Radiographic Pneumonia Uncommon in Children With Wheezing

Because radiographic pneumonia in children with wheezing but without fever is uncommon, the routine use of chest radiography in these children should be discouraged, according to the results of a prospective cohort study reported in the July issue of Pediatrics.

"The diagnosis of pneumonia in children with wheezing can be difficult, because the clinical history and auscultatory findings may be difficult to distinguish from those for children without pneumonia," write Bonnie Mathews, MD, from Children's Hospital Boston and Harvard Medical School in Boston, Massachusetts, and colleagues. "Limited data exist regarding predictors of pneumonia among children with wheezing. The goal was to identify factors associated with radiographically confirmed pneumonia among children with wheezing in the emergency department (ED) setting."

The study sample consisted of 526 individuals not older than 21 years who were seen in the ED, who had wheezing on clinical examination, and who underwent chest radiography because of possible pneumonia. Before learning the chest radiograph results, treating physicians obtained a medical history and performed and recorded a physical examination. Two blinded radiologists independently read the chest radiographs.

Among the included patients, median age was 1.9 years (interquartile range, 0.7 - 4.5 years), 47% had a history of wheezing, 36% were hospitalized, and 4.9% (95% confidence interval [CI], 3.3% - 7.3%) had radiographic pneumonia. Children with wheezing who were afebrile, defined as a temperature of less than 38°C, had a very low rate of pneumonia (2.2%; 95% CI, 1.0% - 4.7%).

Factors linked to an increased risk for radiographic pneumonia were a history of fever at home (positive likelihood ratio [LR], 1.39; 95% CI, 1.13 - 1.70), a history of abdominal pain (positive LR, 2.85; 95% CI, 1.08 - 7.54), triage temperature of 38°C or higher (positive LR, 2.03; 95% CI, 1.34 - 3.07), maximal temperature in the ED of 38°C or higher (positive LR, 1.92; 95% CI, 1.48 - 2.49), and triage oxygen saturation of less than 92% (positive LR, 3.06; 95% CI, 1.15 - 8.16).

Limitations of this study include time constraints, preventing enrollment of all eligible children; reliance on blinded radiologist review; and chest radiographs ordered at the discretion of the physicians caring for the patients, which may have introduced selection bias. The findings are not generalizable to all children with wheezing, and the rate of pneumonia may have been overestimated.

"Radiographic pneumonia among children with wheezing is uncommon," the study authors write. "Historical and clinical factors may be used to determine the need for chest radiography for wheezing children. The routine use of chest radiography for children with wheezing but without fever should be discouraged."

Source : http://www.medscape.com/viewarticle/705639?sssdmh=dm1.497700&src=nldne