Objectives This study was designed to assess the role of chest radiography for the diagnosis of pneumonia and assess the association of clinical characteristics with radiologic findings and predictors of hospitalization among children with severe community acquired pneumonia. Methods A prospective study was conducted on 122 children between ages of 3 month and 14 years admitted to pediatric emergency unit with diagnosis of severe pneumonia from September 1st to November 30th, 2017. Eligible children were subjected to chest radiography which was read by two senior radiologists independently (R1 and R2). Disagreements between R1 and R2 were resolved by a third senior radiologist (R3). Level of agreement between radiologists was assessed using Cohen's kappa coefficient. Clinical and laboratory parameters which could explain the variability in the duration of hospital stay were assessed using a linear regression mode. Independent predictors were assessed using multiple linear regression. Results The median age of the cohort was 10.0 months (interquartile range (IQR): 6.75–24.0); 76 (62.3%) were male. Nearly half, 63 (51.6%) did not have radiologic evidence of pneumonia. There was low level of agreement between R1 and R2 in reporting consolidation (kappa=0.435, p-value≤0.001), haziness (kappa=0.375, p-value≤0.001), and infiltration (kappa=0.267, p-value=0.008). Children with higher recorded temperature were more likely to have radiologic abnormalities suggesting pneumonia (p-value=0.033). The median duration of hospitalization was 3 days (IQR: 1-4 days); 118 (96.7%) were discharged with improvement. Height-for-age z-score (Coef.=0.203, R2=0.041, p-value=0.027); and hemoglobin level (Coef.=-0.249, R2=0.062, p-value=0.006) explained 4.1% and 6.2% of the variability in the duration of hospital stay, respectively. Conclusion Radiologic evidence of pneumonia was absent in half of the children with severe pneumonia. There was low agreement between senior radiologists in reporting chest radiographic findings, potentially necessitating harmonization activities to uniformly implement the WHO guidelines in reading chest radiographs.

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