Routine Chest Radiographs Not Recommended in Suspected Pediatric Pneumonia

Despite the lack of evidence on clinical outcomes, clinicians continue to order chest radiographs for children and adolescents to diagnose uncomplicated community-acquired pneumonia (CAP).¹ Both the American and British infectious disease societies do not recommend using chest radiographs to diagnose CAP because they cannot distinguish between bacterial and viral pathogens.¹ Moreover, there is no evidence that radiographs affect clinical outcomes.¹ Still, the myth persists that radiographs can guide clinicians in diagnosing and treating uncomplicated CAP.¹

Why the Practice Continues

A recent study reveals why clinicians may want to rely on technology to diagnose pneumonia in children and adolescents.² In a single-center prospective study of 128 children (3 months to 18 years), the interrater reliability of examining physician pairs showed that there was no substantial concordance in physical findings in children who were suspected of having CAP.² The study showed that only 3 out of 19 findings had acceptable agreement: wheezing, retractions, and respiratory rate.² Importantly, the findings critical to diagnosing CAP (crackles/rales and diminished breath sounds) had poor to moderate interrater reliability.²

“The results are not surprising given the extent of variation that we’ve found in the emergency department management of children with pneumonia,” said lead study author Todd A. Florin, MD, MSCE, associate professor of pediatrics at the University of Cincinnati College of Medicine and director of research operations in the division of pediatric emergency medicine at Cincinnati Children’s Hospital in Ohio.

The consequences of misdiagnosing are severe. CAP is responsible for 20% of all deaths that occur in children age <5 years and is the single leading cause of death in children worldwide.¹ Despite guidelines recommending clinical diagnosis rather than imaging for CAP, clinicians argue that lower respiratory tract infections have nonspecific signs and symptoms.³  

When clinicians are unsure about a diagnosis, imaging can allay the fears of concerned parents.⁴ In a study of 429 children (median age, 3 years), 90% of caregivers favored children receiving radiographs to ascertain CAP.⁴ When asked 1 week later, the caregivers were more likely to affirm the decision to obtain radiographs in their child if he or she was eventually diagnosed with CAP.⁴

Lead study author Susan C. Lipsett, MD, instructor in pediatrics at Harvard Medical School and Boston Children’s Hospital in Massachusetts, says, “parents are generally accepting of the use of chest radiography as a diagnostic tool for pneumonia in their children. Clinicians ordering chest [radiographs] in children can help mitigate parental concern around radiation exposure by becoming familiar with the data around the radiation exposure involved in a 2-view chest radiograph.”

Exceptions to the Rule: Context Matters

Guideline writers are emphatic that the decision to use chest radiography is context specific.¹ Clinicians worldwide do not have uniform access to imaging and must therefore consider variables such as available resources, the likelihood of complications, and suspected tuberculosis.¹ The divergence between the developed and developing worlds is vast, and nonclinical factors, such as fear of litigation, may contribute to the overuse of radiographs.¹

Although routine chest radiographs are not recommended for pediatric patients who can be treated as outpatients, there are some exceptions for severe cases⁵:

• Suspected hypoxemia
• Respiratory distress
• Failed course of antibiotics

The posteroanterior and lateral radiographs can also rule out pneumonia complications, parapneumonic effusions, necrotizing pneumonia, and pneumothorax.⁵

Dr Lipsett adds that she, “would use chest radiography for cases in which there is diagnostic ambiguity regarding the presence or absence of pneumonia. Given the known challenges in the diagnosis of pneumonia in children, clinicians must balance the risks and costs of radiography against the risks of overtreatment with antibiotics.”

How to Avoid Unnecessary Chest Radiographs and Other Diagnostics

The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America bifurcate the decision making into outpatient vs inpatient status.⁵ For children older than 3 months, the organizations do not advocate a full panel of laboratory tests and imaging in children who otherwise appear well and can be treated as outpatients.⁵

Children who can be treated as outpatients need blood cultures only if their status does not improve.⁵ Children who have documented bacteremia with a Staphylococcus aureus pathogen should undergo culture. The organizations recommend that children who were immunized against pneumococcal virus do not need to be tested.

Clinical experience is associated with less resource utilization. In a qualitative study conducted in a Bristol, United Kingdom, hospital, researchers found that seasoned physicians were less likely to admit patients <5 years old with acute respiratory distress seen in the emergency department.⁶ Experienced clinicians also used the following to decide whether to admit young patients⁶:

• Child’s clinical signs and appearance
• Child’s behavior
• Clinician’s intuition

“It is important to consider the factors generally known to be associated with radiographic pneumonia, including fever, increased work of breathing, and hypoxia (oxygen saturation <92%),” says Dr Florin. “In the absence of these factors, routine chest radiography likely will not be helpful in making a diagnosis and may result in unnecessary prescribing of antibiotics.”                     

Summary and Clinical Applicability

Despite the absence of guidelines that recommend routine chest radiographs for children and adolescents suspected of having pneumonia, clinicians continue to include them in their diagnostic workup. Chest radiographs do not differentiate between viral and bacterial pathogens, and they do not subsequently alter the course of treatment.

References

1. Andronikou S, Lambert E, Halton J, et al. Guidelines for the use of chest radiographs in community-acquired pneumonia in children and adolescents. Pediatr Radiol. 2017;47:1405-1411.
2. Florin TA, Ambroggio L, Brokamp C, et al. Reliability of examination findings in suspected community-acquired pneumonia. Pediatrics. 2017;140(3).
3. Urbankowska E, Krenke K, Drobczyński Ł, et al. Lung ultrasound in the diagnosis and monitoring of community acquired pneumonia in children. Respir Med. 2015;109:1207-1212.
4. Lipsett SC, Monuteaux MC, Bachur RG, Neuman MI. Caregiver valuation of chest radiography for the diagnosis of pneumonia in children [published online October 1, 2017]. Clin Pediatr (Phila). doi: 10.1177/0009922817736768
5. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53:e25-e76.
6. Bowen L, Shaw A, Lyttle MD, Purdy S. The transition to clinical expert: enhanced decision making for children aged less than 5 years attending the paediatric ED with acute respiratory conditions. Emerg Med J. 2017;34:76-81.