Skip to main content
SpringerLink
Log in

Evaluation of the World Health Organization criteria for chest radiographs for pneumonia diagnosis in children

  • Original Paper
  • Published:
European Journal of Pediatrics Aims and scope Submit manuscript

Abstract

Our objective was to compare the inter-observer level of agreement in diagnosing pneumonia using the World Health Organization (WHO) guidelines for the interpretation of radiographs. We conducted a prospective study in a pediatric emergency room. Fifteen observers (13 pediatricians, 2 radiologists) interpreted 200 pediatric (<5 years old) chest radiographs using the WHO guidelines. Observers were blinded to the clinical presentation. Results were analyzed for kappa values. Individual readings were compared to two “gold standard” teams: (1) radiologist and pediatrician and (2) two radiologists. Results: Alveolar pneumonia, non-alveolar pneumonia, and no pneumonia were found (by radiologists) in 12.8%, 2.7%, and 78.6% of readings, respectively. The mean kappa values for alveolar pneumonia, non-alveolar pneumonia, and no pneumonia of observers versus the team consisting of a radiologist and a pediatrician were 0.73, 0.23, and 0.61, respectively. For non-alveolar pneumonia, the mean kappa value was higher for the gold standard consisting of a radiologist and a pediatrician when compared to the two-radiologist team. Pediatricians overdiagnosed “non-alveolar pneumonia” compared with radiologists. In contrast, for the alveolar pneumonia and no-pneumonia diagnoses, no significant differences were found. Conclusions: The WHO guidelines for interpretation of chest radiographs result in high level of agreement between readers for the definition of “alveolar pneumonia” and “no pneumonia” but poor agreement for non-alveolar pneumonia. The disagreement with regard to the latter was associated with overdiagnosis by pediatricians, which may lead to overtreatment. We believe that radiographic non-alveolar pneumonia should not be an endpoint for clinical trials and research, nor should it be implemented in clinical setting.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Albaum MN, Hill LC, Murphy M, Li YH, Fuhrman CR, Britton CA, Kapoor WN, Fine MJ (1996) Interobserver reliability of the chest radiograph in community-acquired pneumonia. PORT Investigators. Chest 110:343–350

    Article  PubMed  CAS  Google Scholar 

  2. Altman D (1991) Practical statistics for medical research. Chapman & Hall, London, p 404

    Google Scholar 

  3. Ayieko P, English M (2007) Case management of childhood pneumonia in developing countries. Pediatr Infect Dis J 26:432–440

    Article  PubMed  Google Scholar 

  4. Bada C, Carreazo NY, Chalco JP, Huicho L (2007) Inter-observer agreement in interpreting chest X-rays on children with acute lower respiratory tract infections and concurrent wheezing. Sao Paulo Med J 125:150–154

    Article  PubMed  Google Scholar 

  5. Black S, Shinefield H, Fireman B, Lewis E, Ray P, Hansen JR, Elvin L, Ensor KM, Hackell J, Siber G, Malinoski F, Madore D, Chang I, Kohberger R, Watson W, Austrian R, Edwards K (2000) Efficacy, safety and immunogenicity of heptavalent pneumococcal conjugate vaccine in children. Northern California Kaiser Permanente Vaccine Study Center Group. Pediatr Infect Dis J 19:187–195

    Article  PubMed  CAS  Google Scholar 

  6. Cherian T, Mulholland EK, Carlin JB, Ostensen H, Amin R, de Campo M, Greenberg D, Lagos R, Lucero M, Madhi SA, O'Brien KL, Obaro S, Steinhoff MC (2005) Standardized interpretation of paediatric chest radiographs for the diagnosis of pneumonia in epidemiological studies. Bull World Health Organ 83:353–359

    PubMed  Google Scholar 

  7. Esposito S, Bosis S, Cavagna R, Faelli N, Begliatti E, Marchisio P, Blasi F, Bianchi C, Principi N (2002) Characteristics of Streptococcus pneumoniae and atypical bacterial infections in children 2–5 years of age with community-acquired pneumonia. Clin Infect Dis 35:1345–1352

    Article  PubMed  Google Scholar 

  8. Hansen J, Black S, Shinefield H, Cherian T, Benson J, Fireman B, Lewis E, Ray P, Lee J (2006) Effectiveness of heptavalent pneumococcal conjugate vaccine in children younger than 5 years of age for prevention of pneumonia: updated analysis using World Health Organization standardized interpretation of chest radiographs. Pediatr Infect Dis J 25:779–781

    Article  PubMed  Google Scholar 

  9. Hazir T, Nisar YB, Qazi SA, Khan SF, Raza M, Zameer S, Masood SA (2006) Chest radiography in children aged 2–59 months diagnosed with non-severe pneumonia as defined by World Health Organization: descriptive multicentre study in Pakistan. BMJ 333:629

    Article  PubMed  Google Scholar 

  10. Jadavji T, Law B, Lebel MH, Kennedy WA, Gold R, Wang EE (1997) A practical guide for the diagnosis and treatment of pediatric pneumonia. CMAJ 156:S703–S711

    PubMed  CAS  Google Scholar 

  11. Korppi M, Heiskanen-Kosma T, Leinonen M (1997) White blood cells, C-reactive protein and erythrocyte sedimentation rate in pneumococcal pneumonia in children. Eur Respir J 10:1125–1129

    Article  PubMed  CAS  Google Scholar 

  12. Leventhal JM (1982) Clinical predictors of pneumonia as a guide to ordering chest roentgenograms. Clin Pediatr (Phila) 21:730–734

    Article  CAS  Google Scholar 

  13. Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH (2000) Summary of Canadian guidelines for the initial management of community-acquired pneumonia: an evidence-based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society. Can J Infect Dis 11:237–248

    PubMed  CAS  Google Scholar 

  14. Margolis P, Gadomski A (1998) The rational clinical examination. Does this infant have pneumonia? JAMA 279:308–313

    Article  PubMed  CAS  Google Scholar 

  15. Mulholland K (1999) Magnitude of the problem of childhood pneumonia. Lancet 354:590–592

    Article  PubMed  CAS  Google Scholar 

  16. Mulholland K, Hilton S, Adegbola R, Usen S, Oparaugo A, Omosigho C, Weber M, Palmer A, Schneider G, Jobe K, Lahai G, Jaffar S, Secka O, Lin K, Ethevenaux C, Greenwood B (1997) Randomised trial of Haemophilus influenzae type-b tetanus protein conjugate vaccine [corrected] for prevention of pneumonia and meningitis in Gambian infants. Lancet 349:1191–1197

    Article  PubMed  CAS  Google Scholar 

  17. Mulholland K, Levine O, Nohynek H, Greenwood BM (1999) Evaluation of vaccines for the prevention of pneumonia in children in developing countries. Epidemiol Rev 21:43–55

    PubMed  CAS  Google Scholar 

  18. Patel AB, Amin A, Sortey SZ, Athawale A, Kulkarni H (2007) Impact of training on observer variation in chest radiographs of children with severe pneumonia. Indian Pediatr 44:675–681

    PubMed  Google Scholar 

  19. Sarria E, Fischer GB, Lima JA, Menna Barreto SS, Flores JA, Sukiennik R (2003) Interobserver agreement in the radiological diagnosis of lower respiratory tract infections in children. J Pediatr (Rio J) 79:497–503

    Article  Google Scholar 

  20. Schuchat A, Dowell SF (2004) Pneumonia in children in the developing world: new challenges, new solutions. Semin Pediatr Infect Dis 15:181–189

    Article  PubMed  Google Scholar 

  21. Stein RT, Marostica PJ (2007) Community-acquired pneumonia: a review and recent advances. Pediatr Pulmonol 42:1095–1103

    Article  PubMed  Google Scholar 

  22. Swingler GH (2001) Observer variation in chest radiography of acute lower respiratory infections in children: a systematic review. BMC Med Imaging 1:1

    Article  PubMed  Google Scholar 

  23. Virkki R, Juven T, Rikalainen H, Svedstrom E, Mertsola J, Ruuskanen O (2002) Differentiation of bacterial and viral pneumonia in children. Thorax 57:438–441

    Article  PubMed  CAS  Google Scholar 

  24. World Health Organization Pneumonia Vaccine Trial Investigator's Group (2001) Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. WHO/V&B/01.35. World Health Organization, Geneva

  25. Wilkins TR, Wilkins RL (2005) Clinical and radiographic evidence of pneumonia. Radiol Technol 77:106–110

    PubMed  Google Scholar 

  26. Wubbel L, Muniz L, Ahmed A, Trujillo M, Carubelli C, McCoig C, Abramo T, Leinonen M, McCracken GH Jr (1999) Etiology and treatment of community-acquired pneumonia in ambulatory children. Pediatr Infect Dis J 18:98–104

    Article  PubMed  CAS  Google Scholar 

  27. Young M, Marrie TJ (1994) Interobserver variability in the interpretation of chest roentgenograms of patients with possible pneumonia. Arch Intern Med 154:2729–2732

    Article  PubMed  CAS  Google Scholar 

  28. Zenteno AD (2008) Utility of chest x-ray like approach to etiology of community acquired pneumonia in children. Rev Chilena Infectol 25:17–21 [Article in Spanish]

    Google Scholar 

Download references

Conflict of interest

The authors have no conflict of interest or financial relationships relevant to this article to disclose.

Author information

Authors and Affiliations

  1. Pediatric Infectious Disease Unit, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

    Shalom Ben Shimol, Ron Dagan, Noga Givon-Lavi & David Greenberg

  2. Department of Pediatrics, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

    Asher Tal & Micha Aviram

  3. Department of Radiology, Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel

    Vadim Zodicov

  4. Department of Radiology, Hadassah University Medical Center, Jerusalem, Israel

    Jacob Bar-Ziv

Authors
  1. Shalom Ben Shimol
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ron Dagan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Noga Givon-Lavi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Asher Tal
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Micha Aviram
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jacob Bar-Ziv
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Vadim Zodicov
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. David Greenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to David Greenberg.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Ben Shimol, S., Dagan, R., Givon-Lavi, N. et al. Evaluation of the World Health Organization criteria for chest radiographs for pneumonia diagnosis in children. Eur J Pediatr 171, 369–374 (2012). https://doi.org/10.1007/s00431-011-1543-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00431-011-1543-1

Keywords

Search

Navigation