Objectives: We sought to understand barriers to high-quality hospital-based child acute lower respiratory infection (ALRI) care at Mchinji District Hospital in Malawi. Methods: In 2020, we conducted focus group discussions (FGDs) with clinical officers (COs) who provided direct clinical care after a half-day refresher course on pediatric ALRI case management. The underpinning research methodology of the FGDs was phenomenology, and they were analyzed using inductive and deductive thematic analysis. Results: We recruited 16 COs to participate in three FGDs. Five themes emerged: lack of confidence in ALRI diagnosis and management, high clinical burden with understaffing, dysfunctional team dynamics, limited physical resources, and the recognition of the importance of vital sign measurements despite barriers to practice. Conclusions: COs shared several barriers and potential interventions to improve child ALRI care delivery. Some solutions were locally implementable, with minimal to modest cost, such as a program for continuing education, standard operating procedures during electricity outages, and posting of job aides. However, many of their suggestions require investments and commitment from the Malawian Ministry of Health to increase staffing capacity and improve the physical infrastructure and are, therefore, of undetermined feasibility. Future research should examine the impact of hospital layout and infrastructure, continuing education programs, and informal vital sign assistants on clinical care delivery.

Abstract Background Accurately measuring vaccination coverage is crucial for programmatic and policy decision making, however accurate measurement of coverage can be challenging. We aimed to understand the extent of, and reasons for, inaccurate vaccination card records in a rural, low-income setting in Jigawa state, Nigeria. Methods We conducted an explanatory sequential mixed-methods study in Kiyawa Local Government Area, Jigawa State, from September 2022 to July 2023, using data from the INSPIRING Jigawa trial (ISRCTN39213655). Quantitative data was gathered from surveyed women aged 16–49 in sampled compounds, who presented their child’s vaccine card. Vaccine documentation was defined as inaccurate when the vaccine card is discordant with caregiver report. Adjusted logistic regression identified factors associated with inaccuracies. We conducted in-depth interviews with healthcare workers and focus groups with community members, analyzing transcripts using conventional content analysis, and triangulated findings with quantitative results. Results Records for 4258 children under five-years, from 3232 women, were examined. Of these children, 441 (10.4%) had vaccine cards that were deemed inaccurate by their caregivers. Inaccuracies were primarily attributed to cards being filled despite the child not receiving the vaccine, misplacement or loss of vaccine cards, vaccine stock-out when cards had already been filled, and vaccine card stock-out when the vaccine had been administered. Our adjusted logistic regression results show the following variables were associated with reporting inaccurate vaccine cards (under or over-reporting): any education compared to none (adjusted odds ratio (aOR): 1.33, 95%CI: 1.03, 1.75), having co-wives compared to no co-wife (aOR: 0.78, 95%CI: 0.62, 0.98), and child’s age: 12–24 months compared to < 12 months (aOR: 2.70, 95%CI: 1.94, 3.75) and 25 months and above compared to < 12 months (aOR: 2.30, 95%CI: 1.69, 3.12). Our qualitative findings highlighted maternal lack of knowledge of vaccination schedule and forgetfulness about the vaccination schedule as common reasons for vaccine card inaccuracy. Conclusion We identified health system failures and caregiver barriers leading to inaccurate reports in vaccine cards. It is essential to sensitize caregivers and healthcare providers on the importance of accurately documenting vaccines and validating immunization recording systems. Clinical trial number Not applicable.

OBJECTIVE:Oxygen is a cornerstone treatment for pneumonia with hypoxaemia. WHO guidelines recommend oxygen therapy for children with a peripheral arterial haemoglobin oxygen saturation (SpO2) <90%. Children in low- and middle-income countries with an SpO2 of 90-93% are at increased risk of mortality and may benefit from oxygen therapy. We aimed to determine the feasibility of a randomised controlled trial comparing standard of care (no oxygen), low-flow nasal cannula (LFNC) and high-flow nasal cannula (HFNC) among children with pneumonia and an SpO2 of 90-93%. DESIGN:Pilot, open-label, three-armed randomised control trial (NCT06176664). SETTING:Salima District Hospital, Malawi. PATIENTS:Children 1-59 months old with WHO-defined pneumonia and an SpO2 of 90-93%. INTERVENTIONS:Standard care (no oxygen), LFNC or HFNC. MAIN OUTCOME MEASURES:The primary outcome was feasibility defined as an average of ≤2 protocol deviations per participant. Secondary outcomes included consent refusal, participant attrition and treatment failure within 14 days. Treatment failure was defined as an SpO2 <90% for standard care participants or <94% in the LFNC and HFNC arms despite maximum therapy as described, any new severe respiratory distress (grunting, very severe chest indrawing) or any new WHO-defined emergency sign. RESULTS:Of the 29 eligible patients, 21 (72%) were enrolled and randomised. There was an average of 0.8 (16/21) deviations per participant. Seven (43.8%) protocol violations were related to study intervention protocols and nine (56.3%) to medication availability and routine care. No participants withdrew from the study. Three of 21 participants (14.3%) had treatment failure. All participants were successfully followed to obtain the 14-day outcome. CONCLUSIONS:A three-armed, open-label randomised control trial is feasible to compare standard of care, LFNC and HFNC oxygen for children with pneumonia and an SpO2 of 90-93% in Malawi. TRIAL REGISTRATION NUMBER:NCT06176664.

Background:Respiratory oscillometry can inform early-life lung function, but evidence supporting its use in Guatemala is limited. We assessed the validity and reliability of respiratory oscillometry in 3-year-old Guatemalan children and whether these improve with quality control (QC). Methods:During home visits, we measured respiratory oscillometry resistance (R) and reactance (X) at 7 Hz (R7 and X7), the frequency dependence of resistance (R7-R19) and the area of reactance (AX) in 666 children participating in the Household Air Pollution Intervention Network trial. Standard measurement QC removed artefacts using commercial software and selected the first three measurements with an R7 coefficient of variation of ≤15%. Alternative investigators' methods varied in QC procedures. We evaluated validity as the proportion of variability in tests predicted by a child's height (R2) and, in a subset of 50 children, as agreement with test results after manual QC by a paediatric pulmonologist. Reliability was assessed by the intraclass correlation coefficient (ICC) of repeated tests. Results:We collected oscillometry results from 537 children. Height explained 5-15% of the variability in R7, X7 and AX, but none in R7-R19. The correlation between standard and manually cleaned tests ranged from 0.66 to 0.97, depending on the parameter. Of the first tests, between-day ICCs using the standard method for R7, R7-R19, X7 and AX were 0.68, 0.45, 0.60 and 0.71, respectively, and the best between-day ICCs using an alternative method were 0.75, 0.57, 0.69 and 0.74, respectively. Discussion:We demonstrated good validity and reliability of respiratory oscillometry measurements collected at home from preschool-aged Guatemalan children. Investigators' automated QC methodology performed equally to or better than standard methodology.

Background: The burden of children with lower respiratory infections and low blood oxygen levels (hypoxemia) is high, and outcomes are poor in low-and middle-income countries (LMICs). Pulse oximeters noninvasively measure the capillary oxyhemoglobin saturation (SpO2) to identify hypoxemia, but high-quality devices designed for the unique needs of children are rarely available in primary health care clinics (PHCs) in LMICs, where children initially access care. Objective: This study aims to evaluate whether 2 pediatric pulse oximeters co-designed with health care workers (HCWs) in LMICs improve the correct SpO2 management of children in PHCs compared to a standard pulse oximeter. Methods: We are conducting a pragmatic 3-arm cluster randomized controlled trial in the Eastern Khayelitsha, Northern, and Tygerberg areas of Cape Town, South Africa, over 18 months between 2024 and 2026. We plan to enroll 1200 children aged younger than 2 years with an acute respiratory infection from 18 PHCs randomized to implement one of 3 pulse oximeters, either 1 standard-of-care device or 2 intervention devices. HCWs in selected PHCs will administer the intervention. Our primary outcome will be "correct SpO2 management," an intermediate clinical end point between device implementation and hypoxemia outcome, defined by the following three elements necessary to reduce inappropriately treated hypoxemia: (1) device adoption-HCW use of the device as evidenced by a HCW-documented SpO2 and pulse rate; (2) quality SpO2 measurement-SpO2 confirmed by reference device measurement within 2% SpO2 above or below the HCW-measured SpO2; and (3) correct SpO2 decision-making-an appropriate referral recommendation by the HCW. A concurrent mixed methods process evaluation will explore how, why, for whom, and to what extent these devices impact the clinical management of hypoxemic children. The primary analysis will be intention-to-treat. For all primary and secondary outcomes, we will conduct pairwise comparisons between the 2 intervention arms and the control arm. Results: Data collection commenced in 2024, and results are expected from 2026 to 2027. As of December 2025, enrollment has been completed in 12 clinics. Conclusions: While there are notable challenges inherent in designing a trial to evaluate whether pulse oximeters improve HCW SpO2 management of children at PHCs, our protocol development process attempted to address all potential limitations and sources of bias to maximize the trial's future impact.

Background:In 2012, World Health Organization (WHO) recommended outpatient oral amoxicillin for children aged 2-59 months with chest indrawing pneumonia without general danger signs, based on randomised trials. We assessed mortality and case management for such children routinely managed at primary healthcare centres (PHCs) in Lagos, Nigeria. Methods:This prospective observational cohort study (September 2021-September 2023) was conducted in Ikorodu Local Government Area (LGA), nested within the Integrated Sustainable childhood Pneumonia and Infectious disease Reduction in Nigeria (INSPIRING) Lagos study across 16 PHCs. PHC healthcare workers (HCWs) trained in Integrated Management of Childhood Illness (IMCI) provided routine care, while INSPIRING staff independently assessed eligibility using IMCI criteria. The primary outcome was the 14-day case fatality rate (CFR) among children with chest indrawing pneumonia without general danger signs; secondary outcomes included antibiotic use, treatment adherence, and referral practices. Results:PHC HCW identified 24 chest indrawing cases, while INSPIRING staff diagnosed 247 cases, including 19 of the 24 identified by PHC HCWs. Among those followed up (n = 16), the CFR was 6.3% (n/N = 1/16; 95% confidence interval (CI) = 0.2-30.2) for PHC HCW identified cases; with the same death identified by INSPIRING staff (n/N = 1/197; CFR = 0.5%). The single event in each cohort, and high loss to follow-up, imply that these CFR estimates are statistically fragile and should be interpreted as indicative only. Only 4% (n/N = 1/24) of children received routine care aligned with IMCI protocols. Of those prescribed antibiotics, 50% (n/N = 4/8) completed the full course, and just 1 of the 6 of referred children was admitted to hospital. Conclusions:PHC HCWs rarely diagnosed chest indrawing pneumonia, and one-third of the patients were lost to follow up leading to a smaller than expected sample and therefore an imprecise CFR. Improving HCW capacity to identify and manage pneumonia, alongside strengthening IMCI implementation, is critical to reducing preventable child deaths in this setting.

BACKGROUND:Hypoxaemic lower respiratory infections (LRIs) are a leading cause of childhood mortality, with the highest burden in low-income and middle-income countries (LMICs). Hypoxaemia-low peripheral capillary oxyhaemoglobin saturation (SpO2)-is a marker of severity, and WHO recommends hospitalisation and oxygen administration for patients with SpO2 <90%. We aimed to update estimates from a 2015 systematic review and meta-analysis examining the association between hypoxaemia and mortality among children with LRIs in LMICs by incorporating studies published over the subsequent decade and evaluating mortality risk across multiple SpO2 thresholds. METHODS:We conducted a systematic review with meta-analysis by searching PubMed, Embase, LILACS, Global Index Medicus, Web of Science, and Scopus for peer-reviewed studies published between Jan 1, 2015, and June 18, 2025, with combined terms related to pneumonia, children, mortality, and LMICs. We also included selected earlier studies through citation checking. Eligible studies reported associations between hypoxaemia and mortality in children younger than 5 years with LRIs in LMICs. We excluded case reports and case series with fewer than five deaths, studies focused exclusively on the neonatal period, and those limited to children with specific comorbidities or to postoperative patients, for consistency with the original review. Two reviewers independently screened studies, extracted data, and assessed quality. Eligible studies were combined with those from the original review and analysed using random-effects models to estimate odds ratios (ORs) by hypoxaemia threshold subgroup. The protocol was registered on PROSPERO (CRD42023433946). FINDINGS:We identified 7734 records; 26 new studies met inclusion criteria and were combined with 18 from the original review. The 44 studies were published between 1993 and 2024 and were primarily from Africa (25 [57%] of 44) or Asia (19 [43%]); some studies spanned multiple locations. Data from 33 studies including 155 633 participants were included in the primary meta-analysis. Hypoxaemia of any threshold was associated with higher odds of LRI mortality (OR 4·36 [95% CI 3·52-5·39]) compared with no hypoxaemia. For SpO2 <90% versus 90-100%, OR for death was 4·75 (95% CI 3·42-6·58). For SpO2 90-94% versus 95-100%, mortality risk was more than twice as high (OR 2·27 [95% CI 1·22-4·25]). Heterogeneity was substantial (I2 64-85% across analyses), and eight (24%) of 33 studies in the primary meta-analysis had a high overall risk of bias; however, a sensitivity analysis restricted to studies with low or moderate risk of bias yielded similar results. INTERPRETATION:SpO2 <90% strongly predicts mortality in children with LRIs in LMICs. Children with SpO2 90-94% also have elevated risk, suggesting that paediatric LRI and pneumonia treatment algorithms should consider management at this hypoxaemia threshold. FUNDING:None.

Bubble continuous positive airway pressure (bCPAP) is a low-cost respiratory support device that has demonstrated different outcomes for children with severe pneumonia in different settings. Some differences in outcomes may be attributable to implementation factors (e.g., patient monitoring and feeding practices). We aimed to characterize bCPAP reach, implementation fidelity, and safety outcomes for children with severe pneumonia in Pakistan. We conducted a prospective cohort study at Aga Khan University Hospital and Abbasi Shaheed Hospital from February through May 2025. We enrolled children 1-59 months who met WHO criteria for severe pneumonia within 24 hours of presentation to the emergency department. Participants were followed daily via chart review, caregiver survey, and physical exam through discharge, transfer, or death. We reported the proportion of children receiving bCPAP ("reach") and constructed a mixed-effects, multinomial logistic regression model with robust standard errors to report: fidelity (child location in a highly monitored area, continuous monitoring, avoidance of unplanned disruptions to bCPAP, and avoidance of oral feeding); safety (aspiration events and pneumothorax); bCPAP failure (death, respiratory support escalation, or leaving against medical advice); and in-hospital mortality. Of 165 children with severe pneumonia, 88 (53%) received bCPAP over 141 bCPAP days. The average predicted probabilities (95% CI) of our fidelity measures were: 85% (78-92%) for location in a highly monitored area; 56% (51-60%) for continuous monitoring; 66% (57-75%) for continuous bCPAP without disruptions; 46% (36-55%) for avoidance of oral feeding while on bCPAP. Among children receiving bCPAP, 9 (10%) experienced an aspiration event, 1 (2.2%) experienced a pneumothorax; 19 (22%) experienced bCPAP treatment failure. One child (1.1%) died; 6 (6.8%) required respiratory support escalation; 14 (16%) left against medical advice. We identified several gaps in bCPAP reach and fidelity. These may be modifiable by individual- and team-targeted strategies to reduce bCPAP-related complications and pneumonia-related child deaths.

Background Respiratory rate is an important part of assessing the clinical state of children, and various methods exist to measure it. However, there is a lack of a universally accepted reference standard to validate the performance of these methods.Aim To identify different reference standards that have been used to evaluate respiratory rate measurement methods in children under 5 years of age and describe their perceived strengths and limitations.Methods MEDLINE and Web of Science were searched for studies in English. Studies of children under 5 years of age, published between 2013 and 2024, in which a method for measuring respiratory rate was compared against a reference standard, were included. Deductive content analysis was used to map perceived strengths and limitations of each standard, and a forest plot analysis was used to compare agreement between the reference standard and the index tests.Results From 992 retrieved studies, 56 were included. The most common reference standard was impedance pneumography (22/56), primarily used in high-income settings, followed by manual counting (19/56), mostly employed in low- and middle-income settings, and capnography (9/56). Child age, clinical condition, setting, training of personnel and the ease of implementation were all important factors in which the reference standard was used and how it performed.Conclusion Three different reference standards were used for most studies; however, their relative performance to each other is unclear. There is a need for research that directly compares the performance of these reference standards across different age strata and settings in order to confidently recommend a reference standard for respiratory rate measurement methods.

Accurate respiratory rate (RR) measurement is essential for diagnosing and classifying pneumonia in children. The Children’s Automated Respiration Monitor (ChARM) can measure RR, but placing the device on the chest may influence a child’s breathing. This study evaluated whether ChARM affects RR measurement and identification of fast breathing. We conducted a cross-sectional study in multiple health facilities in Bangladesh (2021–2022). Children aged 0–59 months presenting with suspected pneumonia were enrolled. RR was first measured manually by a physician or a health worker and then using ChARM, while chest movements during both measurements were video recorded. A six-member video expert panel (VEP) reviewed all recordings and derived manual RR. Differences in RR values and fast breathing classifications between the two measurement methods were examined. Of 339 enrolled children, both manual and ChARM measurements were obtained for 294; the remainder could not be assessed because of crying or movement. The child’s condition remained same during both measurements in 256 cases. After excluding uninterpretable videos and readings without consensus, VEP-determined RR was available for 217 children. The mean difference in RR between the two measurements was 0.5 breaths per minute (standard error 0.4). RR classification (normal vs. fast breathing) changed in 21 children (9.7

This dataset was generated as part of a study aimed at developing a video expert panel (VEP) to serve as a reference standard for respiratory rate assessment in children under five years of age. The overarching goal was to improve the accuracy of diagnosing respiratory illnesses and to support the advancement of automated video-based methods for respiratory rate measurement. Children aged 0–59 months presenting with cough and/or difficulty breathing at different levels of healthcare facilities in Bangladesh were enrolled during 2021–2022. The dataset comprises 332 video recordings, each approximately 60 s in duration, documenting chest wall movements of participating children. All recordings were independently reviewed by members of a trained VEP, who determined respiratory rate using a standardized multi-reviewer process. Alongside the video files, a Stata (.dta) file provides structured metadata, including demographic information (age, sex), clinical variables (history and observation of cough and difficult breathing), and respiratory rate counts. This dataset is intended to support the development and validation of automated video-based diagnostic tools, training and standardization of health workers, and quality assurance initiatives. Its open-access availability fosters interdisciplinary collaboration and international research in pediatric respiratory diagnostics.

Lung auscultation is not included in the WHO Integrated Management of Childhood Illness algorithm, partly due to concerns regarding feasibility and reliability when performed by non-physician primary health workers in low-resource settings. In this feasibility study, we evaluated whether non-physician primary care health workers (community health care providers (CHCPs)) can record quality lung sounds from children aged 2-59 months. Feasibility was predefined as more than 50% of children having quality recordings at the overall sample level. After receiving three days of structured training, nine CHCPs recorded lung sounds from four chest positions using a digital stethoscope (Sonavi Labs, United States) in 990 children attending first-level rural clinics in Bangladesh between November 2019 and December 2020, with enrolment paused during the COVID-19 pandemic. A blinded paediatrician listening panel, trained to a standardised interpretation protocol, classified the recordings. A quality recording was defined a priori as the panel classifying three of four chest positions on a participant as interpretable. Lung sounds were recorded from 990 children, and the panel classified 867 children as having a quality recording (87.6%; 95% confidence interval: 85.4%, 89.6%). Among children with quality recordings and available timing data, 89.8% (766/853) were recorded within five minutes. This study demonstrates CHCPs at rural, first-level clinics in Bangladesh are capable of timely, quality recordings of lung sounds from most children using a digital stethoscope.

Integrated management of childhood illness (IMCI) guidelines have high sensitivity but low specificity for pneumonia diagnosis. Artificial intelligence (AI)-enabled digital stethoscopes capable of analyzing lung sounds may improve IMCI diagnostic performance. We evaluated the performance of an AI algorithm trained to identify normal and adventitial lung sounds in children. Non-physician health workers recorded lung sounds from four chest positions using a digital stethoscope in under-five-year-old children with suspected pneumonia at community clinics in Bangladesh. A trained paediatrician listening panel classified chest position recordings as normal, abnormal (crackles and/or wheeze), or uninterpretable. The AI algorithm similarly classified chest position recordings except for the uninterpretable category. AI algorithm and listening panel comparisons were made at the child-level, and included chest positions considered interpretable, uninterpretable, and high- and low-confidence by the panel. Of 990 enrolled children, 867 (87%) had at least 3 interpretable chest position recordings by the panel and were analyzed. Compared to the panel, AI algorithm sensitivity and specificity for detecting abnormal sounds were 61.8% and 60.7% among all children, and 63.5% and 66.8% in IMCI pneumonia cases. Overall, the AI algorithm achieved moderate classification performance. Classification performance will benefit from further AI algorithm training to categorize recordings as uninterpretable.

Pulse oximeters may be inaccurate in children who are critically ill and/or have darker skin pigmentation. To date no studies have published accuracy metrics that align with proposed regulatory standards. Our objective is to determine if the Nellcor Oximax pulse oximeter has differential accuracy when used in critically ill children with fair, medium, and dark skin tones. This is a prospective single-center study of critically ill children aged 1 month to 17 years hospitalized in an intensive care unit at Texas Children’s Hospital (Houston, USA) undergoing arterial blood gas analysis. We exclude children with conditions known to affect the accuracy of pulse oximeters. We will report the mean bias between the oxygen saturation from the Nellcor pulse oximeter with wrap probe and arterial co-oximetry, stratified by the child’s skin tone. Skin tone is classified by the Individual Typology Angle measured by a skin colorimeter and Monk Skin Tone scale. The Institutional Review Board of Baylor College of Medicine approved this study (H-53514). Results will be shared in peer reviewed journals, conferences, and lay summaries for the public and other stakeholders.

RATIONALE:Household air pollution is a risk factor for obstructive lung diseases. OBJECTIVES:We estimated the effect of an early-life liquefied petroleum gas cooking intervention on childhood lung function. METHODS:The multi-country Household Air Pollution Intervention Network trial randomized 800 pregnant women (9-19 weeks gestation, 18-34 years) in Guatemala to receive a gas cookstove and free fuel intervention or continue cooking with biomass until the child is aged 1 year. The present analysis includes only Guatemalan children. At age 3 years, we measured lung function using oscillometry at 7-41 Hertz (Tremoflo C-100, Thorasys). Outcomes were resistance and reactance at 7 Hertz, area of reactance, resistance at 19 Hertz, resistance difference between 7 and 19 Hertz, and, as exploration, resistance across frequencies. Upper airway artifacts were removed using Tremoflo software. The effect of the intervention was estimated using linear regression models, unadjusted and adjusted (height, weight, age, sex). Children with respiratory infections during a 7-day recall period were excluded. RESULTS:Valid oscillometry was obtained from 525/750 (70%) 3-year-olds. Among the 225 missed oscillometry tests, 129/750 (17%) were due to the children not being willing to perform the measurements. We did not find evidence of an effect on prespecified oscillometry outcomes. Exploratory analysis suggested that resistance across the frequency spectrum was lower in intervention than control participants (adjusted difference: -0.31 cmH2O*S/L, 95% CI: -0.59, -0.03). CONCLUSIONS:Gas cooking compared to biomass cooking from mid-gestation through infancy was not associated with improved prespecified oscillometry outcomes in 3-year-old children. However, lowered resistance across all frequencies in the intervention arm suggests the intervention may have positively impacted airway caliber. Further studies are warranted, including exposure-response analysis and lung function trajectories.

The World Health Organization’s Integrated Management of Childhood Illness guidelines emphasise respiratory rate (RR) counting for diagnosing childhood pneumonia. Community health workers (CHWs) play a crucial role in managing pneumonia in children in low- and middle-income countries (LMICs). In Bangladesh, community clinics (CCs) are the lowest tier of health facilities, where services are provided by CHWs designated as Community Health Care Providers (CHCPs). This study evaluated the ability of CHCPs to measure RR and identify fast breathing for the diagnosis of pneumonia. We conducted a cross-sectional study of children aged 0–59 months presenting with suspected pneumonia at three purposively selected CCs in Bangladesh. CHCPs from respective CCs counted RR manually, with chest movements simultaneously videotaped. Six physicians were trained to form a video expert panel (VEP) that interpreted the RR from the recorded videos. We assessed the ability of CHCPs to count RR and identify fast breathing, using VEP as the reference standard. Among the 123 enrolled children, CHCPs were able to count an RR of 110 children (89.4

Background:Pneumonia is a leading cause of death in under five year olds globally. World Health Organization (WHO) pneumonia diagnostic guidelines rely on non-specific clinical findings. Lung auscultation could improve pneumonia diagnosis, but conventional stethoscopes have implementation challenges. To address this, we developed an artificial intelligence (AI)-enabled digital auscultation system. We evaluated the system's AI lung sound analysis algorithm in children with severe pneumonia in Malawi. Methods:We enrolled children aged 2-59 months hospitalised with WHO-defined severe pneumonia. A study physician recorded lung sounds with a digital stethoscope at six chest positions. Recordings were de-identified, filtered, and interpreted by a trained and certified physician listening panel. Interpretable recordings were analysed by the AI algorithm. We evaluated the agreement of normal (absence of adventitial lung sounds) vs. abnormal (presence of adventitial lung sounds) classifications, by chest position and by patient, between the AI algorithm and the listening panel using raw percent agreement kappa statistics, both unadjusted and adjusted for chance agreement. Results:We enrolled 100 children and analysed 95 with interpretable recordings. The median age was 12.6 months (interquartile range (IQR) = 5.4, 19.0) and 54% (51 / 95) were female. Among interpretable recordings, 59.2% (294 / 497) of chest positions were abnormal per the listening panel compared to 52.7% (262 / 497) per the AI algorithm. The listening panel and AI algorithm agreed on classifications in 83.1% (413 / 497) of chest positions (unadjusted kappa 0.7; adjusted kappa 0.7) and 91.6% (87/95) of patients (unadjusted kappa 0.7; adjusted kappa 0.8). The AI algorithm's sensitivity and specificity for identifying abnormal lung sounds, compared to the listening panel, were 80.3% and 87.2% for chest positions and 96.3%, and 66.7% for patients. Conclusions:This AI lung sound classification algorithm accurately identified abnormal lung sounds in children with severe pneumonia. Next steps include training the algorithm to identify uninterpretable recordings and different abnormal sounds.

The OpenOximetry Dataset stores clinical and lab pulse oximetry data. It supports measurements of arterial oxygen saturation (SaO2) by arterial blood gas co-oximetry and pulse oximetry (SpO2), alongside processed and unprocessed photoplethysmography (PPG) data and other metadata. This includes skin color measurements, finger diameter, vital signs (e.g., arterial blood pressure, end-tidal carbon dioxide), and arterial blood gas parameters (e.g., acid-base balance, hemoglobin concentration). All data, from desaturation studies to clinical trials, are collected prospectively to ensure accuracy. A common data model and standardized protocols for consistent archival and interpretation ensure consistent data archival and interpretation. The dataset aims to facilitate research on pulse oximeter performance across diverse human characteristics, addressing performance issues and promoting accurate pulse oximeters. The initial release includes controlled lab desaturation studies (CLDS), with ongoing updates planned as further data from clinical trials and CLDS become available.

Importance:Household air pollution from biomass cooking is considered an important risk factor for child pneumonia. Objective:To evaluate the longitudinal association between exposure to particulate matter with a diameter of less than or equal to 2.5 µm (PM2.5) or carbon monoxide (CO) and severe pneumonia in infants. Design, Setting, and Participants:This cohort study included infants (aged ≤12 months) whose mothers participated in a 4-country randomized clinical trial. Conducted from May 2018 to September 2021, the trial tested whether an 18-month liquefied petroleum gas stove and fuel distribution intervention reduced the incidence of severe pneumonia in offspring during infancy when compared with biomass cooking. The trial was conducted in communities where residents cooked primarily with biomass fuels in Guatemala, India, Peru, and Rwanda. Data analysis was conducted from December 2024 to July 2025. Exposures:Twenty-four hour personal exposure to PM2.5 and CO was measured 3 times during pregnancy and 3 times during infancy. Main Outcome and Measures:In this exposure-response analysis, severe pneumonia cases were identified using respiratory signs and symptoms with confirmation of consolidation by imaging and hypoxemia by pulse oximetry. The longitudinal association between severe pneumonia in infants and PM2.5 or CO exposures by infant-quarters, adjusted for confounders, was modeled. Results:Overall, 3061 infants (48.2% girls; mean [SD] gestational age at birth, 39.3 [1.7] weeks) contributed 11 996 infant-quarters and 13 910 measurements of personal PM2.5 exposures (range, 5.4-1182.0 µg/m3). A total of 175 episodes of severe pneumonia were identified in 160 infants. Those with at least 1 episode of severe pneumonia had similar mean (SD) prenatal (101 [100] µg/m3 vs 88 [80] µg/m3; P = .11) and postnatal (70 [78] µg/m3 vs 67 [93] µg/m3; P = .68) PM2.5 exposures when compared with infants without severe pneumonia. There were no associations between prenatal (adjusted risk ratio [RR], 1.03; 95% CI, 0.94-1.13) or postnatal (adjusted RR, 0.97; 95% CI, 0.87-1.09) PM2.5 exposures and severe pneumonia or between CO exposures and severe pneumonia. Conclusions and Relevance:In this cohort study with exposure-response analysis, there was no evidence of an association between longitudinal PM2.5 or CO exposures and severe pneumonia in infants. Taken with the intention-to-treat analysis from the randomized clinical trial, these results challenge prior research suggesting that PM2.5 or CO exposures from biomass cooking are an important risk factor for severe pneumonia in infants.