Dr Hamish Graham


Most of us take breathing for granted – yet a lack of oxygen kills hundreds of thousands of children every year. This World Pneumonia Day (12 November) I want people to know that no child needs to die from lack of oxygen.


Oxygen plays such a basic, but crucial role in sustaining life, however in some parts of the world health workers don't have the resources to diagnose when a patient needs oxygen or the equipment to administer oxygen therapy.


Ten years ago, I was working as a doctor in Sudan. One day a young child came in, severely unwell, with pneumonia. She was breathing fast, and barely conscious. I gave her antibiotics and oxygen, but we only had equipment to give oxygen therapy to one patient at a time.


Over the next few days, other children also came in needing oxygen, so we shared it around. Unfortunately, this little girl died. At the time, I was frustrated and angry, thinking that maybe things would have been different if we'd been better able to monitor children's blood oxygen level and administer oxygen.


Blood oxygen level is the amount of oxygen carried by red blood cells from the lungs to the other body cells. Low blood oxygen damages cells and can lead to death.


Hypoxaemia (low blood oxygen levels) is a common complication of pneumonia. It increases the risk of death five-fold and is difficult to detect using clinical signs alone.


Countless children in low and middle-income countries die because oxygen is not administered. The solution to this is not complicated - health workers simply need to be able to identify patients with hypoxaemia, and have access to reliable (and affordable) oxygen supplies. Best estimates suggest that better detection and treatment of hypoxaemia could save more than 148,000 lives globally each year.


In Australia heath workers assess blood oxygen levels with pulse oximeters, those small devices that clip on the tip of your finger. Hypoxaemia can be easily diagnosed using pulse oximeters (which cost around USD$250), but they are not widely available in hospitals in low-and-middle-income countries.


In 2014, I joined a project in Nigeria with the aim of making oxygen available to every child who needs it – that included rolling out pulse oximeters in Nigerian hospitals.


Since then, we've seen oxygen access improve and lives have been saved.


In a new paper, 'Oxygen systems to improve clinical care for children and neonates: a stepped-wedge cluster-randomised trial in Nigeria' [MOU1] published in PLOS


Medicine, we reported results from our Nigeria oxygen project. The 12 participating hospitals successfully introduced pulse oximetry, increasing the proportion of children that had blood oxygen levels recorded on admission from 4% to 92%. With better use of pulse oximetry and improved oxygen supplies, health workers are able to ensure that >80% of children with hypoxaemia received oxygen therapy immediately on admission.


While our study was not large enough to accurately measure mortality reduction, we found evidence of a 50% reduction among children with pneumonia following introduction of pulse oximetry and improved oxygen supplies. This reduction in pneumonia mortality is consistent with results from Papua New Guinea, Laos, and Malawi, that showed reductions in child death rates of between 35% and 50%.


But oxygen therapy doesn't just help children with pneumonia. Low oxygen levels are common, not just in pneumonia, but in many other conditions.


In a second recent paper, 'Hypoxaemia in hospitalised children and neonates: a prospective cohort study in Nigerian secondary-level hospitals' published in Lancet's EClinicalMedicine, we looked at the blood oxygen levels of of 23,926 babies and children with a range of conditions at 12 Nigerian hospitals.


One in 10 children and one quarter of newborns had low blood oxygen. Hypoxaemia was common among children with pneumonia (28 per cent), asthma (20.4 per cent), meningoencephalitis (17.4 per cent), malnutrition (16.3 per cent), sepsis (8.7 per cent) and malaria (8.5 per cent), and neonates with neonatal encephalopathy (33.4 per cent), prematurity (26.6 per cent), and sepsis (21 per cent).


These conditions are among the biggest killers of children in Nigeria: malaria (14 per cent), prematurity (12 per cent), perinatal complications (11 per cent), and neonatal sepsis (5 per cent). Using pulse oximetry, health workers were able to identify these severely ill children and give oxygen for as long as they needed it – typically around two to three days.


A small device can make a big difference


Pulse oximetry and oxygen therapy are essential medical practices, but they are not widely available to the majority of hospitalised children around the world. World


Pneumonia Day reminds us that pneumonia remains the single biggest killer of children globally, and projects such as the Nigeria oxygen project highlight the importance of increasing access to life-saving interventions such as pulse oximetry and pneumonia.


At a policy and planning level, our results support the routine use of pulse oximetry in all babies and children admitted to hospital, regardless of diagnosis. Governments in


Nigeria, Ethiopia, and Uganda are leading the way, promoting pulse oximetry as a central component of their national oxygen scale up strategies. WHO, UNICEF, and other partners are also championing the role of pulse oximetry and oxygen through the international coalitions Every Breath Counts and United for Oxygen.


At a clinical level, our results suggest that promoting pulse oximetry as a "vital sign", along with heart rate, respiratory rate and temperature, may facilitate faster adoption.


We know healthcare workers can use oximeters effectively, and nurses value them for making their work more efficient. However, introducing pulse oximetry is challenging and requires a multi-faceted approach, including clinical guidelines, equipment, education and ongoing encouragement to consolidate oximetry practices into routine care.


In sub-Sahara Nigeria, one in 10 children dies before their fifth birthday and pneumonia is the biggest killer of Nigerian children. They make up one sixth of under-five pneumonia deaths globally. The Nigeria oxygen project shows that many deaths from pneumonia, and other common childhood illnesses, can be averted with better identification of hypoxaemia using pulse oximetry and reliable access to oxygen therapy.


Pulse oximetry is an essential tool for detecting hypoxaemia, and should be part of the routine hospital assessment of all babies and children. Equipping hospitals with pulse oximeters and training nurses to use administer oxygen therapy could save the lives of hundreds of thousands of children every year. Ten years ago I witnessed a young girl die due to lack of basic medical care. Let us pledge today to make such preventable deaths history.