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Updated: Jun 9, 2026
Microbiological Rapid On-Site Evaluation for Pulmonary Infectious Diseases
Published on: March 1, 2024
Detection of occult pneumonia in a pediatric emergency department
Sonal Shah1, Bonnie Mathews, Mark I Neuman
1Division of Emergency Medicine, Department of Medicine, Children's Hospital, Harvard Medical School, 300 Longwood Ave., Boston, MA 02115, USA. sonalnshah@gmail.com
Insights
Occult pneumonia (OP) occurs in 1 in 15 children with fever but no respiratory symptoms. Chest X-rays are not recommended for children with fever less than one day and no cough to avoid unnecessary radiation exposure.
Area of Science:
- Pediatric medicine
- Radiology
- Infectious disease
Background:
- Chest radiography (CXR) is frequently used to evaluate febrile illnesses in children.
- Occult pneumonia (OP) refers to pneumonia without typical respiratory distress or auscultatory findings.
Purpose of the Study:
- To determine the incidence of occult pneumonia (OP) in children undergoing CXR.
- To identify clinical predictors for OP in pediatric patients.
Main Methods:
- Prospective observational study of children undergoing CXR for suspected pneumonia.
- Standardized data collection prior to CXR.
- Univariate analysis and recursive partitioning for predictor identification.
Main Results:
- Occult pneumonia (OP) was found in 6.8% of eligible children (21/308).
- Predictors for OP include fever lasting 1+ day or fever <1 day with worsening cough.
- Children with fever <1 day and no cough had no pneumonia.
Conclusions:
- Occult pneumonia (OP) is present in approximately 1 in 15 children evaluated with CXR for febrile illness without respiratory symptoms.
- Discourage CXR for OP detection in children with fever <1 day and no cough.
Background:
Many children undergo chest radiography (CXR) in their evaluation of a febrile illness. Pneumonia without signs of respiratory distress or ausculatory findings has been previously described (termed occult pneumonia [OP]).
Objective:
The objectives of this study were to determine the incidence of OP among children who have CXR performed and to identify clinical predictors of OP.
Methods:
A prospective observational study of children undergoing CXR for possible pneumonia was conducted. Standardized data forms were completed before the CXR. Univariate analysis and recursive partitioning were used to identify predictors of OP.
Results:
Of 1866 patients enrolled, 308 had no evidence of respiratory distress or lower respiratory tract findings and were studied for OP. Twenty-one patients had radiographic OP (6.8%; 95% confidence interval [CI], 4.0%-10.6%). Age, height of fever, duration or quality of cough, and pulse oximetry were not associated with OP. A decision rule based on fever for 1 day or longer or with a combination of fever for less than 1 day but worsening cough identifies patients at greater risk for OP (likelihood ratio, 1.47; 95% CI, 1.21-1.77). No patient with fever for less than 1 day and without any cough or without worsening cough had pneumonia (likelihood ratio, 0.40; 95% CI, 0.19-0.84).
Conclusions:
Occult pneumonia was identified in 1 of 15 patients undergoing CXR without respiratory distress or ausculatory findings. Obtaining a CXR for the detection of OP in children without cough and with fever for less than 1 day in duration should be discouraged.
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