Oxygen systems to improve clinical care and outcomes for children and neonates: A stepped-wedge cluster-randomised trial in Nigeria

Autoři: Hamish R. Graham aff001;  Ayobami A. Bakare aff002;  Adejumoke I. Ayede aff002;  Amy Z. Gray aff001;  Barbara McPake aff004;  David Peel aff005;  Olatayo Olatinwo aff006;  Oladapo B. Oyewole aff002;  Eleanor F. G. Neal aff001;  Cattram D. Nguyen aff008;  Shamim A. Qazi aff010;  Rasa Izadnegahdar aff011;  John B. Carlin aff008;  Adegoke G. Falade aff002;  Trevor Duke aff001
Působiště autorů: Centre for International Child Health, University of Melbourne, MCRI, Royal Children’s Hospital, Parkville, Australia aff001;  Department of Paediatrics, University College Hospital, Ibadan, Nigeria aff002;  Department of Paediatrics, University of Ibadan, Ibadan, Nigeria aff003;  Nossal Institute for Global Health, University of Melbourne, Parkville, Australia aff004;  Ashdown Consultants, Hartfield, England aff005;  Biomedical Services, University College Hospital, Ibadan, Nigeria aff006;  Asia-Pacific Health, New Vaccines, MCRI, Royal Children’s Hospital, Parkville, Australia aff007;  Clinical Epidemiology and Biostatistics Unit, MCRI, Royal Children’s Hospital, Parkville, Australia aff008;  Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Australia aff009;  Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland aff010;  Bill and Melinda Gates Foundation, Seattle, Washington, United States of America aff011
Vyšlo v časopise: Oxygen systems to improve clinical care and outcomes for children and neonates: A stepped-wedge cluster-randomised trial in Nigeria. PLoS Med 16(11): e1002951. doi:10.1371/journal.pmed.1002951
Kategorie: Research Article
doi: https://doi.org/10.1371/journal.pmed.1002951



Improving oxygen systems may improve clinical outcomes for hospitalised children with acute lower respiratory infection (ALRI). This paper reports the effects of an improved oxygen system on mortality and clinical practices in 12 general, paediatric, and maternity hospitals in southwest Nigeria.

Methods and findings

We conducted an unblinded stepped-wedge cluster-randomised trial comparing three study periods: baseline (usual care), pulse oximetry introduction, and stepped introduction of a multifaceted oxygen system. We collected data from clinical records of all admitted neonates (<28 days old) and children (28 days to 14 years old). Primary analysis compared the full oxygen system period to the pulse oximetry period and evaluated odds of death for children, children with ALRI, neonates, and preterm neonates using mixed-effects logistic regression. Secondary analyses included the baseline period (enabling evaluation of pulse oximetry introduction) and evaluated mortality and practice outcomes on additional subgroups. Three hospitals received the oxygen system intervention at 4-month intervals. Primary analysis included 7,716 neonates and 17,143 children admitted during the 2-year stepped crossover period (November 2015 to October 2017). Compared to the pulse oximetry period, the full oxygen system had no association with death for children (adjusted odds ratio [aOR] 1.06; 95% confidence interval [CI] 0.77–1.46; p = 0.721) or children with ALRI (aOR 1.09; 95% CI 0.50–2.41; p = 0.824) and was associated with an increased risk of death for neonates overall (aOR 1.45; 95% CI 1.04–2.00; p = 0.026) but not preterm/low-birth-weight neonates (aOR 1.30; 95% CI 0.76–2.23; p = 0.366). Secondary analyses suggested that the introduction of pulse oximetry improved oxygen practices prior to implementation of the full oxygen system and was associated with lower odds of death for children with ALRI (aOR 0.33; 95% CI 0.12–0.92; p = 0.035) but not for children, preterm neonates, or neonates overall (aOR 0.97, 95% CI 0.60–1.58, p = 0.913; aOR 1.12, 95% CI 0.56–2.26, p = 0.762; aOR 0.90, 95% CI 0.57–1.43, p = 0.651). Limitations of our study are a lower-than-anticipated power to detect change in mortality outcomes (low event rates, low participant numbers, high intracluster correlation) and major contextual changes related to the 2016–2017 Nigerian economic recession that influenced care-seeking and hospital function during the study period, potentially confounding mortality outcomes.


We observed no mortality benefit for children and a possible higher risk of neonatal death following the introduction of a multifaceted oxygen system compared to introducing pulse oximetry alone. Where some oxygen is available, pulse oximetry may improve oxygen usage and clinical outcomes for children with ALRI.

Trial registration

Australian New Zealand Clinical Trials Registry: ACTRN12617000341325.

Klíčová slova:

Death rates – Hospitals – Malaria – Neonatal sepsis – Neonates – Nigeria – Oxygen – Pneumonia


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