Pediatric X-ray Guidelines

Respiratory Illness

Children with respiratory illness and concerning symptoms such as cough with hypoxia, presence of rales/crackles, high fever, tachycardia, and tachypnea out of proportion to fever should undergo X-rays, following the American College of Emergency Physicians guidelines 1
Well-appearing children with wheezing or signs of bronchiolitis should not receive chest X-rays, as recommended by the American College of Emergency Physicians 1
Routine chest X-rays are not indicated in febrile children with temperature <39°C without clinical evidence of pulmonary disease, according to the American College of Emergency Physicians 2

The American College of Radiology recommends considering chest X-ray in children with temperature >39°C and WBC count >20,000/mm³ even without respiratory symptoms, with a moderate strength of evidence 2
In cases of suspected physical abuse, chest X-ray is part of the skeletal survey, rated 9/9 for appropriateness by the American College of Radiology 4
The American College of Radiology strongly recommends a complete skeletal survey in cases of suspected physical abuse, with a high strength of evidence 4
Follow-up limited skeletal survey after 2 weeks is recommended for children <24 months with high suspicion of abuse, according to the American College of Radiology 4

For children with suspected spine trauma, the American College of Radiology recommends radiographs of the thoracic and lumbar spine as initial imaging for children <16 years, with a moderate strength of evidence 5
For cervical spine trauma in children 3-16 years, the American College of Radiology recommends no imaging if meeting low-risk criteria, and radiographs for initial imaging if at least one risk factor is present, with a moderate strength of evidence 5

Every X-ray must be justified by clinical need, and the lowest dose necessary for diagnostic quality should be used, as recommended by the Thorax journal 6
The decision to perform an X-ray should always balance the diagnostic benefit against the potential radiation risk, with particular attention to the increased radiation sensitivity of pediatric patients, according to the Thorax journal 6