ARTICLEPEDIATRICS Volume 137 , number 3 , March 2016 :e 20152915

Hypoxia Challenge Testing in Neonates for Fitness to FlySusanne Vetter-Laracy, PhD, MD,a Borja Osona, MD,b Jose Antonio Peña-Zarza, MD,b Jose Antonio Gil, MD,b Joan Figuerola, PhD, MDb

abstractBACKGROUND: Preflight hypoxia challenge testing (HCT) in a body plethysmograph has

previously been done only on infants >3 months of corrected gestational age (CGA). This

study aims to determine the earliest fit-to-fly age by testing neonates <1 week old.

METHODS: A prospective observational study was carried out on 3 groups of infants: healthy

term infants ≤7 days old, preterm infants (≥34 weeks CGA) 2 to 3 days before discharge,

and preterm infants with bronchopulmonary dysplasia (BPD). HCT was conducted using a

body plethysmograph with a 15% fraction of inspired oxygen. The oxygen saturation (SpO2)

test fail point was <85%.

RESULTS: Twenty-four term (mean CGA 40 weeks), 62 preterm (37 weeks), and 23 preterm

with BPD (39.5 weeks) infants were tested. One term infant (4.2%) and 12 preterm infants

without BPD (19.4%) failed. Sixteen (69.3%) preterm infants with BPD failed (P < .001),

with a median drop in SpO2 of 16%. At 39 weeks CGA, neither preterm infants without BPD

nor term infants had an SpO2 <85%. However, 7 of 12 term infants with BPD failed the HCT.

CONCLUSIONS: Term and preterm infants without BPD born at >39 weeks CGA do not appear to

be likely to desaturate during a preflight HCT and so can be deemed fit to fly according to

current British Thoracic Society Guidelines.

Divisions of aNeonatology and bPaediatric Respiratory Medicine, Department of Paediatrics, University Hospital

Son Espases, Palma de Mallorca, Spain

Drs Vetter-Laracy and Osona conceptualized and designed the study, carried out the initial

analysis and interpretation of data collection, and drafted the initial manuscript; Drs Peña-Zarza,

Gil, and Figuerola made substantial contributions to conception and design and reviewed and

revised the manuscript; and all authors coordinated and supervised data collection, approved

the fi nal manuscript as submitted, and agree to be accountable for all aspects of the work

in ensuring that questions related to the accuracy or integrity of any part of the work are

appropriately investigated and resolved.

DOI: 10.1542/peds.2015-2915

Accepted for publication Dec 2, 2015

Address correspondence to Susanne Vetter-Laracy, Department of Paediatrics, Division of

Neonatology, University Hospital Son Espases, Carretera Valldemossa 79, 07120 Palma de

Mallorca/Spain. E-mail: vettersusan@yahoo.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant

to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of

interest to disclose.

To cite: Vetter-Laracy S, Osona B, Peña-Zarza JA, et al.

Hypoxia Challenge Testing in Neonates for Fitness to Fly.

Pediatrics. 2016;137(3):e20152915

WHAT’S KNOWN ON THIS SUBJECT: Preterm

infants ≥3 months of corrected gestational age

and without bronchopulmonary dysplasia are at no

greater risk of hypoxia compared with term infants

during a prefl ight hypoxic challenge test in a body

plethysmograph thus can be considered fi t to fl y.

WHAT THIS STUDY ADDS: Preterm and term infants

without pulmonary problems from a corrected

gestational age of >39 weeks are not at risk for

hypoxia during a prefl ight hypoxic challenge test in a

body plethysmograph.

by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

VETTER-LARACY et al

Commercial planes fly at 9000

to 13 000 m, requiring cabin

pressurization to 1530 to 2440 m.

At this altitude, the reduced pO2 is

equivalent to breathing ∼15% oxygen

(fraction of inspired oxygen [FIO2]

0.15) at sea level. It is already well

known that pulse oxygen saturation

(SpO2) declines significantly in

healthy children and adults (∼4%,

down to 94.4%) during commercial

airline travel, but this is not

considered pathologic.1,2 Newborns

are particularly susceptible to

hypoxemic episodes in a hypoxic

environment because of factors

such as an increased tendency for

ventilation-perfusion mismatch and

a left shift of the oxygen dissociation

curve due to fetal hemoglobin in

the first months of life.3 Premature

infants have more apneic pauses

and periodic breathing when they

reach term than term infants, and

apneic pauses may be triggered by

chronic hypoxemia.4–6 Thus, studies

testing term infants and premature

infants during the first months of life

for fitness to fly have been ruled out

by most other researchers despite

the fact that the number of families

wanting to take their newborns on

flights shortly after delivery has

increased.7–11

The British Thoracic Society

(BTS) has published guidelines for

infants stating that term newborns

(>37 weeks) should wait 1 week

after birth term before traveling,

premature infants who have not

reached term should have in-flight

oxygen of 1 to 2 L/min (grade C

evidence), and premature infants

<1 year old with neonatal chronic

respiratory problems should undergo

hypoxia challenge testing (HCT).12,13

Son Espases neonatal unit is located

on Mallorca, the largest of the

Balearic Islands and a major tourism

hub in the Mediterranean Sea. An

average of 29 premature births to

nonresident mothers take place

annually. Approximately 9 premature

infants are born on the surrounding

islands each year and are transferred

to our center for follow-up. It is

therefore necessary to assess the

safety of flying for neonates of

mothers not residing on Mallorca.

No other fitness-to-fly testing

has been conducted in a body

plethysmograph on healthy term

infants in the first week of life and

premature infants at term age.

The objective of this study was to

determine the earliest fit-to-fly age

of preterm and term infants. This

was done by testing preterm infants

at term age, including those with

bronchopulmonary dysplasia (BPD),

and comparing the results with a

control group of healthy infants that

were ≤7 days old.

METHODS

This was a prospective observational

clinical study. Term infants (≥37

weeks gestational age [GA]) and

≥2 days and ≤7 days old were

recruited from the postnatal ward

of the University Hospital Son

Espases, Palma de Mallorca. Preterm

infants (<37 weeks GA and ≥34

weeks of corrected gestational

age [CGA]) were selected shortly

before discharge from the neonatal

unit. All parents of included infants

were planning a flight shortly after

discharge. Written informed consent

was given by all parents. Ethics

approval was granted by the Ethics

Committee of Clinical Investigation of

the Balearic Islands (IB 1231/09).

The condition for all included

infants was a baseline SpO2 of >94%.

Exclusion criteria were respiratory

infection ≥1 week before testing,

current oxygen requirement, and

cardiac, respiratory (other than BPD),

or metabolic disease. Birth history

and all clinical data were obtained

from patient reports.

The infants were divided in 3 groups:

Group 1, term infants; Group 2,

premature infants without BPD; and

Group 3, premature infants with

BPD. BPD was evaluated at 36 weeks

CGA and was defined as the need for

supplemental oxygen for ≥28 days,

per National Institute of Child Health

and Human Development criteria.12

Fitness-to-fly testing was performed

according to the testing protocol in

the Pediatric Pulmonary Function

Testing Laboratory, Pediatric

Respiratory Unit, University Hospital

of Son Espases, from September 2010

to May 2013.

The HCT was performed with the

infant on the caregiver’s lap sitting

inside a sealed body plethysmograph

(MasterScreen Body, Erich Jaeger).

To test all infants in the same

conditions, the infants needed to

remain awake and in a half-seated

position without flexing the neck and

without being fed.

SpO2 and pulse rate of the newborns

were measured continuously with a

Masimo SET Radical-7 Electron pulse

oximeter attached to the infant’s

hand or foot. Readings were taken

after a stable plateau was reached,

and baseline SpO2 and pulse rate in

room air were recorded. Nitrogen

was added into the chamber with

a flow of ∼50 L/min, gradually

reducing the FIO2 to a concentration

of 15% (O2 concentration was

measured by MiniOx3000, Medical

Products). FIO2, SpO2, and pulse

rate were continuously observed for

20 minutes, at which point timing

and any changes were also noted.

If SpO2 dropped to <85%, oxygen

was administered immediately in

a nasal cannula until the baseline

SpO2 was reached. The minimum

amount of supplemental oxygen

given was recorded. An SpO2 of <85%

was counted as a test fail, and the

newborn was deemed not fit to fly.

If the newborns failed the HCT it was

recommended supplemental oxygen

be given on board flights ,as outlined

in BTS guidelines.13,14 Parents were

then requested to repeat the test

every 2 months until obtaining fit-to-

fly status. For families living on the

2 by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

PEDIATRICS Volume 137 , number 3 , March 2016

surrounding islands, a ferry

trip home was recommended in all

cases.

After a power calculation, we

simulated the recruitment of ≥54

patients in the study with 18 patients

in each of the 3 groups. Descriptive

analysis was performed calculating

median and quartiles, or mean and

95% confidence interval (CI) if

variables were normally distributed.

To contrast the hypothesis, the test of

Mann–Whitney and Kruskal–Wallis,

or Student t test and analysis of

variance, were used. To describe

qualitative variables, proportions

and 95% CI were calculated. An

exploratory analysis using binary

logistic regression was used to

3

calculate the adjusted effect over

desaturation as a dependent variable

of several independent variables.

Odds ratios (ORs) are presented with

95% CIs and used for variables with

significant association. All statistical

tests were 2-tailed, and for differences

between groups, a Bonferroni-

corrected P value <.016 was

considered significant. IBM Statistics

SPSS 20.0 software was used.

RESULTS

Demographics

From September 2009 to May 2013,

109 infants were tested: 24 term,

62 preterm without BPD, and 23

preterm with BPD. All term infants

were healthy and had uneventful

deliveries. Complications suffered by

preterm infants during their hospital

stay were resolved by the time of

testing. Demographic and clinical

data for all newborns are listed in

Table 1.

Test Results, Predictors of Test Failure, and Comparison Between Groups

One 5-day-old healthy term infant

(38 weeks, 1 day GA) failed the test

(1 of 24, 4.2%). SpO2 dropped to 82%

and the infant needed 0.5 L/min of

oxygen to recover. Pulmonary or

cardiac diseases were excluded by

image studies in this infant. Twelve

of the 62 preterm infants (19.4%)

without BPD and 16 of 23 preterm

(69.3%) with BPD had SpO2 <85%

during the test. The test results are

listed in Table 2.

After a CGA of 39 weeks, none

of the preterm infants without

BPD and none of the term infants

desaturated <85%, but 7 of 12

infants >39 weeks with BPD failed

the test (Figs 1 and 2). BPD was

a strong predictor of failing the

HCT, with an OR of 17.2 (95% CI

4.8–60.9; P < .001).

TABLE 1 Demographic and Clinical Data of the Tested Groups

Characteristic Group 1, Term Group 2, Preterm Without

BPD

Group 3, Preterm With

BPD

n 24 62 23

Mean GA, wksa 39.6 (39.1–40) 32.5 (31.9–33) 28.2 (27–29.5)

Male, n (%) 12 (50) 36 (58) 10 (43)

Mean birth weight, kga 3.3 (3–3.4) 1.8 (1.7–1.9) 0.9 (0.8–1)

Mean age, da 3 (3–3.8) 27 (14.5–46.5) 78 (64.4–102.3)

Mean corrected age,

wksa

40 (39.6–40.5) 37 (36.5–37.6) 39.5 (38.1–40.9)

Days of oxygen therapyb — 1 (0–4) 47 (44–73)

Days of mechanical

ventilationb

— 2 (1–5) 8 (1–11)

Days of CPAPb — 0 (0–2) 12 (2–26)

Days without oxygen

therapyb

— 25 (12.3–42) 18 (13–36)

Data are a mean (95% CI) or b median (interquartile range).

TABLE 2 Test Results and Comparison of Groups

Characteristic Group 1, Term Group 2, Preterm Without

BPD

Group 3, Preterm With BPD P

Group 1 vs 2 Group 1 vs 3 Group 2 vs 3

n 24 62 23

Baseline SpO2, % 99 (97–100) 99 (98–100) 99 (96.5–99.5) NS NS .015

Change in SpO2 9 (8–11) 8 (6–12) 16 (10–19) NS .001 <.001

Time to reach lowest test SpO2,

min

10 (10–15) 15 (10–18) 8 (5–12) NS NS .003

Lowest test SpO2, % 89 (88–90) 91 (87–94) 81 (80–88) NS .001 <.001

Time until failing test, min 20a 10 (8–12) 8 (5–9) — — NS

Baseline pulse rate, beats per

min

138 (121–153) 159 (147–170) 158 (138–70) <.001 NS NS

Highest test pulse rate, beats

per min

152 (141–162) 169 (160–179) 163 (157–177) NS NS .015

Pulse rate during desaturation,

beats per min

127 148 (143–163) 158 (144–177) — — NS

Test failure SpO2 <85%, n (%) 1 (4.2) 12 (19.4) 16 (69.6) NS <.001 <.001

SpO2 <90% during test, n (%) 12 (50) 21 (33.9) 19 (82.6) NS NS <.001

Data are median (interquartile range). NS, not signifi cant.a Only 1 term infant failed the test.

by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

VETTER-LARACY et al

As mentioned above, a significant

difference was observed between

preterm infants with BPD and

neonates without BPD. There was

a significant drop in SpO2 (P = .001)

during the test comparing infants

who were term or preterm without

BPD (median change −9 and −8,

respectively) versus preterm with

BPD (median change −16).

Minimum SpO2 during the test was

significantly lower in infants with

BPD (median 81%, interquartile

range 80%–88%, P < .001) compared

with the other 2 groups. The BPD

infants reached the minimum SpO2

earlier (8 minutes, P = .003) than

preterm infants without BPD (15

min).

The 16 BPD patients who failed the

test needed 0.5 to 1 L/min of oxygen

to recover, and the 12 preterm

infants without BPD needed 0.5 to

2 L/min (only 2 children needed 2

L/min). Twelve of the infants had

mild BPD, 9 moderate BPD, and 2

severe BPD.12 Unexpectedly, time

without supplementary O2 was not a

significant factor in passing the test

(Table 1).

The term infant who failed the HCT

did not repeat the test 2 months later

as advised. Only 2 of the preterm

infants without BPD repeated the

test, at 5 and 6 months CGA; both

passed the second time.

Seven of 16 preterm infants with

BPD repeated the test. Of these, 3

at 2 months and 2 at 6 months CGA

passed. One child with BPD was

retested at 6 months CGA and failed

again. Another preterm infant with

BPD born at 23 weeks GA was first

tested at 42 weeks CGA and was

retested at 7 and 17 months CGA, but

failed all HCTs.

DISCUSSION

SpO2 declines ∼4% in healthy

children and adults while in flight.1,2

Term and preterm infants without

BPD in our study had an important

drop in SpO2 during the preflight

test (9% and 8%, respectively).

Interestingly, we found that all

neonates >39 weeks CGA and those

without BPD passed the test.

Similar results to these were found in

previous studies conducted on older

infants, as in the studies of Bossley

et al,7 who tested term and preterm

infants of 3 and 6 months CGA, and

Martin et al,15 who tested healthy

term infants (13–221 weeks old)

and found that only 1 of 24 healthy

children desaturated.

Our data are not in accordance with

the results of Udomittipong et al,16

who found that a high proportion

(38 of 47) of preterm infants with a

median corrected age of 1.4 months

are at a high risk of in-flight hypoxia.

The discrepancy in results with

Udomittipong et al may be due to the

different test methods used. We used

a whole-body plethysmograph during

the test, which is recommended in

the BTS guidelines. Udomittingpong

et al16 and other studies on infants

of a similar age used high-flow (15

L/min) 14% oxygen in nitrogen

via a non-rebreathing facemask

incorporating a 1-valve assembly.

This method may not be reliable

when used with infants, as has been

suggested by other authors.15

Neonates >39 weeks CGA without

BPD who reach term age have a test

behavior similar to that of older

infants, so the necessity for an HCT

could be eliminated for this group.

In-flight oxygen may not be necessary

either.

BPD was highly associated with test

failure, with an OR of 17.2. Infants

with BPD also suffered a median

drop in SpO2 of −16% (P = .001), and

69.6% of BPD infants failed the HCT

and thus were deemed unfit to fly. In

2004, Buchdahl et al17 performed a

retrospective review of test results in

infants with BPD and discovered that

8 of 20 patients desaturated during

4

FIGURE 1Individual test results of premature and term infants. SpO2 of infants tested after 39 weeks CGA (16 term and 12 preterm) did not fall below 85%.

by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

PEDIATRICS Volume 137 , number 3 , March 2016

the HCT, whereas Udomittipong

et al in 200616 found that 23 of 32

preterm infants with BPD failed the

HCT.

The improvement of failure rates

in our study observed in term and

preterm infants without BPD when

they reached >39 weeks CGA was not

evident among the infants with BPD

(Fig 2). It has to be mentioned that

infants with BPD had a considerably

lower GA (28.2 vs 32.5 weeks); thus

extreme prematurity might have an

influence on the test result.

The strengths of this study include

the relatively large number of

patients tested and their young

age; infants so young have not been

tested before. Also, the infants were

tested in a body plethysmograph, the

recommended method in the BTS

guidelines. Limitations include the

time of testing and the conditions of

testing (awake without feeding), and

that accuracy of HCT results was not

confirmed by comparison with actual

inflight SpO2 in the tested infants.

It is possible that the testing time of

20 minutes may not be long enough

and thus not generate sufficient

data to predict safety limits for long-

distance flights, as SpO2 usually

decreases in proportion to the

duration of hypoxemia.1,9 Most of our

test patients who failed desaturated

in 8 to 10 minutes; however, the only

term child who failed did not drop

to <85% until the end of the testing

period.

The HCT was carried out with the

infant awake without feeding and

without decubitus position. The

authors are aware that all those

factors and others (duration of the

test, humidity, infections of the upper

airways, noise, etc) vary greatly

during flight. It is true that active

sleep, changes of position (which

can influence the obstruction of the

upper airway), and feeding may have

an impact on oxygen saturation.5–7

Therefore, we decided to standardize

conditions as much as possible and

tried to avoid introducing variables.

The BTS guidelines do not establish

recommendations in reference to

the mentioned conditions even

though they can have an important

impact on the results. Further studies

are needed that analyze similar

populations for the significance of

sleep or change of body position.

Many studies have proved the HCT to

be equivalent to in-flight conditions

and hypobaric chamber results

in adults and children.18–21 Two

studies were recently conducted by

an Australian group to assess HCT

accuracy by using a non-rebreathing

mask on infants. They published data

of 46 preterm (35.8 weeks) and 24

term infants >2 weeks old, finding

false-positive and false-negative

HCT results compared with in-flight

SpO2.10,22

The studies that concluded that the

HCT is unreliable in infants both

used facemasks to do the testing,

and this is thought to be a flaw,

as false-positive results due to

immediate exposure to FIO2 of 14%

or crying or false-negative results

due to insufficient sealing of the mask

and air room entrainment can be

responsible for the discrepancy of

test and in-flight results.15,22,23

In the first study, done on preterm

infants, the range of time between

HCT and flight was 1 to 15 days.10

A delay of 2 weeks might change

the condition of a premature infant

considerably and could explain the

differences between the results. In

the study done on term infants, the

inflight SpO2 nadir was 5% lower

than the HCT nadir. Flight duration

may also play a role, as 3 children

had SpO2 both below and above

85% on different flights. Sitting in

a sealed chamber in 15% oxygen is

presently the best method available

for simulation of in-flight conditions,

5

FIGURE 2Individual test results of premature infants with BPD. Seven of 12 infants >39 weeks CGA failed the HCT.

by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

VETTER-LARACY et al

but further studies are needed to

prove the accuracy of the HCT in a

plethysmograph in term and preterm

infants.

In another recent study from

Australia, SpO2 of infants <6 months

old was monitored during aircraft

transport, and no difference in the

incidence of desaturation was found

between children <6 and >6 weeks

old.24 This could support our data

that young infants are able to fly. The

cutoff limit in the study was 94%,

which explains the high incidence

of desaturations in all age groups

(one-third). In 2011, the cutoff limit

of the HCT was changed in the BTS

guidelines from SpO2 90% to 85%.14

If it is set to 90%, the probability to

fail the test increases in all groups,

especially in healthy infants (Table

2).15,25 An explanation for the high

failure rate of term infants in our

study if SpO2 is set to <90% in

comparison with preterm infants

could be the younger chronological

age of term infants and a shorter

adaptation period to extrauterine

life (eg, higher amount of fetal

hemoglobin in term infants). If a

temporal SpO2 of 85% to 90% has

any negative impact on infants, it is

still not clear.8

The HCT via body plethysmograph

represents a reasonable

approximation of the physiologic

changes infants undergo in a hypoxic

environment and is useful for

advising a family about the risk of

commercial air travel and the need

for oxygen during a flight.

CONCLUSIONS

This study shows that over a period

of 20 minutes in a controlled

environment with an FIO2 of 15%,

SpO2 levels remain within safe limits

for healthy term infants >39 weeks

CGA and also for preterm infants

>39 weeks CGA without BPD. The

majority of infants with BPD do not

maintain safe levels of SpO2 even in

a simulated in-flight environment,

and therefore testing at this early

age might not be useful. It is

recommended to delay the test until

the infant is ≥1 year old.

ACKNOWLEDGMENTS

We thank the nurses of the Paediatric

Functional Testing Laboratory who

gave careful technical effort to the

study. Thanks also to the medical

staff of the maternity ward and to

the families of the participating

infants. Particular thanks to Gerard

Laracy for his extensive effort and

commitment to the editing and

proofreading of this manuscript.

ABBREVIATIONS

BPD:  bronchopulmonary

dysplasia

BTS:  British Thoracic Society

CGA:  corrected gestational age

CI:  confidence interval

FIO2:  fraction of inspired oxygen

GA:  gestational age

HCT:  hypoxia challenge testing

OR:  odds ratio

SpO2:  pulse oxygen saturation

REFERENCES

1. Lee AP, Yamamoto LG, Relles NL.

Commercial airline travel decreases

oxygen saturation in children. Pediatr

Emerg Care. 2002;18(2):78–80

2. Muhm JM, Rock PB, McMullin DL, et

al. Effect of aircraft-cabin altitude on

passenger discomfort. N Engl J Med.

2007;357(1):18–27

3. Samuels MP. The effects of fl ight

and altitude. Arch Dis Child.

2004;89(5):448–455

4. Rigatto H, Brady JP. Periodic breathing

and apnea in preterm infants. II.

Hypoxia as a primary event. Pediatrics.

1972;50(2):219–228

5. Stebbens VA, Poets CF, Alexander JR,

Arrowsmith WA, Southall DP. Oxygen

saturation and breathing patterns

in infancy. 1: Full term infants in the

second month of life. Arch Dis Child.

1991;66(5):569–573

6. Poets CF, Stebbens VA, Alexander JR,

Arrowsmith WA, Salfi eld SA, Southall

DP. Oxygen saturation and breathing

patterns in infancy. 2: Preterm infants

at discharge from special care. Arch

Dis Child. 1991;66(5):574–578

7. Bossley CJ, Cramer D, Mason B,

et al. Fitness to fl y testing in term

and ex-preterm babies without

bronchopulmonary dysplasia.

Arch Dis Child Fetal Neonatal Ed.

2012;97(3):F199–F203

8. Bossley C, Balfour-Lynn IM. Is this baby

fi t to fl y? Hypoxia in aeroplanes. Early

Hum Dev. 2007;83(12):755–759

9. Parkins KJ, Poets CF, O’Brien LM,

Stebbens VA, Southall DP. Effect of

exposure to 15% oxygen on breathing

patterns and oxygen saturation in

infants: interventional study. BMJ.

1998;316(7135):887–891

10. Resnick SM, Hall GL, Simmer

KN, Stick SM, Sharp MJ. The

hypoxia challenge test does not

accurately predict hypoxia in fl ight

in ex-preterm neonates. Chest.

2008;133(5):1161–1166

11. Bossley C, Balfour-Lynn IM. Taking

young children on aeroplanes:

what are the risks? Arch Dis Child.

2008;93(6):528–533

12. Jobe AH, Bancalari E.

Bronchopulmonary dysplasia.

Am J Respir Crit Care Med.

2001;163(7):1723–1729

13. British Thoracic Society Standards

of Care Committee. Managing

passengers with respiratory disease

planning air travel: British Thoracic

Society recommendations. Thorax.

2002;57(4):289–304

14. Ahmedzai S, Balfour-Lynn IM, Bewick

T, et al; British Thoracic Society

Standards of Care Committee.

Managing passengers with stable

respiratory disease planning air

travel: British Thoracic Society

recommendations. Thorax.

2011;66(suppl 1):i1–i30

15. Martin AC, Verheggen M, Stick SM,

et al. Defi nition of cutoff values for

the hypoxia test used for prefl ight

testing in young children with

6 by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

PEDIATRICS Volume 137 , number 3 , March 2016

neonatal chronic lung disease. Chest.

2008;133(4):914–919

16. Udomittipong K, Stick SM, Verheggen

M, Oostryck J, Sly PD, Hall GL. Pre-

fl ight testing of preterm infants with

neonatal lung disease: a retrospective

review. Thorax. 2006;61(4):343–347

17. Buchdahl R, Bush A, Ward S, Cramer D.

Pre-fl ight hypoxic challenge in infants

and young children with respiratory

disease. Thorax. 2004;59(11):1000

18. Kelly PT, Swanney MP, Frampton C,

Seccombe LM, Peters MJ, Beckert LE.

Normobaric hypoxia inhalation test

vs. response to airline fl ight in healthy

passengers. Aviat Space Environ Med.

2006;77(11):1143–1147

19. Kelly PT, Swanney MP, Seccombe LM,

Frampton C, Peters MJ, Beckert L.

Air travel hypoxemia vs. the hypoxia

inhalation test in passengers with

COPD. Chest. 2008;133(4):920–926

20. Scrase E, Laverty A, Gavlak JC, et

al. The Young Everest Study: effects

of hypoxia at high altitude on

cardiorespiratory function and general

well-being in healthy children. Arch Dis

Child. 2009;94(8):621–626

21. Dillard TA, Moores LK, Bilello KL,

Phillips YY. The prefl ight evaluation. A

comparison of the hypoxia inhalation

test with hypobaric exposure. Chest.

1995;107(2):352–357

22. Khanna M, Shackleton C, Verheggen M,

Sharp M, Wilson AC, Hall GL. Evaluating

hypoxia during air travel in healthy

infants. Thorax. 2013;68(12):1163–1164

23. Hall GL, Verheggen M, Stick SM.

Assessing fi tness to fl y in young

infants and children. Thorax.

2007;62(3):278–279

24. Löllgen RM, Woods P, Wall M, Berry A.

Oxygen desaturation in infants during

aeromedical transport. N Engl J Med.

2014;371(16):1560–1561

25. Kobbernagel HE, Nielsen KG, Hanel

B. Hypoxic challenge test applied to

healthy children: infl uence of body

positions and exertion on pulse

oximetric saturation. Arch Dis Child.

2013;98(8):602–606

7 by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

DOI: 10.1542/peds.2015-2915 originally published online February 15, 2016; 2016;137;Pediatrics 

Joan FiguerolaSusanne Vetter-Laracy, Borja Osona, Jose Antonio Peña-Zarza, Jose Antonio Gil and

Hypoxia Challenge Testing in Neonates for Fitness to Fly

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/137/3/e20152915including high resolution figures, can be found at:

References

f-list-1http://pediatrics.aappublications.org/content/137/3/e20152915.full#reThis article cites 25 articles, 15 of which you can access for free at:

Subspecialty Collections

y_subhttp://classic.pediatrics.aappublications.org/cgi/collection/neonatologNeonatologyorn_infant_subhttp://classic.pediatrics.aappublications.org/cgi/collection/fetus:newbFetus/Newborn Infantfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

https://shop.aap.org/licensing-permissions/in its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://classic.pediatrics.aappublications.org/content/reprintsInformation about ordering reprints can be found online:

. ISSN:60007. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print

American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since . Pediatrics is owned, published, and trademarked by the Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from

DOI: 10.1542/peds.2015-2915 originally published online February 15, 2016; 2016;137;Pediatrics 

Joan FiguerolaSusanne Vetter-Laracy, Borja Osona, Jose Antonio Peña-Zarza, Jose Antonio Gil and

Hypoxia Challenge Testing in Neonates for Fitness to Fly

http://pediatrics.aappublications.org/content/137/3/e20152915located on the World Wide Web at:

The online version of this article, along with updated information and services, is

. ISSN:60007. Copyright © 2016 by the American Academy of Pediatrics. All rights reserved. Print

American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since . Pediatrics is owned, published, and trademarked by the Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on April 25, 2018http://pediatrics.aappublications.org/Downloaded from