Clinicians caring for children with suspected pneumonia may rely too heavily on auscultation from the stethoscope and assume hearing wheezing or crackles are objective findings that can be independently used to make a diagnosis.

Two physicians often heard or interpreted stethoscope sounds differently, indicating findings from the physical examination may have limited reliability when clinicians evaluate children for pneumonia, according to a new study published in JAMA Network Open.

“When we think about diagnosing pneumonia in children, we think about listening with a stethoscope and hearing crackles. If different people hear different things, it’s a little bit concerning,” said Shubhada Hooli, MD, MPH, assistant professor of pediatrics at Baylor College of Medicine in Houston, who led the study. “The physical exam still remains central to care, but we need to make sure that we don’t fully anchor on it.”

Pediatric pneumonia accounts for up to 2 million outpatient visits annually. While physicians in emergency departments commonly use chest radiographs to diagnose pneumonia, the Pediatric Infectious Diseases Society recommends against the chest imaging in outpatient settings and instead rely on clinical findings.

Hooli and colleagues sought to find out how reliable clinicians are in interpreting physical findings from listening to children’s breath and lungs and observing symptoms.

They analyzed data from 252 children and infants (median age, 5.7 years; 50% girls; 56.7% White) with a diagnosis of community-acquired pneumonia at seven emergency departments between 2023 and 2025. Children with complex chronic conditions and those recently hospitalized were excluded.

Two clinicians independently examined each patient within 1 hour of each other for altered mental status, delayed capillary refill, decreased breath sounds, fine crackles or rales, grunting, retractions or accessory muscle use, rhonchi, and wheezing. The second examiner was blinded to the first’s findings.

Researchers used a scale of 0-1 to determine clinician agreement, with 0.61 defined as substantial consensus. They agreed most often on the presence of wheezing (0.5), followed by retractions or accessory muscle use (0.49). Scores for the other six findings ranged from 0.11 for decreased breath sounds to 0.38 for grunting.

The research builds on a 2017 study of children with suspected pneumonia that similarly found limited agreement between clinicians on findings from physical examinations.

“If physicians cannot consistently agree on the presence of auscultatory findings, treatment decisions may hinge more on examiner interpretation than underlying pathology,” wrote Susan Lipsett, MD, assistant professor in the Department of Pediatrics at Harvard Medical School in Boston, in an accompanying editorial. “This variability may contribute to well-documented differences in antibiotic prescribing and chest radiograph use across institutions.”

Overdiagnosis can lead to unnecessary antibiotic use, antibiotic resistance, and financial burdens for families, Hooli said.

Undertreatment, however, also comes with risks, said David N. Cornfield, MD, director of the Division of Pediatric Pulmonology, Asthma and Sleep Medicine at Stanford University in Palo Alto, California, who was not involved in the study.

“Overtreatment with antibiotics is not wholly benign, but it’s a lot more benign than missing a diagnosis of Streptococcus pneumoniae pneumonia with a kid who’s febrile and then ends up septic,” Cornfield said.

Variability in auscultation findings also does not necessarily mean one examiner was wrong, Cornfield said. The presence of various sounds can change over relatively short periods, and the study allowed up to 60 minutes between examinations.

Hooli suggested that digital stethoscopes and machinelearning algorithms could eventually provide more standardized, objective assessments.

Physical examination findings should be considered along with symptoms such as fever and cough and risk factors for other respiratory conditions that can be confused with pneumonia, Cornfield said.

The sources cited in this article reported no relevant disclosures.

Brittany Vargas is a journalist covering medicine, mental health, and wellness.