A systematic review has evaluated whether the accuracy of symptoms and physical examination leads to a timely pneumonia diagnosis in children.
With an estimated 900,000 deaths worldwide, pneumonia is a leading cause of illness and mortality in children. The subsequent cost in healthcare in the developed world is significant, with the rate of outpatient visits between 32.3 and 49.6 per 1000 for children aged between one and five years old. However, a universally accepted and standard practice for pneumonia diagnosis does not exist.
How is pneumonia diagnosed?
The most common clinical practice for pneumonia diagnosis is a chest radiograph, but there have been limitations surrounding the accuracy of the radiograph in identifying pneumonia. Evidence also suggests it can be difficult to differentiate between a viral and bacterial disease and predicting the clinical course in children using the radiograph. This uncertainty in pneumonia diagnosis has led to an unnecessary overuse of broad-spectrum antibiotics in children. In the United States, the recommended first-line treatment is amoxicillin (a penicillin antibiotic), but, initially, over 50% of children receive broad-spectrum antibiotics. Therefore, improving pneumonia diagnosis and standardising treatment would potentially significantly reduce the overuse of antibiotics.
Researchers in the United States recently conducted a systemic review of 23 cohort studies to assess the accuracy of identifying children with radiographic pneumonia and their results were published in the Journal of the American Medical Association. Researchers evaluated the accuracy of individual symptoms and physical examination of children for pneumonia diagnosis. The inclusion criteria for 23 diagnostic studies selected for the review were; each study was required to have children younger than five years in the population assessed, patients were suspected to have pneumonia, clinical assessments were described in detail, and chest radiographs were performed on all children.
The 23 studies included 13,833 participants who potentially had pneumonia. The results revealed that in North American studies the prevalence of radiographic pneumonia was 19% compared to 37% for studies conducted around the rest of the world. From the clinical symptoms and physical examinations such as listening to a patient’s breathing using a stethoscope (auscultatory findings), no single symptom or physical factor was identified as having a strong association with pneumonia.
Two studies, however, did show an association between chest pain in adolescents and pneumonia. But vital signs such as the presence of a fever and abnormally rapid breathing (tachypnea) also did not show a strong association with a pneumonia diagnosis. The only sign that did show an association with pneumonia was the presence of moderate hypoxemia (an abnormally low level of oxygen in the blood that can result in symptoms like shortness of breath) and increased work by the patient to simply breathe (such as grunting and nasal flaring). Therefore, patients who presented with a normal level of oxygen in their blood had a decreased chance of being diagnosed with pneumonia.
Some key indicators emerged
Despite the results indicating there was no single factor that significantly differentiated other childhood respiratory illnesses from pneumonia, the presence of hypoxemia and an increase in the work required to breathe appeared to be key indicators for a pneumonia diagnosis compared to tachypnea and auscultatory findings. Therefore, when physicians are considering a pneumonia diagnosis in children presenting with symptoms such as a cough and fever, they should be carefully observed and work of breathing and hypoxia levels assessed. In clinical settings where radiography is available to diagnose pneumonia, these findings could be used to help guide and limit the use of chest radiographs for use only when absolutely necessary.
Written by Lacey Hizartzidis, PhD
Reference: Shah SN, Bachur RG, Simel DL, Neuman MI. Does This Child Have Pneumonia?: The Rational Clinical Examination Systematic Review. JAMA. 2017 Aug 1;318(5):462-471. doi: 10.1001/jama.2017.9039. Review. Erratum in: JAMA. 2017 Oct 3;318(13):1284.
