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Original research
Smartphone app for neonatal heart rate assessment: an observational study
  1. Susanna Myrnerts Höök1,2,3,
  2. Nicolas J Pejovic1,2,3,
  3. Francesco Cavallin4,
  4. Clare Lubulwa5,
  5. Josaphat Byamugisha5,6,
  6. Jolly Nankunda5,7,
  7. Thorkild Tylleskär1,8,
  8. Tobias Alfven2,3
  1. 1Department of Global Public Health and Primary Care, Centre for International Health, University of Bergen, Bergen, Norway
  2. 2Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
  3. 3Sachs' Children and Youth Hospital, Stockholm, Sweden
  4. 4Independent Statistician, Solagna, Italy
  5. 5Mulago National Referral Hospital, Kampala, Uganda
  6. 6Department of Obstetrics and Gynaecology, College of Health Sciences, Makerere University, Kampala, Uganda
  7. 7Department of Paediatrics and Child Health, College of Health Sciences, Makerere University, Kampala, Uganda
  8. 8Centre for Intervention Science in Maternal and Child Health, University of Bergen, Bergen, Norway
  1. Correspondence to Dr Susanna Myrnerts Höök; susanna.hook{at}


Background Heart rate (HR) assessment is crucial in neonatal resuscitation, but pulse oximetry (PO) and electrocardiography (ECG) are rarely accessible in low-resource to middle-resource settings. This study evaluated a free-of-charge smartphone application, NeoTap, which records HR with a screen-tapping method bypassing mental arithmetic calculations.

Methods This observational study was carried out during three time periods between May 2015 and January 2019 in Uganda in three phases. In phase 1, a metronome rate (n=180) was recorded by low-end users (midwives) using NeoTap. In phase 2, HR (n=69) in breathing neonates was recorded by high-end users (paediatricians) using NeoTap versus PO. In phase 3, HR (n=235) in non-breathing neonates was recorded by low-end users using NeoTap versus ECG.

Results In high-end users the mean difference was 3 beats per minute (bpm) higher with NeoTap versus PO (95% agreement limits −14 to 19 bpm), with acquisition time of 5 seconds. In low-end users, the mean difference was 6 bpm lower with NeoTap versus metronome (95% agreement limits −26 to 14 bpm) and 3 bpm higher with NeoTap versus ECG in non-breathing neonates (95% agreement limits −48 to 53 bpm), with acquisition time of 2.7 seconds. The agreement between NeoTap and ECG was good in the HR categories of 60–99 bpm and ≥100 bpm; HR <60 bpm had few measurements (kappa index 0.71, 95% CI 0.63 to 0.79).

Conclusion HR could be accurately and rapidly assessed using a smartphone application in breathing neonates in a low-resource setting. Clinical assessment by low-end users was less accurate with wider CI but still adds clinically important information in non-breathing neonates. The authors suggest low-end users may benefit from auscultation-focused training. More research is needed to evaluate its feasibility in clinical use.

  • neonatology
  • resuscitation
  • monitoring
  • intensive care
  • circulatory

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  • Contributors SMH was responsible for the study design, preparation of the study site, acquisition of data, data analysis and interpretation of data. She conducted the literature search and was responsible for the writing process of the manuscript and approval of the final draft. NJP contributed to study design and acquisition of data. He revised the work draft and approved the final draft. FC, an independent statistician, contributed to the analyses of the data. He revised the work draft and approved the final draft. CL, JB and JN contributed to study design, manuscript revision and approved the final draft. TT contributed to interpretation of data, manuscript revision and approved the final draft. TA contributed to the study design, data analysis, manuscript revision and approval of the final draft.

  • Funding The work was supported by the Laerdal Global Health Foundation, the Research Council of Norway through FRIMEDBIO grant 250 531, and by the Centre for Intervention Science in Maternal and Child Health (CISMAC; project number 223269), which is funded by the Research Council of Norway through its Centre of Excellence scheme, and the University of Bergen, Norway. In-kind contributions were received from the University of Bergen, Makerere University and the Karolinska Institutet.

  • Disclaimer The funding agencies had no involvement in the study or the manuscript. Tap4Life, a non-profit organisation, is funded by donations.

  • Competing interests The authors have no financial relationships relevant to this article to disclose. SMH, NJP, CL, TT and TA are co-founders of the non-profit organisation Tap4Life (, which produced the free-of-charge application NeoTap. The authors do not get any salary from Tap4Life.

  • Patient consent for publication Not required.

  • Ethics approval The Institutional Review Board of Mulago National Referral Hospital, the Uganda National Council for Science and Technology, the National Drug Authority of Uganda, and the Regional Committee for Research Ethics in Norway (REK South-East 2013/2096 and 2017/989) approved the protocols.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

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