Helping kids breathe easy in hospital
Professor Britta Regli-von Ungern-Sternberg
Paediatric anaesthesia is high-risk and research is needed to ensure that care is evidence-based and safe. Additionally, undergoing surgery can be daunting, especially for children. Improving the experience for patients helps to ensure the best possible outcomes for every child.
A multidisciplinary team led by Professor Britta Regli-von Ungern-Sternberg is using a holistic approach at the heart of their research to focus on ensuring children are safe and comfortable and receive the best possible health care during a hospital stay. Their research has led to practical changes across the world in how medical professionals interact with children in preoperative care, during anaesthesia and surgery, and in their recovery.
Professor Britta Regli-von Ungern-Sternberg is an internationally recognised researcher and paediatric anaesthetist at the University of Western Australia (UWA) Emergency Medicine, Anaesthesia and Pain Medicine, Perth Children’s Hospital (PCH) and UWA Centre for Child Health Research (affiliated with Telethon Kids Institute). She also leads the newly established UWA Institute of Paediatric Perioperative Excellence.
Her team works with anaesthetists and surgeons from Australia and globally, nurses, technicians as well as children and their families, and are passionate about improving the child’s health at all stages of treatment.
“Our primary goal is to ensure that if a child needs surgery, that it is as safe and comfortable for the child as it possibly can be.”
Children as ambassadors of change
The team include children and families within each project, as advisors, testers and content creators. These children have lived experience and often see things from a different perspective to adults and researchers.
The research program works closely with a consumer group panel, which is made up of members from diverse cultural and socio-economic backgrounds:
- adults with a lived experience
- parents of child patients
The team also speaks with children directly. For example, young children are asked about their hospital experience, whilst older children comment on whether ideas will work on a practical level, while youth ambassadors (aged 11-16) look for issues in patient and parent documentation and help with development of protocols.
The team are passionate about making sure their research is safe for everyone, and in 2023 with support from the National Health and Medical Research Council (NHMRC) published the results from an Australia-wide study on the perioperative research priorities of Australian consumers.
“Despite the team’s diverse backgrounds, we know that children see things differently. I love when they find things that were overlooked or need to change.”
Put on your Magic Coat and relax!
Between 80-85% of children have a significant amount of anxiety when they come to hospital. Managing a child’s anxiety and reducing fear of the unknown can affect post-surgery recovery and pain management and can shape the child’s future behaviour toward healthcare.
The team recognised that care needed to start before the child even arrives at the hospital. In 2022, they partnered with the Magic Coat Foundation, whose books and program developed using a Cognitive Behavioural Therapy approach were being used in schools, communities and refugee centres to strengthen resilience in children. Dr David Preece, UWA School of Psychological Science has worked with The Magic Coat Foundation for several years to help build the program.
The Magic Coat APP (Google Play) or Magic Coat Hospital Adventure (APP Store) is designed to gently and interactively assist children in preparing for their hospital journey. Launched in January 2024, it is specially designed for patients at PCH, with parents advised to download it as part of the booking process. Di Wilcox from the Magic Coat Foundation and Professor Regli-von Ungern Sternberg worked closely together and with numerous other clinical colleagues from the Department of Anaesthesia and Pain Medicine at PCH to make the APP adaptable for the needs of PCH.
Consumer group children and parents were also heavily involved in testing, and all the videos feature children.
The APP takes the child through the hospital journey step by step, starting at home with what to pack and until they wake up after surgery. The Magic Coat contains many pockets, and within each there lives a sea creature which represents a new behavioural strategy. Strategies in the form of interactive games and videos aim to increase the coping and resilience skills of these children.
Characters include:
- Tate the sea turtle: faces the world head on, and when things seem scary, he tries them out and realises that they’re actually OK.
- Me’Shell: represents when family might not be available to be there with the child, but they are always there in their thoughts.
- Worry ladder: helps children breakdown the anxiety and the likelihood of it occurring. It can often help them to shelve that worry.
Additional support by the Magic Coat Foundation has resulted in key areas of the hospital being decorated with the APP characters to prompt children when they come in, and an interactive treasure hunt for children to complete
The overwhelming positive feedback from patients since the launch has encouraged the team to continue to find ways to make the hospital experience even easier for children. Plans are being made to expand the APP to help children with additional needs and children from culturally and linguistically diverse backgrounds.
Perth Children’s Hospital wall decals reinforce positive messaging about the hospital experience.
Sweet medicine
For parents, getting children to take medicine is often difficult. And masking the taste of bitter prescription medications by mixing them with something sweet can even render them ineffective.
Supported by the Australian & New Zealand College of Anaesthetists (ANZCA), the team are working with Professor Lee Yong Lim at the UWA School of Allied Health, Pharmacy to reformulate existing drugs and make them palatable and easy to swallow. Their focus is on drugs that taste very bitter and are prescribed when undergoing surgery or cancer treatment. The chocolate delivery system has also been supported over its lifetime by UWA Pathfinder Fund, Telethon-Perth Children’s Hospital Research Fund, and a UWA HMS Research Impact Grant.
“A doctor might prescribe the best medicine, but if a child refuses to take it, it just won’t work.”
In 2018, they successfully developed a chocolate tablet version of Midazolam, a pre anaesthesia drug. The breakthrough was widely publicised by media outlets in Western Australia. Whilst the medication has been patented, it has not yet been fully rolled out for use in hospitals. The self-administration of chocolate just prior to taking certain prescribed drugs is also being studied by the team.
Most parents consulted about the novel ‘confectionary-like’ medication supported their use and to improve compliance with medications.
A second successful trial was performed using the painkiller, Tramadol. Other medications being worked on include Prednisolone (funded by ANZCA) and a range of other bitter drugs. Successful outcomes will have a flow on effect beyond paediatrics into areas including for the elderly, or patients with swallowing difficulties.
Reformulating prescription of the pre anaesthesia and pain management drugs have had the strong support of several organisations including the PCH Foundation, NHMRC, and ANZCA.
A good REACTion to anaesthesia
In Australia, about 1 in 20 children receive anaesthesia every year, with 1 in 7 experiencing breathing problems. In infants this rises to 1 in 3 and 1 in 2 for neonates. In paediatric anaesthesia more than 75% of all critical incidents in theatre relate to a child’s breathing, including in children who are otherwise completely well.
Whilst most issues resolve, some can cause long term neurological damage or death, and this compounds for children with pre-existing conditions. The team conducts a range of research aimed at improving lung function and the safety of anaesthesia for children and in 2010 undertook a landmark risk assessment of known respiratory complications. The study included over 9000 children and characterised risk factors and the impacts of using different techniques. They developed a framework for clinicians to identify children at high risk of respiratory complications and provided recommendations for a targeted management approach.
Tonsillectomy is one of the most frequently performed surgeries in children. In 2019, their world-first REACT (Respiratory Adverse Events in Children Undergoing Tonsillectomies) study demonstrated that children under eight years undergoing a tonsillectomy who were given two puffs of asthma medication Salbutamol (Ventolin) prior to surgery had fewer breathing issues than those who did not receive it. It was even more effective for those with the pre-existing condition of sleep apnoea.
Before the REACT trial, the use of preoperative asthma medication was practiced, however it was not routinely administered by clinicians. Professor Regli-von Ungern Sternberg’s team were the first to demonstrate that this cheap and readily available procedure resulted in a significant decrease in respiratory complications, particularly in high-risk children.
The solution is inexpensive, safe, and available globally, including in developing countries. The practice is now part of global clinical guidelines and used widely, when planning anaesthesia for children undergoing tonsillectomy. The implementation of the research into routine clinical practice has reduced complication rates globally in this high-risk population. The trial was supported by an NHMRC Fellowship Grant and ANZCA.
Administering Ventolin prior to tonsillectomy surgery reduced respiratory complications
An OPTIMSEd approach to securing the airway
Securing the airway gently and safely during general anaesthesia is essential, particularly in neonates and infants who are at a higher risk for complications.
Traditionally, two methods were used interchangeably:
- Endotracheal tube – stops in the lungs. European guidelines deemed this safer for patients under 12 months.
- Laryngeal mask – stops just before the vocal cords.
The team’s 2017 trial published in the Lancet found that in 239 infants undergoing minor elective surgery, the laryngeal mask was much safer than the endotracheal tube. Whilst there are occasions where an endotracheal tube is required, the study proved contrary to existing guidelines.
“We’re trying to get anaesthesia safer by comparing standard techniques being used.”
As part of a global trial of over 500 infants in 2020, again published in the Lancet, including centres in the USA, two techniques for intubation of young infants were studied. They demonstrated a 93% success rate in first attempt intubation of infants when using video laryngoscopy, compared to 88% without the use of video, providing a safer and more effective way to secure the airway. Further research looking at the airway management of children identified with difficult airways was included into the American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway in 2022 and in the European Guidelines: Airway management in neonates and infants: European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia joint guidelines. Support was received from the Anaesthesia Patient Safety Foundation, Society for Airway Management, and Karl Storz Endoscopy.
In their 2023 OPTIMISE trial, (Lancet Child and Adolescent Health) 599 patients were assessed across seven tertiary paediatric hospitals across Australia, Canada, Italy, Switzerland, and the USA. The team found that video laryngoscopy with standard blades in combination with oxygen increased the success rate of first-attempt intubation in neonates and infants, when compared with direct laryngoscopy. This trial was supported by the Swiss Pediatric Anaesthesia Society, Swiss Society for Anaesthesia and Perioperative Medicine, Foundation for Research in Anaesthesiology and Intensive Care Medicine, Channel 7 Telethon Trust, Stan Perron Charitable Foundation, and the NHMRC.
In 2023, the team changed global practice when their recommendations were included into joint Practice Guidelines by the European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia. This provides anaesthetists working in a variety of settings, with a safer, evidence-based best practice approach to airway management and anaesthesia in neonates and infants.
“We’ve seen a significant reduction in respiratory adverse events, particularly in theatre, and improved outcomes in the children.”
Intubation with oxygen and video is now practiced more widely.
Brain behaviour
For many years, Professor Regli-von Ungern Sternberg and her team have researched the effect of anaesthesia on the developing brain. Whilst the effect of anaesthesia is usually short-lived, changes in a child’s behaviour (e.g. sleeping and eating disorders, nightmares, tantrums) occur in over 50% of children directly postoperatively. Risk factors include underlying anxiety in the child or parent, a previous bad hospital experience, and preschool age.
Working with the BRAIN Network, an international research network of paediatric anaesthetists, the team are researching whether children who have been exposed at an early age, and repeatedly to anaesthesia have a higher risk for neurodevelopmental issues later in life.
Research is focused on implementing more precise monitoring of brain function during surgery and adjusting the level of anaesthesia and medication or the amount of oxygen depending on the levels.
“If you can make one more child have a smile on their face when they walk out, and they’re doing well, that’s just what keeps me going.”
Better monitoring during surgery ensures better outcomes for patients.
Award winning team
An international leader in medical research and a prominent figure in paediatric anaesthesia governance and practice, Professor Britta Regli-von Ungern-Sternberg sits on multiple committees, advisory boards and associations and has been recognised with numerous awards. She recognises that her research achievement is possible thanks to the collaborative nature of researchers within the field of paediatric anaesthesia globally and the common goal of finding solutions for better healthcare for children.
“I’m really privileged to work with this amazing team of people in Perth, nationally and internationally. We really collaborate and draw on our individual strengths to find the best way forward.”
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