DOES THIS INFANT HAVE PNEUMONIA

Acute lower respiratory tract illness is common among children seen in primary care. We reviewed the accuracy and precision of the clinical examination in detecting pneumonia in children. Although most cases ar e viral, it is important to identify bacterial pneumonia to provide ap propriate therapy. Studies were identified by searching MEDLINE from 1 982 to 1995, reviewing reference lists, reviewing a published compendi um of studies of the clinical examination, and consulting experts. Obs erver agreement is good for most signs on the clinical examination. Ea ch study was reviewed by 2 observers and graded for methodologic quali ty. There is better agreement about signs that can be observed leg, us e of accessory muscles, color, attentiveness; kappa, 0.48-0.66) than s igns that require auscultation of the chest leg, adventitious sounds; kappa, 0.3). Measurements of the respiratory rate are enhanced by coun ting for 60 seconds. The best individual finding for ruling out pneumo nia is the absence of tachypnea. Chest indrawing, and other signs of i ncreased work of breathing, increases the likelihood of pneumonia. If all clinical signs (respiratory rate, auscultation, and work of breath ing) are negative, the chest x-ray findings are unlikely to be positiv e. Studies are needed to assess the value of clinical findings when th ey are used together.