Evaluating Chest X-Ray Necessity in Febrile Infants

Reference: Florin TA, et al. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J. 2023 Date: May 29, 2024 Guest Skeptic: Dr. Christina Lindgren is a Pediatric Emergency Medicine Attending at Children’s National Hospital and Assistant Professor of Pediatrics and Emergency Medicine at the The George Washington University School of Medicine and Health Sciences in Washington, DC. She also serves as the Associate Program Director for the Pediatric Emergency Medicine Fellowship. Dr. Christina Lindgren Guest Author: Dr. Todd Florin is a Pediatric Emergency Medicine Attending at Lurie Children’s Hospital of Chicago where he is also the Director of Research and Associate Professor of Pediatrics and Emergency Medicine at Northwestern University Feinberg School of Medicine.  Case: A 6-week-old boy is brought by his family to the emergency department for fever. He was found to have a temperature of 38.4C at home this evening. His parents tell you that he has been congested for the past few days and his cough seems to have worsened. They have been using a bulb suction device at home to help him breathe better, and he is still tolerating breastmilk and formula. There is a school-age sibling at home with cough and congestion as well which she has successfully passed on to the rest of the family. On your physical exam, you note that he has clear nasal secretions, normal oxygen saturation, and appears well. His parents ask you, “He’s so little. Do you think he has pneumonia? His sister had pneumonia in the past and got a chest x-ray. Does he need a chest x-ray as well?” Background: We’ve covered the topics of febrile infants and pediatric pneumonia multiple times on the SGEM: SGEM #171: Step-by-Step Approach SGEM #296: PECARN Clinical Prediction Rule for Low-Risk Febrile Infants  SGEM #241: American Academy of Pediatrics (AAP) Guidelines for the Management of Febrile Infants 8-60 days old SGEM #338: SAFER Short-Course Antimicrobial Therapy for Pediatric Community-Acquired Pneumonia SGEM #359: SCOUT-CAP Short vs Standard-Course Antibiotics for Community-Acquired Pneumonia in Children SGEM #387: Lumbar Punctures in Febrile Infants with Positive Urinalysis Dr. Todd Florin It only makes sense that today, we get to combine both topics in one episode and talk about pneumonia in febrile infants <60 days. Pneumonia is tough to diagnose in this very young population based on just clinical examination alone. This can be particularly challenging because there is a lot of crossovers with bronchiolitis. There is no evidence-based guidance as to who gets a chest X-ray (CXR) and who does not. This leads to a lot of practice variation.    Clinical Question: What factors (demographic, clinical, laboratory) are associated with radiographic pneumonia in febrile infants? Reference: Florin TA, et al. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J. 2023 Population: Febrile infants ≤ 60 days with rectal temperature ≥38॰C with CXR performed Excluded: Infants who appeared critically ill, already receiving antibiotics, premature <37 weeks gestation), significant comorbidities, indwelling devices, focal bacterial infections (cellulitis) Intervention: Evaluation of radiographic pneumonia, classified into definite pneumonia, possible pneumonia, and no pneumonia. Comparison: None Outcome: Demographic, clinical, and laboratory factors associated with radiographic pneumonia. Trial: Secondary analysis of data from previous PECARN study conducted from June 2016 to April 2019 Authors’ Conclusions: Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors.