Pediatric Chest XRay

Aka: Pediatric Chest XRay, Chest XRay in Children, Chest Radiograph in Children

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II. Precautions: Pearls

  1. Lateral view is just as important as PA/AP View (abnormalities may only be seen on lateral)

III. Findings: Cardiomegaly or Thymus Shadow in Infants

  1. Thymus Shadow
    1. See Thymus
    2. Increases in size until age 12 months, then becomes much less evident by age 2 years
    3. Mass in this region in an older child or teen suggests possible malignancy (e.g. Hodgkin Lymphoma)
    4. Typically larger on the right side of the upper chest (AP/PA)
  2. Cardiomegaly Findings
    1. See Congenital Heart Disease
    2. See Pediatric Congestive Heart Failure
    3. Boot-shaped heart (AP/PA)
    4. Posterior heart shadow edge overlap with Vertebral bodies (lateral)
    5. Anterior tracheal line displaced by posterior heart border (lateral)

IV. Findings: Bronchiolitis

  1. See Bronchiolitis
  2. Indications for Chest XRay
    1. Not routinely recommended in Bronchiolitis (very low yield)
      1. Chest XRay risks False Positives (e.g. Pneumonia) and Antibiotics overuse
    2. High fever
    3. Hypoxemia (Oxygen Saturation <90%)
    4. Severe symptoms (e.g. ICU admission)
    5. Comorbid cardiopulmonary disease
    6. Respiratory complications (e.g. Pneumonia, Pneumothorax)
  3. Findings consistent with Bronchiolitis
    1. Hyperexpansion or hyperinflation (flattened diaphragms)
    2. Peribronchial thickening or cuffing
    3. Increased interstitial or peribronchial markings
    4. Atelectasis
    5. Variable infiltrates or Viral Pneumonia
      1. May lead to False PositivePneumonia diagnoses (and unnecessary Antibiotics)

V. Findings: Round Pneumonia

  1. See Round Pneumonia
  2. Streptococcus Pneumoniae (Pneumococcus) is most common cause
  3. Peak age at 5 years old (uncommon after age 12 years)
  4. Mass-like appearance with round shape and well demarcated borders
    1. Less interconnected lung lobules in children localizes Pneumonia into mass-like infection
    2. Contrast with adults with more interconnected lung lobules allowing for more diffuse Pneumonia spread
  5. Distribution
    1. Most common in the upper segments of the lower lobe
    2. May also occur in the lower segment of the upper lobe
    3. May be more visible on lateral film in some cases
  6. Differential Diagnosis
    1. Cavitary lesions (e.g. necrotizing Pneumonia, empyema, Lung Abscess)
      1. Findings include air fluid levels or radiolucent pockets
      2. Causes include Pneumococcus, Staphylococcus Aureus (including MRSA), Group A Streptococcus

VI. Findings: Rib Fractures as a Sign of Non-accidental Trauma

  1. See Non-Accidental Trauma Related Fractures
  2. See Non-accidental Trauma
  3. Findings
    1. Oblique rib films may better demonstrate posterior Rib Fractures
    2. Rib Fractures are often subtle in children (displaced Rib Fractures are uncommon)
    3. Rib Fracture appearance
      1. Asymmetry of ribs (esp. rib necks)
      2. Sudden rib angulation
      3. Callus formation (subacute Rib Fractures, >10-14 days after injury)
  4. Rib Fractures overall are unusual in younger children, esp. age <2 years (aside from major Trauma)
    1. Children have very compliant chest walls making Rib Fractures uncommon
    2. Probability of Non-accidental Trauma 71% for Rib Fractures without major Trauma
  5. Posterior or posteromedial Rib Fractures (without history of MVA or metabolic bone disease)
    1. Seen especially in infants related to compression from assailant's fingers wrapped around chest
    2. Highly predictive of Nonaccidental Trauma in age <3 years (PPV 95%)

VII. Findings: Miscellaneous

  1. See Chest XRay in Pneumonia
  2. See Lung Lesion
  3. See Chest XRay in Pneumothorax
  4. See Hilar Adenopathy on Chest XRay
  5. See Alveolar Infiltrate on Chest XRay
  6. See Interstitial Infiltrate on Chest XRay

VIII. References

  1. Tubbs and Janicki (2025) Mastering Emergency Imaging, CCME, accessed 6/13/2026

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