Three Part Question
In [asymptomatic children with prior radiological evidence of pneumonia] are [routine follow up chest radiographs] necessary [to assist in management decisions]?
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.
Cochrane Database of Systematic Reviews and Pubmed
"pneumonia" AND "radiography" AND "follow-up"
Cochrane - none relevant
Pubmed - 480 references (4 pertinent articles, 3 in English)
|Author, date and country
||Study type (level of evidence)
|Grossman LK et al,|
|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|
|Gibson NA et al,|
|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|
|Heaton P and Arthur K,|
|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.|
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.
Clinical Bottom Line
In asymptomatic children with prior radiological evidence of pneumonia routine chest radiology provides no benefit.
- Grossman LK, Wald ER, Nair P, et al. Roentgenographic follow-up of acute pneumonia in children. Pediatrics. 1979 Jan;63(1):30-1.
- Gibson NA, Hollman AS, Paton JY. Value of radiological follow up of childhood pneumonia. BMJ 1993 Oct 30;307(6912):1117.
- Heaton P, Arthur K. The utility of chest radiography in the follow-up of pneumonia. N Z Med J. 1998 Aug 28;111(1072):315-7.