A little cough

by Adam Herbstritt

6 year old presents unwell, febrile, viral, coryzal with some focal chest signs.
This Xray was performed in ED - what do you see?

Look carefully and you'll see some LEFT peri diaphragmatic changes consistent with pneumonia. Its subtle.
Does this indicate a bacterial focus and therefore antibiotics?

When to perform CXRs in kids

There is no good concordance between even radiologists in Xray interpretation of pneumonia. There is also no evidence that we can differentiate bacterial from viral pneumonia.  So when is a CXR useful?

NICE 2013 guidelines on Fever in Children suggest limiting CXRs to only those with respiratory signs AND sick enough to warrant admission. Specifically, those with...

 - Any 'red' signs (including grunting, RR>60, indrawing)
 - Any 'amber' signs AND no clear infection source AND fever >39 AND WCC>20
 - Children under 3months with fever and respiratory symptoms
 
So in summary;
 - CXR's in kids usually not helpful and poorly distinguish viral from bacterial infection
 - Consider performing if needing admission and respiratory signs of severe pneumonia present