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

Educational Objective
To review the accuracy of clinical findings for the diagnosis of pneumonia in children.
1 Credit CME
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.


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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Article Information

Corresponding Author: Sonal N. Shah, MD, MPH, Division of Emergency Medicine, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (sonal.shah@childrens.harvard.edu).

Accepted for Publication: June 21, 2017.

Correction: This article was corrected on October 3, 2017, for typographical errors and for incorrect data in the Statistical Methods section.

Author Contributions: Drs Shah, Bachur, and Neuman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The data were shared with Dr Simel, and all authors are responsible for the accuracy of the data analyses.

Concept and design: Shah, Bachur, Neuman.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Shah, Simel.

Administrative, technical, or material support: Shah, Neuman.

Supervision: Bachur, Neuman.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Bachur reports receipt of royalties from UpToDate.com (editorial duties) and Wolters-Kluwer (textbook editor); a stipend as the medical editor for the American Board of Pediatrics Sub-board of Pediatric Emergency Medicine; and research funded by Astute Medical related to biomarkers of appendicitis (patent US20120028268 A). Dr Simel reports receipt of honoraria for contributions to JAMAEvidence.com. Dr Neuman reports receipt of royalties from UpToDate.com for content unrelated to this manuscript and receives a stipend for his service as an Assistant Editor for Pediatrics. No other disclosures were reported.

Disclaimer: Dr Simel, Section Editor of The Rational Clinical Examination Series, was not involved in the editorial review of, or decision to publish, this article.

Additional Contributions: We thank Aimee Chung, MD, Department of Pediatrics, Duke University; Emily Sterrett, MD, Department of Pediatrics, Duke University; and George Robert Parkerson, MD, MPH, Infectious Diseases, Baylor University, for providing helpful advice on the manuscript. We also thank Allison Clapp, MLS, former director, Boston Children's Hospital Library; and Meaghan Muir, MLS, director, Boston Children’s Library, for their assistance with the literature query. None of these individuals received any compensation for their contributions.

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