The inter-observer agreement of examining pre-school children with acute cough: a nested study

A nested study comparing two clinical assessments within a prospective cohort of 256 pre-school children with acute cough recruited from eight general practices in Leicestershire, UK. We examined agreement (using kappa statistics) between unstandardised and standardised clinical assessments of tachypnoea, chest signs and fever.Kappa values were poor or fair for all clinical signs (range 0.12 to 0.39) with chest signs the most reliable.Primary care clinicians should be aware that clinical signs may be unreliable when making diagnosis, prognosis and treatment decisions in pre-school children with cough. Future research should aim to further our understanding of how best to identify abnormal clinical signs.Cough is the most frequently managed problem in primary care and becomes increasingly common at the extremes of age [1,2]. Cough in pre-school children is usually due to simple, self limiting respiratory tract infection, but more severe causes need to be ruled out including pneumonia, bronchiolitis, pertussis, croup and asthma[2]. The presence of clinical signs may have diagnostic, prognostic, and treatment implications. The absence of tachypnoea has been shown to be most useful for ruling out pneumonia[3], and fever is associated with poor outcome in children with cough[4] and otitis media[5]. In a study of cough in adults, antibiotics were eight times more likely to be prescribed in patients with abnormal chest signs[6], and in another study 93% of adults presenting with the combination of cough and chest signs received antibiotics[7].The reliability and accuracy of respiratory symptoms and signs have been assessed almost exclusively in secondary care[8], where relatively serious illness is more prevalent[9]. Given the diagnostic, prognostic and treatment implications of these clinical signs, we decided to examine the inter-observer agreement between a standardised and non-standardised clinical assessment in pre-school children presenting with acute cough in primar