**4. Discussion**

Video-based respiratory monitoring is at the earliest stages of development. However, our study shows the potential for MSD, making this technology equivalent to induction pneumography for at least a stable neonate in an open crib. While there are still a lot of qualifiers to its comparison, it is a major step toward a future without contact respiratory monitoring. Video-based monitoring could be integrated into incubator designs and attached to preexisting hospital cribs. With further validation, this technology could decrease the need for cardiac leads in more stable infants and be an adjunct monitoring tool for critically ill patients as a means to possibly decrease false alarms from patient movement.

A next major step for video-based respiratory monitoring systems is to validate the technology in a large cohort study inclusive of a diverse population with varying skin tone, race, sex, age, and clinical stability. Once validated, conducting studies that allow providers to view RR in real time would demonstrate the ability of video-monitoring to screen for apneas and tachypnea in infants. To be trusted in clinical settings, this technology must be shown to be as sensitive as induction pneumography. While preliminary data from this study sugges<sup>t</sup> that it is as sensitive and specific as ECG-based systems, a longer and larger study focused on comparing significant events between the two systems is needed. There may also be opportunities for this technology to reduce false positive alarms, a known issue for hospitalized patients, either by being a more accurate monitor or by providing negative feedback to current monitors.

As MSD amplifies and tracks movement by averaging background noise, it has an advantage over induction pneumography which often falls short because of increased noise with faster respiratory rates. A future study comparing video-based respiratory monitoring and ECG induction pneumography to the gold standard of counting breaths for a minute in clinically ill and tachypneic patients could potentially show superiority of video-based systems in monitoring RR.

With the majority of pediatric illnesses being respiratory-related and the accessibility of high-quality cameras, such as those present in most personal cell phones, a video-based monitoring system could also have a large impact on outpatient medicine. It is conceivable that this technology could allow healthcare providers to measure RR throughout a telehealth video visit. This would provide valuable information that would aid in the decision-making process of whether or not a patient needs to go to an emergency room or would be safe to be cared for at home. With the SARS-CoV-2 pandemic increasing demand and showing the value of telemedicine visits, this technology could be invaluable.
