title: Identification of radiological alveolar pneumonia in children with high rates of hospitalized respiratory infections: comparison of WHO-defined and pediatric pulmonologist diagnosis in the clinical context.
abstract: BACKGROUND
  A reliable standardized diagnosis of pneumonia in children has long been difficult to achieve. Clinical and radiological criteria have been developed by the World Health Organization (WHO), however, their generalizability to different populations is uncertain. We evaluated WHO defined chest radiograph (CXRs) confirmed alveolar pneumonia in the clinical context in Central Australian Aboriginal children, a high risk population, hospitalized with acute lower respiratory illness (ALRI).
  
  
  METHODS
  CXRs in children (aged 1-60 months) hospitalized and treated with intravenous antibiotics for ALRI and enrolled in a randomized controlled trial (RCT) of Vitamin A/Zinc supplementation were matched with data collected during a population-based study of WHO-defined primary endpoint pneumonia (WHO-EPC). These CXRs were reread by a pediatric pulmonologist (PP) and classified as pneumonia-PP when alveolar changes were present. Sensitivities, specificities, positive and negative predictive values (PPV, NPV) for clinical presentations were compared between WHO-EPC and pneumonia-PP.
  
  
  RESULTS
  Of the 147 episodes of hospitalized ALRI, WHO-EPC was significantly less commonly diagnosed in 40 (27.2%) compared to pneumonia-PP (difference 20.4%, 95% CI 9.6-31.2, P < 0.001). Clinical signs on admission were poor predictors for both pneumonia-PP and WHO-EPC; the sensitivities of clinical signs ranged from a high of 45% for tachypnea to 5% for fever + tachypnea + chest-indrawing. The PPV range was 40-20%, respectively. Higher PPVs were observed against the pediatric pulmonologist's diagnosis compared to WHO-EPC.
  
  
  CONCLUSIONS
  WHO-EPC underestimates alveolar consolidation in a clinical context. Its use in clinical practice or in research designed to inform clinical management in this population should be avoided.
authors.affiliation: Cough, Asthma and Airways Research Group, Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Queensland, Australia. k.ogrady@uq.edu.au
authors.forename: Kerry-Ann F
authors.initials: KA
authors.lastname: O'Grady
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Torzillo
authors.forename: Alan R
authors.initials: AR
authors.lastname: Ruben
authors.forename: Debbie
authors.initials: D
authors.lastname: Taylor-Thomson
authors.forename: Patricia C
authors.initials: PC
authors.lastname: Valery
authors.forename: Anne B
authors.initials: AB
authors.lastname: Chang
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001315:Australia; D002675:Child, Preschool; D019587:Dietary Supplements; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011014:Pneumonia / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000188:drug therapy; D013902:Radiography, Thoracic / Q000379:methods*; D016032:Randomized Controlled Trials as Topic; D012141:Respiratory Tract Infections / Q000175:diagnosis / Q000000981:diagnostic imaging* / Q000188:drug therapy; D014801:Vitamin A / Q000008:administration & dosage; D014944:World Health Organization; D015032:Zinc / Q000008:administration & dosage
chemical_list: D000900:Anti-Bacterial Agents; D014801:Vitamin A; D015032:Zinc