Even though hypoxia is a major risk factor for death in children with acute respiratory infection in developing countries, oxygen is not part of first line treatment. Because oxygen is not readily available in developing countries it tends to be given to the most seriously ill children, whose outcome is poor. Oxygen might be useful if given earlier in the course of the disease. Clinical signs are not clear cut, however, though the presence of cyanosis and grunting together with a raised respiratory rate can significantly increase the detection of hypoxaemia. A simple oximeter would make detection easier, and oxygen concentrators are more cost effective than bottled oxygen. Ideally oxygen should be given to children in the early stages of clinical pneumonia to prevent deterioration.

Acute respiratory infection is a major killer of children in developing countries, especially of those aged less than 6 months.1 Although many cases of acute respiratory infection are initially caused by viruses, children are often secondarily infected with bacteria by the time they present to a health facility. The use of standard protocols for antibiotic use has been a major part of control programmes for acute respiratory infection throughout the world and is advocated by the World Health Organisation.2 Bacteraemia in acute respiratory infection has shown a significant association with hypoxaemia in terms of recorded cyanosis,3 but oxygen has not been considered as first line treatment in the same way as antibiotics.

Hypoxaemia has been recognised as a risk factor for death in children presenting with acute respiratory infection,4 but there have been no controlled trials in the developing world of the therapeutic value of administering oxygen. Paradoxically, those children who receive oxygen have a poorer outcome because they are more seriously ill when oxygen is started (Papua …