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The Rational Clinical Examination
August 1, 2017

Does This Child Have Pneumonia?The Rational Clinical Examination Systematic Review

Author Affiliations
  • 1Division of Emergency Medicine, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
  • 2Durham Veterans Medical Center, Durham, North Carolina
  • 3Duke University, Durham, North Carolina
JAMA. 2017;318(5):462-471. doi:10.1001/jama.2017.9039
Key Points

Question  What is the accuracy of symptoms and physical examination findings in identifying children with pneumonia?

Findings  In this systematic review and meta-analysis, the presence of hypoxia and increased work of breathing (grunting, nasal flaring, and retractions) were associated with the diagnosis of pneumonia. Fever, tachypnea, and auscultatory findings were not associated with pneumonia diagnosis.

Meaning  In children with cough or fever, when considering the diagnosis of pneumonia, the presence of hypoxia should be assessed and the child carefully observed. Although no single finding reliably differentiates pneumonia from other causes of childhood respiratory illness, hypoxemia and increased work of breathing are more important than tachypnea and auscultatory findings.

Abstract

Importance  Pneumonia is a leading cause of morbidity and mortality in children. It is important to identify the clinical symptoms and physical examination findings associated with pneumonia to improve timely diagnosis, prevent significant morbidity, and limit antibiotic overuse.

Objective  To systematically review the accuracy of symptoms and physical examination findings in identifying children with radiographic pneumonia.

Data Sources and Study Selection  MEDLINE and Embase (1956 to May 2017) were searched, along with reference lists from retrieved articles, to identify diagnostic studies of pediatric pneumonia across a broad age range that had to include children younger than age 5 years (although some studies enrolled children up to age 19 years); 3644 unique articles were identified, of which 23 met inclusion criteria.

Data Extraction and Synthesis  Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes.

Main Outcomes and Measures  Likelihood ratios (LRs), sensitivity, and specificity were calculated for individual symptoms and physical examination findings for the diagnosis of pneumonia. An infiltrate on chest radiograph was considered the reference standard for the diagnosis of pneumonia.

Results  Twenty-three prospective cohort studies of children (N = 13 833) with possible pneumonia were included (8 from North America), with a range of 78 to 2829 patients per study. The prevalence of radiographic pneumonia in North American studies was 19% (95% CI, 11%-31%) and 37% (95% CI, 26%-50%) outside of North America. No single symptom was strongly associated with pneumonia; however, the presence of chest pain in 2 studies that included adolescents was associated with pneumonia (LR, 1.5-5.5; sensitivity, 8%-14%; specificity, 94%-97%). Vital sign abnormalities such as fever (temperature >37.5°C [LR range, 1.7-1.8]; sensitivity, 80%-92%; specificity, 47%-54%) and tachypnea (respiratory rate >40 breaths/min; LR, 1.5 [95% CI, 1.3-1.7]; sensitivity, 79%; specificity, 51%) were not strongly associated with pneumonia diagnosis. Similarly, auscultatory findings were not associated with pneumonia diagnosis. The presence of moderate hypoxemia (oxygen saturation ≤96%; LR, 2.8 [95% CI, 2.1-3.6]; sensitivity, 64%; specificity, 77%) and increased work of breathing (grunting, flaring, and retractions; positive LR, 2.1 [95% CI, 1.6-2.7]) were signs most associated with pneumonia. The presence of normal oxygenation (oxygen saturation >96%) decreased the likelihood of pneumonia (LR, 0.47 [95% CI, 0.32-0.67]).

Conclusions and Relevance  Although no single finding reliably differentiates pneumonia from other causes of childhood respiratory illness, hypoxia and increased work of breathing are more important than tachypnea and auscultatory findings.

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