Dr Megan Jensen

© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Background: The use of fractional exhaled nitric oxide (FeNO)-based asthma management during pregnancy can significantly reduce asthma exacerbations in non-smoking pregnant women. The feasibility of implementing this strategy into antenatal care has not been explored. Aims: To examine the feasibility of implementing FeNO-based asthma management into antenatal clinics in New South Wales (NSW) Australia. Materials and Methods: Semi-structured face-to-face interviews with video elicitation were conducted with healthcare professionals (HCPs) providing antenatal care in one of two hospital-based antenatal clinics in NSW, Australia. The video shown demonstrated the use of the FeNO instrument and other aspects of the management strategy, in antenatal care. Interviews were recorded, transcribed and analysed using qualitative content analysis. Results: A total of 20 interviews were conducted with 15 midwives, four obstetricians, and one general practitioner. Two main themes and ten sub-themes arose: Getting a number (sub-themes: engaging, technically easy, objective, predictive, reassuring); and Resourcing (sub-themes: time and timing, systems, staff, education and cost). Comments included: ¿It's easy, fast and effective¿ and ¿the main barrier is time¿. All HCPs felt capable of facilitating the FeNO-based management strategy, with appropriate education, and were willing to undertake this strategy, saying: ¿¿it would be perfectly acceptable for a midwife or doctor to do it¿; also, ¿they don't necessarily need to see a physician, it's something that midwives would take on generally¿¿. Conclusion: Participants in this study considered FeNO-based asthma management for pregnant women to be a feasible addition to antenatal care following appropriate provision of resources and education.

© 2019 Australian College of Midwives Background: Asthma affects approximately 12.7% of pregnant women in Australia. Increased maternal and infant morbidity is closely associated with poorly controlled asthma during pregnancy. Midwives are well placed to provide antenatal asthma management but data on current asthma management during pregnancy is not available, nor is the use of guidelines for clinical practice by this health professional group. Aim: To explore self-reported antenatal asthma management provided by midwives across Australia and how this reflects guideline recommendations. Method: An online survey was developed and distributed throughout Australia via the Australian College of Midwives, social media and healthcare facilities. Results: Responses from 371 midwives were obtained. Ten percent of midwives rated their knowledge as ¿good¿ and 1% as ¿very good¿, with 39% ¿poor¿ or ¿very poor¿. Being ¿somewhat¿ or ¿not at all¿ confident to provide antenatal asthma management was noted by 87% of midwives. Clinical guidelines were referred to by 50% of midwives and 40% stated that their main role was to refer women to other healthcare professionals. Only 54% reported that a clear referral pathway existed. Most respondents (>90%) recognised key recommendations for asthma management such as smoking cessation, appropriate vaccinations, and the continuation of prescribed asthma medications. Conclusion: Although midwives appear aware of key clinical recommendations for optimal antenatal asthma management, low referral to clinical practice guidelines and lack of knowledge and confidence was evident. Further research is required to determine what care pregnant women with asthma are actually receiving and identify strategies to improve antenatal asthma management by midwives.

© The Author(s) 2020. Asthma and gestational diabetes mellitus are prevalent during pregnancy and associated with adverse perinatal outcomes. The risk of gestational diabetes mellitus is increased with asthma, and more severe asthma; yet, the underlying mechanisms are unknown. This review examines existing literature to explore possible links. Asthma and gestational diabetes mellitus are associated with obesity, excess gestational weight gain, altered adipokine levels and low vitamin D levels; yet, it¿s unclear if these underpin the gestational diabetes mellitus¿asthma association. Active antenatal asthma management reportedly mitigates asthma-associated gestational diabetes mellitus risk. However, mechanistic studies are lacking. Existing research suggests asthma management during pregnancy influences gestational diabetes mellitus risk; this may have important implications for future antenatal strategies to improve maternal-fetal outcomes by addressing both conditions. Addressing shared risk factors, as part of antenatal care, may also improve outcomes. Finally, mechanistic studies, to establish the underlying pathophysiology linking asthma and gestational diabetes mellitus, could uncover new treatment approaches to optimise maternal and child health outcomes.

© 2019 American Academy of Allergy, Asthma & Immunology Background: Maternal asthma is associated with perinatal complications and respiratory illness in offspring. Obesity increases asthma exacerbation risk in pregnancy and risk of wheeze in offspring. Objectives: In this secondary analysis of a randomized controlled trial, we investigated the influence of maternal body mass index, gestational weight gain (GWG), and fractional exhaled nitric oxide (FENO)-based management on asthma exacerbations in pregnancy and offspring wheeze. Methods: A total of 220 women were randomized to asthma treatment adjustment according to symptoms (control group), or FENO and symptoms (FENO group). Exacerbations were recorded prospectively. Height and weight were measured at baseline, and in late pregnancy. GWG was categorized according to Institute of Medicine guidelines. A validated parent-completed questionnaire assessed infant wheeze-related outcomes. Results: FENO-based management was associated with a significantly lower incidence rate ratio for maternal exacerbations in nonobese mothers (0.52, 95% confidence interval [CI], 0.31-0.88, P = .015, n = 129), and women with GWG within recommendations (0.35, 95% CI, 0.12-0.96, P = .042, n = 43), but not for obese mothers (0.59, 95% CI, 0.32-1.08, P = .089, n = 88), or women with excess GWG (0.58, 95% CI, 0.32-1.04, P = .07, n = 104). Recurrent bronchiolitis occurred in 5.3% (n = 1) of infants born to non-overweight mothers, 16.7% (n = 3) of infants of overweight mothers, and 21.7% (n = 5) of infants of obese mothers in the control group. In the FENO group, 2 infants of obese mothers had recurrent bronchiolitis (7.1%, P = .031). Conclusions: The benefits of FENO-based management are attenuated among obese mothers and those with excess GWG, indicating the importance of weight management in contributing to improved asthma management in pregnancy.

© 2019 John Wiley & Sons Ltd Background: Studies demonstrate the prescription rate for inhaled corticosteroids (ICS) decreases in early pregnancy, possibly increasing exacerbation risk. This could be related to non-adherence to prescribed asthma medication or medication cessation by the patient or doctor. ICS use during pregnancy has not previously been summarized in a systematic review. Objective: The aim of this systematic review and meta-analysis was to evaluate the use of ICS during pregnancy among asthmatic women, specifically: (1) the prevalence of use, (2) changes of use during pregnancy compared with pre-pregnancy and (3) medication adherence among ICS users. Methods: We systematically searched literature in Embase, MEDLINE, CINAL and Cochrane, using terms related to asthma, pregnancy and medication use. All English articles reporting ICS among pregnant women with asthma were included. Prevalence, changes in ICS use during pregnancy and ICS adherence were pooled using STATA (version 15.0, StataCorp USA). Results: A total of 4237 references were retrieved in the initial search. Screening and review led to the inclusion of 52 articles for one or more aims (Aim 1: N¿=¿45; Aim 2, N¿=¿13; and Aim 3, N¿=¿5). The pooled prevalence of ICS use during pregnancy was 41% (95%CI 36%-45%); 49% (95%CI 44%-55%) in Europe, 39% (95%CI 32%-47%) in Australia and 34% (95%CI 27%-41%) in North America. In eight prescription databases, ICS prescription rates lowered in the first trimester of pregnancy, compared with pre-pregnancy, increased in the second trimester and decreased in the third trimester. Five studies reported ICS adherence among pregnant women, using four measures of self-reported non-adherence. In two comparable studies, pooled ICS non-adherence was 40% (95%CI 36%-44%). Conclusions: The prevalence of ICS use among pregnant women with asthma is 41% and varies widely between countries and continents, and prescription rates for ICS change throughout pregnancy. More studies are needed to investigate ICS adherence during pregnancy in women with asthma.

© 2018, © 2018 Informa UK Limited, trading as Taylor & Francis Group. Background: Vitamin D may influence pregnancy and infant outcomes, especially infant respiratory health. This study aimed to examine vitamin D status in pregnant women with asthma, and whether higher vitamin D levels are associated with fewer adverse respiratory outcomes in their infants. Methods: Pregnant women with asthma, recruited from John Hunter Hospital Newcastle Australia (latitude 33°S), had serum total 25-hydroxyvitamin-D (25(OH)D) measured at 16 and 35 weeks gestation. Infant respiratory outcomes were collected at 12 months by parent-report questionnaire. Mother¿infant dyads were grouped by serum 25(OH)D during pregnancy: 25(OH)D < 75 nmol/L (at both time-points) versus 25(OH)D = 75 nmol/L (at one or both time-points). Results: In 52 pregnant women with asthma, mean serum 25(OH)D levels were 61 (range 26¿110) nmol/L at 16 weeks, and 65 (range 32¿116) nmol/L at 35 weeks, gestation. Thirty-one (60%) women had 25(OH)D < 75 nmol/L at both time-points; 21 (40%) had 25(OH)D = 75 nmol/L at one or both time-points. Maternal 25(OH)D < 75 nmol/L during pregnancy was associated with a higher proportion of infants with ¿wheeze ever¿ at 12 months, compared with 25(OH)D = 75 nmol/L (71 versus 43%, p =.04). Infant acute-care presentations (45 versus 13%, p =.02) and oral corticosteroid use (26 versus 4%, p =.03) due to ¿asthma/wheezing¿ were higher in the maternal group with 25(OH)D < 75 nmol/L, versus =75 nmol/L. Conclusions: Most pregnant women with asthma had low vitamin D status, which persisted across gestation. Low maternal vitamin D status was associated with greater risk of adverse respiratory outcomes in their infants, a group at high risk of developing childhood asthma.

© 2018 Australian College of Midwives Background: Asthma affects 12.7% of pregnancies in Australia. Poorly controlled asthma is associated with increased maternal and infant morbidity and mortality. Optimal antenatal management of asthma during pregnancy has the potential to reduce complications relating to asthma. Evidence-based clinical practice guidelines help to translate health research findings into practice and when implemented can improve health outcomes. National and International guidelines currently provide recommendations for optimal asthma care in pregnancy. Aim: To appraise the existing asthma in pregnancy guidelines with respect to their evidence for recommendations, consistency of recommendations and appropriateness for clinical practice. Method: The Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to appraise four English language asthma in pregnancy guidelines, published or updated between 2007 and 2016. The recommendations, range and level of evidence was analysed. Results: Two of the four guidelines scored highly in most domains of the appraisal. Many of the recommendations made in the appraised guidelines were consistent. Due to the lack of randomised controlled trials involving pregnant women with asthma, most recommendations were evidenced by consensus and expert opinion rather than high quality meta-analysis, systematic reviews of randomised controlled trials. Conclusion: The recommended antenatal asthma management was generally consistent among the guidelines but lacked clarity in some areas which then leave them open to interpretation. More randomised controlled trials involving pregnant women with asthma are required to fortify the recommendations made and asthma management guidelines should be included in Australian Antenatal Care Guidelines as they currently are not.

© 2017 American Society for Nutrition. Background: Prebiotic soluble fibers are fermented by beneficial bacteria in the colon to produce short-chain fatty acids (SCFAs), which are proposed to have systemic anti-inflammatory effects. Objective: This review examines the effect of SCFAs, prebiotics, and pre- and probiotic combinations (synbiotics) on systemic inflammation. Design: Relevant English language studies from 1947 to May 2017 were identified with the use of online databases. Studies were considered eligible if they examined the effects of SCFAs, prebiotics, or synbiotics; were delivered orally, intravenously, or per rectum; were on biomarkers of systemic inflammation in humans; and performed meta-analysis where possible. Results: Sixty-eight studies were included. Fourteen of 29 prebiotic studies and 13 of 26 synbiotic studies reported a significant decrease in =1 marker of systemic inflammation. Eight studies compared prebiotic and synbiotic supplementation, 2 of which reported a decrease in inflammation with synbiotics only, with 1 reporting a greater anti-inflammatory effect with synbiotics than with prebiotics alone. Meta-analyses indicated that prebiotics reduce C-reactive protein (CRP) [standardized mean difference (SMD): -0.60; 95% CI: -0.98, -0.23], and synbiotics reduce CRP (SMD: -0.40; 95% CI: -0.73, -0.06) and tumor necrosis factor-a (SMD -0.90; 95% CI: -1.50, -0.30). Conclusions: There is significant heterogeneity of outcomes in studies examining the effect of prebiotics and synbiotics on systemic inflammation. Approximately 50% of included studies reported a decrease in =1 inflammatory biomarker. The inconsistency in reported outcomes may be due to heterogeneity in study design, supplement formulation, dosage, duration, and subject population. Nonetheless, meta-analyses provide evidence to support the systemic anti-inflammatory effects of prebiotic and synbiotic supplementation.

© 2017 American Academy of Allergy, Asthma & Immunology Background Obesity is a risk factor for exacerbations of asthma, but the mechanisms of this effect in pregnancy are unknown. Objective This study determined the influence of maternal body mass index, gestational weight gain, eosinophilic inflammation, and systemic macrophage activation on the risk of exacerbations during pregnancy. Methods Women with asthma (n = 164) participated in the study. Body mass index recorded at baseline (17 weeks gestation) was categorized as healthy weight (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2), or obese (>30 kg/m2). Exacerbations requiring medical intervention were recorded prospectively. Asthma control, medication use, and fractional exhaled nitric oxide were assessed monthly; additional visits occurred during exacerbations. Peripheral blood was collected at baseline for the measurement of eosinophils, soluble CD-163, C-reactive protein, and IL-6. Results Exacerbations occurred in a higher proportion of overweight (51.1%) and obese (48.4%) women compared with healthy weight women (25%; P =.026). Excess weight gain during pregnancy was not associated with exacerbation risk. Macrophage activation (elevated serum soluble CD-163) was associated with exacerbations requiring oral corticosteroids (P =.043), whereas high peripheral blood eosinophils or fractional exhaled nitric oxide were not associated with exacerbation or oral corticosteroid use. Conclusions Being overweight or obese confers a greater risk of asthma exacerbation during pregnancy, and may be due to systemic macrophage activation.

© 2014 John Wiley & Sons Ltd Studies have identified prenatal flavour exposure as a determinant of taste preferences in infants; however, these studies have focused on relatively small samples and limited flavours. As many parents struggle with getting children to accept a variety of nutritious foods, a study of the factors influencing food acceptance is warranted. The objective of this study was to determine whether exposure to a wider variety of fruit and vegetables and overall higher diet quality in utero results in acceptance of a greater variety of these foods and better diet quality for offspring during childhood. This study is a secondary data analysis of pregnant women (n = 52) and their resulting offspring recruited for the Women and Their Children's Health study in NSW, Australia. Dietary intake of mothers and children was measured using food frequency questionnaires. Diet quality and vegetable and fruit variety were calculated using the Australian Recommended Food Score and the Australian Child and Adolescent Recommended Food Score. Associations between maternal and child diet quality and variety were assessed using Pearson's correlations and the total effect of in utero maternal pregnancy diet on childhood diet was decomposed into direct and indirect effect using mediation analysis. Maternal pregnancy and post-natal diet were both correlated with child diet for overall diet quality and fruit and vegetable variety (P < 0.001). Mediation analyses showed that the indirect effect of maternal pregnancy diet on child diet was mediated through maternal post-natal diet, particularly for fruit (P = 0.045) and vegetables (P = 0.055). Nutrition intervention should therefore be aimed at improving diet quality and variety in mothers with young children, in order to subsequently improve eating habits of offspring.

© 2016 Elsevier B.V. Background: Venous blood is the usual sample for measuring various biomarkers, including 25-hydroxyvitamin D (25OHD). However, it can prove challenging in infants and young children. Hence the finger-prick capillary collection is an alternative, being a relatively simple procedure perceived to be less invasive. We elected to validate the use of capillary blood sampling for 25OHD quantification by liquid chromatography tandem-mass spectrometry (LC/MS-MS). Methods: Venous and capillary blood samples were simultaneously collected from 15 preschool-aged children with asthma 10 days after receiving 100,000 IU of vitamin-D3 or placebo and 20 apparently healthy adult volunteers. 25OHD was measured by an in-house LC/MS-MS method. Results: The venous 25OHD values varied between 23 and 255 nmol/l. The venous and capillary blood total 25OHD concentrations highly correlated (r2 = 0.9963). The mean difference (bias) of capillary blood 25OHD compared to venous blood was 2.0 (95% CI: -7.5, 11.5) nmol/l. Conclusion: Our study demonstrates excellent agreement with no evidence of a clinically important bias between venous and capillary serum 25OHD concentrations measured by LC/MS-MS over a wide range of values. Under those conditions, capillary blood is therefore adequate for the measurement of 25OHD.

Copyright © ERS 2015. Obese asthma is characterised by infiltration of adipose tissue by activated macrophages and mast cells. The aim of this study was to examine the age and sex effects of immunometabolism in obese asthma. Obese and non-obese asthmatic children and adults underwent spirometry, body composition assessment by dual energy X-ray absorptiometry and measurement of serum soluble CD163 (sCD163), tryptase, C-reactive protein (CRP) and other adipocytokines. Plasma CRP (p<0.01) and leptin (p<0.01) were elevated in obese asthmatic adults, and sCD163 (p=0.003) was elevated in obese asthmatic children. We observed significantly higher sCD163 in obese female children compared to obese female adults and male children, and higher CRP in obese female adults compared to obese male children and adults. Serum tryptase concentrations were not significantly different across age groups. sCD163 positively correlated with the proportion of android fat in obese female children (r=0.70, p=0.003) and obese female adults (r=0.65, p=0.003). In obese female children, sCD163 was inversely associated with forced expiratory volume in 1 s % predicted (r=-0.55, p=0.02) and was positively associated with the Asthma Control Questionnaire (r=0.57, p=0.02). Obese children with asthma have sex-specific macrophage activation, which may contribute to worse asthma control and lung function. The heterogeneous systemic inflammatory profile across age and sex suggests the existence of sub-phenotypes in obese asthma at the molecular level.

© 2015 The Authors. Published by Elsevier Ltd. Background Previous research has demonstrated that plasma carotenoids are a reliable biomarker of usual fruit and vegetable intake. The review aims were to synthesize (i) the mean dietary intake and (ii) plasma concentrations of carotenoids reported from validation studies (iii) compare the strength of the relationship between the two, measured using different dietary assessment methods. Methods Six databases were used to locate studies that included: adult populations, assessment of dietary intake, measurement of plasma carotenoids and reported the comparison between the two measures. Results One hundred and forty-two studies were included with 95,480 participants, the majority of studies were cross-sectional (n = 86), with randomized controlled trials (RCTs) (n = 18), 14 case-control studies and 13 cohorts. The most common reported dietary carotenoid and plasma carotenoid was lycopene: weighted dietary mean intake (4555.4 ug/day), and plasma concentration 0.62 umol/L (95% CI: 0.61, 0.63, n = 56studies. The strongest weighted correlation between the two measures was found for cryptoxanthin (r = 0.38, 95% CI 0.34, 0.42) followed by a-carotene (r = 0.34, 95% CI 0.31, 0.37). Conclusion This review summarizes typical dietary intakes and plasma concentrations and their expected associations based on validation studies conducted to date which provides a benchmark for future validation studies.

Background:Whether body composition is associated with lung function in asthmatic children has not been investigated. This study aimed to primarily investigate whether BMI z-score and body composition were associated with respiratory function in asthmatic children.Methods:In a cross-sectional study, male (n = 27; mean age: 11.9 y (SD: 2.3)) and female (n = 21; mean age: 13.6 y (SD: 2.2)) asthmatic children underwent clinical assessment.Results:BMI z-score was associated with forced expiratory volume in 1 s (FEV 1; r = 0.458), forced vital capacity (FVC; r = 0.477), and total lung capacity (TLC; r = 0.451) in males only (P < 0.05). Total lean mass was associated with FEV 1 (r = 0.655), FVC (r = 0.562), and TLC (r = 0.635) in males, as was thoracic lean mass (FEV 1 (r = 0.573), FVC (r = 0.526), and TLC (r = 0.497); P < 0.05). TLC was associated with total (r = 0.522) and thoracic (r = 0.532) lean mass in females (P < 0.05). Fat mass was not associated with lung function in this group.Conclusion:Lean mass, not fat mass, is associated with lung function in children with asthma. The positive association between BMI z-score and respiratory function in male children is driven by lean mass. Although body weight can be easily monitored in the clinical setting, body composition can provide important information. Future research exploring lean mass and lung function associations could inform future interventions. Copyright © 2014 International Pediatric Research Foundation, Inc.

Asthma is a chronic inflammatory disorder of the airways. The inflammatory response in asthma is heterogeneous. Allergen specific responses lead to activation of the acquired immune system, via a predominantly IL-5 mediated, eosinophilic pathway. Stimuli such as viruses and bacteria activate the innate immune system, via a predominantly IL-8 mediated, neutrophilic pathway. Asthma has also been demonstrated to involve a systemic inflammatory component. Glucocorticoids are the predominant pharmacological treatment used to control inflammation in asthma. However, compliance with medications can be compromised due to patient concerns about side effects. Hence dietary interventions that target the inflammatory response in asthma have great potential. Various aspects of dietary intake are known to modulate inflammation. Saturated fatty acids can induce an inflammatory response via activation of pattern recognition receptors. Omega-3 fatty acids can be anti-inflammatory, via mechanisms such as modification of eicosanoid production. Antioxidants can have anti-inflammatory effects as they scavenge free radicals, preventing activation of transcription factors including NF-¿B. Chronic excess energy intake can lead to obesity, which augments inflammation due to the release of inflammatory mediators by adipose tissue. Here we review the role of these dietary components in asthma. © 2014 Bentham Science Publishers.

©2013 Asian Oceanian Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved. Background: Obese men are more likely to have poor dietary patterns compared to women, increasing diet-related chronic disease risk. The impact of a male-only weight loss intervention on dietary intakes is under-evaluated. The aim was to deter-mine whether overweight/obese men randomised to self-help paper-based resources with or without online support, achieved greater improvements in diet compared with Wait-list controls at 3 and 6 months following a gender tailored weight-loss intervention.Methods: Dietary intake was assessed using a 120-item semi-quantitative food fre-quency questionnaire (FFQ), in a secondary analysis of a three-arm weight lossRCT grounded in Social Cognitive Theory; (1) Resources: gender-tailored weight lossresources (DVD, handbooks, pedometer, tape measure); (2) Online: resources pluswebsite and efeedback, (3) Wait-list control.Results: Energy, total fat, saturated fat, and carbohydrate intakes decreased in theonline group, which differed significantly from controls at 3- and 6-month follow-up(P <0.05). There was a significant reduction in energy, fat and carbohydrate intakesin the Resource group at 3 and 6 months, but no difference from controls (P>0.05).In the online group there was an increase in %energy from core foods and decreasein %energy from energy-dense nutrient-poor foods (P<0.05) that was significantlydifferent compared to controls at 3 and 6 months (P<0.05).Conclusion: Results suggest that men randomised to the SHED-IT intervention armswere able to implement key dietary messages up to 6 months compared to con-trols. Future interventions should include targeted and gender-tailored messages asa strategy to improve mens dietary intake within weight loss interventions.© 2013 Asian Oceanian Association for the Study of Obesity.