To assess if chest radiographic findings present on admission are associated with severity of childhood community-acquired pneumonia (CAP), a total of 161 children hospitalized with pulmonary infiltrate were enrolled in the study; 48 (30%) patients were excluded because of presence of bilateral chest radiographic alterations (33; 20%) and presence of underlying diseases (15; 9%). According to WHO and BTS criteria, severe CAP was present in 57 (50%) and in 96 (85%) cases, respectively; 29 (26%) were aged less than 1 year. The median age (months) was 22 (mean 24 +/- 14, range 2-58). Overall, radiographic finding was right-sided in 77 (68%) cases and the upper lobe was compromised in 36 (32%) cases. By analyzing data stratified to age, the frequency of upper lobe involvement was significantly higher among severe cases (WHO criteria) only for those patients aged > or =1 year (13/35 [37%] vs. 7/45 [16%], P = 0.03, OR [95% CI] 3.2 [1.1-9.2]). The specificity and positive predictive value of upper lobe involvement for severity among the latter group of patients were 84% (95% CI 70-93%) and 65% (95% CI 41-84%), respectively. No association was found by using the BTS criteria. The admission chest radiography was useful to predict severity of children aged > or =1 year hospitalized with CAP.