Pediatric contrast-enhanced ultrasound in clinical practice: evidence maturity and workflow integration

Contrast-enhanced ultrasound (CEUS) has become an important adjunct in pediatric imaging because it enables real-time assessment of microvascular perfusion without ionizing radiation and without nephrotoxic contrast media. This narrative review synthesizes current evidence and practical applications of pediatric CEUS, with emphasis on intravenous blood-pool CEUS, contrast-enhanced voiding urosonography (ceVUS), and selected luminal or hydrosonographic gastrointestinal applications. Literature was identified through targeted searches of PubMed/MEDLINE and Google Scholar, with priority given to pediatric-specific reviews, systematic reviews, consensus or implementation papers, and key original studies, supplemented by recent publications through March 2026. Current evidence is strongest for ceVUS, focal liver lesion characterization, and targeted CEUS for hemodynamically stable blunt abdominal trauma; in contrast, many non-hepatic abdominal, bowel, interventional, emergency, and critical-care applications remain center-dependent or exploratory and require more standardized pediatric validation. Among pediatric applications, ceVUS remains the most mature and reproducible, offering high diagnostic performance without radiation while also allowing detection of intrarenal reflux. However, evidence maturity differs substantially across indications, and regulatory heterogeneity, operator dependence, reimbursement barriers, differences in technology availability, professional training requirements, limited cost-effectiveness data, and the need for standardized protocols remain important implementation challenges. This review proposes an indication-specific evidence-maturity framework that distinguishes mature applications suitable for broader adoption from center-dependent applications requiring local expertise and local protocolization, and from emerging applications requiring stronger prospective validation. The framework is intended as a pragmatic, non-validated clinical organizing tool rather than as a formal evidence-grading system. Overall, CEUS is well positioned to expand within child-centered imaging pathways that seek to maximize diagnostic yield while minimizing radiation exposure, sedation, and procedural burden.