Background: When available, chest radiographs are used widely in acute lower-respiratory-tract infections in children. Their impact on clinical outcome is unknown.
Methods: 522 children aged 2 to 59 months who met the WHO case definition for pneumonia were randomly allocated to have a chest radiograph or not. The main outcome was time to recovery, measured in a subset of 295 patients contactable by telephone. Subsidiary outcomes included diagnosis, management, and subsequent use of health facilities.
Findings: There was a marginal improvement in time to recovery which was not clinically significant. The median time to recovery was 7 days in both groups (95% CI 6-8 days and 6-9 days in the radiograph and control groups respectively, p=0.50, log-rank test) and the hazard ratio for recovery was 1.08 (95% CI 0.85-1.34). This lack of effect was not modified by clinicians' experience and no subgroups were identified in which the chest radiograph had an effect. Pneumonia and upper-respiratory infections were diagnosed more often and bronchiolitis less often in the radiograph group. Antibiotic use was higher in the radiograph group (60.8% vs 52.2%, p=0.05). There was no difference in subsequent use of health facilities.
Interpretation: Chest radiograph did not affect clinical outcome in outpatient children with acute lower-respiratory infection. This lack of effect is independent of clinicians' experience. There are no clinically identifiable subgroups of children within the WHO case definition of pneumonia who are likely to benefit from a chest radiograph. We conclude that routine use of chest radiography is not beneficial in ambulatory children aged over 2 months with acute lower-respiratory-tract infection.
PIP: The impact of chest radiographs on the diagnosis, treatment, follow-up, and clinical outcome of children with ambulatory acute lower-respiratory infections was assessed in 518 children 2-59 months old who presented to the Red Cross Hospital in Cape Town, South Africa, with symptoms consistent with the World Health Organization case definition of pneumonia. 257 were randomly assigned to receive a radiograph and 261 were controls (no diagnostic intervention). The median time to recovery, measured in a subset of 295 children whose parents were reachable by telephone, was 7 days for both cases and controls (95% confidence intervals, 6-8 and 6-9 days, respectively). The unadjusted Cox proportional hazards ratio for recovery for the radiograph group compared with controls was 1.08 (95% confidence interval, 0.85-1.34). This rate was unaffected by adjustment for age, weight for age, duration of symptoms before presentation, respiratory rate, clinician's postgraduate pediatric qualifications, and clinician's perception of the need for chest radiograph. More radiograph patients were diagnosed with pneumonia or upper-respiratory infection, while a higher proportion of controls were diagnosed as having bronchiolitis. 149 children in the radiograph group (60.8%) compared with 133 controls (52.2%) received antibiotics. There was no difference in subsequent use of health facilities. These findings indicate that there are no clinically identifiable subgroups of children likely to benefit from routine use of chest radiography.