Chest Xrays in Wheezing Children?

Radiographic Pneumonia Uncommon in Children With Wheezing
by Laurie Barclay & Penny Murata

July 10, 2009 — 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.

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.

Factors linked to an increased risk for radiographic pneumonia were a history of fever at home; a history of abdominal pain, triage temperature of 38°C or higher, maximal temperature in the ED of 38°C or higher and triage oxygen saturation of less than 92%.

"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."

Pediatrics. 2009;124:e29-e36.

Clinical Context

In children with wheezing, underlying pneumonia can be difficult to diagnose. In the July 1999 issue of Clinical Pediatrics, a retrospective study by Mahabee-Gittens and colleagues found that in wheezing children younger than 18 months, the factors associated with radiographic pneumonia were a history of fever, a temperature of at least 38.4°C, and crackles by examination. A prospective study by Mahabee-Gittens in the July 2000 issue of Clinical Pediatrics noted that in wheezing children younger than 18 months, the factors associated with radiographic pneumonia were grunting and oxygen saturation less than 94% but not fever or tachypnea.

This prospective cohort study of wheezing children who undergo chest radiography in the ED evaluates which historical and examination features are associated with pneumonia.

Clinical Implications

•In children with wheezing in the ED, the rate of radiographic pneumonia is 4.9%.
•In children with wheezing in the ED, the risk for pneumonia is increased by fever at home, at triage, and in the ED, as well as by a history of abdominal pain and triage oxygen saturation less than 92%. The rate of pneumonia in afebrile, wheezing children is 2.2%.