What is the role of chest radiographs in the emergent management of pediatric patients with fever?

Updated: Jul 23, 2019
  • Author: Hina Z Ghory, MD; Chief Editor: Russell W Steele, MD  more...
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Answer

Answer

Chest radiographs are most useful for patients with high fever accompanied by focal pulmonary examination findings. Chest radiographs should not be routinely performed for fever alone, in the absence of lower respiratory tract findings or hypoxemia.

A study from Spain found that 13% of young children with fever above 39.0°C and a peripheral white blood cell (WBC) count of greater than 20 × 109/L had occult pneumonia. [102] However, just 20% of the radiographs were interpreted by radiologists, and the authors estimate that just one third to one half of the children had received the pneumococcal vaccine.

Given the very low positive predictive value of the WBC count, its routine acquisition in the setting of high fever should be discouraged. On the other hand, if the WBC is obtained and is markedly elevated, consideration should be given to obtaining a chest radiograph, in the absence of an alternative source of fever.

In febrile neonates and young infants, a chest radiograph may only be a routine part of a sepsis workup in the presence of respiratory signs in neonates (eg, rales, grunting, flaring, retractions, hypoxia) or lower respiratory tract findings (eg, cough, tachypnea) in infants. An increased respiratory rate is the earliest indicator of respiratory distress and should be considered in the overall decision to obtain a chest radiograph.

In febrile children aged 3-24 months, pneumonia may be present even in the absence of definite auscultatory signs. An abnormal respiratory rate or pulse oximetry should alert the emergency physician to the need for a chest radiograph. Chest radiography is indicated if the child shows signs of respiratory distress, such as tachypnea; grunting, flaring, or retractions; or hypoxia, as determined with pulse oximetry. A history of prolonged fever or cough may also be predictors of occult respiratory tract infection. [103]

In children older than 2 years, chest radiography is not routinely ordered unless a specific indication is present, such as prolonged cough, tachypnea, or hypoxia. [104]


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