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 investigated 526 patients of age less than 21 years who had wheezing in the ED and who underwent chest radiography because of possible pneumonia. The physicians first obtained a medical history and performed and recorded a physical examination. Chest radiographs were studied by two blinded radiologists independently.
Among patients with median age 1.9 years (interquartile range, 0.7 – 4.5 years), 47% had a history of wheezing, hospitalized were 36%, and 4.9% (95% confidence interval [CI], 3.3% – 7.3%) had radiographic pneumonia. Afebrile wheezing children, who had defined temperature of less than 38°C, had a very low rate of pneumonia (2.2%; 95% CI, 1.0% – 4.7%).
Factors that increased risk for radiographic pneumonia included 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).
The study limitation included 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.
