Building a maternal and child cohort amidst Lebanon's socioeconomic collapse: preliminary results and navigating research challenges

The impact of conflict and crisis on maternal and child health underscores the need for reliable research in vulnerable populations. Lebanon, amidst ongoing economic collapse, political instability, and healthcare system strain, offers a case study for exploring these impacts, particularly on preterm babies and their development. This study aims to assess the feasibility of establishing a prospective cohort of mothers and their full-term and preterm babies in Lebanon, examining the association between social determinants, preterm birth, and developmental outcomes amidst the nation's multifaceted crises. The planned cohort involves 50 full-term and 50 preterm mother-baby pairs recruited at birth and followed up to 9-12 months post-birth. Data collection spans social determinants, perceived stress, social support, quality of life, and developmental assessments. Challenges in recruitment, follow-up, and data collection in the context of Lebanon's socio-political and economic turmoil are evaluated, alongside ethical considerations for research in vulnerable populations. Preliminary findings highlight substantial recruitment and follow-up challenges, notably due to population mobility, economic instability, and healthcare access issues. Despite these obstacles, 113 mother-baby pairs have been recruited. Early analysis reveals significant stress and reduced quality of life among mothers, particularly those with preterm infants, against a backdrop of declining birth rates and healthcare worker exodus. Conducting research in crisis settings like Lebanon presents unique methodological and ethical challenges but remains crucial for understanding and improving health outcomes in vulnerable populations. The study underscores the importance of adaptable research designs and ethical diligence in crisis research, highlighting the need for interventions tailored to these contexts. Establishing a mother and child cohort in Lebanon's crisis-ridden setting is faced with many challenges but is essential for guiding future interventions. Research in such contexts is needed to address health disparities and supporting vulnerable populations, emphasizing the need for dedicated funding and innovative research approaches in times of crisis.

Determinants of human papillomavirus vaccine hesitancy among Lebanese parents

INTRODUCTION

Human papillomavirus (HPV) is the most common sexually transmitted infection. HPV is responsible for cancer of cervix uteri. Despite its safety and immunogenicity, HPV vaccine hesitancy is one of the most challenging topics that pediatricians face.

METHODS

We aimed to describe the impact of knowledge, attitude, and practice towards vaccines in general, on practice related to HPV vaccination in Lebanon. A questionnaire addressed to parents of students (3-18 years of age) was distributed in 2 public and 2 private schools randomly selected from the greater Beirut area during the school year 2017-2018. Questionnaires covered knowledge, attitude, and practices of vaccination in general and HPV vaccine in particular.

RESULTS

Out of 400 distributed questionnaires, 306 (76.5%) were returned. Of the 185 parents aware of HPV vaccine, 60% hadn't given or were not planning to give the HPV vaccine to their children. Of parents not in favor of HPV vaccine, 7.5 thought that vaccines aren't necessary versus none among those in favor of HPV vaccine(p = 0.02). Thirteen percent of those not in favor of HPV vaccine thought that vaccines are not safe versus 2.7% in the group in favor (p = 0.02). An effect of gender on vaccine acceptance was noted: mothers vs fathers and daughters vs sons. Lack of recommendation by pediatricians and the thought that too little is known about the vaccine were the most selected reasons for parents not wanting to vaccinate their children against HPV, whereas cost and religious and cultural beliefs seemed to have no impact.

CONCLUSION

Most parents in our study did not vaccinate or weren't willing to vaccinate their children against HPV even when they were in favor of vaccines in general. Physician recommendation was shown to be one of the most important predictors of vaccination. Effort should be put into educating parents about the importance of the vaccine and its well-established safety and efficacy regardless of gender. Lebanese physicians should also be educated and empowered to recommend HPV vaccine more strongly and consistently.

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.

Music as an adjunct to combination analgesia for neonatal circumcision: A randomized controlled trial

INTRODUCTION

Neonatal circumcision is one of the most frequently performed procedures in male infants; it is also particularly painful. In a previous trial, we showed that the combination of Eutectic Mixture of Local Anesthetics (EMLA) + Sucrose + Ring Block (RB) was significantly effective in reducing pain during circumcision.

OBJECTIVE

In this study, we added music as an adjunct aiming to further reduce the pain scores.

STUDY DESIGN

This was a double-blinded randomized controlled trial comparing EMLA + Sucrose + RB (Control) to EMLA + Sucrose + RB + Music (Intervention). The trial setting was the normal nursery of a university teaching hospital. One hundred and three healthy newborn males were randomized to each of the intervention and control groups. Babies were videotaped (face and torso) during the procedure for assessment of pain by two blinded and independent reviewers. The primary outcome measure was the NIPS score; secondary outcomes included heart rate, oxygen saturation and crying time.

RESULTS

The NIPS score of the intervention group (EMLA + Sucrose + RB + Music [2.6 ± 1.6]) was significantly higher than that of the control group (EMLA + sucrose + RB [1.4 ± 0.9]) (p = 0.00). Inter-rater reliability was high (κ .89). The intervention group registered significantly higher mean heart rate (142 bpm) and increased mean crying time (5.44 s) compared to the control group (135 bpm and 1.63s, respectively) (p = 0.01) and (p = 0.00). No adverse events were noted. Delivery music medicine by playing it from an iPad in the procedure room did not reduce pain during circumcision.

DISCUSSION

There is overwhelming evidence in the literature describing the effectiveness of music on pain management especially in the NICU. However, our results did not align with the general trend; not only did music medicine fail to enhance analgesia but it might have had the opposite effect, further agitating the infants, as indicated by the significantly increased heart rate, crying time and NIPS scores of the participants in the intervention group. Limitations of our study include the fact that this is a single center study and the method of delivering music via iPads instead of noise-canceling headphone.

CONCLUSION

Our results showed that music, delivered in this manner, may have increased agitation. We affirm the fact that the combination of EMLA + Sucrose + RB is highly effective for managing pain during circumcision and further reduction of already low scores might not be possible.

CLINICAL TRIAL REGISTRATION

Registry Name: ClinicalTrials.gov; Registration number: NCT04252313; link: https://clinicaltrials.gov/ct2/show/NCT04252313.

Implementing NIDCAP training in a low-middle-income country: Comparing nurses and physicians' attitudes

BACKGROUND

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) provides developmentally supportive environment for preterm infants and their families. Few studies evaluated staff perceptions about NIDCAP implementation and its effect on infant and parents and working conditions.

AIMS

To assess the perception and experience of NICU staff during the NIDCAP implementation.

STUDY DESIGN

Cross-sectional anonymous online survey.

SUBJECTS

57 NICU staff (29 nurses and 28 doctors) who were present at least one year prior to and during the implementation of NIDCAP training in a tertiary care center.

OUTCOME MEASURES

A standard questionnaire addressing attitude, perceived behavioral control, subjective norm, intention, behavior and NIDCAP impact related to NICU conditions was used after initiating developmental care activities and NIDCAP training in the unit from June 2014 to May 2018.

RESULTS

Forty-six doctors and nurses filled the questionnaire; they scored ≥3 out of 5 on all the questionnaire items. Nurses scored significantly higher than doctors (mean 4.00 ± 036) versus (3.57 ± 0.30) (p < 0.001) on the overall NIDCAP score. Specifically, nurses scores were significantly higher for attitude (p < 0.001), perceived behavioral control (p = 0.029); subjective norm (p = 0.011), intention (p = 0.024) and behavior (p < 0.001) questions.

CONCLUSION

The implementation of NIDCAP in a low-middle income country was perceived as a positive experience for both nurses and doctors: It was thought to have improved infant care and wellbeing as well as the staff relationship with parents, however working conditions remained a challenge. More studies are needed to address areas of improvement for implementation.

Validation of the Arabic version of the breastfeeding behavior questionnaire among Lebanese women

BACKGROUND

The Breastfeeding Behavior Questionnaire (BBQ) assesses women's perceptions of their breastfeeding behavior. It was adapted to several languages and used in different settings, but has not been validated in Arabic-speaking populations. None of the previous studies that used the BBQ in other cultures examined its ability to predict the actual breastfeeding behaviors of mothers postpartum. This study validated the BBQ in a cohort of Lebanese pregnant women between December 2013 and January 2016, and examined whether it can predict exclusive breastfeeding at one, three and six months.

METHODS

The internal consistency reliability and construct validity of the Arabic BBQ (BBQ-A) were tested on 354 pregnant women. Its predictive ability was assessed by correlating the women's BBQ-A scores with their breastfeeding outcomes at one, three and six months post-delivery.

RESULTS

The BBQ-A had a good internal consistency reliability (Cronbach's alpha = 0.78). Exploratory factor analysis revealed that it is unidimensional. Inter-item correlations ranged between - 0.016 and 0.934, with corrected-item total correlations ranging from 0.273 to 0.678. Perceived positive breastfeeding behavior correlated with positive breastfeeding attitudes, good breastfeeding knowledge and stronger breastfeeding intention supporting its external validity. However, in binomial multivariate logistic regression analysis, the BBQ-A did not predict exclusive breastfeeding at one, three or six months.

CONCLUSIONS

The BBQ-A is a reliable and valid instrument to assess women's perceptions of their breastfeeding behavior in an Arab context. Availability of this instrument is important for investigators conducting breastfeeding research in the Arab world. However, the BBQ-A does not predict exclusive breastfeeding at one, three or six months. Further research on the Breastfeeding Behavior Questionnaire is needed to examine its predictive validity in other cultures.

A multi-component intervention to support breastfeeding in Lebanon: A randomized clinical trial

Background

Effective evidence-based breastfeeding support interventions can bolster breastfeeding practices. This study investigated the effect of a multi-component breastfeeding support intervention delivered in hospital and home settings on six-month exclusive breastfeeding (EBF) relative to standard care.

Methods

This is a parallel group, randomized clinical trial, in which 362 healthy pregnant women with singleton pregnancy were randomly allocated to a multi-component intervention that included antenatal breastfeeding education, professional, and peer support, delivered in hospital and home settings for six months (experimental, n = 174), or to standard care (control, n = 188). The primary outcome was six-month EBF rate. Secondary outcomes were exclusive and any breastfeeding rates at one and three months, maternal breastfeeding knowledge, attitude, and behavior at six months, and satisfaction with the intervention.

Results

The crude six-month EBF rate was similar in both groups (35.2% vs. 28.1% in the experimental and control groups, respectively, p = 0·16). In adjusted analysis, six-month exclusivity was twice as likely in the experimental group relative to standard care (OR = 2.02; 95%CI: 1.20 to 3.39); whereas the odds for any breastfeeding were similar. Participants compliant with all three components were six times more likely to practice EBF for six months relative to standard care (OR = 6.63; 95% CI: 3.03 to 14.51). Breastfeeding knowledge of the experimental group, at six months, was significantly improved compared to the control. No changes were observed in breastfeeding attitude or behavior.

Conclusions

Combining education with peer and professional breastfeeding support improved six-month breastfeeding exclusivity and knowledge.

Establishing an ECMO program in a developing country: challenges and lessons learned

Aim:

The ECMO (extracorporeal membrane oxygenation) Program at the American University of Beirut Medical Center was established in November 2015 as the first program serving adult and pediatric population in a low-resource setting. The aim of the study is to describe the challenges faced during the establishment of the program and factors leading to its success.

Methods:

The program establishment is described. The preparation phase, included the strategic, financial, and clinical planning by administration, nursing, and a multidisciplinary team of physicians. The training and education phase included all the involved nurses, perfusionists, and physicians. Concerns were heard from various stakeholders, and the challenges were analyzed and discussed.

Results:

The preparation committee chose the adequate equipment, responded to the concerns, defined roles and responsibilities through credentialing and privileging, wrote policies and protocols, and established a strategy to decide for the ECMO indication. Selected team of nurses, physicians, and perfusionists are identified and trained locally, and abroad. A full-time ECMO physician was recruited to launch the program. Twelve patients (6 adults, 3 children, and 3 neonates) were supported by ECMO, for cardiac and respiratory indications. Eleven patients were supported by veno-arterial ECMO, and 1 patient (a neonate) with veno-venous ECMO. Overall, 75% survived to decannulation and 41% survived to discharge.

Conclusion:

With limited human and financial resources, new ECMO centers need to carefully establish selection criteria that may differ from those used in developed countries. Indications should be discussed on a case by case basis, taking into account clinical, social, and financial issues. This experience might help other institutions in developing countries to build their own program despite financial and human limitations.

Targeted educational program improves infant positioning practice in the NICU

Quality problem or issue

Infant positioning may interfere with neuromotor development. Bedside education and Infant Positioning Assessment Tool (IPAT) improve nurses' and doctors' proficiency in applying proper infant positioning.

Initial assessment

Nursing compliance with proper positioning is suboptimal due to many factors. One factor was the inadequate knowledge and practice of infant positioning, since the baseline mean IPAT score was 3.4.

Choice of solution

Three experienced neonatal intensive care unit (NICU) nurses were chosen as position champions to help other NICU nurses apply proper positioning and monitor IPAT scores. Education and hands-on demonstration sessions were developed based on the observed baseline practice.

Implementation

Periodic education with hands-on demonstration was given to NICU nurses and residents. Infants' positions were objectively scored using IPAT. Two Plan, Do, Study and Act cycles were completed and adjustments were made based on each cycle's achieved results.

Evaluation

Mean IPAT scores increased from 3.4 at baseline and 6.3 in the second cycle to 7.3 in the third cycle of intervention.

Lessons learned

A systematic approach targeting infants' positioning succeeded in improving nurses' and residents' clinical performance. Not reaching significant change until after 18 months highlights the difficulty and complexity in changing behaviors.

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.

When a physician and a clinical ethicist collaborate for better patient care

Bioethics is a relatively new addition to bedside medical care in Arab world which is characterized by a special culture that often makes blind adaptation of western ethics codes and principles; a challenge that has to be faced. To date, the American University of Beirut Medical Center is the only hospital that offers bedside ethics consultations in the Arab Region aiming towards better patient-centered care. This article tackles the role of the bedside clinical ethics consultant as an active member of the medical team and the impact of such consultations on decision-making and patient-centered care. Using the case of a child with multiple medical problems and a futile medical condition, we describe how the collaboration of the medical team and the clinical ethics consultant took a comprehensive approach to accompany and lead the parents and the medical team in their decision-making process and how the consultations allowed several salient issues to be addressed. This approach proved to be effective in the Arab cultural setting and indeed did lead to better patientcentered care.

Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial

OBJECTIVES

There is no consensus on the most effective pain management for neonatal circumcision. We sought to compare different modalities.

METHODS

This is a double-blinded randomized controlled trial comparing 3 combination analgesics used during circumcision (EMLA + sucrose; EMLA + sucrose + dorsal penile nerve block [DPNB]; EMLA + sucrose + ring block [RB]) with the traditional topical analgesic cream EMLA alone. The trial was set in the normal nursery of a teaching hospital. The sample included 70 healthy male newborns, randomly assigned to intervention and control groups at a 2:1 ratio. Infants were videotaped (face and torso) during the procedure for assessment of pain by 2 blinded, independent reviewers. The primary outcome measure is the Neonatal Infant Pain Scale score. Secondary outcomes include heart rate, oxygen saturation, and crying time.

RESULTS

Neonatal Infant Pain Scale scores were significantly lower in the intervention groups (EMLA + sucrose, mean [SD]: 3.1 [1.33]; EMLA + sucrose + DPNB: 3 [1.33]; EMLA + sucrose + RB: 2.45 [1.27]) compared with the control (5.5 [0.53]). Between-group analyses showed RB + EMLA + sucrose to be significantly more effective than EMLA + sucrose; EMLA + sucrose + DPNB (P = .009 and P = .002, respectively). Interrater reliability was κ = 0.843. Significant increase in heart rate (139.27 [9.63] to 163 [13.23] beats per minute) and crying time (5.78 [6.4] to 45.37 [12.39] seconds) were noted in the EMLA group.

CONCLUSIONS

During neonatal circumcision in boys, the most effective analgesia is RB combined with oral sucrose and EMLA cream.

NeoSeal to Prevent Nasal Injury in Preterm Infants Receiving Oxygen Therapy

PURPOSE

To determine if a foam septum protector prevents nasal injury in preterm infants receiving nasal heated humidified oxygen.

DESIGN

A retrospective before and after comparative design was used.

SAMPLE

Medical records of 101 preterm infants receiving either nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV) were reviewed; 50 were in the control group and 51 were in the intervention group that had the NeoSeal septum protector applied. The groups were not different in terms of gender, birth weight, gestational age, days intubated, or on days on NCPAP/NIPPV. Skin condition of nares was scored daily using the Neonatal Skin Risk Assessment Scale (NSRAS).

RESULTS

Infants who had the NeoSeal applied had significantly less nasal injuries, OR = 4.08; 95% confidence interval (CI), 1.22-9.59; p = .01. The best predictors of nasal injury were gestational age and whether the NeoSeal was applied or not.

Preterm infants exhibited less pain during a heel stick when they were played the same music their mothers listened to during pregnancy

AIM

Playing music during painful procedures has shown inconsistent benefits for preterm infants. This study observed preterm infants during a heel stick procedure to assess whether listening to the music their mothers listened to during pregnancy had any impact on their pain and physiological and behavioural parameters.

METHODS

We randomly exposed 42 preterm infants, with a mean gestational age of 31.8 ± 2.79 weeks, to the music their mothers listened to during pregnancy, recorded lullabies and no music, before, during and after a heel stick. Pain responses were measured using the Neonatal Pain, Agitation and Sedation Scale (N-PASS), and physiological and behavioural responses were recorded by a nurse blinded to the intervention.

RESULTS

N-PASS pain scores were lowest during mothers' music, with a mean of 1.40 (±1.28), compared to 2.33 (±1.64) for no music and 1.62 (±2.27) for the lullabies [F(3/121) = 4.86, p = 0.009]. Physiological parameters were not significantly different between the conditions. During the mothers' music, infants spent more time in a quiet alert state, with a significant decrease in their respiratory rates.

CONCLUSION

The music mothers listened to during pregnancy was more beneficial for preterm infants, as it decreased pain and improved behavioural states during a heel stick.

Ophthalmologic Outcomes of Children Born Premature Without ROP: Correlations With Gestational Age and Psychomotor Development

PURPOSE

To study ophthalmological outcomes of premature children with no retinopathy of prematurity (ROP) and correlate with neurodevelopmental outcomes.

METHODS

A total of 69 former preterm infants were evaluated at 2 to 7 years of age. Detailed ophthalmologic examinations were performed. Neurodevelopment was assessed using the Peabody Developmental Motor Scale and Wechsler Preschool and Primary Scale of Intelligence. Another 69 healthy children served as controls.

RESULTS

The 69 preterm children (38 of 69 boys) and 69 controls (38 of 69 boys) had a mean age of 4.9 ± 1.5 and 4.9 ± 1.4 years, respectively. Compared to controls, preterm infants had vision impairment of 19% versus 1.4% (P = .001), hyperopia of 87% versus 98.5% (P = .21), myopia of 11% versus 1.4% (P = .017), and astigmatism of 39% versus 30.4% (P = .37). Children with any motor disability tended to have worse vision.

CONCLUSIONS

In the absence of ROP, hyperopia was more common in infants 32 weeks or older who weighed more than 1,500 g at birth; other vision problems were similar in subgroups. This may represent impending myopia in those younger than 32 weeks weighing less than 1,500 g. [J Pediatr Ophthalmol Strabismus. 2017;54(1):32-38.].

Adaptation and Validation of the Arabic Version of the Infant Breastfeeding Knowledge Questionnaire among Lebanese Women

BACKGROUND

Valid instruments that can reliably assess maternal breastfeeding knowledge in Arabic-speaking populations are nonexistent. The availability of such an instrument is essential for investigators working in this field.

OBJECTIVE

This study aimed to describe the adaptation and validation of the Arabic Breastfeeding Knowledge Questionnaire (BFK-A) from the original 20-item English version.

METHODS

A translated version of the 20-item BFK was validated among 417 Lebanese women after pilot testing for clarity, comprehension, length, and cultural appropriateness. Exploratory factor analysis was run to examine dimensionality of the instrument and Kuder-Richardson-20 (KR-20) was used to assess its internal consistency.

RESULTS

The BFK-A is a unidimensional scale with acceptable internal consistency reliability (KR-20 = 0.652) after the exclusion of 4 items. Higher breastfeeding knowledge levels were strongly and statistically significantly associated with higher mean scores for the validated Arabic Iowa Infant Feeding Attitude Scale ( P < .001), thus confirming its construct validity.

CONCLUSION

The Arabic 16-item BFK-A has an acceptable reliability, similar to the original instrument. Further studies are encouraged to confirm the validity of the 16-item BFK-A among other Arab populations. There is also a need to develop more reliable instruments to use in lactation research in this context.

Sensorimotor therapy and time to full oral feeding in <33weeks infants

BACKGROUND

Previous research has shown that oral stimulation improves feeding skills in preterm infants. However, it remains unclear whether other sensorimotor therapies have similar effect.

OBJECTIVE

To investigate the effect of sensorimotor therapy on the time to reach full oral feeding (FOF) in infants <33weeks.

METHODS

Retrospective review compared two time periods between 2009 and 2014, before (PRE TX) and after (POST TX) initiation of sensorimotor therapy to infants <33weeks. Type and number of sensorimotor therapy, time to FOF and length of stay (LOS) were collected. Statistical analysis used SPSS 22 for descriptive, non-parametric testing, chi-square and multivariate linear regression computation.

RESULTS

Of 245 records, 137 were excluded due to death, record unavailability/incompleteness or transfer. The remaining 55 in PRE TX and 53 in POST TX infants differed by small for gestational age (SGA) (36.4% vs. 28.3%, p=0.02); sepsis (81.8% vs. 54.7%, p=0.002); patent ductus arteriosus (PDA) (5.5% vs. 22.6%, p=0.01) and bradycardia (47.3% vs. 83%, p<0.0001). Infants in (POST TX) achieved FOF in 6.3±4.3days vs. 8.8±6.6days in (PRE TX) (p=0.02); their LOS was 56.8±26.4 vs. 52.2±25.1 (p=0.36). Predictors of days to FOF were any number of therapy sessions (β=-4.31; 95% CI: -6.47:-2.15), LOS (β=0.05; 95% CI: 0.004:0.09), PDA (β=3.23; 95% CI: 0.27:6.19) and bradycardia (β=2.94; 95% CI: 0.62:5.26).

CONCLUSION

Providing any type of sensorimotor therapy decreased time to reach FOF in infants <33weeks. Structured guidelines may help optimize this effect.

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.

Validation of the Arabic Version of the Iowa Infant Feeding Attitude Scale among Lebanese Women

BACKGROUND

There is need in the Arab world for validated instruments that can reliably assess infant feeding attitudes among women. The 17-item Iowa Infant Feeding Attitude Scale (IIFAS) has consistently shown good reliability and validity in different cultures and the ability to predict breastfeeding intention and exclusivity.

OBJECTIVE

This study assessed the psychometric properties of the Arabic version of the IIFAS (IIFAS-A).

METHODS

After translating to classical Arabic and back-translating to English, the IIFAS-A was pilot tested among 20 women for comprehension, clarity, length, and cultural appropriateness. The IIFAS-A was then validated among 170 women enrolled in a breastfeeding promotion and support clinical trial in Lebanon.

RESULTS

The IIFAS-A showed acceptable internal consistency reliability (Cronbach's α = 0.640), with principal components analysis revealing that it is unidimensional. The 17 items had good interitem reliabilities ranging between 0.599 and 0.665. The number of breastfed children was the only predictor of the overall IIFAS-A score in a multivariate stepwise regression model (β = 1.531, P < .0001).

CONCLUSION

The 17-item IIFAS-A is a reliable and valid instrument for measuring women's infant feeding attitudes in the Arab context.

Association of Pre-Pregnancy Body Mass Index and Gestational Weight Gain with Preterm Births and Fetal Size: an Observational Study from Lebanon

BACKGROUND

Pre-pregnancy body mass index (BMI) and gestational weight gain (GWG) are reported to impact the preterm birth (PTB) rate and newborn size. Most studies have been conducted in developed countries, although PTB and adverse pregnancy outcomes are more frequent in the developing world. The aim of this study is to elucidate the association of pre-pregnancy BMI and GWG on the occurrence of PTB and sub-optimal fetal size in Lebanon.

METHODS

This is a retrospective cohort study using a hospital-based register covering 35% of births in Lebanon between 2001 and 2012. Data were collected on 170 428 pregnancies from 32 hospitals using medical records and interviews.

RESULTS

After adjusting for confounders, underweight women had increased odds of having very preterm [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.16, 2.14], preterm (OR 1.42, 95% CI 1.28, 1.58), and small for gestational age (SGA) (OR 1.50, 95% CI 1.37, 1.63) neonates. When BMI was analysed with GWG, only SGA remained significant in underweight women with low GWG. For all BMI groups, low GWG was protective against large for gestational age (LGA) and high GWG increased the odds of LGA. GWG, both low (OR 1.25, 95% CI 1.15, 1.35) and high (OR 1.43, 95% CI 1.32, 1.55) increased the risk of PTB in normal weight women. The same result was obtained for overweight women.

CONCLUSIONS

High GWG increased the risk of LGA for all groups and PTB in normal weight and overweight women, whereas low GWG increased the risk of SGA and PTB. Given that there are not many studies from middle income/developing countries on patterns of weight gain during pregnancy, findings from this study may help with pre-conception counselling with emphasis on the importance of an optimal pre-pregnancy BMI and appropriate weight gain during pregnancy.

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.

Axillary and rectal thermometry in the newborn: do they agree?

Background

Accurate measurement of body temperature is critical for the assessment of a newborn’s general well-being. In nursery settings, the gold standard rectal thermometry has been replaced by the axillary method. However, evidence pertaining to the agreement between axillary and rectal thermometry in the newborn is controversial. In this cross-sectional study, the agreement between axillary and rectal temperature in newborns, as well as the effects of neonatal, maternal and environmental factors on this agreement were investigated.

Methods

The mean difference between axillary and rectal temperatures was compared in stable term and preterm newborns using paired t-test for the means of differences, Pearson correlation coefficient (r), and the Bland-Altman plot. Stepwise multivariate regression assessed predictors of this difference in the overall group and by gestational age categories.

Results

The study included 118 newborns with gestational ages ranging from 29 to 41 weeks, median birth weight of 2980 grams (IQR: 2321.3-3363.8). Axillary and rectal temperatures correlated significantly (r = 0.5, p = 0.000) and had similar overall means but differed in 34–36 weeks gestation newborns (p = 0.01). Correlation between both methods increased with advancing gestational age being highest in term newborns (r = 0.6, p = 0.000). Bland-Altman plots revealed good agreement in gestational ages above 29 weeks. The difference between measurements increased with Cesarean delivery (ß = 0.2; 95% CI: 0.02, 0.38), but decreased with advancing chronological age (ß = -0.01; 95% CI: -0.02,-0.01), and with gestational age (ß = -0.05; 95% CI: -0.08,-0.01).

Conclusion

In clinically stable term and preterm infants, axillary thermometry is as reliable as rectal measurement. Predictors of agreement between the two methods include gestational age, chronological age and mode of delivery. Further studies are needed to confirm this agreement in sick newborns and in extremely premature infants.

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.

Noninvasive Nitric Oxide Therapy in Right Ventricular Systolic Dysfunction Following Arterial Switch Procedure

Right ventricular dysfunction is uncommon following surgical repair of dextrotransposition of great arteries (d-TGA) by the arterial switch procedure. Inhaled nitric oxide (iNO) is a specific pulmonary vasolidator that has proven successful in treating pulmonary hypertension when delivered via endotracheal tube. We present a five-month-old infant with d-TGA and ventricular septal defect (VSD) who developed pulmonary hypertensive crisis, causing severe right ventricular dysfunction with hemodynamic deterioration at day 6 postsurgical repair by VSD closure and arterial switch. He was successfully treated with iNO via nonrebreather face mask avoiding endotracheal reintubation. This modality should be considered in the management of such infants.

Simulation training in endotracheal intubation in a pediatric residency

BACKGROUND

Airway management and endotracheal intubation are essential skills for pediatric residents. Simulation-based technology is used for training residents but it remains unclear whether high fidelity simulation results in better retention of skills compared to low fidelity. The study assesses high fidelity simulation of endotracheal intubation and traditional low fidelity training in improving pediatric residents' knowledge retention and technical skills; and if the difference translates into higher "real time" intubation success rates.

METHODS

Second and third year pediatric residents were randomized into high fidelity (intervention) or low fidelity simulation (control) groups. Airway management and intubation skills were taught using a didactic lecture and demonstration on low fidelity mannequins. Knowledge was assessed before randomization (T0) and 6 months after training (T6). Other outcome measures were: 1) airway management and intubation skills at T6 and T12 (12 months later) and 2) successful intubation of actual patients by T12.

RESULTS

10 out of 11 residents completed the intervention. Theoretical knowledge improved for both groups. Participants made less mistakes (M) overtime: M (T0) = 3.2 and M (T6) = 2.6 for the intervention group, and M (T0) = 4 and M (T6) = 2.40 for the control. There was no significant effect of fidelity on intubation skills or the number of successful intubations recorded in logbooks (allp > 0.05). In some instances intubation skills showed regression over time.

CONCLUSION

High fidelity simulation showed no impact on residents' airway management and intubation skills. Retention of theoretical knowledge persisted over time while practical skills remained at baseline or declined.

Survival at the threshold of viability: a nationwide survey of the opinions and attitudes of physicians in a developing country

BACKGROUND

To explore physicians' opinions and attitudes regarding resuscitation of extremely premature infants (EPIs) in a developing country with suboptimal resources.

METHODS

A survey was developed, revised, and pilot-tested. All 964 paediatricians registered in the Lebanese Order of Physicians were contacted; physicians involved in resuscitation of EPIs were eligible. Between February and April of 2009, anonymous surveys were mailed to consenting participants.

RESULTS

Three hundred twenty-eight eligible physicians agreed to participate. One hundred twenty (36%) returned the survey, 45.3% of which were neonatologists. The vast majority agreed that parents would like to be informed and to participate in the resuscitation decision of an EPI. The majority of physicians considered infants at gestational age of ≤25 weeks (78%) or ≤800 g (89%) as non-viable. Physician's age, years of practice, and practising neonatal intensive care unit level were significantly associated with the choice of birthweight at which infants were considered non-viable.

CONCLUSIONS

The majority of surveyed physicians consider infants at gestational age less than or equal to 25 weeks gestation or 800 g at birth as non-viable, and therefore would not attempt their resuscitation. Factors influencing threshold of viability in developing countries need to be addressed and explored further.

A complex breastfeeding promotion and support intervention in a developing country: study protocol for a randomized clinical trial

Background

Breastfeeding has countless benefits to mothers, children and community at large, especially in developing countries. Studies from Lebanon report disappointingly low breastfeeding exclusivity and continuation rates. Evidence reveals that antenatal breastfeeding education, professional lactation support, and peer lay support are individually effective at increasing breastfeeding duration and exclusivity, particularly in low-income settings. Given the complex nature of the breastfeeding ecosystem and its barriers in Lebanon, we hypothesize that a complex breastfeeding support intervention, which is centered on the three components mentioned above, would significantly increase breastfeeding rates.

Methods/Design

A multi-center randomized controlled trial. Study population: 443 healthy pregnant women in their first trimester will be randomized to control or intervention group. Intervention: A “prenatal/postnatal” professional and peer breastfeeding support package continuing till 6 months postpartum, guided by the Social Network and Social Support Theory. Control group will receive standard prenatal and postnatal care. Mothers will be followed up from early pregnancy till five years after delivery. Outcome measures: Total and exclusive breastfeeding rates, quality of life at 1, 3 and 6 months postpartum, maternal breastfeeding knowledge and attitudes at 6 months postpartum, maternal exclusive breastfeeding rates of future infants up to five years from baseline, cost-benefit and cost-effectiveness analyses of the intervention. Statistical analysis: Descriptive and regression analysis will be conducted under the intention to treat basis using the most recent version of SPSS.

Discussion

Exclusive breastfeeding is a cost-effective public health measure that has a significant impact on infant morbidity and mortality. In a country with limited healthcare resources like Lebanon, developing an effective breastfeeding promotion and support intervention that is easily replicated across various settings becomes a priority. If positive, the results of this study would provide a generalizable model to bolster breastfeeding promotion efforts and contribute to improved child health in Lebanon and the Middle East and North Africa (MENA) region.

Trial registration

Current Controlled Trials ISRCTN17875591

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.

A Lebanese family with autosomal recessive oculo-auriculo-vertebral (OAV) spectrum and review of the literature: is OAV a genetically heterogeneous disorder?

Oculo-auriculo-vertebral (OAV) spectrum summarizes a continuum of ocular, auricular, and vertebral anomalies. Goldenhar syndrome is a variant of this spectrum and is characterized by pre-auricular skin tags, microtia, facial asymmetry, ocular abnormalities, and vertebral anomalies of different sizes and shapes. Most cases are thought to be sporadic. However, a few families were reported to have an autosomal recessive inheritance and other families' presentation of the syndrome strongly supported an autosomal dominant inheritance. We report OAV in a female infant presenting with tracheomalacia, diaphragmatic hernia, encephalomeningocele, sacral neural tube defect, and cardiac defect and her brother having no more than dysmorphic features. The mode of inheritance in this family supports an autosomal recessive inheritance where the transmission was from normal first-degree consanguineous parents to one of the sons and to the daughter. This report further broadens the clinical presentation and symptoms of OAV and supports the hypothesis advancing OAV as a genetically heterogeneous disorder.

Transient bilirubin encephalopathy and apnea of prematurity in 28 to 32 weeks gestational age infants

OBJECTIVE

Apnea of prematurity (AoP) is, in part, a reflection of brainstem-mediated respiratory control system maturation. We previously demonstrated changes in brainstem function in relation to hyperbilirubinemia (bilirubin encephalopathy, (BE)) as evaluated by auditory brainstem evoked responses (ABR) in infants 28 to 32 weeks gestational age (GA). We hypothesized that in this population, as bilirubin increases and causes auditory brainstem dysfunction, respiratory control system may also be adversely affected leading to increased frequency of AoP.

STUDY DESIGN

We studied 100, 28 to 32 weeks GA infants and identified 66 with normal and 34 with abnormal ABR progression in temporal relation to hyperbilirubinemia (BE). The abnormal ABR progression was associated with elevated bilirubin, specifically elevated unbound bilirubin levels. A blinded, retrospective chart review quantified the amount of weekly apnea and bradycardia events during the hospital stay, total duration of methylxanthine treatment, total duration of mechanical ventilation, CPAP, and/or nasal cannula, and risk factors for apnea (sepsis, IVH grade >II, asphyxia). Since mechanical ventilation confounds the identification of apnea, infants requiring mechanical ventilation were excluded from further review (n = 60; 21 with BE and 39 with normal ABR progression). Data from the remaining 40 infants were analyzed. Student's t-test was used to analyze continuous variables if the distribution was normal otherwise Wilcoxon-ranked-sum test was used. chi(2) was used to analyze nominal variables. A p < or =0.05 was considered significant.

RESULTS

There was no difference in risk factors between infants with and without BE. BE was identified on day 3 (median; range 1 to 6 days). Patients with BE had significantly more apneic events (15 vs 2, p = 0.0009), bradycardic events (14 vs 1, p = 0.02), and required more prolonged treatment with CPAP (2.2 vs 0.5 days, p = 0.007), nasal cannula (6.6 vs 2.2 days, p = 0.02), and methylxanthines (9.5 vs. 1.9 days, p = 0.002) than those with normal ABR progression. The difference in the incidence of apnea and bradycardia between infants with and without BE was most pronounced during the first week.

CONCLUSIONS

Premature infants with transient bilirubin encephalopathy as defined by abnormal ABR progression in relation to hyperbilirubinemia have more concurrent apneic events and require more prolonged respiratory support and medications.

A critical birth weight and other determinants of survival for infants with severe intrauterine growth restriction

Our objective was to assess the perinatal management and neonatal outcomes of premature, severely intrauterine growth-restricted (IUGR) neonates. A cohort of neonates <1000 grams, < or = first percentile for weight, and <37 weeks' gestation was identified and matched 2:1 to two control sets of premature, appropriate-for-gestational age (AGA) infants-one with similar gestational age (AGA-GA group) and the other with similar birth weight (AGA-BW group) to determine the effect of IUGR on the outcome of the premature infant. The IUGR group was then examined in detail for descriptive statistics. Data were analyzed by t-tests and Chi-square analyses where appropriate. The IUGR infants had worse outcomes than AGA-GA controls but had somewhat better results than the AGA-BW controls. In the IUGR group, a birth weight less than 550 grams was significantly associated with neonatal death (p < 0.001). However, increasing gestational age was not associated with neonatal survival (p = 0.661) if birthweight remained below 550 grams. Classical cesarean delivery was associated with neonatal death (p = 0.003). Neonatal variables associated with poor outcome included patent ductus arteriosus (p = 0.034), feeding intolerance (p = 0.046), and failure to thrive (p = 0.05). Overall, neonatal survival was 73%. Of the surviving neonates, 69% had evidence of neurodevelopmental delay when tested at 6 and 12 months. Premature, growth-restricted neonates with birth weights of <550 grams versus those of >550 grams have dismal outcomes despite a gestational age that is compatible with survival.

Atypical chronic lung disease patterns in neonates

OBJECTIVE

To determine, in the postsurfactant era, the incidence and clinical characteristics of infants with atypical versus traditionally defined bronchopulmonary dysplasia (BPD) among premature infants with birth weights <1251 g.

DESIGN

Retrospective cohort study.

SETTING

A single regional neonatal intensive care unit (level III/IV).

PATIENTS

Two hundred thirty-two premature infants <1251 g at birth consecutively admitted during a 2-year period.

MAIN OUTCOME MEASURE

Incidence of classic BPD and atypical chronic lung disease (CLD) (occurring without preceding respiratory distress or after recovery from respiratory distress).

RESULTS

Among 177 infants <1251 g who survived to 28 days, 27 (15%) had atypical CLD and 61 (34.5%) had classic BPD. Atypical CLD infants were significantly heavier and more mature than classic BPD infants (mean birth weights, 922 +/- 152 g vs 854 +/- 173 g; and mean gestational age, 26.8 +/- 1.3 weeks vs 26.1 +/- 1.6 weeks). Median duration of ventilator support (31 days; range, 2 to 127 vs 42 days; range, 4-145 days) and oxygen therapy (30 days; range, 11 to 163 vs 48 days; range, 19-180 days) were shorter in atypical CLD infants than in classic BPD infants.

CONCLUSION

Atypical CLD comprised 31% of total cases of CLD. Atypical CLD appears to be less severe than classic BPD. These data suggest that initial, acute lung injuries are not the sole antecedents of neonatal CLD.

Hyperoxia increases keratinocyte growth factor mRNA expression in neonatal rabbit lung

Acute hyperoxic lung injury remains a major factor in the development of chronic lung disease in neonates. A critical step in the repair of acute lung injury is the proliferation of type II alveolar epithelial cells. Type II cell proliferation is stimulated by keratinocyte growth factor (KGF), an epithelial cell-specific mitogen. We sought to investigate KGF mRNA expression in relation to type II cell proliferation during hyperoxic lung injury. We studied a previously described newborn (NB) rabbit model of acute and chronic hyperoxic injury [C. T. D'Angio, J. N. Finkelstein, M. B. LoMonaco, A. Paxhia, S. A. Wright, R. B. Baggs, R. H. Notter, and R. M. Ryan. Am. J. Physiol. 272 (Lung Cell. Mol. Physiol. 16): L720-L730, 1997]. NB rabbits were placed in 100% O2 for 9 days and then recovered in 60% O2. RT-PCR was used to synthesize and amplify a 267-bp fragment of rabbit KGF cDNA from whole lung RNA. KGF mRNA expression was analyzed by ribonuclease protection assay, and mRNA abundance was quantified by phosphorimaging. Proliferating cell nuclear antigen immunohistochemistry was used on lung sections to identify proliferating cells. The rabbit partial cDNA sequenced was >95% homologous to human cDNA, and all amino acids were conserved. Whole lung KGF mRNA expression was increased 12-fold after 6 days of hyperoxia compared with control lungs, and remained increased throughout the 100% O2 exposure period. Proliferating cell nuclear antigen immunohistochemistry showed an increase in type II cell proliferation after 8-12 days of hyperoxia. NB rabbits exposed to hyperoxic injury exhibit increased whole lung KGF mRNA expression preceding type II cell proliferation. KGF may be an important mitogen in the regulation of alveolar epithelial repair after hyperoxic lung injury.

Disseminated coagulopathy associated with transtorcular embolization of vein of Galen aneurysm in a neonate

We describe in this report the development of disseminated intravascular coagulopathy in a neonate after transtorcular embolization of an unusual vein of Galen aneurysm. This rare but potentially fatal complication associated with transtorcular embolization should be considered in decision-making and prognostic evaluation processes, especially in neonates with severe heart failure.