Abstract Rationale Pediatric lung disorders that affect the airways such as bronchopulmonary dysplasia (BPD), asthma, cystic fibrosis (CF), and congenital lung malformations require accurate imaging for diagnosis, monitoring and treatment planning. Imaging methods such as X-ray and CT are commonly used but expose children to ionizing radiation. MRI offers a radiation-free alternative with potential for improved spatial and temporal resolution. However, the diagnostic performance, clinical utility, and reproducibility has not been evaluated across various pediatric lung diseases. Methods We conducted a systematic review of studies evaluating lung MRI in children (0-18 years) with airway disorders, including BPD, asthma, CF, and congenital lung malformations. We included studies comparing MRI (any sequence or protocol) against other imaging modalities, pulmonary function testing, clinical diagnosis, or histopathology, and reported outcomes such as diagnostic accuracy, image quality, and feasibility. Search of PubMed yielded 1,027 titles and abstracts for screening. 38 studies met inclusion criteria. QUADAS-2 was used for risk of bias assessment and reporting. Results 38 studies evaluated lung MRI in pediatric populations with airway disorders, predominantly BPD, asthma, and CF. Most were prospective observational designs in NICU or pediatric hospital settings, with ages ranging from preterm neonates (23 weeks gestational age) to adolescents (up to 21 years of age). MRI protocols primarily used 1.5T or 3T scanners, employing ultrashort echo time (UTE) and radial 3D sequences for structural imaging and hyperpolarized gas MRI for functional assessment, typically under free-breathing or short breath-hold conditions without sedation. Comparators included spirometry, MBW, and CT. Diagnostic performance varied, with some studies reporting AUC up to 0.86 and strong correlations with pulmonary function (e.g., Ventilation Defect Volume vs FEV₁, r = −0.77). Feasibility was reportedly high and reproducibility was high (ICC0.9). MRI demonstrated added sensitivity for detecting subclinical abnormalities and predicting short term outcomes. Limitations included small samples, single center designs, lack of longitudinal data and technical variability. QUADAS-2 assessment found an overall moderate risk of bias across studies, mainly in patient selection (unclear or high in around 65%) and reference standard bias (40%), while index test bias was low (80% studies). Flow and timing were often unclear, potentially inflating sensitivity and specificity estimates. Conclusion Lung MRI is a promising radiation free tool for pediatric airway disease, but multicenter validation and standardized protocols are essential to establish diagnostic accuracy and clinical utility. This abstract is funded by: None
Medeleanu et al. (Fri,) studied this question.