Hypoxaemia, or low levels of oxygen in the blood, is a common complication of pneumonia in children and can lead to serious consequences, including death. In rural areas of Bangladesh, where healthcare resources are limited, identifying and managing hypoxaemia among children with suspected pneumonia is particularly challenging. A new study examines the risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh, shedding light on the need for improved strategies for managing pneumonia in low-resource settings.
Lower respiratory infections (LRIs) are a leading cause of paediatric deaths worldwide, accounting for around 800,000 deaths annually, with the majority occurring in low- and middle-income countries (LMICs), particularly among children under one year of age. In South Asia, Bangladesh has one of the highest rates of pneumonia, with approximately 20,000 child deaths attributed to the illness each year. During severe LRIs, air sacs in the lungs, known as alveoli, become inflamed or collapse, leading to hypoxaemia, or low blood oxygen levels, which can be fatal. Hypoxaemia is a major risk factor among hospitalised children in LMICs with pneumonia. However, pulse oximeter devices, which measure peripheral arterial oxyhaemoglobin saturation (SpO2) and identify hypoxaemia, are not widely available or affordable in LMICs.
To address this issue, the Bangladesh Ministry of Health recently recommended introducing pulse oximetry into routine child health services, including clinics following World Health Organization (WHO) Integrated Management of Childhood Illnesses (IMCI) guidelines. In rural Bangladesh, a prospective cohort study was conducted on three outpatient IMCI clinics to estimate the outpatient hypoxaemia burden and assess the mortality risk and prognostic accuracy of outpatient hypoxaemia identification in children with suspected pneumonia. The study period covered 2015 to 2017, and a total of 7,440 children aged 3-35 months, with their first suspected pneumonia episode identified during the study period, were enrolled, and followed up for three months.
The study found that hypoxaemia is prevalent among young children with suspected pneumonia in rural Bangladesh. Out of the 3,848 children aged 3-11 months suspected to have pneumonia, 102 (2.7%) had an SpO2 of less than 90%, and 306 (8.0%) had an SpO2 of 90-93%, while 67 (1.7%) had a failed SpO2 measurement. Among all children aged 3-11 months with suspected pneumonia, 10.6% (408/3848) had an SpO2 of less than 94%. However, most caregivers refused hospitalisation despite severe pneumonia requiring hospitalisation being advised by study physicians. The primary outcome of death at two weeks after enrolment was low at 0.6% (24 of 3848), though case fatality doubled to 1.2% (47 of 3848) after three months. Most deaths at two weeks and three months occurred among children with non-severe pneumonia. The study provides data to aid the Bangladesh Ministry of Health in refining pulse oximetry implementation approaches and helps international agencies and other LMIC health ministries decide whether to invest in pulse oximeters for outpatient child pneumonia care.
In conclusion, this study highlights the prevalence of hypoxaemia and the significant burden of pneumonia in rural Bangladesh. Furthermore, it provides an improved understanding of the challenges and barriers to implementing pulse oximetry in outpatient settings in LMICs. It highlights the urgent need to widen access to affordable, quality pulse oximeters for children’s health care in such regions, to identify and appropriately treat hypoxaemia, and reduce the mortality burden associated with paediatric pneumonia in these regions.
In conclusion, this study highlights the significant risk and accuracy of outpatient-identified hypoxaemia for death among suspected child pneumonia cases in rural Bangladesh. Further investigation and interventions are needed to improve the diagnosis and management of pneumonia in children, especially in resource-limited settings. This study serves as a reminder of the importance of ongoing research to develop effective strategies to reduce childhood mortality and improve global health outcomes. We hope this information can be used to inform policies and practices that prioritize the health and well-being of all children, regardless of where they live.
