A blood clot in the lungs, called a pulmonary embolism (PE), is uncommon in children. But when it is missed, the consequences can be serious. Until now, doctors have had little tested guidance for evaluating a child with possible PE, and no simple bedside way to decide who can safely skip blood tests and imaging.
A new PECARN study called BEEPER (Bedside Exclusion of Pulmonary Embolism without Radiation in Children), published in The Lancet Respiratory Medicine, set out to change that. It tested whether a short bedside checklist could safely rule out PE in low-risk children without any labs or scans [1].
What the Study Tested
The checklist is called PERC-Peds, a children’s version of a rule long used in adults [2]. A child is considered low-risk only if all eight of these are true:
- The clinician’s overall judgment puts the risk of PE below 15%
- No prior PE or proximal deep vein clot (DVT)
- No surgery requiring a breathing tube in the last 30 days
- No current estrogen use
- No coughing up blood
- Heart rate below 100 (over age 12) or below 120 (age 12 and under)
- Oxygen level consistently above 94%
- No suspected DVT
Study Design
BEEPER enrolled 3,988 children ages 4 to 17 with suspected PE across 21 emergency departments in PECARN (the Pediatric Emergency Care Applied Research Network). It is the first large, prospective test of a bedside rule-out strategy for PE in children.
Results
- Of the children evaluated, 254 (6.3%) turned out to have a clot.
- When a child passed all eight PERC-Peds checks, the rule was highly reliable: 99.6% sensitive. Only one child who passed later turned out to have a clot.
- About 1 in 5 children could be cleared by the checklist alone, with no blood test or scan.
- For children who did not pass, adding a simple blood test (D-dimer) as the next step could rule out most of the rest. Using the checklist first, then D-dimer, would have safely cleared about 55% of all children and cut CT scans by roughly 18.5%.
Why This Matters
The usual test for PE is a CT scan, which uses radiation. That radiation carries a small long-term cancer risk that matters more in children than in adults. A reliable way to identify low-risk children who do not need a scan means fewer unnecessary tests, less radiation, and faster care. BEEPER is the first prospective evidence supporting this kind of bedside approach in children.
Two cautions come with the findings. BEEPER watched how the rule performed but did not test what happens when clinicians actually use it to make decisions, so the next step is putting it into practice. And because many children will not pass the checklist and go on to further testing, the rule is meant to support clinical judgment, not replace it.
Take Home Message
For children being evaluated for a possible blood clot in the lungs, a short bedside checklist (PERC-Peds) can safely identify those at low enough risk to skip further testing. Children who pass every item need no blood test and no CT scan; for those who do not, a single blood test can still spare many of them a scan. It is a practical step toward safer, more consistent, lower-radiation care.
Why is this important for patients and caregivers
- A pulmonary embolism is a blood clot in the lungs. It is rare in children but can be serious if missed.
- Checking for it often means blood tests and a CT scan, which uses radiation. This study found a simple set of bedside questions that can safely tell which children are low-risk and may not need those tests.
- If your child is being evaluated for a possible clot, the care team may use this checklist, sometimes with a single blood test, to decide whether a CT scan is needed. The goal is fewer tests and less radiation without missing a dangerous clot.
This blog post is a summary of the following journal publication:
Ellison AM, Kuppermann N, Shihabuddin BS, et al. PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study. Lancet Respir Med. Published online July 2026. doi:10.1016/S2213-2600(26)00086-X
Interested in other PECARN research?
A few recent PECARN studies covered on the PECARN and ALiEM blogs:
- The End of Routine Lumbar Punctures for the Febrile Infant 28 Days and Younger? — Burstein et al, JAMA, 2025. An updated PECARN rule helps clinicians safely avoid routine lumbar punctures in many young febrile infants. Read more on ALiEM and PECARN.
- PECARN Cervical Spine Injury Prediction Rule — Leonard et al, Lancet Child & Adolescent Health, 2024. A validated decision rule for safely clearing the cervical spine in injured children. Read more on ALiEM and PECARN.
References
- Ellison AM, Kuppermann N, Shihabuddin BS, et al. PERC-Peds rule for bedside exclusion of pulmonary embolism without radiation in children in the USA (BEEPER): a multicentre, prospective, observational, diagnostic accuracy study. Lancet Respir Med. Published online July 2026. doi:10.1016/S2213-2600(26)00086-X
- Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772-780. PMID: 18318689. doi:10.1111/j.1538-7836.2008.02944.x
