title: Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi.
abstract: OBJECTIVE
  To investigate implementation of outpatient pulse oximetry among children with pneumonia, in Malawi.
  
  
  METHODS
  In 2011, 72 health-care providers at 18 rural health centres and 38 community health workers received training in the use of pulse oximetry to measure haemoglobin oxygen saturations. Data collected, between 1 January 2012 and 30 June 2014 by the trained individuals, on children aged 2-59 months with clinically diagnosed pneumonia were analysed.
  
  
  RESULTS
  Of the 14 092 children included in the analysis, 13 266 (94.1%) were successfully checked by oximetry. Among the children with chest indrawing and/or danger signs, those with a measured oxygen saturation below  90% were more than twice as likely to have been referred as those with higher saturations (84.3% [385/457] vs 41.5% [871/2099];P< 0.001). The availability of oximetry appeared to have increased the referral rate for severely hypoxaemic children without chest indrawing or danger signs from 0% to 27.2% (P< 0.001). In the absence of oximetry, if the relevant World Health Organization (WHO) guidelines published in 2014 had been applied, 390/568 (68.7%) severely hypoxaemic children at study health centres and 52/84 (61.9%) severely hypoxaemic children seen by community health workers would have been considered ineligible for referral.
  
  
  CONCLUSIONS
  Implementation of pulse oximetry by our trainees substantially increased the referrals of Malawian children with severe hypoxaemic pneumonia. When data from oximetry were excluded, retrospective application of the guidelines published by WHO in 2014 failed to identify a considerable proportion of severely hypoxaemic children eligible only via oximetry.
authors.affiliation: Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Rubenstein Building, 200 North Wolfe Street, Baltimore, MD 21287, United States of America .
authors.forename: Eric D
authors.initials: ED
authors.lastname: McCollum
authors.affiliation: Institute for Global Health, University College London, London, England .
authors.forename: Carina
authors.initials: C
authors.lastname: King
authors.affiliation: Parent and Child Health Initiative Trust, Lilongwe, Malawi .
authors.forename: Rashid
authors.initials: R
authors.lastname: Deula
authors.affiliation: Parent and Child Health Initiative Trust, Lilongwe, Malawi .
authors.forename: Beatiwel
authors.initials: B
authors.lastname: Zadutsa
authors.affiliation: Parent and Child Health Initiative Trust, Lilongwe, Malawi .
authors.forename: Limangeni
authors.initials: L
authors.lastname: Mankhambo
authors.affiliation: Institute for Global Health, University College London, London, England .
authors.forename: Bejoy
authors.initials: B
authors.lastname: Nambiar
authors.affiliation: Parent and Child Health Initiative Trust, Lilongwe, Malawi .
authors.forename: Charles
authors.initials: C
authors.lastname: Makwenda
authors.affiliation: Parent and Child Health Initiative Trust, Lilongwe, Malawi .
authors.forename: Gibson
authors.initials: G
authors.lastname: Masache
authors.affiliation: Ministry of Health, Lilongwe, Malawi .
authors.forename: Norman
authors.initials: N
authors.lastname: Lufesi
authors.affiliation: Ministry of Health, Lilongwe, Malawi .
authors.forename: Charles
authors.initials: C
authors.lastname: Mwansambo
authors.affiliation: Institute for Global Health, University College London, London, England .
authors.forename: Anthony
authors.initials: A
authors.lastname: Costello
authors.affiliation: Institute for Global Health, University College London, London, England .
authors.forename: Tim
authors.initials: T
authors.lastname: Colbourn
mesh_terms: D002675:Child, Preschool; D003150:Community Health Workers / Q000458:organization & administration; D006801:Humans; D007318:Inservice Training; D008295:Malawi; D010045:Outpatients; D010092:Oximetry / Q000592:standards* / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000097:blood / Q000503:physiopathology*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000458:organization & administration; D019035:Rural Health Services / Q000458:organization & administration* / Q000592:standards