Prevalence and characteristics of smoking cigarette and narghile among Syrian refugee parents in Ontario, Canada

This study aimed to explore the prevalence and associated sociodemographic, migration, and health-related factors of smoking cigarettes and narghile among Syrian refugee parents resettled in Ontario, Canada since 2015. A total of 540 Syrian refugee parents, with at least one child less than 18 years of age, were interviewed. Multivariate logistic regression analysis was performed to assess the independent relationship between each of the associated sociodemographic, migration, and health-related factors and smoking cigarettes and narghile. The overall prevalence of smoking was 43% (cigarette = 22%, narghile = 25.6%). The average number of cigarettes smoked per day was 15.4 (SD = 10.1). With regard to smoking narghile, 18.2% of the sample smoked daily, while 35.5% and 52.9% smoked at least once weekly and occasionally, respectively. Results from multivariate logistic regression analysis showed that more fathers were at increased odds of smoking cigarettes than mothers OR (95% CI) = 6.6 (3.7-11.9), while no such difference was found for narghile smokers OR (95% CI) = 1.5 (0.9-2.6). Results showed that smoking cigarettes was associated with lower education levels and being Muslim, whereas smoking narghile was associated with younger age and alcohol use. Poor perceived mental health was significant/approached significance for both types of smoking. Greater understanding of smoking patterns of resettled refugees is needed to direct healthcare providers to offer targeted interventions for those who are most at risk.

Characteristics of Self-Rated Oral Health among Syrian Refugee Parents in Ontario

Background

Canada has been hosting Syrian refugees since early 2015. Almost half of the Syrian refugee population lives in Ontario, with dental health being at the top of the list of important immediate needs. The objective of the study was to evaluate self-rated oral health and its associated factors among Syrian refugee parents residing in Ontario.

Methods

This was a cross-sectional study where 540 Syrian refugee parents, residing in Ontario and with at least one child less than 18 years of age, were interviewed. Information about self-rated oral health was collected based on the question "In general, how would you rate the health of your teeth and mouth?" with answers ranging from 1 representing "excellent" and 5 representing "very poor." Multiple linear regression analysis was performed to assess the independent relationship between each of the sociodemographic-, migration-, health-, dental-related factors, and self-rated oral health.

Results

The overall prevalence of poor and very poor self-rated oral health was 43.5%. The results showed that the presence of dental health insurance, private sponsorship, improved physical and mental health, and regular visits to the dentist were factors related to improved oral health. Discussion. To achieve better oral health outcomes among refugee populations, including Syrian refugees, efforts should be focused on improving dental care and dental insurance for vulnerable populations.

Research priorities for care of preterm or low birth weight infants: health policy

Research priorities for preterm or low birth weight (LBW) infants were advanced in 2012, and other research priority-setting exercises since then have included more limited, context-specific research priorities pertaining to preterm infants. While developing new World Health Organization (WHO) guidelines for care of preterm or LBW infants, we conducted a complementary research prioritisation exercise. A diverse, globally representative guideline development group (GDG) of experts - all authors of this paper along with WHO steering group for preterm-LBW guidelines - was assembled by the WHO to examine evidence and consider a variety of factors in intervention effectiveness and implementation, leading to 25 new recommendations and one good practice statement for care of preterm or LBW infants. The GDG generated research questions (RQs) based on contributions to improvements in care and outcomes of preterm or LBW infants, public health impacts, answerability, knowledge gaps, feasibility of implementation, and promotion of equity, and then ranked the RQs based on their likelihood to further change or influence the WHO guidelines for the care of preterm or LBW infants in the future. Thirty-six priority RQs were identified, 32 (89%) of which focused on aspects of intervention effectiveness, and the remaining four addressed implementation ("how") questions. Of the top 12 RQs, seven focused on further advancing new recommendations - such as family involvement and support in caring for preterm or LBW infants, emollient therapy, probiotics, immediate KMC for critically ill newborns, and home visits for post-discharge follow-up of preterm or LBW infants - and three RQs addressed issues of feeding (breastmilk promotion, milk banks, individualized feeding). RQs prioritised here will be critical for optimising the effectiveness and delivery of new WHO recommendations for care of preterm or LBW infants. The RQs encompass unanswered research priorities for preterm or LBW infants from prior prioritisation exercises which were conducted using Child Health and Nutrition Research Initiative (CHNRI) methodology.

Funding

Nil.

New World Health Organization recommendations for care of preterm or low birth weight infants: health policy

Approximately 11% of infants are born preterm, and complications of prematurity are the most common cause of death in children aged under five years. Almost one million preterm infants die each year across low, high and middle income countries. In 2021, the World Health Organization (WHO) convened a Guideline Development Group (GDG) to examine evidence and formulate recommendations for care of preterm or low birthweight (LBW) infants according to WHO Guideline Review Committee (GRC) criteria. GRADE methods were used to assess the certainty of evidence and the GDG developed judgements using the DECIDE (Developing and Evaluating Communication strategies to support Informed Decisions and practice based on Evidence) framework. Twenty-five recommendations were made; 11 recommendations were new, and 16 were for preventive and promotive care. Kangaroo Mother Care (KMC) was recommended to start immmediately after birth as routine care for all preterm or LBW newborns (except for critically ill infants who are in shock, unable to breath spontaneously after resuscitation, or require ventilatory support) both in the facility and at home. New recommendations were also made for caffeine to treat apnoea and for extubation; family involvement in routine care for preterm or LBW infants; and for post-discharge home-visit follow-up care. New recommendations were also made to consider use of probiotics, emollient therapy, caffeine for prevention of apnoea, continuous positive airway pressure (CPAP) immediately after birth (with or without respiratory distress) in infants less than 32 weeks gestational age; and for family support to enable the care of preterm or LBW infants. The recommendations confirm the pivotal role of preventive and promotive care for preterm and LBW infants, especially the importance of keeping the baby and mother together, and empowering and supporting families to care for their preterm or LBW infant. WHO is now working to help scale up care for small and sick newborns, including organizational shifts in all 'health system building blocks' such as infrastructure, commodities, workforce and monitoring.

Funding

Nil.

A Quality improvement initiative to reduce central line-associated bloodstream infections in a neonatal intensive care unit in a low-and-middle-income country

BACKGROUND

Premature and sick neonates in the neonatal intensive care unit (NICU) are in need of central lines placing them at high risk of contracting a central line-associated bloodstream infection (CLABSI). CLABSI extends length of stay to 10-14 days post negative cultures and increases morbidity, use of multiple antibiotics, mortality and hospital cost. To reduce CLABSI rate at the American University of Beirut Medical Center NICU, the National Collaborative Perinatal Neonatal Network developed a quality improvement project to reduce CLABSI rate by 50% over a 1-year period and to sustain reduced CLABSI rate.

METHODS

Central line insertion and maintenance bundles were implemented for all infants admitted to the NICU necessitating central lines placement. Bundles included hand washing, wearing protective material and sterile drapes during central lines insertion and maintenance.

RESULTS

CLABSI rate decreased by 76% from 4.82 (6 infections; 1244 catheter days) to 1.09 (2 infection; 1830 catheter days) per 1000 CL days after 1 year. Following the bundles' success in reducing CLABSI rate, they were incorporated permanently to NICU standard procedure and bundle checklists were added to the medical sheets. CLABSI rate was maintained at 1.15 per 1000 CL days during the second year. It then decreased to 0.66 per 1000 CL days in the third year before reaching zero in the fourth year. In total, zero CLABSI rate was sustained for 23 consecutive months.

CONCLUSION

Reducing CLABSI rate is necessary to improving newborn quality of care and outcome. Our bundles were successful in drastically reducing and sustaining a low CLABSI rate. It was even successful in achieving a zero CLABSI unit for 2 years.

Global research priorities related to the World Health Organization Labour Care Guide: results of a global consultation

BACKGROUND

The World Health Organization (WHO) published the WHO Labour Care Guide (LCG) in 2020 to support the implementation of its 2018 recommendations on intrapartum care. The WHO LCG promotes evidence-based labour monitoring and stimulates shared decision-making between maternity care providers and labouring women. There is a need to identify critical questions that will contribute to defining the research agenda relating to implementation of the WHO LCG.

METHODS

This mixed-methods prioritization exercise, adapted from the Child Health and Nutrition Research Initiative (CHNRI) and James Lind Alliance (JLA) methods, combined a metrics-based design with a qualitative, consensus-building consultation in three phases. The exercise followed the reporting guideline for priority setting of health research (REPRISE). First, 30 stakeholders were invited to submit online ideas or questions (generation of research ideas). Then, 220 stakeholders were invited to score "research avenues" (i.e., broad research ideas that could be answered through a set of research questions) against six independent and equally weighted criteria (scoring of research avenues). Finally, a technical working group (TWG) of 20 purposively selected stakeholders reviewed the scoring, and refined and ranked the research avenues (consensus-building meeting).

RESULTS

Initially, 24 stakeholders submitted 89 research ideas or questions. A list of 10 consolidated research avenues was scored by 75/220 stakeholders. During the virtual consensus-building meeting, research avenues were refined, and the top three priorities agreed upon were: (1) optimize implementation strategies of WHO LCG, (2) improve understanding of the effect of WHO LCG on maternal and perinatal outcomes, and the process and experience of labour and childbirth care, and (3) assess the effect of the WHO LCG in special situations or settings. Research avenues related to the organization of care and resource utilization ranked lowest during both the scoring and consensus-building process.

CONCLUSION

This systematic and transparent process should encourage researchers, program implementers, and funders to support research aligned with the identified priorities related to WHO LCG. An international collaborative platform is recommended to implement prioritized research by using harmonized research tools, establishing a repository of research priorities studies, and scaling-up successful research results.

Successful establishment and five-year sustainability of a neonatal-specific antimicrobial stewardship program in a low middle-income country

Introduction: Antibiotic use varies substantially among neonatal intensive care units (NICUs) without any appreciable impact on outcomes. An increased use of antimicrobials has been reported in low-middle income countries. This raises the concern for potential overuse of antibiotics in a fragile patient population, thus increasing the rates of multidrug resistant organisms and affecting the developing microbiome. The presence of a neonatal-specific antimicrobial stewardship program can aid with the judicious use of antibiotics in the neonatal population and thus decrease the overuse of such medications. Methods: In this quality improvement project, we established and implemented a neonatal-specific antimicrobial stewardship program with the aim of reducing antimicrobial use in the neonatal intensive care units within a year of starting. Several interventions using a multidisciplinary approach included implementing standard algorithms, direct audit and feedback, and automated hard stops. Results: These series of interventions led to a 35% decrease in antimicrobial usage in the first 3 months and further decrease was seen with a median of 63% decline for a total of 5 years after project implementation. The use of the most commonly prescribed antibiotics, ampicillin and gentamicin, decreased by 63% and 79%, respectively. There was no evidence that this change in practice affected or jeopardized patient outcomes. Additionally, it showed sustainability and resilience despite the many challenges such as COVID-19 pandemic, political and financial unrest, and healthcare sector collapse. Discussion: This model-based and multidisciplinary low-cost approach can lead to marked improvement affecting neonatal outcomes and can be replicated in other similar centers.

Tamponade and massive pleural effusions secondary to peripherally inserted central catheter in neonates-A complication to be aware of

Background

Peripherally inserted central catheters (PICC) are frequently used in neonatal intensive care units (NICU) to assist premature and critically ill neonates. Massive pleural effusions, pericardial effusions, and cardiac tamponade secondary to PICC are extremely uncommon but have potentially fatal consequences.

Objective

This study investigates the incidence of tamponade, large pleural, and pericardial effusions secondary to peripherally inserted central catheters in a neonatal intensive care unit at a tertiary care center over a 10-year period. It explores possible etiologies behind such complications and suggests preventative measures.

Study design

Retrospective analysis of neonates who were admitted to the NICU at the AUBMC between January 2010 and January 2020, and who required insertion of PICC. Neonates who developed tamponade, large pleural, or pericardial effusions secondary to PICC insertion were investigated.

Results

Four neonates developed significant life-threatening effusions. Urgent pericardiocentesis and chest tube placement were required in two and one patients, respectively. No fatalities were encountered.

Conclusion

The abrupt onset of hemodynamic instability without an obvious cause in any neonate with PICC in situ should raise suspicion of pleural or pericardial effusions. Timely diagnosis through bedside ultrasound, and prompt aggressive intervention are critical.

CFTR mutational screening by next-generation sequencing reveals novel variants and a high carrier rate in a Middle Eastern population

Cystic fibrosis is the most common life-limiting autosomal recessive disease in western countries with an incidence of 1:2500 in United States and 1:1000 in some European countries. Similar incidences were noted for the Middle East with variations from 1 in 2560 to 1 in 15,876 according to the degree of consanguinity. This is a preliminary systematic study that aims to assess the incidence and carrier rate of cystic fibrosis in the Middle Eastern Lebanese population; known for a high frequency of consanguinity. One hundred thirteen DNA samples were collected from neonatal blood cards obtained from newborns to healthy unrelated families with no previous history of Cystic fibrosis. Screening for Cystic Fibrosis-causing pathogenic variants was performed using next generation sequencing, and 17 different single nucleotide variants were detected, including six pathogenic and likely pathogenic. 5.5%-7% newborns were found to be carriers of a variant strongly suggestive of pathogenicity and comparable to published literature worldwide. This pilot analysis highlights the challenging interpretation of CFTR variants in a country underrepresented by large ethnic population analyses, and stresses the importance of premarital screening programs for Cystic fibrosis.

Prenatal exposure to criteria air pollutants and associations with congenital anomalies: A Lebanese national study

Maternal exposure to air pollution has been associated with a higher birth defect (BD) risk. Previous studies suffer from inaccurate exposure assessment methods, confounding individual-level variations, and classical analytical modelling. This study aimed to examine the association between maternal exposure to criteria air pollutants and BD risk. A total of 553 cases and 10,214 controls were identified from private and public databases. Two subgroups were then formed: one for a matched case-control design, and another for Feature Selection (FS) analysis. Exposure assessment was based on the mean air pollutant-specific levels in the mother's residential area during the specific BD gestational time window of risk (GTWR) and other time intervals. Multivariate regression models outcomes consistently showed a significant protective effect for folic acid intake and highlighted parental consanguinity as a strong BD risk factor. After adjusting for these putative risk factors and other covariates, results show that maternal exposure to PM_2.5 during the first trimester is significantly associated with a higher overall BD risk (OR:1.05, 95%CI:1.01-1.09), and with a higher risk of genitourinary defects (GUD) (OR:1.06, 95%CI:1.01-1.11) and neural tube defects (NTD) (OR:1.10, 95%CI:1.03-1.17) during specific GTWRs. Maternal exposure to NO₂ during GTWR exhibited a significant protective effect for NTD (OR:0.94, 95%CI:0.90-0.99), while all other examined associations were not statistically significant. Additionally, maternal exposure to SO₂ during GTWR showed a significant association with a higher GUD risk (OR:1.17, 95%CI:1.08-1.26). When limiting selection to designated monitor coverage radiuses, PM_2.5 maintained significance with BD risk and showed a significant gene-environment interaction for GUD (p = 0.018), while NO₂ protective effect expanded to other subtypes. On the other hand, FS analysis confirmed maternal exposure to PM_2.5 and NO₂ as important features for GUD, CHD, and NTD. Our findings, set the basis for building a novel BD risk prediction model.

A global point prevalence survey of antimicrobial use in neonatal intensive care units: The no-more-antibiotics and resistance (NO-MAS-R) study

BACKGROUND

Global assessment of antimicrobial agents prescribed to infants in the neonatal intensive care unit (NICU) may inform antimicrobial stewardship efforts.

METHODS

We conducted a one-day global point prevalence study of all antimicrobials provided to NICU infants. Demographic, clinical, and microbiologic data were obtained including NICU level, census, birth weight, gestational/chronologic age, diagnoses, antimicrobial therapy (reason for use; length of therapy), antimicrobial stewardship program (ASP), and 30-day in-hospital mortality.

FINDINGS

On July 1, 2019, 26% of infants (580/2,265; range, 0-100%; median gestational age, 33 weeks; median birth weight, 1800 g) in 84 NICUs (51, high-income; 33, low-to-middle income) from 29 countries (14, high-income; 15, low-to-middle income) in five continents received ≥1 antimicrobial agent (92%, antibacterial; 19%, antifungal; 4%, antiviral). The most common reasons for antibiotic therapy were "rule-out" sepsis (32%) and "culture-negative" sepsis (16%) with ampicillin (40%), gentamicin (35%), amikacin (19%), vancomycin (15%), and meropenem (9%) used most frequently. For definitive treatment of presumed/confirmed infection, vancomycin (26%), amikacin (20%), and meropenem (16%) were the most prescribed agents. Length of therapy for culture-positive and "culture-negative" infections was 12 days (median; IQR, 8-14) and 7 days (median; IQR, 5-10), respectively. Mortality was 6% (42%, infection-related). An NICU ASP was associated with lower rate of antibiotic utilization (p = 0·02).

INTERPRETATION

Global NICU antibiotic use was frequent and prolonged regardless of culture results. NICU-specific ASPs were associated with lower antibiotic utilization rates, suggesting the need for their implementation worldwide.

FUNDING

Merck & Co.; The Ohio State University College of Medicine Barnes Medical Student Research Scholarship.

Antenatal Dexamethasone for Early Preterm Birth in Low-Resource Countries

BACKGROUND

The safety and efficacy of antenatal glucocorticoids in women in low-resource countries who are at risk for preterm birth are uncertain.

METHODS

We conducted a multicountry, randomized trial involving pregnant women between 26 weeks 0 days and 33 weeks 6 days of gestation who were at risk for preterm birth. The participants were assigned to intramuscular dexamethasone or identical placebo. The primary outcomes were neonatal death alone, stillbirth or neonatal death, and possible maternal bacterial infection; neonatal death alone and stillbirth or neonatal death were evaluated with superiority analyses, and possible maternal bacterial infection was evaluated with a noninferiority analysis with the use of a prespecified margin of 1.25 on the relative scale.

RESULTS

A total of 2852 women (and their 3070 fetuses) from 29 secondary- and tertiary-level hospitals across Bangladesh, India, Kenya, Nigeria, and Pakistan underwent randomization. The trial was stopped for benefit at the second interim analysis. Neonatal death occurred in 278 of 1417 infants (19.6%) in the dexamethasone group and in 331 of 1406 infants (23.5%) in the placebo group (relative risk, 0.84; 95% confidence interval [CI], 0.72 to 0.97; P = 0.03). Stillbirth or neonatal death occurred in 393 of 1532 fetuses and infants (25.7%) and in 444 of 1519 fetuses and infants (29.2%), respectively (relative risk, 0.88; 95% CI, 0.78 to 0.99; P = 0.04); the incidence of possible maternal bacterial infection was 4.8% and 6.3%, respectively (relative risk, 0.76; 95% CI, 0.56 to 1.03). There was no significant between-group difference in the incidence of adverse events.

CONCLUSIONS

Among women in low-resource countries who were at risk for early preterm birth, the use of dexamethasone resulted in significantly lower risks of neonatal death alone and stillbirth or neonatal death than the use of placebo, without an increase in the incidence of possible maternal bacterial infection. (Funded by the Bill and Melinda Gates Foundation and the World Health Organization; Australian and New Zealand Clinical Trials Registry number, ACTRN12617000476336; Clinical Trials Registry-India number, CTRI/2017/04/008326.).

Establishing a High-Quality Congenital Cardiac Surgery Program in a Developing Country: Lessons Learned

Background: Developing countries are profoundly affected by the burden of congenital heart disease (CHD) because of limited resources, poverty, cost, and inefficient governance. The outcome of pediatric cardiac surgery in developing countries is suboptimal, and the availability of sustainable programs is minimal. Aim: This study describes the establishment of a high quality in-situ pediatric cardiac surgery program in Lebanon, a limited resource country. Methods: We enrolled all patients operated for CHD at the Children's Heart Center at the American University of Beirut between January 2014 and December 2018. Financial information was obtained. We established a partnership between the state, private University hospital, and philanthropic organizations to support the program. Results: In 5 years, 856 consecutive patients underwent 993 surgical procedures. Neonates and infants constituted 22.5 and 22.6% of our cohort, respectively. Most patients (82.6%) underwent one cardiac procedure. Our results were similar to those of the Society of Thoracic Surgeons (STS) harvest and to the expected mortalities in RACHS-1 scores with an overall mortality of 2.8%. The government (Public) covered 43% of the hospital bill, the Philanthropic organizations covered 30%, and the Private hospital provided a 25% discount. The parents' out-of-pocket contribution included another 2%. The average cost per patient, including neonates, was $19,800. Conclusion: High standard pediatric cardiac surgery programs can be achieved in limited-resource countries, with outcome measures comparable to developed countries. We established a viable financial model through a tripartite partnership between Public, Private, and Philanthropy (3P system) to provide high caliber care to children with CHD.

Higher Incidence Rates of Hypothyroidism and Late TSH Rise in Preterm Very-Low-Birth-Weight Infants at a Tertiary Care Center

BACKGROUND/AIMS

Preterm newborns with a very low birth weight (VLBW) of < 1,500 g have an atypical form of hypothyroidism with a delayed rise in TSH, necessitating a second newborn screening specimen collection. The aims of this study were to survey the compliance with second newborn screening to detect delayed TSH rise in VLBW preterm infants at a tertiary care center, and to determine the rate of atypical hypothyroidism.

METHODS

Retrospective review of the records of 104 preterm VLBW infants. Late TSH rise was defined as an increase in TSH concentration after 14 days of age in the presence of a normal initial screen.

RESULTS

The compliance rate was 92% for the second screening. High rates of hypothyroidism (16.3%) and of late TSH rise (4.8%) were detected. Patients with hypothyroidism had a significantly lower birth weight (p = 0.01) and longer hospital stay (p = 0.004). Patients with late versus those with early TSH rise had a significantly lower mean birth weight (851 ± 302 vs. 1,191 ± 121 g, p = 0.004).

CONCLUSION

The rates of early and late TSH rise in this VLBW population were higher than those in the literature and could be due to the use of povidone-iodine disinfectants. The yield of a second TSH screening in this study was high indicating the need for vigilance in screening VLBW preterm infants.

Antenatal corticosteroids for women at risk of imminent preterm birth in low-resource countries: the case for equipoise and the need for efficacy trials

The scientific basis for antenatal corticosteroids (ACS) for women at risk of preterm birth has rapidly changed in recent years. Two landmark trials—the Antenatal Corticosteroid Trial and the Antenatal Late Preterm Steroids Trial—have challenged the long-held assumptions on the comparative health benefits and harms regarding the use of ACS for preterm birth across all levels of care and contexts, including resource-limited settings. Researchers, clinicians, programme managers, policymakers and donors working in low-income and middle-income countries now face challenging questions of whether, where and how ACS can be used to optimise outcomes for both women and preterm newborns.

In this article, we briefly present an appraisal of the current evidence around ACS, how these findings informed WHO’s current recommendations on ACS use, and the knowledge gaps that have emerged in the light of new trial evidence. Critical considerations in the generalisability of the available evidence demonstrate that a true state of clinical equipoise exists for this treatment option in low-resource settings. An expert group convened by WHO concluded that there is a clear need for more efficacy trials of ACS in these settings to inform clinical practice.

Strategic assessment of implementation of neonatal resuscitation training at a national level

BACKGROUND

Structuring and implementation of an endorsed neonatal resuscitation program (NRP) results in decreased neonatal mortality. This study evaluated the implementation of formal training using the NRP in a private sector context of a middle income country.

METHODS

Between 2008 and 2011, the National Collaborative Perinatal Neonatal Network (NCPNN) supported by the Ministry of Health piloted the implementation of NRP training in member hospitals throughout the country. Training of trainers (TOT) then providers (TOP) took place via workshops where a lecture was given followed by hands-on training using low-fidelity manikins. Pre- and post-workshop knowledge assessment and hands-on training evaluation were done. t-test and one-way ANOVA were used to compare mean differences in pre- and post-workshop scores and percent improvement across specialties and locations.

RESULTS

Of 20 TOT participants, nine (45%) conducted NRP in their hospitals. Ten TOP workshops included 256 professionals. The majority were doctors (128, 50%), followed by nurses (99, 39%) and midwives (20, 8%). Overall pre-training scores (67.25 ± 16.00%) were significantly lower than post-training scores (87.48 ± 11.89%; P = 0.000); percent improvement among all participants was 37.12 ± 41.15%; P = 0.82). Nurses and participants from the northern governorate had highest mean difference in before/after scores (21.56 ± 12.32 and 23.29 ± 6.62, respectively). Midwives had the highest percent improvement (40.44 ± 47.28). All but 25 participants (9.8%) passed the megacode at the first attempt.

CONCLUSIONS

Implementing NRP training is essential to increase the knowledge and skills of health-care professionals. It is sustainable with support from the Ministry and other sources. Continuing education should be mandated at the Ministry of Health level.

Predictors of RSV LRTI Hospitalization in Infants Born at 33 to 35 Weeks Gestational Age: A Large Multinational Study (PONI)

BACKGROUND

Preterm infants are at high risk of developing respiratory syncytial virus (RSV)-associated lower respiratory tract infection (LRTI). This observational epidemiologic study evaluated RSV disease burden and risk factors for RSV-associated LRTI hospitalization in preterm infants 33 weeks+0 days to 35 weeks+6 days gestational age not receiving RSV prophylaxis.

METHODS

Preterm infants ≤6 months of age during RSV season (1 October 2013-30 April 2014) were followed at 72 sites across 23 countries from September 2013-July 2014 (study period). RSV testing was performed according to local clinical practice. Factors related to RSV-associated hospitalization for LRTI were identified using multivariable logistic regression with backward selection.

RESULTS

Of the 2390 evaluable infants, 204 and 127 were hospitalized for LRTI during the study period and RSV season, respectively. Among these subjects, 64/204 and 46/127, respectively, were hospitalized for confirmed RSV LRTI. Study period and RSV season normalized RSV hospitalization rates (per 100 infant years) were 4.1 and 6.1, respectively. Factors associated with an increased risk of RSV-related LRTI hospitalization in multivariable analyses were smoking of family members (P<0.0001), non-hemodynamically significant congenital heart disease diagnosis (P = 0.0077), maternal age of ≤25 years at delivery (P = 0.0009), low maternal educational level (P = 0.0426), household presence of children aged 4 to 5 years (P = 0.0038), age on 1 October ≤3 months (P = 0.0422), and presence of paternal atopy (P<0.0001).

CONCLUSIONS

During the 2013-2014 RSV season across 23 countries, for preterm infants 33-35 weeks gestation ≤6 months old on 1 October not receiving RSV prophylaxis, confirmed RSV LRTI hospitalization incidence was 4.1 per 100 infant years during the study period and 6.1 per 100 infant years during the RSV season. This study enhances the findings of single-country studies of common risk factors for severe RSV infection in preterm infants and suggests that combinations of 4-6 risk factors may be used to accurately predict risk of RSV hospitalization. These findings may be useful in the identification of infants most at risk of severe RSV infection.

Preconception health assessment in China, Lebanon and the Philippines: applicability to other countries

To test the utility of a preconception checklist tool in identifying preconception health needs of women in three countries; China, Lebanon and the Philippines. An academic medical center within each country participated in the development and testing of a preconception checklist tool, which was administered over a 6 month period to selected target groups in each country. The checklist provided valuable data on the preconception health of 6,530 women. Aggregated data identified common preconception health needs across all countries, including provision of modern contraceptives and adequate immunization coverage; HIV and STI screening; treatment for anemia; and counseling for maintenance of a healthy weight. A preconception checklist tool was found to be useful in distinct cultural settings. The study was a pilot. Future steps include validation and standardization of the checklist, data from which could be used to help shape preconception care policies and implementation strategies.

Improving awareness of preconception health among adolescents: experience of a school-based intervention in Lebanon

BACKGROUND

Maternal behavior before and after conception affects maternal and child health. Limited awareness of adolescents in preconception health may be addressed through school education. The aim of this intervention is to assess preconception health awareness among adolescents in Lebanese high schools and to test the effectiveness of a one-time educational session in improving preconception knowledge.

METHODS

The intervention consisted of a 30-minute educational session about good practices in preconception health, developed by the National Collaborative Perinatal Neonatal Network's (NCPNN) research team. A convenience sample of high school Lebanese students in grades 10 to 12, aged 14 to 26 years old, from 70 private and public schools in all six Lebanese provinces, participated in the intervention in 2011 and 2012. A multiple-choice questionnaire administered prior to and 2 months after the session was used to assess knowledge improvement among the students.

RESULTS

A total of 7,290 students were enrolled. After the session, mean scores of correct answers increased from 4.36 to 6.42 out of 10, representing a 47.2% improvement (p < 0.001). The percent of correct answers increased for all the questions regarding health practices (p < 0.001). The greatest improvement was observed for questions about Trisomy 21, folic acid intake and toxoplasmosis with percentages improvement of 96%, 172% and 83% respectively. Being female or in private school was a significant predictor of higher scores in both pre-test and post-test (p < 0.001).

CONCLUSIONS

Awareness campaigns in schools increased the preconception health knowledge among high school students. We recommend expanding the scope of this intervention into universities in Lebanon.

The effect of consanguinity on neonatal outcomes and health

Consanguineous marriages constitute a significant fraction of marriages worldwide and confer a major public health concern on newborns. In addition to the risk of acquiring a recessive genetic disease, the offspring of consanguineous parents are plausibly at an increased risk of preterm birth, decreased anthropometric measurements, congenital defects and mortality. How consanguinity confers such an increased risk is still largely unknown. In this review, we discuss the effect of consanguinity on selected gestational outcomes by delineating the different studies that have led to such findings. We also investigate the different conclusions that have emerged regarding the effect of consanguinity on gestational outcomes.

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study

BACKGROUND

We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities.

METHODS

In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios.

RESULTS

From May 1, 2010, to Dec 31, 2011, we included 314,623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23,015 (7.3%) women had potentially life-threatening disorders and 3024 (1.0%) developed an SMO. 808 (26.7%) women with an SMO had post-partum haemorrhage and 784 (25.9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0.826 [95% CI 0.802-0.851]).

INTERPRETATION

High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy.

FUNDING

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

In-hospital neonatal mortality and the role of consanguinity

BACKGROUND

Consanguinity which increases the risk of genetic disorders has been implicated at times in infant mortality. The aim of this study was to determine the association between consanguinity and in-hospital mortality in newborns.

METHODS

Data was collected prospectively on all births from 26 hospitals in Lebanon from January 2004 to December 2008 and admitted to the National Collaborative Perinatal Neonatal Network. Secondary analysis was done on 65,402 singletons, after exclusion of stillbirths, infants of multiple gestation and infants of second cousin progeny.

RESULTS

In-hospital mortality was 6.7 per 1000 live births (439/65,402). The rate of first cousin marriage was 9.9%. Consanguinity was significantly associated with in-hospital mortality (odds ratio 2.4; 95% confidence interval (CI): 1.8, 3.1); consanguinity remained a significant predictor of mortality (odds ratio 1.8 [95% CI: 1.2, 2.9]) after adjusting for maternal age and education, crowding index, history of abortion, prenatal care, mode of delivery, gender, birthweight and apgar score at 5 minutes.

CONCLUSIONS

This association of consanguinity with in-hospital mortality points to potential genetic factors leading to this increased risk. Designing public health interventions, including raising the awareness and taking into consideration such risks in neonatal mortality studies are indicated.

Goldenhar syndrome associated with prenatal maternal Fluoxetine ingestion: Cause or coincidence?

Goldenhar syndrome, also known as oculo-auriculo-vertebral spectrum, is a complex, heterogeneous condition characterized by abnormal prenatal development of facial structures. We present the occurrence of Goldenhar syndrome in an infant born to a woman with a history of prenatal Fluoxetine ingestion throughout her pregnancy. Because this is the first reported case associating maternal Fluoxetine intake with fetal craniofacial malformations, a potential mechanism of injury is discussed. The propositus, a male born from nonconsanguinous parents, had facial asymmetry with right microtia and mandibular hypoplasia; he also had bilateral hypoplastic macula, scoliotic deformity of the thoracic spine, and ventricular septal defect. The mother was under treatment with Fluoxetine 20 mg/day prior to conception and maintained the same dosage throughout her pregnancy. The drug is a selective serotonin re-uptake inhibitor, the most widely prescribed for the treatment of depression. The occurrence of developmental aberrations may be caused by a profound serotonin receptor suppressive state in utero leading to aberrant clinical manifestations of the first and second branchial arches. Despite the very many limitations of case reporting of teratogenic events, it remains an important source of information on which more advanced research is based.

Mutational spectrum of cystic fibrosis in the Lebanese population

BACKGROUND

Cystic fibrosis (CF) is the most common autosomal recessive disease in Caucasians; it is however, considered to be rare in the Arab populations. Reports of the cystic fibrosis transmembrane regulator (CFTR) mutations from Arabs, especially from the Lebanese population, are limited.

METHODS

Twenty-two unrelated Lebanese families, with at least one child with CF, were studied. DNA extracts from blood samples of patients and parents were screened for CFTR gene mutations.

RESULTS

Eleven different mutations were identified. Of the 44 alleles studied, the most common mutations were: F508del (34%), N1303K (27%), W1282X (7%), and S4X (7%). Five mutations - not previously reported in the Lebanese population - were identified; these are: S549N, G542X, 2043delG, 4016insG, and R117H-7T.

CONCLUSIONS

The most common CFTR mutations in addition to five mutations not previously described in the Lebanese population were identified. Identification of CFTR mutations in the Lebanese population is important for molecular investigations and genetic counseling.

Prenatal and neonatal Group B Streptococcus screening and serotyping in Lebanon: incidence and implications

The study aimed at determining the prevalence, risk factors, perinatal transmission, and serotypes of Group B Streptococcus (GBS) among pregnant women and their newborns in Beirut, Lebanon. This was a cross-sectional study of all pregnant women admitted from February to September 2006 to three major hospitals. Overall, 137 of 775 (17.7%) mothers and 50 of 682 newborns (7.3%) tested positive for GBS. Maternal colonization was not associated with maternal age, household income, gravidity, intrapartum fever, preterm labor, or premature rupture of membrane. Transmission rate was 40/120 (30%). Serotype 5 (24.1%) was the most common followed by serotype 1a (15.0%), 3 (14.4%), 2 (11.8%) and 1b (7.5%). Pregnant women in Lebanon appear to have a relatively high prevalence of GBS colonization with no identifiable risk factors for its acquisition. These results could provide basis for the institution of a national policy for universal maternal GBS screening to reduce neonatal morbidity and mortality.

Prospective study on antibiotics misuse among infants with upper respiratory infections

BACKGROUND

The judicious prescription of antibiotics has become a central focus of professional and public health measures to combat the spread of resistant organisms.

MATERIALS AND METHODS

A one-year multi-center prospective follow-up study of 1,320 healthy infants was conducted. The study aim was to determine the prevalence and identify the predictors of antibiotics misuse in viral respiratory illnesses among healthy infants in the first year of life. Infants born between August 2001 and February 2002 were recruited through the clinics and dispensaries of 117 pediatricians located in the Greater Beirut area of Lebanon. On each routine visit from birth until one year of life, pediatricians reported any episodes of upper respiratory tract infection (URTI; common cold) and bronchiolitis, as well as the treatment type, duration, and dose. Predictors that were considered included infant, maternal, and pediatrician characteristics.

RESULTS

Of the 1,320 recruited infants, 770 (58.3%) had common cold or acute bronchiolitis on at least one occasion during the study period. Pediatricians prescribed antibiotics at least once in 21.4% of cases diagnosed as the common cold and 45.5% of cases of acute bronchiolitis. Logistic regression analysis revealed that antibiotics misuse was more common among infants born to mothers with lower educational levels (odds ratio [OR] = 1.6; 95% confidence interval [CI]: 1.1-2.3). Furthermore, pediatricians tend to prescribe antibiotics in dispensaries more often than in private clinics (OR = 1.4; 95% CI: 1.0-2.3).

CONCLUSION

This study shows a substantial quantity of antibiotics prescriptions for common cold and acute bronchiolitis in our population. Our findings suggest that lower maternal education and pediatricians working in dispensaries (versus private clinics) are associated with increased antibiotics misuse.

Consanguinity and reproductive wastage in the Palestinian Territories

Many studies have found that consanguinity poses a threat to child mortality and health and can also pose a threat to offspring survival before birth. However, there are conflicting findings with some studies having found no increased risk on offspring survival associated with consanguinity. Data from a population-based survey conducted in 2004 in the Palestinian Territories was used to assess the risk of consanguinity on offspring survival. The analysis was conducted on 4418 women aged 15-49 who were asked whether or not they had experienced a stillbirth or a spontaneous abortion. These two outcomes were combined together for the analysis of reproductive wastage. Multivariable negative binomial regression was conducted to calculate the incidence risk ratios (IRR) for each region in the Palestinian Territories separately. The strongest risk factors for reproductive wastage, after controlling for other variables, were found to be consanguinity, age and parity with age presenting the highest IRRs. Standard of living, locality type, education level, women's employment and past intrauterine device use were not found to be significant risk factors for reproductive wastage. In the West Bank only first cousin level of consanguinity was found to be significant and 'hamola' level (or from same family clan) lost its significance after adjusting for other variables. In the Gaza Strip both the first cousin and 'hamola' levels of consanguinity were significant and presented almost equal IRRs of 1.3. In conclusion, consanguinity was found to be a significant risk factor for reproductive wastage.

Dextrocardia and corrected transposition of the great arteries (I,D,D) in a case of Kartagener's syndrome: a unique association

Kartagener's syndrome (KS) usually includes mirror-image dextrocardia. The incidence of congenital heart disease in KS is comparable with that in the general population. This paper reports on a case of Kartagener's syndrome associated with dextrocardia, corrected transposition of the great arteries (I,D,D), ventricular septal defect, and valvar pulmonary stenosis in an 8-year-old girl.

Incidence and correlates of cesarean section in a capital city of a middle-income country

OBJECTIVE

To determine the prevalence and correlates of cesarean deliveries (CS) in Beirut.

METHODS

A cross-sectional study conducted on 18,837 consecutive infants born at nine hospitals from the National Collaborative Perinatal Neonatal Network (NCPNN). Stepwise Logistic Regression was performed to determine CS correlates.

RESULTS

The rate of CS was 26.4% and correlated with socio-demographic, obstetrical and provider-related variables. Regression analysis identified age, paternal occupation, mode of payment, parity, birth weight, gestational age, multiple pregnancies, adequate prenatal care, complications during pregnancy, body mass index at delivery, hospital teaching status, day of the week and year of delivery to be significant correlates of CS.

CONCLUSION

This study shows an increased CS rate in a middle-income country, and identifies the correlates of women delivering by the abdominal route. These correlates may be used for effective reduction policies in the future.

Consanguineous marriage and congenital heart defects: a case-control study in the neonatal period

The independent effect of consanguinity on the prevalence of congenital heart defects (CHDs), all and specific types, was investigated in newborns admitted to nine hospitals located in Beirut, Lebanon and members of the National Collaborative Perinatal Neonatal Network (NCPNN). Cases were 173 newborns admitted to the Neonatal Intensive Care Units (NICU) of participating hospitals during the 3-year period from January 1, 2000 to December 31, 2002 and diagnosed during their hospital stay as having one or more CHD. Cases with chromosomal abnormalities were excluded. Cases with more than one CHD were assigned one principal malformation. Controls consisted of a random sample of 865 newborns without a CHD admitted to the NICU during the same period. After controlling for confounders, first cousin consanguinity remained significantly associated with an increased risk of CHD: infants born to first cousin marriages had a 1.8 times higher risk of having a CHD diagnosed at birth compared to those born to unrelated parents (95% CI: 1.1-3.1). In particular, first-cousin marriage was a significant risk factor for ventricular septal defect (VSD), atrial septal defect (ASD), hypoplastic left heart (HLH), and single ventricle (SV). No association was found with d-transposition of the great arteries, coarctation, pulmonary atresia (PA), atrioventricular septal defect (AVSD), and tetralogy of Fallot (TOF). The results of this study suggest a familial factor in the multifactorial etiology of CHDs. Additional epidemiologic and family-based genetic studies are needed to understand the complex cause of CHDs.

Low socioeconomic status and neonatal outcomes in an urban population in a developing country

OBJECTIVE

To investigate the effect of low socioeconomic status indicators, specifically parental educational and occupational characteristics on neonatal health outcomes.

METHODS

Analysis of 3372 newborn infants admitted to five National Collaborative Perinatal Neonatal Network centers (1 February 2000 to 31 January 2002). Outcomes included birth weight, gestational age, admission to the neonatal intensive care unit (NICU) and length of hospital stay. The independent effects of mother's education and occupation as well as father's occupation on health outcomes were assessed by means of stepwise logistic regression analysis.

RESULTS

A total of 271 (8.0%) infants were of low birth weight, 306 (9.1%) were preterm, 410 (12.2%) had NICU admissions and 240 (7.1%) were hospitalized for more than a week. After adjusting for maternal gravidity, age, smoking during pregnancy and pregnancy-related complications, parental socioeconomic characteristics had no significant impact on low birth weight or preterm birth. NICU admission and prolonged hospitalization were significantly correlated with skilled, semi-skilled and unskilled paternal occupations. Illiterate mothers had nearly 3-5 times the risk of NICU admission and prolonged hospitalization.

CONCLUSION

Both father's occupation and mother's education play an important role as determinants of neonatal morbidity characteristics.

Impact of maternal age on preterm delivery and low birthweight: a hospital-based collaborative study of nulliparous Lebanese women in Greater Beirut

OBJECTIVES

To analyze the impact of maternal age at first childbirth on the incidence of preterm delivery and low birthweight among single live births delivered to nulliparous Lebanese women in Greater Beirut.

STUDY DESIGN

Eligible subjects were selected from a consecutive sample of neonatal admissions to nine National Collaborative Perinatal Network participating hospitals over a three-year period (April 1, 1999 to March 31, 2002). Chi-square tests and logistic regression analyses were applied.

RESULTS

Out of 5556 nulliparous mothers, 5.4% had a preterm delivery and 5.2% a low-birthweight infant. In the multivariate analysis, preterm delivery was not significantly affected by old maternal age. Mothers aged 25 years or more remained a high-risk group for low birthweight even after controlling for potentially confounding characteristics.

CONCLUSIONS

Maternal age at first childbirth above 25 years is an independent risk factor for low birthweight, but not for preterm delivery, an outcome influenced mainly by obstetric complications.

Consanguinity and apnea of prematurity

Consanguinity, marriage between relatives, has been associated with perinatal mortality and morbidity. Apnea of prematurity is defined as the cessation of breathing for longer than 20 seconds or that of any duration if accompanied by cyanosis and sinus bradycardia, for infants born before 37 weeks of gestation. The objective of the study was to examine the association between consanguinity and apnea of prematurity in Greater Beirut, an area having a relatively high prevalence rate of consanguineous marriages. The study was cross-sectional. Between September 1, 1998, and March 31, 2001, 21723 newborn infants were admitted to the National Collaborative Perinatal Neonatal Network in Greater Beirut, Lebanon. The inclusion criteria were infants less than 37 weeks of gestation who were admitted to the intensive care unit, with no congenital malformations, sepsis, or neurologic disorders. Analysis was based on 597 infants of whom 66 had apnea of prematurity. With adjustment for weeks and type of gestation, pregnancy complications, and Apgar score, the odds ratio of apnea of prematurity for first-degree consanguineous parents as compared with other marriages was 2.9 (95% confidence interval: 1.3, 6.4). In addition to the recognized etiologic factors for apnea of prematurity, this study suggests a role played by genetic factors.

Exposure of children to environmental tobacco smoke (ETS) and its association with respiratory ailments

OBJECTIVES

To assess the impact of domestic passive smoking (cigarettes or narghile) on the development of respiratory ailments among children ages 10-15 years.

METHODS

Students were recruited from five private schools in Beirut, and information on demographic, in-home smoking, and students' respiratory tract illnesses (cough, wheezing, runny nose, or nasal congestion) were collected from each participant.

RESULTS

Of 625 students surveyed, 438 (70.1%) had at least one individual smoking at home. Compared with the nonexposed group, the odds ratio of having respiratory illness for children exposed to narghile or cigarette smoke were 2.3 (95% Confidence Interval [CI] 1.1-5.1) and 3.2 (95% CI 1.9-5.4), respectively.

CONCLUSIONS

In addition to the well-established effect of smoking, domestic passive smoking of the misconceived "innocuous" habitual smoking device, narghile, is associated with significant respiratory health ailments.

Efficacy, tolerability, and kinetics of lamotrigine in infants

OBJECTIVES

To investigate the efficacy, tolerability, and kinetics of lamotrigine during the first year of life.

STUDY DESIGN

We studied 13 infants with intractable seizures; 7 had partial seizures and 7 had infantile spasms (1 had both). Patients received open-label lamotrigine as add-on therapy for 3 months. Seizure frequency, response ratio, and side effects score were determined and compared with the baseline period.

RESULTS

The rate of partial seizures per day decreased from 8.57 +/- 2.29 to 4.00 +/- 2.15 (P =.027) and infantile spasms from 8.71 +/- 2.15 to 3.61 +/- 2.762 (P =.028). Apparent clearance increased during the first year of life, with a break point at 2 months of age (mean, 0.119 +/- 0.021, 0.217 +/- 0.094 L/h per kilogram for infants <2 months and those 2 to 12 months old, respectively,P <.001). Twenty-four-hour concentration to time plots of three 3- to 4-week-old neonates showed a half-life of 23.44 +/- 3.57 hours. Compared with a group of 17 older children, LTG had similar efficacy (response ratios, -0.68 +/- 0.12 and -0.74 +/- 0.11, P =.504), and similar adverse effects scores (0.67 +/- 0.67 and 0.23 +/- 0.166, P =.95).

CONCLUSIONS

Lamotrigine is a useful and well tolerated drug for partial seizures and infantile spasms in infants <1 year of age. However, lamotrigine has age-dependent kinetics that must be taken into consideration.

Dynamics of breathing in the hypoxic awake lamb

Newborn mammals respond to hypoxia with an immediate hyperventilation that is rapidly dampened. Changes in mechanical properties of the respiratory system during hypoxia have been considered an important reason for this fall in minute ventilation (VE). We have studied the dynamic mechanical behavior of the respiratory system in eight unanesthetized intact newborn lambs (mean age 2 days) during normoxia and hypoxia (FIO2 = 0.08). Mouth pressure (P), airflow (V), and volume (V) were recorded while lambs were breathing through a leak-proof face mask and a pneumotachograph. Active compliance (C') and resistance (R') of the respiratory system were computed from P developed during an inspiratory effort against airway closure at end expiration and V and V of the preceding breaths. Tidal expiratory V-V curves were analyzed to estimate the elevation in functional residual capacity (FRC) over resting volume (Vr). After hypoxia, there was an immediate increase in VE in the first 2 min, from 0.49 to 1.13 l.kg-1.min-1, followed by a rapid decrease to 0.80. After 8 min of hypoxia, C' was unchanged. The inspiratory R' decreased during hypoxia, probably reflecting a drop in inspiratory laryngeal resistance. The expiratory V-V curves during hypoxia showed considerable braking, often with a double peak in expiratory V. This pattern was only occasionally seen during normoxia. In animals with a linear segment of the expiratory V-V curves the FRC-Vr difference could be calculated and averaged 1.93 ml/kg during normoxia and 3.47 during hypoxia. The recoil P of the respiratory system at end expiration was 0.75 cmH2O during normoxia vs. 1.63 cmH2O during hypoxia (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)