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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.

Search Strategy

Cochrane Database of Systematic Reviews and Pubmed
"pneumonia" AND "radiography" AND "follow-up"

Search Outcome

Cochrane - none relevant
Pubmed - 480 references (4 pertinent articles, 3 in English)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Grossman LK 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
Gibson NA et al, 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
Heaton P and 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.

Comment(s)

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.

References

1. Grossman LK, Wald ER, Nair P, et al. Roentgenographic follow-up of acute pneumonia in children. Pediatrics. 1979 Jan;63(1):30-1.
2. Gibson NA, Hollman AS, Paton JY. Value of radiological follow up of childhood pneumonia. BMJ 1993 Oct 30;307(6912):1117.
3. 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.