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Published in final edited form as: J Ultrasound Med. 2019 Aug 16;39(2):223–230. doi: 10.1002/jum.15114

Liver, Spleen, and Kidney Size in Children as Measured by Ultrasound

A Systematic Review

Juan S Calle-Toro 1, Susan J Back 1, Bernarda Viteri 1, Savvas Andronikou 1, Summer L Kaplan 1
PMCID: PMC6980276  NIHMSID: NIHMS1056612  PMID: 31418892

Abstract

Ultrasound is commonly the first-line imaging modality for assessing the pediatric abdomen. An abnormal size of the liver, spleen, or kidneys may indicate disease, but the evaluation is challenging because the normal size changes with age. In addition, published normal value charts for children may vary by population and methods. In this systematic review, we summarized published data on the normal size of the pediatric liver, spleen, and kidneys as measured by ultrasound in which we found similar values across different populations, ages, and sexes.

Keywords: kidney, liver, normal size, pediatric, spleen, ultrasound

Ultrasound (US) is an important imaging modality in children because it is safe, quick, and portable. It is an established diagnostic and screening tool to assess a variety of clinical concerns.1 Ultrasound is used in everyday practice for emergency, inpatient, and outpatient care. Measurement of abdominal organ dimensions in children of all ages is performed in the monitoring of abdominal organ growth patterns, diagnosis, and follow-up of patients with a variety of diseases.2

Organ size is crucial to the image interpretation of disease: for example, diseases of the liver, spleen, and kidneys can affect organ size and development, but a physical examination is not enough accurate to detect small increases in organ size.3 For example, the spleen may be palpable in 15% to 17% of healthy neonates4 and 10% of healthy children, but in most children, it must be 2 to 3 times its normal size before it is palpable.1 Ultrasound may therefore first detect organ size abnormalities that indicate disease. Normative data for organ size are challenging in the pediatric population because of changes that occur with growth and development and the effects of the body habitus, including height and weight.

In contrast to adults, for whom there are established normal ranges of organ size, organ size in children relies on growth and development.5–8 Studies exist that define the normal ranges of organ size in healthy children.1,3,4,7–23 For example hepatomegaly is a frequent clinical finding in children that may be caused by intrinsic liver diseases or by other diseases with liver involvement.16 With the growing epidemic of childhood obesity, early detection of hepatic steatosis is critical to avoiding premature liver failure.24 In children with kidney disease, the renal size may be increased or decreased.15 Measurements of renal length and volume reportedly correlate with height and weight, but the exact measurements are not homogeneous in the available literature.3,9,21 This systematic review was conducted to establish available literature published in indexed journals of US measurements of the liver, spleen, and kidneys in healthy children.

Methods

This study was approved by our Institutional Review Board, as well was registered on the PROSPERO registry, with number CRD42018094714, and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses and the Meta-analysis of Observational Studies in Epidemiology guidelines.25

Literature Search and Selection of Studies

A PICO strategy for searching in the databases was used, with P (population): healthy children from 0 to 18 years old; I (intervention): measurement of the spleen, liver, and kidney using US; C (comparison): not applicable; and O (outcome): determination of abdominal organ sizes. The Institutional Review Board at Children’s Hospital of Philadelphia approved the study, and a waiver of informed consent was obtained.

A systematic review was performed of all cross-sectional, case-control, and cohort studies, clinical trials, and randomized clinical trials related to the abdominal organ size of the liver, spleen, and kidneys in children published in the English language. A bibliographic search was performed using the following databases: Embase, MEDLINE, PubMed, SciELO, CINAHL, and Lilacs, using medical subject heading key words (spleen, liver, kidney, ultrasonography, child, pediatrics), with search dates up to May 1, 2018. The search terms were entered as shown in the following example used for PubMed: (ultrasonography and organ size) or (ultrasonography and spleen) or (ultrasonography and liver) or (ultrasonography and kidneys) and (children or pediatric). In addition, the reference lists of the retrieved articles were screened for further material for inclusion. In addition, we searched using the same search terms on Google Scholar. For extracting those articles suitable for our research, we performed a number of exclusion steps, as highlighted in the flow diagram (Figure 1). The first exclusion step was removing duplicated studies (using My EndNote Web; Clarivate Analytics, Philadelphia, PA); the second step involved exclusion of studies performed in patients with previous disease in the target organ, studies of contrast-enhanced US, studies using imaging modalities other than US, studies in animals and phantoms, and those studies that included adults who had escaped the age-filtering process of the search.

Figure 1.

Figure 1.

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Systematic review flowchart: organ size study selection process.

Assessment of Methodological Quality

The qualitative assessment of articles selected for retrieval was based on methodological validity before inclusion in the review, using standardized critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (Appendix 1). A cutoff score of 70% was used in this review.26

Data Extraction

The information extracted from each study included study setting, population demographics and baseline characteristics, US technique, study methods, outcomes, and assessment of the risk of bias. Information was organized in a general table (Appendixes 1 and 2) and in 4 subtables by each organ.

Data Synthesis

The data analysis was conducted from the findings of the included studies, structured according to the type of intervention, the target population characteristics and outcome measures. It was anticipated that there would be a small number of studies on this topic.

Results

We selected from the 504 studies only those suitable for our research as summarized in the flow diagram (Figure 1). The first exclusion step was for duplicated studies (195), resulting in 309 abstracts for review. A total of 272 studies in patients with prior disease in the target organ, studies performed with contrast-enhanced US, studies using imaging modalities other than US, studies in animals and phantoms, and those studies that included adults who had escaped the age-filtering process of the search were excluded. This resulted in 37 full-text studies remaining for complete review. From these, 27 were further excluded for 1 of 3 reasons: the organ size was reported by volume instead of a linear measure; the study focused on preterm neonates and fetuses; or the study assessed patients with a previous organ disease. The 10 studies remaining for evaluation in this review were published between 1991 and 2018 (Figure 1). Five studies included data of the liver,7,8,17,27,28 6 of the spleen,1,7,8,22,28,29 and 4 of both kidneys.7,28,30,31

The studies included patients from 0 to 20 years of age; however, only data from those aged 0 to 18 years are included here because those 19 years and older are considered young adults. Two studies included patients from 0 to 18 years1,7; 1 study included infants from 0 to 1 year30; and the remainder included groups between 0 and 16 years.7,8,17,27–29,31

Most were prospective studies (6 or 10), and none were multicenter. Application of the Joanna Briggs Institute Qualitative Assessment and Review Instrument tool for assessment of study quality showed that 8 of 10 studies had at least 80% of the required characteristics for a good-quality research study; the other 2 had scores of 70% and 75%, respectively (Appendixes 1 and 2).

In general, similar organ sizes were reported between the included studies. The liver was measured in the sagittal plane longitudinally in all 5 studies included for liver measurement and ranged from 7 cm7 in younger patients, to a maximum of 12.1 cm7 in older patients (Table 1), although not all of them used the same technique to measure the liver size (Figure 2), and the craniocaudal measurement was the most commonly used.32,33 The spleen in all studies was measured in the sagittal plane longitudinally and ranged from 5.2 cm18,22 in younger patients, to a maximum of 12.5 cm7 in older patients (Table 2). The right kidney in all studies was measured in the sagittal plane longitudinally, and the reported measurements ranged from 4.5 cm23 in younger patients, to a maximum of 10.7 cm23 in older patients (Table 3). The left kidney size ranged from 4.5 cm23 in younger patients to a maximum of 10.7 cm7 in older patients (Table 4).

Table 1.

Included Studies Measuring Liver Size in Healthy Children

Age Turkey, Konuş et al, 1998 Brazil, da Rocha et al, 2009 India, Dhingra, 2010 India, Amatya et al, 2014 Nepal, Thapa et al, 2016
n Mean SD 5th 95th n Mean SD 5th 95th n Mean SD 3th 97th n Mean SD 5th 95th n Mean SD 5th 95th
0–<3 mo 53 61.0 10.4 48.0 90.0 32 66.0 5.7 47.0 75.0 21 63.5 9.3 48.5 80.5 45 53.0 5.2 44.0 57.0 36 68.0 7.0 54.0 80.0
3–<6 mo 40 73.0 10.8 53.0 86.0 34 76.0 7.2 58.0 90.0 35 71.5 8.6 56.0 84.5 45 64.0 9.2 49.0 83.0
6–<9 mo 20 79.0 8.0 70.0 90.0 72 84.0 9.1 62.0 101.0 51 77.0 9.0 62.0 95.5 35 76.0 9.3 47.0 75.0
9–<12 mo 36 84.0 6.9 65.0 96.0
l–<2 y 18 85.0 10.0 68.0 98.0 102 92.3 7.5 77.3 110.3 77 85.5 11.8 67.0 106.5 45 89 8.6 71 103 62 84.0 7.4 69.5 94.5
2–<4 y 27 86.0 11.8 63.0 105.0 48 99.0 6.7 78.0 11.0 132 89.5 11.4 70.5 116.0 43 87.3 8.9 73.4 105.2
4–<6 y 30 100.0 13.6 77.0 124.0 181 104.0 8.2 86.5 126.0 115 100.5 12.6 69.0 140.0 45 92.0 9.1 80.0 108.0 41 92.2 9.1 75.3 106.6
6–<8 y 38 105.0 10.6 90.0 123.0 109 109.0 8.7 91.0 133.0 51 108.5 11.2 86.0 128.0 25 98.7 8.7 84.6 117.6
8–<10 y 30 105.0 12.5 83.0 128.0 62 118.0 11.0 97.0 140.5
10–<12 y 16 115.0 14.0 95.0 136.0 53 132.5 12.5 103.5 153.5 45 107 11.1 91 129 19 106.3 10.7 92.0 127.0
12–<14 y 23 118.0 14.6 94.0 136.0 11 116.1 8.8 104.0 130.0
14–<18 y 12 121.0 11.7 104.0 139.0
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Measurements are reported in millimeters

Figure 2.

Figure 2.

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Custom representation of the linear measurements performed in the longitudinal plane in 5 of the main studies as well as a diagram of possible methods, with a being the ventrodorsal dimension (depth), b the maximum dimension, and c the craniocaudal dimension.

Table 2.

Included Studies Measuring Spleen Size in Healthy Children

Age USA, Rosenberg et al, 1991 Turkey, Konus et al, 1998 USA, Megremis et al, 2004 India, Dhingra, 2010 Nepal, Thapa et al, 2016 Turkey, Özdikici et al, 2018
n Median 10th 90th n Mean SD 5th 95th n Mean SD Min Max n Mean SD 3th 97th n Mean SD 5th 95th n Mean SD 5th 95th
0–<3 mo 28 45.0 33.0 58.0 53 53.0 7.8 40.0 65.0 57 45.0 7.1 30.0 61.5 21 47.0 9.7 34.5 69.5 36 50.0 7.9 36.1 62.4 21 46 10 33 61
3–<6 mo 13 53.0 49.0 64.0 40 59.0 6.3 47.0 67.0 16 55.0 5.6 47.0 63.0 35 54.5 5.1 45.5 65.5 24 54 5 47 62
6–<9 mo 17 62.0 52.0 68.0 20 63.0 7.6 53.0 74.0 27 63.5 7.3 52.5 74.5 51 58.0 7.4 45.5 77.5 35 60.0 7.9 47.2 75.8 24 62 7 54 74
9–<12 mo
l–<2 y 12 69.0 54.0 75.0 18 70.0 9.6 55.0 85.0 35 65.5 7.1 53.5 82.5 77 62.5 8.8 46.0 87.0 62 61.0 8.2 48.5 76.5 30 70 8 57 80
2–<4 y 24 74.0 64.0 86.0 27 75.0 8.4 61.0 88.0 46 75.5 9.5 58.0 94.0 132 68.0 8.8 47.0 88.0 43 68.1 9.2 54.2 81.6 27 75 11 62 89
4–<6 y 39 78.0 69.0 88.0 30 84.0 9.0 70.0 100.0 54 80.5 8.8 65.5 97.0 115 72.5 9.5 51.0 101.0 28 69.3 7.0 55.4 80.6 27 79 10 67 94
6–<8 y 21 82.0 70.0 96.0 38 85.0 10.5 69.0 100.0 51 85.5 9.5 70.0 102.5 51 77.5 9.7 59.0 96.0 38 95.5 9.3 79.0 110.5 31 86 11 74 101
8–<10 y 16 92.0 79.0 105.0 30 86.0 10.7 70.0 100.0 41 88.5 9.7 69.0 108.5 62 82.0 10.2 66.5 103.5 26 92 12 76 107
10–<12 y 17 99.0 86.0 109.0 16 97.0 9.7 81.0 108.0 53 94.5 10.7 70.5 113.5 53 87.0 15.2 65.0 115.0 19 106.3 10.7 92.0 127.0 27 97 14 73 111
12–<14 y 26 101.0 87.0 114.0 23 101.0 11.7 85.0 118.0 48 100.0 9.2 82.0 116.5 11 116.1 8.8 104.0 130.0 38 100 10 85 114
14–<18 y 17 101.0 95.5 121.5 12 101.0 10.3 88.0 115.0 26 130.0 8.0 91.0 117.5 35 104 9 94 118
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Measurements are reported in millimeters.

Table 3.

Included Studies Measuring Right Kidney Size in Healthy Children

Age Turkey, Konuş et al, 1998 Serbia, Vujic et al, 2007a India, Otiv et al, 2012a Nepal, Thapa et al, 2016a
n Mean SD 5th 95th n SD Mean 3th 97th n Mean SD n Mean SD 5th 95th
0–<3 mo 50 50.0 5.8 40.0 58.0 582 5.6 48.0 38.0 60.0 71 43.0 6.0 36 48.0 4.8 40.0 60.0
3–<6 mo 39 53.0 5.3 50.0 64.0 448 4 57.0 50.0 65.0 49 47.0 7.0
6–<9 mo 17 59.0 5.2 52.0 66.0 496.0 4.1 58.0 51.0 67.0 61 55.0 7.0 35 54.0 6.4 44.0 68.0
9–<12 mo 458 5 61.0 50.0 69.0 81 56.0 6.0
1–<2 y 18 61.0 3.4 55.0 65.0 122 57.0 4.0 62 56.0 5.5 49.1 66.5
2–<4 y 22 67.0 5.1 59.0 75.0 133 64.0 6.5 43 63.0 6.8 52.0 74.0
4–<6 y 26 74.0 5.5 65.0 83.0 129 67.5 6.0 28 69.8 5.6 60.0 80.1
6–<8 y 32 80.0 6.6 70.0 91.0 102 69.5 5.0 38 74.5 6.2 62.5 84.5
8–<10 y 27 80.0 7.0 69.0 89.0 115 78.0 6.5
10–<12 y 15 89.0 6.2 82.0 100.0 75 82.5 7.5 19 83.0 7.2 68.0 95.0
12–<14 y 22 94.0 5.9 85.0 102.0 62 86.0 8.0 11 91.0 5.3 82.0 97.0
14–<18 y 11 92.0 7.0 83.0 102.0
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Measurements are reported in millimeters.

a

Study did not divide by side.

Table 4.

Included Studies Measuring Left Kidney Size in Healthy Children

Age Turkey, Konuş et al, 1998 Serbia, Vujic et al, 2007a India, Otiv et al, 2012a Nepal, Thapa et al, 2016a
n Mean SD 5th 95th n Mean SD 3th 97th n Mean SD n Mean SD 5th 95th
0–<3 mo 50 50.0 5.5 42.0 59.0 582 48.0 5.6 38.0 60.0 71 43.0 6.0 36 50.3 5.0 41.7 59.1
3–<6 mo 39 56.0 5.5 47.0 64.0 448 57.0 4 50.0 65.0 49 47.0 7.0
6–<9 mo 17 61.0 4.6 54.0 68.0 496.0 58.0 4.1 51.0 67.0 61 55.0 7.0 35 55.8 5.2 48.6 67.2
9–<12 mo 458 61.0 5 50.0 69.0 81 56.0 6.0
1–<2 y 18 66.0 5.3 57.0 72.0 122 570 4.0 62 59.2 5.4 51.0 67.5
2–<4 y 22 71.0 4.5 610 76.0 133 64.0 6.5 43 66.4 8.0 53.8 81.4
4–<6 y 26 79.0 5.9 70.0 87.0 129 67.5 6.0 28 71.2 5.8 63.0 83.1
6–<8 y 32 84.0 6.6 73.0 93.0 102 69.5 5.0 38 77.1 6.4 64.8 88.5
8–<10 y 27 84.0 7.4 75.0 97.0 115 78.0 6.5
10–<12 y 15 91.0 8.4 77.0 102.0 75 82.5 7.5 19 85.6 6.2 74.0 98.0
12–<14 y 22 96.0 8.9 84.0 110.0 62 86.0 8.0 11 94.0 6.2 86.0 105.0
14–<18 y 11 99.0 7.5 90.0 110.0
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Measurements are reported in millimeters.

a

Study did not divide by side.

Discussion

Normative liver, spleen, and kidney sizes as measured by US change with the child’s age, which is expected because of the normal growth and development in a healthy child. Currently published evidence demonstrates that there is no difference in abdominal organ size between boys and girls.1,4,7,9–11,14,15,18–20,22,23,27,31,34–36 However, a correlation was demonstrated between the organ length and the child’s weight, height, body mass index, and body surface area,12,27,28,37 in which patients with a higher weight, height, body mass index, and body surface area tended to have larger organs.1,13,21,22,27,30,31,38

In clinical practice, differences of just a centimeter may make a difference between a read of “normal” versus “hepatomegaly,” with the latter prompting further testing and even biopsy. Standard practice in our institution and many others is to only measure the craniocaudal dimension.39 Radiologists and their ordering clinicians need valid measurements that account for variability in the organ measurement, patient size, and statistical analysis. Although we cannot be sure of the technical differences in transducer placement and the technique descriptions provided, taken as a true representation, we have provided an image (Figure 2).

This review had several strengths: there were no restrictions regarding the year of publication; quality criteria were based on the available evidence and were agreed on independent of the reviewers; and the use of a quality score form allowed an objective rather than empirical assessment of quality for determining the risk of bias.

However, we recognize several limitations: the data were entirely from observational studies; different inclusion and exclusion criteria were used in the studies, including different patient populations and ethnicities; and only English-language studies were included for practical reasons. Additionally, the tool that was used to rate the quality of each study was developed more recently than some of the article publication dates.

One limitation of US is the user-dependent image acquisition, resulting in interobserver variability.5,6,40–46 Novel problems include improved visualization of different anatomic layers resulting from more advanced US scanners, which can lead to erroneous placement of measurement markers.2,45 Biometric studies in children by means of US have been reported; however, some of them used different measurement methods.9,13,14,19

In conclusion, the size of the liver, spleen, and kidneys increases consistently as the patient grows, and according to the data from the included studies, dimensions of these organs have a similar growth pattern. A true meta-analysis of available data from around the globe would be of international value.

Abbreviation

US

ultrasound

Appendix 1.

Critical Appraisal Results for Included Studies Using the Joanna Briggs Institute Qualitative Assessment and Review Instrument Critical Appraisal Checklist

Author Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Total %
Amatya et al Y Y Y Y N N Y Y U U 75
da Rocha et al Y Y Y Y Y Y Y NA NA Y 80
Dhingra Y Y Y Y Y Y Y NA NA Y 80
Konuş, et al Y Y Y Y Y Y Y Y NA Y 90
Megremis et al Y Y Y Y Y Y Y NA NA Y 80
Otiv et al Y Y Y Y Y Y Y NA NA N 70
Özdikici Y Y Y Y N Y Y Y U U 88
Rosenberg et al Y Y Y Y Y Y Y Y NA Y 90
Thapa et al Y Y Y Y Y Y Y Y U U 100
Vujic et al Y Y Y Y Y Y Y NA NA Y 80
Average score 83
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N indicates no; NA, not applicable; U, unclear; and Y, yes.

Appendix 2.

Included Studies List

Year Journal 1st Author Country Age Range, y Organ n Modality
2018 J Ultrasound Özdikici Turkey 0–16 Spleen 310 Retrospective
2016 Kathmandu Univ Med J Thapa Nepal 0–15 Left kidney, right kidney, liver, spleen 272 Prospective
2014 Indian J Pediatr Amatya India 0–15 Liver 500 Cross-sectional
2012 Indian Pediatr Otiv India 0–12 Left kidney, right kidney 1000 Cross-sectional
2009 Radiol Brasil da Rocha Brazil 0–7 Right kidney, 584 Prospective
2010 Indian Pediatr Dhingra India 1–12 Liver, spleen 597 Cross-sectional
2007 Pediatr Nephrol Vujic Serbia 0–1 Left kidney, right kidney 992 Prospective
2004 Radiology Megremis USA 0–18 Spleen 512 Prospective
1998 AJR Am J Roentgenol Konuş Turkey 0–16 Left kidney, right kidney, liver, spleen 307 Prospective
1991 AJR Am J Roentgenol Rosenberg USA 0–20 Spleen 230 Prospective
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Footnotes

All of the authors of this article have reported no disclosures.

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