Are follow up chest X-rays helpful in the management of children recovering from pneumonia?
Date First Published:
August 6, 2002
Last Updated:
May 2, 2003
Report by:
Ian Wacogne, Robert J S Negrine, Spr and SHO respectively (Department of Paediatrics, North Staffordshire Hospital, Stoke-On-Trent.)
Search checked by:
Bob Phillips, Department of Paediatrics, North Staffordshire Hospital, Stoke-On-Trent.
Three-Part Question:
In [asymptomatic children with prior radiological evidence of pneumonia] are [routine follow up chest radiographs] necessary [to assist in management decisions]?
Clinical Scenario:
A 4 year-old boy with a cough and a fever is referred by his general practitioner. On auscultation of his chest there are focal signs suggestive of a lower respiratory tract infection; a chest X-ray confirms right lower lobe collapse and consolidation. He is started on oral antibiotics and discharged home within 24 hours. He is given a follow-up appointment in 4 weeks time in the "registrar clinic" to be reviewed after having a repeat chest X-ray as per your unit's protocol.
At the follow-up appointment he is clinically well and has a normal radiograph. After discharging him you wonder whether the "routine" exposure to radiation outweighs the detection of persistent radiological changes.
At the follow-up appointment he is clinically well and has a normal radiograph. After discharging him you wonder whether the "routine" exposure to radiation outweighs the detection of persistent radiological changes.
Search Strategy:
Cochrane Database of Systematic Reviews and Pubmed
Search Details:
"pneumonia" AND "radiography" AND "follow-up"
Outcome:
Cochrane - none relevant
Pubmed - 480 references (4 pertinent articles, 3 in English)
Pubmed - 480 references (4 pertinent articles, 3 in English)
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Roentgenographic follow-up of acute pneumonia in children. Grossman LK, Wald ER, Nair P, et al. 1979 | 129 children with a radiological diagnosis of pneumonia. (6 weeks – 15 years) | Prospective cohort (level 4) | Chest radiograph findings at follow up | 56/70 (80%) children normal CXR by 4 weeks. 9/9 (100%) children with residual CXR changes at 4 weeks had normal CXR by 3 months | 59 were lost to first follow up No data regarding clinical symptoms and signs was collected at follow up |
| Value of radiological follow up of childhood pneumonia. Gibson NA, Hollman AS, Paton JY. 1993 | 77 children with pneumonia (history, clinical and radiological diagnosis) | Prospective cohort (level 4) | Clinical symptoms, signs and chest radiograph findings at follow up | 59/72 children asymptomatic. 51 (87%) normal CXR. 8 (13%) improved CXR | 5 patients defaulted follow up. 7 of the 8 patients with symptoms, signs and radiological findings at follow up had pleural effusions on their original chest X-ray |
| The utility of chest radiography in the follow-up of pneumonia. Heaton P, Arthur K. 1998 | 65 children with pneumonia (history, clinical and radiological diagnosis). Mean age 3.5 years (0.4 – 13 years) | Retrospective cohort (level 4) | Chest radiograph findings at follow up | 37/41 children asymptomatic: 35 (95%) normal CXR (95% CI 87% to 100%). 2 improved (5%) CXR | Only 41/65 children followed up fully; 11 were not offered follow up and a further 13 were lost to follow up. |
Author Commentary:
There were only 2 studies, Heaton and Gibson, which looked at both clinical and radiological features at follow up. The study by Grossman et al provided no information about clinical features at follow up but gave similar overall resolution rates.
The studies by Heaton et al and Gibson et al came to similar conclusions despite significant differences in study design. The study by Heaton et al was retrospective; Gibson’s prospective. Heaton’s study included children with asthma as it was felt that their exclusion would compromise the practical value of the study. By contrast, Gibson et al excluded children with “pre-existing disease” – which may have included asthma – and excluded children presenting with acute asthma even if radiological findings suggested pneumonic consolidation.
The issue of inter-observer variation in the interpretation of X-rays was raised by both Heaton and Gibson. In Gibson’s study a paediatric radiologist (Hollman) described minor, but improved radiological findings in 8 chest X-rays of asymptomatic children. When viewed by other radiologists 4 were reported as clear and 4 with minor changes and when viewed by clinicians 7 were reported clear and one with minor changes. This has practical implications for the paediatrician reviewing the child at follow up.
The studies by Heaton et al and Gibson et al came to similar conclusions despite significant differences in study design. The study by Heaton et al was retrospective; Gibson’s prospective. Heaton’s study included children with asthma as it was felt that their exclusion would compromise the practical value of the study. By contrast, Gibson et al excluded children with “pre-existing disease” – which may have included asthma – and excluded children presenting with acute asthma even if radiological findings suggested pneumonic consolidation.
The issue of inter-observer variation in the interpretation of X-rays was raised by both Heaton and Gibson. In Gibson’s study a paediatric radiologist (Hollman) described minor, but improved radiological findings in 8 chest X-rays of asymptomatic children. When viewed by other radiologists 4 were reported as clear and 4 with minor changes and when viewed by clinicians 7 were reported clear and one with minor changes. This has practical implications for the paediatrician reviewing the child at follow up.
Bottom Line:
In asymptomatic children with prior radiological evidence of pneumonia routine chest radiology provides no benefit.
References:
- Grossman LK, Wald ER, Nair P, et al.. Roentgenographic follow-up of acute pneumonia in children.
- Gibson NA, Hollman AS, Paton JY.. Value of radiological follow up of childhood pneumonia.
- Heaton P, Arthur K.. The utility of chest radiography in the follow-up of pneumonia.