Characterization of chest-X-ray in young children and adolescents with PCR confirmed SARS-CoV-2 infection

Rationale: The specific chest X-ray (CXR) abnormalities in pediatric COVID19 and their relation to clinical outcomes remain to be defined. Addressing this gap is important given the age-related differences in the clinical and imaging features of COVID-19 and the challenge of differentiating SARS-CoV-2 infections from other types of viral lower respiratory infections (LRTIs) in young children. Methods: We conducted a single-center crosssectional study that included a sample of children, adolescents, and young adults (0-25 years) who had a (+) PCR test for SARS-CoV-2 and a CXR. We also included a random sample of young children (0-2 years, n=68) diagnosed with PCR-confirmed viral LRTI during 2018-2019 to compare CXR features with those seen in pediatric COVID-19. Results: A total of 422 pediatric COVID19 cases were identified during the study period. We enrolled 104 individuals with (+) PCR for SARS-CoV-2 and available CXR and sub-divided them according to age groups including young children (0-2 years, n=27), school-age children (3-10 years, n= 27), adolescents (11-18 years, n=41) and young adults (19-25 years, n=9). Overall, 52 (50%) of pediatric patients with COVID-19 were hospitalized and 26 (25%) required admission to PICU. The most common imaging abnormality identified was the presence of ground-glass opacifications (GGO)/focal consolidations (36%). The presence of GGO/consolidation was affected by age being more common among young adults (44%). Individuals requiring hospitalization or ICU admission had significantly more GGO/opacities in CXR (p<0.05). Typical lung imaging features of viral respiratory infections in the pediatric population such as increased perihilar markings and hyperinflation were more common in non-COVID-19 viral LRTI cases than in SARS-CoV-2 infection in young children (p<0.05) Conclusions: Chest X-ray imaging is a useful non-invasive tool to evaluate lung compromise in pediatric COVID-19 cases. The severity of GGO/consolidations is predictive of clinically relevant outcomes (e.g. hospitalization). Hyperinflation/perihilar markings could potentially aid in distinguishing COVID-19 from other types of viral LRTI in young children.