Prevalence of hypoxemia among sick children, aged under-five years, seeking healthcare at primary health facilities in Uttar Pradesh, India: an observational-cohort study.

Background: Hypoxemia or low blood oxygen saturation (SpO2) increases risk of mortality in children aged under-five years. Integrated Management of Neonatal and Childhood Illness guidelines in India recommend referral to higher centre at SpO2 <90%. The primary objective was to assess prevalence of hypoxemia among sick under-five, seeking healthcare at rural primary health facilities in Uttar Pradesh, India. Secondary objective assessed completion of referral (defined as reaching higher referral facilities) in hypoxemic children by day-7. Methods: Secondary data analyses from pulse oximetry (POx) arm of a cluster randomized trial. Hypoxemia, defined as SpO2 <94%, was assessed on day-0 and completion of referral through telephonic follow-up on day-7 (+2 days). Severe hypoxemia was defined as SpO2 <90%. Registration number: CTRI/2022/03/041325. Findings: From 20-June-2022 to 21-April-2023, 24,966 children were enrolled, among whom SpO2 readings were available for 94·4% (n = 23,560) children. Prevalence of hypoxemia was 1·3% (308/23,560) and severe hypoxemia was 29·2% (90/308). Lost to follow-up among hypoxemic was 9·4% (29/308). Among hypoxemic 27·9% (86/308) and among severe hypoxemic 46·7% (42/90) children were referred. Referral completion among hypoxemic was 20·3% (16/79) and severe hypoxemic 23·8% (10/40). Mortality in hypoxemic children was 3·9% (11/279), vs 0·05% (11/20,292) in non-hypoxemic ones. Interpretation: Prevalence of hypoxemia is low among sick children presenting to rural health facilities of northern India. Less than one-third of hypoxemic children (and less than half of severely hypoxemic) were referred to higher facility, and only one in five completed referrals. Therefore, identifying and addressing the factors associated with these findings, would strengthen the integration of POx in primary healthcare facilities. Funding: This work is supported by Unitaid as part of the Tools for Integrated Management of Childhood Illness (TIMCI) project under grant number n°2019-35-TIMCI to PATH.