthesia | Year: 2014

Background Difficult epidural insertion and accidental dural puncture are more likely in the obese pregnant population. Low-level evidence suggests that the risk of post-dural puncture headache declines as body mass index increases.Methods We retrospectively reviewed prospective data on 18 315 obstetric epidural and combined spinal-epidural insertions, identifying 125 (0.7%) accidental dural punctures or post-dural puncture headaches between 2007 and 2012. The audit record and patient medical record were examined to determine patient body mass index, headache characteristics and use of a therapeutic epidural blood patch. Women were classified into two groups: non-obese (body mass index <30 kg/m2, Group <30) or obese (body mass index ≥30 kg/m2, Group ≥30). Statistical analysis was by chi-square or Fisher exact tests, with P < 0.05 considered significant.Results Compared to Group <30 (n = 65), women in Group ≥30 (n = 60) did not significantly differ in the incidence of post-dural puncture headache (82% vs 80%, P = 0.83); its intensity (severe 36% vs. 23%, P = 0.34); or the need for epidural blood patch (57% vs. 54%, P = 0.81). Groups also did not differ significantly when confining analysis to those who had a witnessed accidental dural puncture (n = 93) or to women with a body mass index >40 kg/m2 (n = 10) vs. Group <30.Conclusion This retrospective study found no evidence that women of higher body mass index are less likely to develop a post-dural puncture headache or that the characteristics of the headache and use of epidural blood patch were different. © 2014 Elsevier Ltd. All rights reserved.


Paech M.,University of Western Australia | Paech M.,King Edward Memorial Hospital for Women | Sng B.,KKWomens and Childrens Hospital | Ng L.,King Edward Memorial Hospital for Women | And 3 more authors.
British Journal of Anaesthesia | Year: 2015

Background. Intrathecal morphine-induced pruritus is a very common side-effect that is difficult to prevent or treat. Central and peripheral mechanisms are believed to be involved. The aim of this study was to determine if a peripherally acting, μ-opioid antagonist would reduce morphine-induced pruritus. Methods.We conducted amulticentre, randomized, blinded, placebo-controlled trial ofwomen having elective Caesarean section under spinal anaesthesiawith intrathecal morphine 100 mg. After delivery, participants received either subcutaneous methylnatrexone bromide 12 mg (MNTX group, n=69) or saline (placebo group, n=68). Pruritus, nausea, pain, analgesic use and side-effects were assessed at 2, 4, 8, and 24 h. The primary outcome was the severity of pruritus (0-10 score). Results. One hundred and thirty-seven women completed the study, with five major protocol violations. There was no statistically significant difference between the MNTX and placebo groups for the median (IQR) pruritus AUC scores [24 (9-47) vs 36 (11-68), median difference 8.5, 95% confidence interval (CI) 0-20, P=0.09] or the worst pruritus score [3 (2-7) vs 5 (2-6) median difference 1, 95% CI 0-2, P=0.24]. The incidence of pruritus was 84% in the MNTX group and 88% in the placebo group (P=0.48). Analgesic and gastrointestinal outcomes did not significantly differ between the groups. Conclusions.Asingledose of subcutaneousmethylnaltrexone bromide 12mgdid not reduce the overall severity or incidence of pruritus. In this study, treatment with a peripherally acting m-opioid antagonist was generally ineffective against intrathecal morphine-induced pruritus but a small clinical effect cannot be excluded. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.


Mcleod G.,University of Western Australia | Sherriff J.,Curtin University Australia | Nathan E.,Women and Infants Research Foundation | Hartmann P.E.,University of Western Australia | Simmer K.,University of Western Australia
Journal of Paediatrics and Child Health | Year: 2013

Aim Preterm nutritional audits have previously been conducted using assumed milk composition. We audited protein and energy intakes in the first 28 days of preterm life using both assumed milk composition and milk analysis to assess their effect on weight gain and to determine if the recommended reasonable range of intakes were met. Methods Parenteral and enteral intakes and weight gain were recorded daily for infants (n = 63) born <33 weeks gestation, using assumed milk composition. Macronutrient composition was determined by milk analysis for a subset of infants (n = 36). Linear mixed models analysis was used to assess the influence of energy and protein intakes on weight gain. Results (Data median (range)): Infants (n = 63) gestation and birth weight were 30 (24-32) weeks and 1400 (540-2580) g, respectively. Macronutrient milk composition was variable: protein 16.6 (13.4-27.6) g/L, fat 46.1 (35.0-62.4) g/L, lactose 68.0 (50.9-74.8) g/L, energy 3074 (2631-3761) kJ/L. Intakes based on measured composition differed from assumed. Protein intake was significantly associated with weight gain. Compared to infants with longer gestations, those born <28 weeks gestation were fed lower volumes, were more reliant on parenteral nutrition, took an additional seven days to transition to fortified feeds and median weight gain velocity took a fortnight longer to reach targets. Conclusion Preterm milk composition is variable and routine fortification using assumed composition may result in inappropriate nutrition. Fortification regimens stratified by birth gestation may be necessary to achieve preterm nutrition and growth targets. Milk analysis is required for accurate nutritional audit. © 2012 The Authors. Journal of Paediatrics and Child Health © 2012 Paediatrics and Child Health Division (Royal Australasian College of Physicians).


Alkiaat A.,King Edward Memorial Hospital | Hutchinson M.,King Edward Memorial Hospital | Jacques A.,Women and Infants Research Foundation | Sharp M.J.,King Edward Memorial Hospital | And 3 more authors.
Australian and New Zealand Journal of Obstetrics and Gynaecology | Year: 2013

Introduction Approximately 10-15% of term babies may require admission to neonatal special care units. This level of care is frequently an unexpected event for parents. Aims To review the frequency and obstetric risk factors associated with the admission of term neonates to a tertiary hospital special care unit (SCN). Materials and Methods All babies born ≥37-weeks gestation admitted to the SCN at King Edward Memorial Hospital between 2004 and 2006 were identified from the institutional maternity and neonatal databases. Maternal and obstetric factors were reviewed to identify potential predictors of admission to the SCN. Results During the study period, 1671 term neonates born to 1624 women were admitted to the SCN (14.4% of term deliveries). Neonatal intensive care unit admissions accounted for 10.6% of the term admissions. The most common reasons for SCN admission were respiratory complications (n = 421, 25.2%), observation postresuscitation (n = 402, 24.1%) and hypoglycaemia (n = 152, 9.1%). Elective caesarean delivery was significantly associated with admission to the special care unit for respiratory complications compared with all other delivery modes (37 vs 23%, P < 0.001), particularly if the birth occurred at <39-weeks gestation (38 vs 24%, P < 0.001). Conclusions In our population of women delivering at a tertiary maternity facility, approximately 1:8 term babies were admitted to the neonatal special care unit. Elective caesarean delivery was associated with a significant risk of admission for respiratory complications compared with other birth modes, especially when <39-weeks gestation. © 2013 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.


Strunk T.,King Edward Memorial Hospital for Women | Strunk T.,University of Western Australia | Doherty D.,University of Western Australia | Doherty D.,Women and Infants Research Foundation | And 9 more authors.
Pediatrics | Year: 2012

BACKGROUND: Histologic chorioamnionitis (HCA) is implicated in the onset of preterm labor and delivery. Chorioamnionitis is a known risk factor for early-onset sepsis and may modulate postnatal immunity. Preterm infants are at greatly increased risk of late-onset sepsis (LOS), particularly with coagulase-negative staphylococci (CoNS), but the impact of HCA on the risk of LOS is unknown. METHODS: Eight hundred thirty-eight preterm infants born at <30 weeks gestational age at a single tertiary center were included. Histologic examination of placenta and extraplacental membranes was performed, and clinical data were extracted from hospital databases. The influence of HCA on the incidence of early-onset sepsis and LOS was examined using logistic regression analysis and Cox proportional hazards regression. RESULTS: Mean gestational age was 26.9 ± 1.9 weeks, and mean birth weight was 936 ± 277 g. Two hundred and seventy-six (33%) of 838 infants developed LOS. The presence of fetal or maternal HCA, or maternal HCA and fetal HCA alone, was associated with a significantly decreased risk of LOS with any organism. Histologic chorioamnionitis correlated with a significantly decreased risk of CoNS LOS. CONCLUSIONS: HCA is associated with a significantly reduced risk of acquiring LOS, both with CoNS and other bacteria. Perinatal inflammation may enhance the functional maturation of the preterm immune system and provide protection against LOS in high-risk preterm infants. Copyright © 2012 by the American Academy of Pediatrics.


Dickinson J.E.,University of Western Australia | Dickinson J.E.,Women and Infants Research Foundation | Brownell P.,University of Western Australia | McGinnis K.,University of Western Australia | Nathan E.A.,Women and Infants Research Foundation
Australian and New Zealand Journal of Obstetrics and Gynaecology | Year: 2010

Objective: To determine the impact on the process of second trimester medical termination for fetal abnormality following the introduction of adjunctive mifepristone in an Australian tertiary hospital. Methods: All second trimester medical terminations for fetal abnormality between July 2006 and June 2009 were prospectively identified. Two temporal therapeutic cohorts were created: the first (1 July 2006 to 31 December 2007) using vaginal misoprostol alone and the second (1 January 2008 to 30 June 2009) using mifepristone priming prior to the administration of misoprostol. The primary outcome was to evaluate the impact of mifepristone priming upon the duration of pregnancy termination. Results: During the study period, 388 women with prenatally recognised fetal anomalies between 14 and 24 weeks gestation underwent medical termination: 189 with misoprostol alone and 199 with mifepristone priming followed by misoprostol. There was no difference between the groups for maternal age, parity or prior caesarean delivery. The median abortion duration was 15.5 h (interquartile ranges (IQR) 11.2-22.7) in the misoprostol group and 8.6 h (IQR 5.6-13.8) in the mifepristone primed group (P < 0.001). In both the groups, nulliparity and advancing gestation were associated with a significant prolongation of the abortion interval. Duration of hospitalisation was significantly longer in the misoprostol alone group (31.5 h (27-48.9) vs 27.2 h (22-31.5), misoprostol vs mifepristone priming, respectively, P < 0.001). Conclusions: The introduction of mifepristone priming prior to second trimester medical termination with misoprostol has resulted in a significant reduction in the duration of the termination procedure and length of inpatient stay. These observed benefits of mifepristone provide objective support for the decision to permit use of this medication in Australia. © 2010 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.


McLeod G.,University of Western Australia | Geddes D.,University of Western Australia | Nathan E.,Women and Infants Research Foundation | Sherriff J.,Curtin University Australia | And 2 more authors.
Early Human Development | Year: 2013

Background and aims: To assess ultrasound as a method for (i) measuring body composition (BC) of preterm infants and for (ii) assessing the influence of macronutrient intakes on tissue accretion rates. Methods: Preterm ultrasound studies of four anatomical sites were performed approximately every three weeks from birth to corrected-term age. Preterm measurements were compared to foetal reference data. Duplicate scans at each site were taken on a subset of infants to test the reproducibility of the method, assessed as the coefficient of variation (CV). The influence of measured macronutrient intakes on preterm BC was assessed by regression analysis. Results: Median (range) gestation and birth weight of 40 preterm infants were 27 (23-29) weeks and 1022 (480-1475) g, respectively. Accretion rates of adipose and muscle tissues were not uniform across the four sites. Relative to the foetus, preterm adipose tissue thickness was reduced at an equivalent (corrected) gestation, but towards term, a faster accretion rate of subcutaneous abdominal adipose and limb muscle tissue was evident. Timing of fortification (p = 0.012), enteral carbohydrate intake (p = 0.008) and the protein energy ratio of intakes (p = 0.038) moderated the ratio of adipose to muscle tissue accretion over the four sites by - 0.004, - 0.048 and - 0.042, respectively. Conclusions: Ultrasound provides a non-invasive, portable method of assessing changes in subcutaneous adipose tissue and muscle accretion and appears sufficiently sensitive to detect influences of macronutrient intakes on accretion rates from birth. The method warrants further investigation as a bedside tool for measuring BC of preterm infants. © 2013.


Paech M.J.,University of Western Australia | Doherty D.A.,University of Western Australia | Doherty D.A.,Women and Infants Research Foundation | Christmas T.,King Edward Memorial Hospital for Women | Wong C.A.,Northwestern University
Anesthesia and Analgesia | Year: 2011

Background: Our aim in this multinational, multicenter, randomized, blinded trial was to determine the optimum of 3 volumes of autologous blood for an epidural blood patch. Methods: Obstetric patients requiring epidural blood patch after unintentional dural puncture during epidural catheter insertion were allocated to receive 15, 20, or 30 mL of blood, stratified for the timing of epidural blood patch and center. Participants were followed for 5 days. The primary study end point was a composite of permanent or partial relief of headache, and secondary end points included permanent relief, partial relief, persisting headache severity, and low back pain during or after the procedure. Results: One hundred twenty-one women completed the study. The median (interquartile range) volume administered was 15 (15-15), 20 (20-20), and 30 (22-30) mL, with 98%, 81%, and 54% of groups 15, 20, and 30 receiving the allocated volume. Among groups 15, 20, and 30, respectively, the incidence of permanent or partial relief of headache was 61%, 73%, and 67% and that of complete relief of headache was 10%, 32%, and 26%. The 0- to 48-hour area under the curve of headache score versus time was highest in group 15. The incidence of low back pain during or after the epidural blood patch was similar among groups and was of low intensity, although group 15 had the highest postprocedural back pain scores. Serious morbidity was not reported. Conclusions: Although the optimum volume of blood remains to be determined, we believe these findings support an attempt to administer 20 mL of autologous blood when treating postdural puncture headache in obstetric patients after unintentional dural puncture. © 2011 International Anesthesia Research Society.

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