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A4 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 examination 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 four weeks time in the “registrar clinic” to be reviewed after having a repeat chest x ray examination according to 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.
Structured clinical question
In asymptomatic children with prior radiological evidence of pneumonia [patient] are routine follow up chest radiographs [intervention] necessary to assist in management decisions [outcome]?
Search strategy and outcome
Cochrane Database of Systematic Reviews—none relevant.
Pubmed—“pneumonia” AND “radiography” AND “follow-up”—480 references (four pertinent articles, three in English).
See table 3.
There were only two studies, Heaton and Arthur, and Gibson et al, 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 and Arthur, and Gibson et al came to similar conclusions despite significant differences in study design. The study by Heaton and Arthur was retrospective; Gibson et al’s prospective. Heaton and Arthur’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 interobserver variation in the interpretation of x rays was raised in both studies. In Gibson et al’s study a paediatric radiologist (Hollman) described minor, but improved radiological findings in eight chest x rays of asymptomatic children. When viewed by other radiologists four were reported as clear and four with minor changes; and when viewed by clinicians seven 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.