Eduardo Just da Costa e Silva, Pediatric Radiologist. Instructor of the Radiology Department of Instituto de Medicina Integral Prof. Fernando Figueira-IMIP

Abstract
Background:Despite the 2001 standardized interpretation criteria established by the World Health Organization, the radiological identification of pneumonia in childrenremains challenging, with significant inter-observer variability persisting.Objectives: To describe the epidemiological and clinical characteristics of community-acquired pneumonia in children and to evaluate inter-observer radiological agreement in the diagnosis of pneumonia in children under five years of age. Materials andMethods: A descriptive, observational study involving452 patientshospitalized in a pediatric referral centerbetween October 2010 and September 2013. Clinical and sociodemographic variables were evaluated. Two independent radiologists evaluated the images according to the World Health Organization’s standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children, modified to take not only consolidation, alveolar infiltrate and pleural effusion into consideration, but also interstitial infiltrate.Results: Around 70% of the children were under two years of ageand family income was one minimum salary or less in half the households. Pneumonia was classified as severe or very severe in 83.9% and complicated in 22.6%. The deathrate was 1.5%. Inter-observer agreement was almost perfectfor pleural effusion (kappa 0.825). Consolidation was the most common finding (66.8%),with inter-observer agreement considered substantial (kappa 0.696). Conversely, agreement was poor for interstitial or alveolar infiltrate (kappa 0.533). Conclusion: Agreement was high for the radiographicfinding of pleural effusion; however, interstitial and alveolar infiltrates proved difficult to interpret. Consolidation was the most common abnormality in hospitalized children with severe pneumonia.

Keywords
pneumonia; epidemiology; chest radiography; inter-observer agreement.

Cite this paper
Eduardo Jorge da Fonseca Lima, Maria Anáide Zacchê de Sá Abreu e Lima, Eduardo Just da Costa e Silva, Analysis of radiological inter-observeragreement in the diagnosis of pneumonia in children: a challenge in clinical practice , SCIREA Journal of Clinical Medicine. Volume 4, Issue 6, December 2019 | PP. 239-256.

References

[ 1 ]	Sociedade Brasileira de Pediatria (2007)Diretrizes brasileiras em pneumonia adquirida na comunidade em pediatria - 2007. J BrasPneumol33suppl1:S31–S50
[ 2 ]	Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, O'Brien KL, Campbell H, Black RE (2013)Global burden of childhood pneumonia and diarrhoea. Lancet 381:1405–1416
[ 3 ]	World Health OrganizationandThe United Nations Children’s Fund (2009)Global action plan for prevention and control of pneumonia. WHO Press, Geneva
[ 4 ]	World Health Organization Pneumonia Vaccine Trial InvestigatorsGroup (2001) Standardization of interpretation of chest radiographs for the diagnosis of pneumonia in children. WHO, Geneva
[ 5 ]	Harris M, Clark J, Coote N, Fletcher P, Harnden A, McKean M, Thomson A; BritishThoracic Society Standards of Care Committee (2011)British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 66 Suppl 2:ii1–ii23
[ 6 ]	Korppi M, Don M, Valent F, Canciani M (2008)The value of clinical features in differentiating between viral, pneumococcal and atypical bacterial pneumonia in children.Acta Paediatr 97:943–947
[ 7 ]	Swingler GH, Hussey GD, Zwarenstein M (1998)Randomised controlled trial of clinical outcome after chest radiograph in ambulatory acute lower-respiratory infection in children. Lancet 351:404–408
[ 8 ]	SarriaE, Lima JA, Fisher GB, Barreto SS, Flôres JA, Sukiennik R (2003) Interobserver agreement in the radiological diagnosisof lower respiratory tract infections in children. J Pediatr79:497-503
[ 9 ]	Neuman MI, Lee EY, Bixby S, Diperna S, Hellinger J, Markowitz R, Servaes S, Monuteaux MC, Shah SS (2012) Variability in the interpretation of chest radiographs for the diagnosis of pneumonia in children. J Hosp Med 7:294–298
[ 10 ]	Robinson PJ (1997) Radiology's Achille's heel: error and variation in theinterpretation of the Röntgen image. Br J Radiol70:1085-1098
[ 11 ]	Felson B, Morgan WK, Bristol LJ, Pendergrass EP, Dessen EL, Linton OW, Reger RB (1973)Observations on the results of multiple readings of chest films in coal miners’ pneumoconiosis. Radiology 109:19-23
[ 12 ]	Kundel HL (1989)Perception errors in chest radiography. Seminars in Respiratory Medicine 10:203-210
[ 13 ]	MoncadaDC, Rueda ZV, Macías A, Suárez T, Ortega H, Vélez LA (2011) Reading and interpretation of chest X-ray in adults with community-acquired pneumonia.Braz J Infect Dis15:540-546
[ 14 ]	Viera AJ, Garrett JM (2005)Understanding interobserver agreement: the kappa statistic. Fam Med 37:360–363
[ 15 ]	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 Organ83:353-359
[ 16 ]	Elemraid MA, Muller M, Spencer DA, Rushton SP, Gorton R, Thomas MF, Eastham KM, Hampton F, Gennery AR, Clark JE; North East of England Paediatric Respiratory Infection Study Group (2014) Accuracy of the interpretation of chest radiographs for the diagnosis of paediatric pneumonia. PLoS One9:e106051
[ 17 ]	Branstetter BF 4th, Morgan MB, Nesbit CE, Phillips JA, Lionetti DM, Chang PJ,Towers JD(2007) Preliminary reports in the emergency department: is a subspecialist radiologist more accurate than a radiology resident?AcadRadiol14:201–206
[ 18 ]	Halsted MJ, Kumar H, Paquin JJ, Poe SA, Bean JA, Racadio JM, Strife JL, Donnelly LF (2004) Diagnostic errors by radiology residents in interpreting pediatric radiographs in an emergency setting. PediatrRadiol 34:331–336
[ 19 ]	Cooper VF, Goodhartz LA, Nemcek AAJr, Ryu RK (2008) Radiology resident interpretations of on-call imaging studies: the incidence of major discrepancies. AcadRadiol 15:1198–1204
[ 20 ]	Ojutiku O, HaramatiLB, Rakoff S, Sprayregen S (2005)Radiology residents' on-call interpretation of chest radiographs for pneumonia. AcadRadiol 12:658–664
[ 21 ]	Fonseca Lima EJ, Mello MJ, Albuquerque MF, Lopes MI, Serra GH, Lima DE, CorreiaJB (2016) Risk factors for community-acquired pneumonia in children under five years of age in the post-pneumococcal conjugate vaccine era in Brazil: a case control study. BMC Pediatr 16:157
[ 22 ]	World Health Organization (2005)Pocket book of hospital care for children: guidelines for the management of common illnesses with limited resources. World Health Organization, Geneva
[ 23 ]	Riccetto AG, Zambom MP, Pereira IC, Morcillo AM (2003) Influence of social-economical and nutritional factors on the evolution to complications in children hospitalized with pneumonia.Rev Assoc Med Bras 49:191–195
[ 24 ]	Muenchhoff M, Goulder PJ (2014) Sex differences in pediatric infectious diseases. J Infect Dis 209 Suppl3:S120–S126
[ 25 ]	Falagas ME, MourtzoukouEG, Vardakas KZ (2007)Sex differences in the incidence and severity of respiratory tract infections. Respir Med 101:1845–1863
[ 26 ]	Wonodi CB, Deloria-Knoll M, Feikin DR, DeLuca AN, Driscoll AJ, Moïsi JC, Johnson HL, Murdoch DR, O'Brien KL, Levine OS, Scott JA; Pneumonia Methods Working Group and PERCH Site Investigators (2012) Evaluation of risk factors for severe pneumonia in children: The Pneumonia Etiology Research for Child Health Study. Clin Infect Dis 54Suppl 2:S124–131
[ 27 ]	Rudan I, O’Brien KL, Nair H, Theodoratou E, Qazi S, Lukšić I, Fischer Walker CL, Black RE, Campbell H; Child Health Epidemiology Reference Group (CHERG) (2013) Epidemiology and etiology of childhood pneumonia in 2010: estimates of incidence, severe morbidity, mortality, underlying risk factors and causative pathogens for 192 countries. J Glob Health 3:010401
[ 28 ]	Thörn LK, Minamisava R, Nouer SS, Ribeiro LH, Andrade AL (2011) Pneumonia and poverty: a prospective population-based study among children in Brazil. BMC Infect Dis 11:180
[ 29 ]	Suzuki M, Thiem VD, Yanai H, Matsubayashi T, Yoshida LM, Tho LH, Minh TT, Anh DD, Kilgore PE, Ariyoshi K (2009) Association of environmental tobacco smoking exposure with an increased risk of hospital admissions for pneumonia in children under 5 years of age in Vietnam. Thorax 64:484–489
[ 30 ]	Lamberti LM, Zakarija-Grković I, Fischer Walker CL, Theodoratou E, Nair H, Campbell H, Black RE (2013) Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis. BMC Public Health 13 Suppl 3:S18
[ 31 ]	Rodrigues FE, Tatto RB, Vauchinski L, Leães LM, Rodrigues MM, Rodrigues VB,Catharino A, Cainelli M, Prates GP, Cerqueira TM, Zhang L(2011) Pneumonia mortality in Brazilian children aged 4 years and younger. J Pediatr 87:111–114
[ 32 ]	Nascimento-Carvalho CM, Madhi SA, O’Brien KL (2013) Review of guidelines for evidence-based management for childhood community-acquired pneumonia in under-5 years from developed and developing countries. PediatrInfectDis J 32:1281–1282
[ 33 ]	Correia MA, Mello MJ, Petribú NC, Silva EJ, Bezerra PG, Duarte MC, CorreiaJB (2011) Agreement on radiological diagnosis of acute lower respiratory tract infection in children. J TropPediatr 57:204-207
[ 34 ]	Galanski M, Dettmer S, Keberle M,OpherkJP, Ringe KI (2011)Diagnóstico por imagem: Tórax [ThoracicImaging].Translation: Jacques Vissoky. Artmed, Porto Alegre
[ 35 ]	Chiappini E, Venturini E, Galli L, Novelli V, de Martino M (2013)Diagnostic features of community-acquired pneumonia in children: what’s new? Acta Paediatr 102:17–24