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When Roentgen reported his discovery of a newform of radiation in 1895(1), the excitement wasimmediate, and a radiology handbook was publishedwithin a year(2). Screening of apparently healthypeople was being recommended by 1928(3), and theUS Army and Navy screened approximately 10

million personnel during World War II(4). In 1980alone an estimated 30 million routine admissionchest x-rays were taken in the United States, costingconsumers $1.5 billion(5). The development of thescientific basis for the use of chest radiography hashowever received little attention. Recognition ofinter-observer variation took almost 50 years(6), andwidespread acceptance even longer(7). In thecentennial of Roentgens discovery, a prestigiousradiological journal published a paper stating that,As the most common radiographic examination, the

chest radiographic examination rose to this positionnot on the basis of medical science but faith thattechnology in any form would aid in the care ofpatients(8).

The use of chest radiography in the initialassessment of acute lower respiratory infection restson the assumptions that; (i) clinical assessment plusradiography results in a more accurate diagnosis thanclinical assessment alone; (ii) this leads to changes inclinical management; and (iii) the changes benefitthe patient. Any such benefits must be weighed

against the costs and potential adverse effects of theprocedure, which include the effects of false positiveand false negative findings, and exposure to ionisingradiation. Costs of radiography include the cost ofthe radiograph itself and the time spent waiting forradiography and to be seen again by a clinician. Iftravel to another facility for radiography isnecessary, the cost is further increased. The resource

Chest Radiography for Children with Pneumonia: A Century of Folly?

G H SWINGLERProfessor of Paediatrics and Child Health, and Director, School of Child and Adolescent Health,

University of Cape Town, Red Cross Childrens Hospital, Klipfontein Road, Rondebosch,

Cape Town 7700 , South Africa. E-mail: george.swingler@uct.ac.za

implications are perhaps most acute in middleincome countries, where chest radiography ispotentially affordable but with many prioritiescompeting for resources. In this situation it isparticularly important to know whether chestradiography has clinical benefit and, if so, by how

much and at what cost.

The diagnostic accuracy of chest radiography isdifficult to study because of the lack of a crediblereference standard for pneumonia (other than biopsyor autopsy). When microbiological findings havebeen used as reference standards for the etiology ofpneumonia, chest radiography has been found to beof little use in distinguishing bacterial from viralpneumonia in both adults(9) and children(10,11).The poor agreement between different observersassessing the same films, or even when later

assessing the same films themselves(12,13), castsfurther doubt on diagnostic accuracy, althoughtraining has been found to increase the agreementfrom poor to moderate(14).

There is little evidence to support a beneficialimpact of a radiograph when used to follow upradiological pneumonia(15), or in screening fortuberculosis children with clinical pneumonia in ahigh prevalence population(16). In this issue ofIndian Pediatrics, Bharti, et al.(17) suggest thatchest radiography also has limited value in

predicting clinical improvement in childrenhospitalized with severe pneumonia.

The most direct way to assess clinical benefit isto compare the effect on clinical outcome ofmanagement using a chest radiograph with thatwithout its use, by means of a randomized controlledtrial. A recent careful search has identified two such

E D I T O R I A L S

INDIAN PEDIATRICS 889 VOLUME45__NOVEMBER17, 2008

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EDITORIALS

INDIAN PEDIATRICS 890 VOLUME45__NOVEMBER17, 2008

trials(18). One was performed in adults presentingfor the first time to a US emergency room or walk-inclinic with a cough for less than one month(19), andthe other in ambulatory children presenting to aprimary-level outpatient department in a SouthAfrican childrens hospital(20). Neither found

clinical benefit, despite higher antibiotic use in theradiograph group in the study of children.

Given the poor observer agreement, the lack ofbenefit in less severely affected children, and thepotential harms and costs of the procedure, carefullyplanned randomized controlled trials in moreseverely affected children with pneumonia appear tobe ethically justified, if not mandated.

Funding:None.

Competing interests:None stated.

REFERENCES

1. Rntgen WC. ber eine neue Art von Stralen.Vorlufige Mitteilung. Sitzungberichte derWurzburger Physik-mediz Gesellschaft. 1895; 29:132.

2. Ward HS. Practical Radiography. A Hand Book ofthe Applications of theX-rays. London: Photogram;1896.

3. Fisk EL. Roentgenology: the hand-maid ofdiagnosis. Radiology 1928; 11: 153-155.

4. Haygood TM, Briggs JE. World War II military ledthe way in screening chest radiography. Mil Med1992; 157: 113-116.

5. Hubbell FA, Greenfield S, Tyler JL, Chetty K,Wyle FA. The impact of routine admission chest

X-ray films on patient care. N Eng J Med 1985; 312:209-213.

6. Garland LH. On the scientific evaluation ofdiagnostic procedures. Radiology 1949; 52: 309-327.

7. Garland LH. Studies on the accuracy of diagnosticprocedures. AJR 1959; 82: 25-38.

8. Gurney JW. Why chest radiography becameroutine. Radiology 1995; 195: 245-246.

9. Graffelman AW, Willemssen FE, Zonderland HM,Neven AK, Kroes AC, van den Broek PJ. Limitedvalue of chest radiography in predicting aetiology

of lower respiratory tract infection in generalpractice.Br J Gen Pract 2008; 58: 93-97.

10. Swingler GH. The radiologic differentiationbetween bacterial and viral lower respiratoryinfection in children: a systematic literature review.Clin Pediatr (Phila) 2000; 39: 627-633.

11. Virkki R, Juven T, Rikalainen H, Svedstrm E,Mertsola J, Ruuskanen O. Differentiation of

bacterial and viral pneumonia in children.Thorax2002; 57: 438-441.

12. Swingler GH. Observer variation in chestradiography of acute lower respiratory infections inchildren: a systematic review. BMC Med Imag2001; 1: 1.

13. Bada C, Carreazo NY, Chalco JP, Huicho L. Inter-observer agreement in interpreting chest X-rays onchildren with acute lower respiratory tract

infections and concurrent wheezing. Sao PauloMed J 2007; 125: 150-154.

14. Patel AB, Amin A, Sortey SZ, Athawale A,Kulkarni H. Impact of training on observervariation in chest radiographs of children withsevere pneumonia. Indian Pediatr 2007; 44: 675-681.

15. Wacogne I, Negrine RJS.Are follow up chestX-rayexaminations helpful in the management of childrenrecovering from pneumonia? Arch Dis Child 2003;88: 457-458.

16. Swingler GH. Chest radiography in ambulatorychildren with acute lower respiratory infections:effective tuberculosis case finding? Ann TropPediatr 2000; 20: 11-15.

17. Bharti B, Kaur L, Bharti S. Role of chestX-ray inpredicting outcome of acute severe pneumonia.Indian Pediatr 2008; 45: 893-898.

18. Swingler GH, Zwarenstein M. Chest radiograph inacute respiratory infections. Cochrane DatabaseSyst Rev 2008; 1: CD001268.

19. Bushyhead JB, Wood RW, Tompkins RK. Theeffect of chest radiographs on the management and

clinical course of patients with acute cough. MedCare 1983; 21: 661-673.

20. Swingler GH, Hussey GD, Zwarenstein M.Randomised controlled trial of clinical outcomeafter chest radiograph in acute ambulatory lower-respiratory infection in children. Lancet 1998; 351:404-408.