ORIGINAL

ARTICLES
Significance of Sonographic Subcentimeter, Subpleural Consolidations in
Pediatric Patients Evaluated for Pneumonia
Cynthia A. Gravel, MD, Mark I. Neuman, MD, MPH, Michael C. Monuteaux, ScD, Jeffrey T. Neal, MD,
Andrew F. Miller, MD, and Richard G. Bachur, MD

Objectives To investigate the rates of radiographic pneumonia and clinical outcomes of children with suspected
pneumonia and subcentimeter, subpleural consolidations on point-of-care lung ultrasound.
Study design We enrolled a prospective convenience sample of children aged 6 months to 18 years undergoing
chest radiography (CXR) for pneumonia evaluation in a single tertiary-care pediatric emergency department. Point-
of-care lung ultrasound was performed by an emergency medicine physician with subsequent expert review. We
determined rates of radiographic pneumonia and clinical outcomes in the children with subcentimeter, subpleural
consolidations, stratified by the presence of larger (>1 cm) sonographic consolidations. The children were followed
prospectively for 2 weeks to identify a delayed diagnosis of pneumonia.
Results A total of 188 patients, with a median age of 5.8 years (IQR, 3.5-11.0 years), were evaluated. Of these pa-
tients, 62 (33%) had subcentimeter, subpleural consolidations on lung ultrasound, and 23 (37%) also had larger
(>1 cm) consolidations. Patients with subcentimeter, subpleural consolidations and larger consolidations had the
highest rates of definite radiographic pneumonia (61%), compared with 21% among children with isolated sub-
centimeter, subpleural consolidations. Overall, 23 children with isolated subcentimeter, subpleural consolidations
(59%) had no evidence of pneumonia on CXR. Among 16 children with isolated subcentimeter, subpleural consol-
idations and not treated with antibiotics, none had a subsequent pneumonia diagnosis within the 2-week follow-up
period.
Conclusions Children with subcentimeter, subpleural consolidations often had radiographic pneumonia; howev-
er, this occurred most frequently when subcentimeter, subpleural consolidations were identified in combination
with larger consolidations. Isolated subcentimeter, subpleural consolidations in the absence of larger consolida-
tions should not be viewed as synonymous with pneumonia; CXR may provide adjunctive information in these
cases. (J Pediatr 2022;243:193-9).

L
ung ultrasound has been observed to have reasonable diagnostic performance for the evaluation of pneumonia in chil-
dren and may be a potential alternative or adjunctive imaging modality to chest radiography (CXR).1-5 The presence of
large consolidations on lung ultrasound has been shown to correlate with radiographic pneumonia; however, the sig-
nificance of smaller subpleural consolidations is poorly defined.
Subcentimeter, subpleural consolidations are distinctive findings on lung ultrasound that are not visualized on CXR3,6-10 and
have been reported in patients with multiple types of lung pathology, including pneumonia, viral lower respiratory tract illness,
bronchiolitis, pulmonary embolism,11-13 and acute respiratory distress syndrome.5,14,15 Among children being evaluated for
pneumonia, it is unclear whether these findings represent early focal consolidation (ie, early pneumonia), viral lower respira-
tory tract changes, focal atelectasis, or possibly a combination.16-18 Some pediatric studies have specifically defined small sub-
pleural consolidations as missed or silent pneumonia or have recommended antibiotic treatment,3,9,10,19 whereas others have
included small subpleural consolidations in their definition of viral pneumonia.8,20-24 Two studies also have suggested that
visualization of these sonographic subpleural consolidations could lead to antibiotic overuse, thereby elevating the significance
of accurate interpretation to guide clinical management and antibiotic stewardship.3,25 This may be of particular importance
given the high likelihood of a viral etiology in children with pneumonia.
In an effort to further elucidate the significance of sonographic subcentimeter, subpleural consolidations in children under-
going evaluation for pneumonia, we examined data from a local prospective lung
ultrasound registry of children who underwent both point-of-care lung ultra-
sound and CXR for suspected pneumonia. Although imperfect, CXR is often
considered a diagnostic reference standard for pediatric pneumonia, given the From the Division of Emergency Medicine, Boston
Children’s Hospital Department of Pediatrics, Harvard
Medical School, Boston, MA
Supported by the Dr. Michael Shannon Emergency
CXR Chest radiography Medicine Award (Boston Children’s Hospital), to C.G.
The authors declare no conflicts of interest.
ED Emergency department
EMR Electronic medical record 0022-3476/$ - see front matter. ª 2021 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jpeds.2021.12.052

193
THE JOURNAL OF PEDIATRICS  www.jpeds.com
limitations of physical examination26 and its high negative
predictive value.27 The main objectives of this study were
to investigate the association of sonographic subcentimeter,
subpleural consolidations with radiographic pneumonia in
a prospective cohort of children and to report the clinical
outcomes of children with sonographic subcentimeter, sub-
pleural consolidations. We hypothesized that isolated sub-
centimeter, subpleural consolidations are not indicative of
bacterial pneumonia and thus do not require anti-
biotic treatment.
Methods
Our prospective convenience sample of pediatric patients
with acute respiratory complaints and possible pneumonia
was collected over a 3-year period from March 2017 to March
2020 at a single tertiary care pediatric emergency department
(ED) with an annual census of approximately 60 000 visits
per year. Patients between age 6 months and 18 years who
presented to the ED with acute respiratory complaints and
underwent CXR for possible pneumonia were assessed for in-
clusion. Patients were identified by research coordinators
based on chief complaint (eg, fever, cough, respiratory
distress, chest pain) on an electronic tracking board during
times when a study sonographer was available. Patients
were excluded if they were immunocompromised, had un-
derlying chronic lung disease (including cystic fibrosis) or a
complex chronic condition, were deemed too ill for interven-
tion by the treating physician, were unable to comply with
the study scanning protocol, or were non–English-speaking.
For eligible patients, caregivers were approached for consent,
and assent was obtained from children when appropriate.
This study was approved by the hospital’s Institutional Re-
view Board.
Sonographers and Scanning Protocol
Our study sonographers were 7 board-certified pediatric
emergency medicine physicians who were credentialed by
our department in point-of-care lung ultrasound. Each
physician completed >50 lung ultrasounds and a study-
specific didactic session lead by the principal investigator
and passed both a knowledge assessment evaluation and a
proctored lung ultrasound to ensure compliance with the
study scanning protocol.
Our study scanning protocol was initially established by
Copetti and Cattarossi28 and is described in detail else-
where.7,10,22,23 The protocol consisted of scanning 6 zones
on each hemithorax, with transverse and longitudinal clips
saved in each zone. Study clips were obtained with a portable
ultrasound machine (TE-7; Mindray) with a 12-4 mHZ
linear transducer and archived using a web-based applica-
tion, Q-path (Telexy Healthcare). All study clips were subse-
quently reviewed by a blinded expert reviewer, an American
Registry for Diagnostic Medical Sonography–certified or
emergency ultrasound fellowship-trained pediatric emer-
gency medicine physician, for image quality and accuracy
of interpretation.
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Volume 243  April 2022
Data Collection
A physician survey was completed by the treating physician
after obtaining patient/caregiver consent. This survey re-
corded clinical details (including history of fever) and phys-
ical examination findings (including presence of rales/
crackles, decreased breath sounds, or wheeze). A lung ultra-
sound was then performed by a study sonographer, and find-
ings were recorded on a standardized data collection form.
The treating physician was blinded to the results of the
lung ultrasound, so management decisions were made
without knowledge of the lung ultrasound findings. Small
subpleural consolidations were defined a priori as sub-
centimeter (<1 cm in size and <1 cm in depth from the
pleural line) hypo hypoechoic pleural-based regions of
consolidation with poorly defined margins5,10,20,29; larger
consolidations were defined as subpleural hypoechoic or
tissue-like regions measuring >1 cm with or without bron-
chograms (Figure 1; available at www.jpeds.com).5 Isolated
subpleural consolidations were defined as those small,
subcentimeter consolidations not associated with a larger
(>1 cm) consolidation in any lung zone.
A standardized data collection form, completed by both
the study sonographer and subsequently by a blinded expert
reviewer, was used to record any of the following lung ultra-
sound findings in each of 12 zones scanned: small (<1 cm)
subpleural consolidations, larger (>1 cm) consolidations,
B-lines, pleural effusion, and pleural line irregularity. The
final assessment of the presence or absence of sonographic
findings was based on the blinded expert review. Overall im-
age quality was rated by the expert reviewer on a scale of 1 (no
recognizable structures, no objective data can be gathered in
1 or more zones) to 5 (at least minimal criteria met for a
complete lung US study protocol, all structures imaged
with excellent image quality and diagnosis completely sup-
ported), and studies rated at <3 were excluded from
our analysis.
A caregiver follow-up survey was emailed to each enrolled
patient/family after the ED visit. If the survey was not
completed, the caregiver was contacted by phone or email
twice more until 14 days after the visit. The follow-up survey
consisted of structured questions, with responses recorded
directly in a REDCap database. Caregivers of children who
were not diagnosed with pneumonia during the initial ED
visit were asked “Since leaving the emergency department,
was your child diagnosed with pneumonia?”
The electronic medical record (EMR) was reviewed for all
enrolled patients for the 30 days following the ED visit to
determine whether follow-up visits or CXRs occurred. De-
mographic information, vital signs data, ED management de-
tails including antibiotic administration and prescriptions
with reason for treatment, CXR results, ED final diagnosis,
and hospitalization details if appropriate were recorded for
the index ED visit. CXR results were documented as the
attending radiologist’s final reading and classified as positive,
equivocal or negative for pneumonia based on a previously
published classification system.30 We defined definite pneu-
monia as those children with positive CXR and probable
Gravel et al
April 2022
pneumonia as those children with equivocal CXR based on
the previously published definitions.30
Outcome Measures
Our primary outcomes were the rates of definite and prob-
able radiographic pneumonia and the clinical diagnosis of
pneumonia (ie, the percentage treated with antibiotics for
pneumonia) in children with subcentimeter, subpleural con-
solidations, stratified by the presence of a larger sonographic
consolidation. Our secondary outcome was the rate of subse-
quent pneumonia diagnosis during the 14-day follow-up of
children with isolated subcentimeter, subpleural consolida-
tions who did not receive antibiotics during or after their
ED visit. A subsequent pneumonia diagnosis was determined
either from a completed caregiver survey or from EMR re-
view, if a caregiver survey was unavailable.
Data Analyses
Descriptive statistics of demographic and clinical characteris-
tics (including the presence of additional lung ultrasound
findings) were calculated using medians with IQRs for
continuous variables and frequencies with proportions for
categorical variables. Proportions with 95% CIs were used
to estimate the prevalence of the primary outcomes.
Demographic and clinical characteristics of children with
and without subpleural consolidations were compared using
the Wilcoxon rank-sum test for continuous variables and the
c2 test (or Fisher exact test for rare outcomes) for categorical
variables. We also examined the subset of patients with sub-
centimeter, subpleural consolidations and compared demo-
graphic and clinical characteristics between those with and
those without larger consolidations. All analyses were con-
ducted using Stata 16.0 (StataCorp). The a value was set at
0.05, and all tests were 2-tailed.
Results
During the study period, 352 eligible patients were ap-
proached for enrollment, and 232 were enrolled
(Figure 2). A total of 188 patients with both CXR and
complete lung ultrasound data were available for analysis.
The median patient age was 5.8 years (IQR, 3.5-
11.0 years), and 40% were female. Overall, 62 children
(33%; 95% CI, 26%-40%) had at least 1 subcentimeter,
subpleural consolidation on lung ultrasound; 40 (21%)
had a single subcentimeter, subpleural consolidation,
and 22 (12%) had multiple subcentimeter, subpleural
consolidations. Twenty-three children (37%) with a
subcentimeter, subpleural consolidation also had a larger
(>1 cm) consolidation (Figure 3).
Patients with and without Subcentimeter,
Subpleural Consolidations
The children with and without subcentimeter, subpleural
consolidations were similar in terms of age, sex, and history
of fever (Table I). Children with subcentimeter, subpleural
Significance of Sonographic Subcentimeter, Subpleural Consolidations in Pediatric Patients Evaluated for Pneumonia
ORIGINAL ARTICLES
approached for
enrollment
N = 352
N = 232
Withdrawn prior to ultrasound (N = 28)
No chest radiograph performed (N = 7)
Image quality <3 (N = 6)
Incomplete lung ultrasound data (N = 3)
data for analysis
N = 188
Figure 2. Patient enrollment flow diagram.
consolidations had significantly lower minimum oxygen
saturation and were more likely to have decreased breath
sounds compared with children without subcentimeter,
subpleural consolidations. Definite radiographic
pneumonia was detected in 22 of the 62 patients with
subcentimeter, subpleural consolidations on lung
ultrasound (35%), compared with 13 of 126 (10%) without
subcentimeter, subpleural consolidations (P < .001). In
addition, 35 of the 62 children with subcentimeter,
subpleural consolidations on lung ultrasound (56%) had
definite or probable radiographic pneumonia, compared
with 29 of 126 children (23%) without subcentimeter,
subpleural consolidations (P < .001).
Subcentimeter, Subpleural Consolidations in
Combination with Larger Consolidations
Of the 62 children with subcentimeter, subpleural consolida-
tions, 23 (37%) also had a larger (>1 cm) consolidation on
lung ultrasound, and 39 (63%) did not (Table II). There
were no statistically significant differences in age, sex,
history of fever, or physical examination findings between
the 2 groups. Patients with subcentimeter, subpleural
consolidations and larger consolidations were significantly
more likely to have definite or probable radiographic
pneumonia and to receive antibiotics in the ED (Table II).
Isolated Subcentimeter, Subpleural Consolidations
Thirty-nine of the 62 patients with subcentimeter, subpleural
consolidations (63%) did not have a larger (>1 cm)
195
THE JOURNAL OF PEDIATRICS  www.jpeds.com
ultrasound data
n = 188
35% definite1 pna by CXR (n = 22)
56% definite or probable2 pna by CXR (n = 35)
61% definite pna (n = 14) 21% definite pna (n = 8)
83% definite or probable pna (n = 19) 41% definite or probable pna (n = 16)
Figure 3. CXR results stratified by presence of small (<1 cm) subpleural and larger (>1 cm) consolidations on lung ultrasound.
1
Definite PNA, patients with evidence of pneumonia on CXR (ie, positive CXR). 2Probable PNA, patients with equivocal evidence
of pneumonia on CXR (ie, equivocal CXR).
consolidation on lung ultrasound (Figure 3). Of these 39
patients, 8 (21%) had definite radiographic pneumonia and
16 (41%) had definite or probable radiographic
pneumonia. In this group of patients with isolated
subcentimeter, subpleural consolidations, 18 were treated
with antibiotics at the index ED visit and 5 others
continued on a course of antibiotics initiated before their
visit. None of the remaining 16 children (41%) who were
not prescribed antibiotics had a subsequent pneumonia
diagnosis within the 2-week follow-up period (6 based on
negative caregiver survey results and 11 based on
EMR review).
Additional Lung Ultrasound Findings
Children with subcentimeter, subpleural consolidations were
significantly more likely than those without subcentimeter,
subpleural consolidations to have larger consolidations
(P < .001), B-lines (P < .001), pleural effusion (P < .001),
and pleural line irregularities (P < .001). B-lines were more
frequent in children with both subcentimeter, subpleural
consolidations and larger consolidations compared with
those without larger consolidations; however, the presence
of pleural effusion and pleural line irregularities were similar
in patients with subcentimeter, subpleural consolidations
with larger consolidations and without larger consolidations
(Table III; available at www.jpeds.com).
Discussion
In this prospective cohort of children evaluated for pneu-
monia, we observed that children with subcentimeter, sub-
pleural consolidations often had radiographic findings of
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Volume 243
10% definite pna by CXR (n = 13)
23% definite or probable pna by CXR (n = 29)
40% definite pna (n = 6) 6% definite pna (n = 7)
60% definite or probable pna (n = 9) 18% definite or probable pna (n = 20)
pneumonia; 35% had definite radiographic pneumonia,
and 56% had definite or probable radiographic pneumonia.
When subcentimeter, subpleural consolidations were present
in combination with larger consolidations (>1 cm) on lung
ultrasound, children had the highest rates of definite and
probable radiographic pneumonia. However, 59% of chil-
dren with isolated subcentimeter, subpleural consolidations
(ie, subcentimeter, subpleural consolidations in the absence
of larger consolidations) did not have radiographic findings
of pneumonia, and among 16 children not treated with anti-
biotics, all recovered without a subsequent diagnosis of pneu-
monia during the immediate follow-up period. This suggests
that a majority of children with isolated subcentimeter, sub-
pleural consolidations do not have bacterial pneumonia.
This study focused on a cohort of children undergoing
evaluation for suspected pneumonia and specifically exam-
ined the radiographic and clinical outcomes of children
with sonographic subcentimeter, subpleural consolidations.
The pediatric literature contains subanalyses of subpleural
consolidations in a variety of settings and patient popula-
tions, although there is significant heterogeneity in study def-
initions of pneumonia and inferred clinical implications of
this sonographic finding.1,3,4,18,24 There is ongoing debate
as to whether these findings represent early or missed pneu-
monia, viral changes, or focal atelectasis (or possibly all 3).
There are also variable or frequently unreported size mea-
sures to define small subpleural consolidations, making
interpretation and application to clinical management diffi-
cult.6,8,22,24,31 The present study provides insight into the
clinical significance of both isolated subcentimeter, subpleu-
ral consolidations and the combination of subcentimeter,
subpleural consolidations with larger consolidations for
Gravel et al
April 2022 ORIGINAL ARTICLES

Table I. Patient demographics and characteristics of children based on presence of subcentimeter, subpleural
consolidations
No subcentimeter, Subcentimeter, subpleural
subpleural consolidation consolidation
Characteristics on lung ultrasound (N = 126) on lung ultrasound (N = 62) P value
Age, y, median (IQR) 5.7 (3.5-11.2) 6.0 (3.4-9.0) .700
Female sex, n (%) 47 (38) 27 (44) .383
History of fever, n (%) 81 (64) 42 (68) .639
Minimum oxygen saturation, median (IQR) 97 (96-98) 95 (93-97) <.001
Physical examination findings, n (%)
Rales/crackles 32 (25) 21 (34) .225
Decreased breath sounds 27 (21) 27 (44) .002
Wheezing 20 (16) 12 (19) .550
Hospitalized, n (%) 30 (24) 24 (39) .034
Inpatient floor bed 22 (76) 18 (75)
ICU or higher level of care 7 (24) 6 (25)
CXR results, n (%)
Definite pneumonia 13 (10) 22 (35) <.001*
Definite or probable pneumonia 29 (23) 35 (56) <.001†
Negative 97 (77) 27 (44)
Antibiotic prescribed or given in the ED, n (%) 50 (40) 35 (56) .030
Antibiotic given for pneumonia‡ 28 (22) 31 (50) <.001

ICU, intensive care unit.

*Compared with equivocal and negative CXR.
†Compared with negative CXR.
‡Other antibiotic indications included acute otitis media, sinusitis, pharyngitis, and urinary tract infection.

guiding clinical management and antibiotic therapy in chil-
dren with suspected pneumonia.
In the pediatric pneumonia literature, subcentimeter, sub-
pleural consolidations are frequently represented as small or
early pneumonia that warrant antibiotic treatment. Although
larger (>1 cm) consolidations are equated with sonographic
pneumonia,1,2,4,5 subcentimeter, subpleural consolidations
are frequently reported as representing missed pneumonia
or radiographic false-negatives. Lung ultrasound makes it
easy to visualize these small consolidations and thus is inter-
preted as being more sensitive for the diagnosis of pneu-
monia.7,9,10,19 With this assumption, several studies
support treating these small subpleural consolidations if the
clinical course is concerning for pneumonia, although previ-
ous work has shown that examination findings and clinical
presentation are poorly reliable for the diagnosis of pediatric
pneumonia.26,32
Our data show that a large number of children with sub-
centimeter, subpleural consolidations in combination with
larger consolidations have either definite (61%) or definite

Table II. Characteristics of children with subcentimeter, subpleural consolidations stratified by the presence of larger
consolidation
Subpleural consolidation Subpleural consolidation
without larger with larger
Characteristics consolidation (N = 39) consolidation (N = 23) P value
Age in y, median (IQR) 5.1 (2.2-12.2) 6.6 (4.2-8.6) .457
Female sex, n (%) 14 (39) 13 (57) .134
History of fever, n (%) 25 (64) 17 (74) .425
Minimum oxygen saturation, median (IQR) 96 (93-97) 95 (94-96) .27
Physical examination findings, n (%)
Rales/crackles 12 (31) 9 (39) .502
Decreased breath sounds 16 (41) 11 (48) .602
Wheezing 10 (26) 2 (9) .182
Hospitalized, n (%) 18 (46) 6 (26) .117
Inpatient floor bed 12 (67) 6 (100)
ICU or higher level of care 6 (33) 0 (0)
CXR results, n (%)
Definite pneumonia 8 (21) 14 (61) .001*
Definite or probable pneumonia 16 (41) 19 (83) .002†
Negative 23 (59) 4 (17)
Antibiotic prescribed or given in the ED, n (%) 18 (46) 17 (74) .033
Antibiotic given for pneumonia, n (%)‡ 15 (38) 16 (70) .23
*Compared with equivocal and negative CXR.
†Compared with negative CXR.
‡Other antibiotic indications included pharyngitis and unspecified lower respiratory tract illness.

Significance of Sonographic Subcentimeter, Subpleural Consolidations in Pediatric Patients Evaluated for Pneumonia 197
THE JOURNAL OF PEDIATRICS  www.jpeds.com
or probable (83%) pneumonia on CXR, suggesting that these
children potentially could be treated empirically for pneu-
monia without CXR. However, when isolated subcentimeter,
subpleural consolidations are identified, those rates decrease
to 21% with definite and 41% with definite or probable
radiographic pneumonia (ie, 59% negative for radiographic
pneumonia). As such, our data suggest that some, but not
all, patients with clinical concern for pneumonia and evi-
dence of subcentimeter, subpleural consolidations will
benefit from antibiotic treatment; CXR may provide adjunc-
tive information in these cases.
Although the present study focused on children with
concern for pneumonia, it is important to note that studies
of children with bronchiolitis and viral respiratory illness
have reported a substantial prevalence of subpleural consol-
idations, ranging from 25% to 100%.8,20-22,24,29,33 In these
studies, patients showed clinical improvement without anti-
biotics. Some studies also have reported that patients with
bronchiolitis and/or viral lower respiratory tract infections
can have multiple, small subpleural consolidations, which
are often correlated with severity of disease.20,22,33 These
findings highlight the likely heterogeneous pathophysiologic
etiology of subcentimeter, subpleural consolidations, as focal
atelectasis and viral changes are much more likely in these pa-
tients who improve without antibiotics.
Two studies that used lung ultrasound instead of CXR as
the initial imaging modality reported a 10% increase in anti-
biotic administration in the lung ultrasound group.3,25 These
studies highlight the importance of determining the clinical
relevance of small subpleural consolidations to guide appro-
priate antibiotic use. Our present findings demonstrate that
antibiotic treatment is not warranted in a large percentage
of children with clinical suspicion of pneumonia and sub-
centimeter, subpleural consolidations identified on lung ul-
trasound. Of note, none of the children in our cohort with
isolated small, subpleural consolidations discharged from
the ED without antibiotic treatment were diagnosed with
pneumonia during the follow-up period.
This study has several limitations. Our patient population
was limited to children undergoing CXR for evaluation of
pneumonia, which limited the study to a specific subpopula-
tion of those children with presentations concerning for
pneumonia. However, our institution had established guide-
lines during the study period that recommended obtaining
CXRs for all children with suspected pneumonia, in an effort
to reduce antibiotic overuse. As such, our study population is
representative of the majority of children seen for pneumonia
evaluation at this site. The study methodology, with a conve-
nience sample of eligible patients enrolled, has the potential
for selection bias. As evidence against selection bias within
our sample, the rates of radiographic pneumonia and hospi-
talization within our patient population are similar to those
in a larger, recently published study from our ED.34
We also acknowledge that the use of CXR results for clas-
sification has its own set of limitations, notably variable inter-
rater reliability and poor ability to distinguish viral from
bacterial disease.35-37 Although CXR might not be the ideal
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Volume 243
gold standard for comparison, it is the most widely available
and least subjective measure by which to compare lung ultra-
sound at this time. Along those lines, antibiotic treatment
was at the discretion of the treating physician and likely
multifactorial. This is reflective of typical practice; however,
it is possible that some children with subpleural consolida-
tions treated with antibiotics did not have bacterial pneu-
monia and might have recovered fully without antibiotics.
Our follow-up data were limited in that we used caregiver
self-report to determine subsequent diagnoses of pneu-
monia. It is unlikely that this misclassified the patients whose
caregivers reported no subsequent pneumonia diagnosis or
initiation of antibiotics after the ED visit. EMR review for
follow-up of children without caregiver surveys could have
missed follow-up visits if care was obtained outside of our
network. Regarding the study scanning protocol, we limited
our protocol to the use of a linear, high-frequency transducer
despite age or body habitus considerations. This might have
affected our ability to fully characterize lung US findings in
older patients or patients with greater body mass index. We
also did not assess for the presence of bronchograms within
subpleural consolidations and used the arbitrary, previously
published size definition of 1 cm to define small vs large con-
solidations. It remains to be determined whether this size
threshold is the most appropriate clinically, although it
does appear to accurately represent sonographic consolida-
tions that are not visualized on CXR.6,7,9,10
We conclude that although many children with sub-
centimeter, subpleural consolidations on point-of-care lung
ultrasound have radiographic findings of pneumonia, the
overwhelming majority of these are children who also have
larger consolidations on lung ultrasound. A minority of chil-
dren with isolated subcentimeter, subpleural consolidations
have evidence of definite radiographic pneumonia. In addi-
tion, all children with isolated subcentimeter, subpleural
consolidations discharged without antibiotics recovered
fully, suggesting that isolated small subpleural consolidations
should not prompt routine antibiotic treatment
for pneumonia. n
Submitted for publication Sep 10, 2021; last revision received Nov 19, 2021;
accepted Dec 22, 2021.
Reprint requests: Cynthia A. Gravel, MD, Boston Children’s Hospital, Division
of Emergency Medicine, BCH 3066, 300 Longwood Ave, Boston, MA 02115.
E-mail: cynthia.gravel@childrens.harvard.edu
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Figure 1. Lung ultrasound consolidations. A, Small (<1 cm) subpleural consolidation (arrow). B, Larger (>1 cm) consolidation
with air and fluid bronchograms.

199.e1 Gravel et al
April 2022 ORIGINAL ARTICLES

Table III. Lung ultrasound findings for children stratified by the presence of subcentimeter and larger subpleural
consolidations
No subcentimeter, Subcentimeter, subpleural Subcentimeter, subpleural
subpleural consolidation consolidation without consolidation with larger
Lung ultrasound findings on lung ultrasound (N = 126), n (%) larger consolidation (N = 39), n (%) consolidation (N = 23), n (%) P value*
B-lines 47 (37) 32 (82) 23 (100) .04
Consolidation (>1 cm) 15 (12) 0 (0) 23 (100) n/a
Pleural effusion 2 (2) 5 (13) 7 (30) .09
Pleural line irregularity 31 (25) 21 (54) 9 (39) .263
Single subpleural consolidation n/a 28 (72) 12 (52)
Multiple subpleural consolidations n/a 11 (28) 11 (48)
*Comparison of children with subcentimeter, subpleural consolidations with and without larger consolidation.

Significance of Sonographic Subcentimeter, Subpleural Consolidations in Pediatric Patients Evaluated for Pneumonia 199.e2