Hypoxaemia as a Mortality Risk Factor in Acute Lower Respiratory Infections in Children in Low and Middle-Income Countries: Systematic Review and Meta-Analysis

Marzia Lazzerini, Michela Sonego, Maria Chiara Pellegrin, Marzia Lazzerini, Michela Sonego, Maria Chiara Pellegrin

Abstract

Objective: To evaluate the association between hypoxaemia and mortality from acute lower respiratory infections (ALRI) in children in low- and middle-income countries (LMIC).

Design: Systematic review and meta-analysis.

Study selection: Observational studies reporting on the association between hypoxaemia and death from ALRI in children below five years in LMIC.

Data sources: Medline, Embase, Global Health Library, Lilacs, and Web of Science to February 2015.

Risk of bias assessment: Quality In Prognosis Studies tool with minor adaptations to assess the risk of bias; funnel plots and Egger's test to evaluate publication bias.

Results: Out of 11,627 papers retrieved, 18 studies from 13 countries on 20,224 children met the inclusion criteria. Twelve (66.6%) studies had either low or moderate risk of bias. Hypoxaemia defined as oxygen saturation rate (SpO2) <90% associated with significantly increased odds of death from ALRI (OR 5.47, 95% CI 3.93 to 7.63) in 12 studies on 13,936 children. An Sp02 <92% associated with a similar increased risk of mortality (OR 3.66, 95% CI 1.42 to 9.47) in 3 studies on 673 children. Sensitivity analyses (excluding studies with high risk of bias and using adjusted OR) and subgroup analyses (by: altitude, definition of ALRI, country income, HIV prevalence) did not affect results. Only one study was performed on children living at high altitude.

Conclusions: The results of this review support the routine evaluation of SpO2 for identifying children with ALRI at increased risk of death. Both a Sp02 value of 92% and 90% equally identify children at increased risk of mortality. More research is needed on children living at high altitude. Policy makers in LMIC should aim at improving the regular use of pulse oximetry and the availability of oxygen in order to decrease mortality from ALRI.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. PRISMA 2009 Flow Diagram.
Fig 1. PRISMA 2009 Flow Diagram.
Fig 2. Risk of bias in the…
Fig 2. Risk of bias in the included studies.
Red = High risk of bias. Yellow = Moderate risk of bias. Green = Low risk of bias. White = Unknown risk of bias.
Fig 3. Association between hypoxemia and death.
Fig 3. Association between hypoxemia and death.
Notes: seventeen studies were able to be pooled in the meta-analysis. The remaining study that could not be meta-analysed used an SpO2 cut-off of 92% and found an HR of 12.2 (95% CI 1.6–92.0).29.
Fig 4. Subgroup analysis in the population…
Fig 4. Subgroup analysis in the population living at 0–1,499 meters above sea level.
Fig 5. Subgroup analysis in the studies…
Fig 5. Subgroup analysis in the studies with a population living at 1,500–2,500 meters above sea level.
Fig 6. Funnel plot to explore publication…
Fig 6. Funnel plot to explore publication bias.

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