Background <p>Complicated community-acquired pneumonia (CCAP) in children can result in severe morbidities. While computed tomography (CT) is the gold standard for diagnosis, its radiation exposure has led to the increased use of lung ultrasound (LUS) as a safer radiation-free alternative. This study aimed to evaluate the diagnostic accuracy of LUS in detecting complications in pediatric patients with CCAP and determine its value in their follow up as well as its value in determining patients liable for surgical intervention as pleural decortication comparing its efficacy with chest CT.</p> Methods <p>This is a prospective observational cohort study that was conducted on 56 pediatric patients with CCAP at our tertiary-level referral pediatric hospital. Patients underwent clinical evaluation, laboratory investigations, chest X-ray, CT, and LUS. The sensitivity, specificity, and accuracy of LUS were compared with CT for detecting consolidations, pleural thickening, effusions, lung abscesses, and hydropneumothorax.</p> Results <p>Compared to CT chest, LUS showed high sensitivity (92.6% for the right lung and 94.1% for the left lung) and specificity (88% and 100%, respectively) in detecting pleural effusions and consolidations, with substantial agreement with CT (<i>p</i> &lt; 0.001). However, it had lower sensitivity in detecting lung abscesses (33.3% for the right lung, 0% for the left lung) and hydropneumothorax. Pleural thickness measured by LUS was a predictor for surgical intervention (cut-off &gt; 2.2&#xa0;mm). Follow-up LUS indicated significant improvement in lung lesions after one month.</p> Conclusion <p>LUS is a reliable tool for detecting pleural effusions and consolidations in pediatric CCAP, reducing the need for CT in many cases. However, its limitations in identifying abscesses and hydropneumothorax highlight the need for combined diagnostic approaches.</p>