Recommendations for Imaging in Children in Non-Dedicated Paediatric Centres
UPDATED May 2021 Version 2 1. INTRODUCTION
1.1 Purpose
The purpose of this document is to provide information to assist radiologists in supplementing adult imaging protocols, and to highlight when an imaging protocol needs to be changed for children (patients <16 years).
1.2 Scope
The scope of this document is to provide guidance on the performance of paediatric imaging for radiology practices and hospital departments that are not dedicated paediatric centres. It also provides radiologists and radiology practices with a list of useful references that complement the recommendations contained within this guide.
1.3 Background
Most radiology practices and hospital departments perform some paediatric imaging; however, the majority of their patients are likely to be adults. Under the auspice of the Australian and New Zealand Society for Paediatric Radiology (ANZSPR) Special Interest Group, the College has reviewed the original document produced by the Paediatric Imaging Reference Group in 2017. This document supports a consistent approach to paediatric imaging so that all practices are aware of the particular issues that need to be addressed when imaging children.
The Alliance for Radiation Safety in Paediatric Imaging, of which the College is a member body, began as a committee within the Society for Paediatric Radiology in late 2006. This resulted in the Image Gently Campaign whose goal is to change practice by increasing awareness of the opportunities to promote radiation protection in the imaging of children and raise awareness of the opportunities to lower radiation dose in the imaging of children.
This guidance document is a College strategy that supports this goal, but is specific to the Australian and New Zealand context.
The position statement will be reviewed in a 3-yearly cycle.
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The original 2017 version of this document was written by the Paediatric Imaging Reference Group (PIRG). PIRG was formed to provide a forum for discussion and provision of advice to the College Council, College members and external enquiries on issues relating to Paediatric Imaging. It did this by identifying and recommending mechanisms by which standards relating to Paediatric Imaging may be promoted and implemented through the College membership and the health sector.
In 2020, the role of the PIRG was assumed by ANZSPR (SIG). ANZSPR, like the PIRG, consists of radiologists with a particular interest in paediatric imaging, and is representative of all states and territories across Australia and New Zealand. ANZSPR also represents rural and remote regions as well as both the public and private sectors.
In developing the original document, the PIRG undertook a critical review of various protocols and guidelines used within Paediatric Imaging. This resulted in a final list of recommendations to assist others in making decisions about appropriate use of paediatric imaging. The 2021 review of this document was performed by the ANZSPR executive committee with the final version being determined by consensus. The final version was then considered by the Standards of Practice and Accreditation Committee of the College before being formally considered, approved and endorsed by the College Council.
2. DEFINITIONS
In this Guideline:
College means The Royal Australian and New Zealand College of Radiologists
Member means a member of the College
PIRG means the Paediatric Imaging Reference Group of the College
ANZSPR means the Australian and New Zealand Society for Paediatric Radiology
3. PROFESSIONAL DOCUMENT STATEMENT
3.1 General Principles
Imaging in children should be specifically tailored so that required information is obtained with the fewest images and least radiation with the aim of performing the most appropriate test the first time.
It is strongly recommended that technical staff liaise with radiologists prior to taking plain x-rays if these are performed infrequently at the practice or if there are any concerns regarding a particular request. It is strongly recommended that technical staff liaise with radiologists prior to performing Computed Tomography (CT).
For CT, it is recommended that the radiologist consider whether ultrasound or Magnetic Resonance Imaging (MRI) could be performed as an alternative.
As a principle, for plain x-rays and CT the overall coverage of the imaging should be limited to the area of interest.
Recommendations for Imaging in Children in Non-Dedicated Paediatric Centres Version 2 © The Royal Australian and New Zealand College of Radiologists® May 2021 Page 2 of 8 3.2 Anaesthesia, Sedation and Other Techniques
It is important not to perform a study, especially CT, unless it is likely that the child will be either cooperative enough to remain still or can be satisfactorily immobilised.
A fast feed and wrap protocol may be considered in some situations for performing a CT or MRI. This is best performed and usually successful before the age of 3 months, The child is fasted approximately 4 hours prior to the CT/MRI appointment, brought into the scanner, fed and tightly wrapped/swaddled. A light sedation over and above this will ensure a successful study on most occasions.
Unsuccessful attempts at fast feed and wrap or in children over the age of 3 months leads to the cross sectional imaging needing to be performed under general anaesthesia. General Anaesthesia and Sedation require the appropriate medical and nursing expertise, monitoring equipment and recovery facilities as outlined in the Position Statement on the Use of Sedation and Anaesthesia in Paediatric Imaging.
3.2.1 Important Principles
x Some movement artefact may be acceptable depending on the clinical indication for the scan. The technician should check with the radiologist, before rebooking or repeating the scan. x If the child is not cooperating the study should be quickly terminated. x Only use IV contrast when absolutely necessary.
3.2.2 For CT
x Do not perform a routine noncontrast scan if a contrast scan is required. x Noncontrast studies can usually be performed without general anaesthesia on a multislice CT scan if adequate immobilisation can be utilised. x A contrast CT can usually be performed on a child >6 years without anaesthesia. A contrast CT <6 years and especially <3 years will usually require general anaesthesia. The use of a local anaesthetic cream 30 mins prior to cannulation for a contrast scan will improve compliance even in children 3-6 years. x Usually fast feed and wrap scans are non contrast studies. However, a radiologist will need to liaise with the treating team and the technologists if it is imperative that contrast be administered, x If general anaesthesia is required, strongly consider the use of MRI. x The use of radiation shielding devices is generally not used and should only be considered when staff are trained in their use to ensure that a reduction in radiation dose is achieved.
3.2.3 For MRI
x Perform the most important sequences first. x Age <3 months: a dedicated beanbag can reliably be used to immobilise a patient for approximately 30 minutes for a brain scan. Refer to the paragraph on fast feed and wrap studies. x Age 3 months – 4 years: usually requires general anaesthesia. Depending on availability and urgency, a noncontrast CT should be considered if appropriate. x Age 4 – 10 years: usually can have an MRI with appropriate patient preparation (see other techniques). x Age >10 years: can usually be performed as for an adult.
Recommendations for Imaging in Children in Non-Dedicated Paediatric Centres Version 2 © The Royal Australian and New Zealand College of Radiologists® May 2021 Page 3 of 8 3.3 Other Techniques:
It is often possible to achieve satisfactory patient cooperation in a child that would otherwise have required a general anaesthetic with appropriate patient and parent preparation. The following techniques should be considered:
x Explanation and Information pamphlets (see Inside Radiology link www.insideradiology.com.au), which can be child or parent orientated. x Session playing with model of CT or MRI unit. x Session on Mock CT or MRI where available. x Short instructional videos that can be web based. x Tour of CT or MRI prior to scan. x Facility to listen to favourite music or watch DVD during scan.
3.4 Plain X-Rays
3.4.1 Skull X-Rays for Plagiocephaly
When performed an anteroposterior (AP), Lateral, Townes and Basal view are required. Low dose CT is an alternative investigation when the imaging site is experienced in the low dose technique.
The basal view is often omitted as it is very difficult to obtain in children; however, it is important in determining skull deformity i.e in craniosynostoses.
3.4.2 Cervical Spine X-Ray for Trauma
As a routine omit the oblique views.
<4 years the odontoid view is not contributory and should be omitted unless the Medical Imaging Technologist (MIT) feels the patient is likely to be compliant.
3.4.3 Chest X-Ray
As a routine the lateral view is usually not performed. The AP should be non-rotated and inspiratory.
3.4.4 Abdominal X-Ray
As a routine the erect view should not be performed. Fluid levels are not useful in children occurring more commonly in the absence of obstruction. An erect chest x-ray should be performed if free intraperitoneal air is the clinical question. For children aged 0-24 months a shoot through lateral or decubitus film is substituted. An abdominal X-Ray should only be performed in the setting of suspected constipation when the referrer is of the opinion that the result will alter management.
3.4.5 Pelvic and Hip X-Ray
X-Ray of the hip in a child requires an AP view of the pelvis (to assess the other hip and look for an effusion) and a frogleg view or lateral view of the symptomatic side.
The exception is for Developmental Dysplasia of the Hip (DDH) where, as a routine, an AP view is only required. It is important that the AP is not rotated, as this will affect the
Recommendations for Imaging in Children in Non-Dedicated Paediatric Centres Version 2 © The Royal Australian and New Zealand College of Radiologists® May 2021 Page 4 of 8 assessment of the acetabulum for dysplasia. For children <6 months with actual or suspected DDH, an ultrasound is preferred to a plain radiograph of the pelvis
Gonadal shielding is now not recommended for abdominal or pelvic X-rays. Shielding has been shown to often be misplaced, hide abnormalities and to potentially increase dose to the area.
3.4.6 Foot X-Ray for “clubfoot”
Where possible, two views, AP and lateral weight-bearing views should be performed to assess for varus/valgus deformity.
3.5 Ultrasound
3.5.1 Renal Ultrasound
x Record 3 coronal, 3 sagittal and 3 transverse images improving the assessment for renal scarring. x If collecting system dilation is present, comment in the report on the calyceal dilation and measure the antero-posterior pelvic dilation transversely as the pelvis leaves the renal parenchyma. If the ureter is dilated, state whether the dilatation is proximal or distal. x If pelvicalyceal dilatation is present, do not routinely recommend an Micturating Cysto-uretherogram (MCU), as the presence of vesicoureteric reflux (VUR) usually does not affect patient management. Recommending an MCU may make it difficult for the referrer to not perform an MCU.
3.5.2 Hip Ultrasound for Assessment of Dysplasia
There are many pitfalls to Hip ultrasound in dysplasia and it is not recommended that it is performed unless the sonographer/radiologist is experienced in the technique. When reporting Hip Ultrasound, describe the presence and severity of acetabular dysplasia, the stability of the joint and whether the hip is enlocated, subluxed or dislocated.
3.6 Fluoroscopy
For all fluoroscopic procedures, satisfactory patient immobilisation, appropriate collimation, minimal fluoroscopic time and a minimal number of exposures should be performed. Captured fluoroscopic images would be preferable to keep the dose level down. However, the clinical question should dictate if the screen-captured (and hence unsharp) images are sufficient or not.
3.6.1 MCU
The MCU is used most commonly for diagnosing VUR and, more rarely, posterior urethral valves in boys. The significance of VUR is controversial. Most imaging guidelines do not routinely recommend performing an MCU following a urinary tract infection. In view of the radiation dose and associated trauma it is reasonable to discuss the procedure with the referring doctor to determine if a positive finding of VUR will alter the child’s management.
Recommendations for Imaging in Children in Non-Dedicated Paediatric Centres Version 2 © The Royal Australian and New Zealand College of Radiologists® May 2021 Page 5 of 8 3.7 CT
Both pre- and post-contrast scans should be avoided if possible. The KVp should be reduced to 80-100. See the section on anaesthesia, sedation and other techniques for appropriate patient immobilisation techniques.
3.7.1 CT Brain
If possible perform an MRI, which is more sensitive to most pathologies and does not use radiation. When a CT of the brain is performed:
x Use 100KVp or less and Automated Exposure Control. x Use a narrow window (80) to view the brain.
3.7.2 CT Abdomen
Abdominal CT without IV contrast is usually not useful and should not be performed if IV access cannot be achieved.
CT of the abdomen for nonspecific abdominal pain is usually non-contributory. If a good quality abdominal ultrasound is normal, specialist referral is more appropriate. CT is often unnecessary as a first line investigation if ultrasound and / or MRI are available except in the case of major trauma or malignancy at the discretion of the referrer and in consultation with the radiologist.
4. USEFUL REFERENCES
The following list provides useful references for radiologists, radiology practices and hospital departments which engage in paediatric imaging. These references are only a starting point.
4.1 General
x Image Gently (USA). Digital Radiography Safety Checklist – Safety Steps to Do and Verify for your paediatric patient [Internet]. Image Gently (USA); 2010 [cited 2017 Dec 19]. Available from: http://www.imagegently.org/Procedures/Digital-Radiography/Quality- Improvement
4.2 Patient Preparation
x InsideRadiology (Aus)(NZ); 2017 [cited 2017 Oct 19]. www.insideradiology.com.au; www.insideradiology.co.nz. x Hallowell LM, Stewart SE, de Amorim e Silva CT and Ditchfield MR. Reviewing the process of preparing children for MRI. Paediatr Radiol. 2008 [cited 2017 Oct 19]; 38:271- 279. Available from [may require purchase]: https://www.researchgate.net/publication/5763485_Reviewing_the_process_of_preparin g_children_for_MRI x RANZCR Position Statement on the Use of Sedation and Anaesthesia in Paediatric Imaging. Available from: https://www.ranzcr.com/college/document-library/the-ranzcr- position-statement-on-the-use-of-sedation-and-anaesthesia-in-paediatric-imaging x Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures (PS09). 2014 [cited 2017 Oct 19]. Available from: http://www.anzca.edu.au/documents/ps09-2014-guidelines-on-sedation-and-or-analgesia
Recommendations for Imaging in Children in Non-Dedicated Paediatric Centres Version 2 © The Royal Australian and New Zealand College of Radiologists® May 2021 Page 6 of 8 x ANZCA. Statement on Anaesthesia Care of Children in Healthcare Facilities Without Dedicated Paediatric Facilities (PS29). 2008 [cited 2017 Oct 19]. Available from: http://www.anzca.edu.au/documents/ps29-2008-statement-on-anaesthesia-care-of- childre x ANZCA. Recommendations on Minimum Facilities for Safe Administration of Anaesthesia in Operating Suites and Other Anaesthetising Locations (PS55). 2012 [cited 2017 Oct 19]. Available from: http://www.anzca.edu.au/documents/ps55-2012- recommendations-on-minimum-facilities-fo
4.3 Radiation in Children
x Image Gently (USA); 2014 [cited 2017 Oct 19]. www.imagegently.com x McCollough CH, Bruesewitz MR and Kofler [Jr] JM. CT Dose Reduction and Dose Management Tools: Overview of Available Options. RadioGraphics. 2006 [cited 2017 Oct 19]; 26:503-512. Available from: http://pubs.rsna.org/doi/10.1148/rg.262055138 x Greenberg SB. Rebalancing the risks of Computed Tomography and Magnetic Resonance imaging. Paediatr Radiol. 2011 [cited 2017 Oct 19]; 41:951-952. Available from (may require purchase): https://www.researchgate.net/publication/51178178_Rebalancing_the_risks_of_Compute d_Tomography_and_Magnetic_Resonance_imaging x NCRP Recommendations for Ending Routine Gonadal Shielding During Abdominal and Pelvic Radiography NCRP Statement No. 13, January 12, 2021
4.4 Ultrasound
x Siegel M, editor. Paediatric Sonography, 4th Edition. Philadelphia: Lippincott Williams & Wilkins; 2010.
4.5 Micturating Cystourethrogram and Vesicoureteric Reflux
x Finnel SME, Carroll AE, Downs SM, the Subcommittee on Urinary Tract Infection. Diagnosis and Management of an Initial UTI in Febrile Infants and Young Children. Paediatrics. 2011 [cited 2017 Oct 19];128(3):e749. Available from: http://pediatrics.aappublications.org/content/128/3/e749 x Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management Paediatrics. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Paediatrics. 2011 [cited 2017 Oct 19]; 128(3):595-610. Available from: http://pediatrics.aappublications.org/content/pediatrics/early/2011/08/24/peds.2011- 1330.full.pdf x National Institute for Health and Clinical Excellence (NICE). Urinary Tract Infection in under 16s: Diagnosis and Management. c. 2007 [updated 2017 September; cited 2017 Oct 19]. Available from: http://guidance.nice.org.uk/CG54 x Pennesi M, Travan L, Peratoner L, Bordugo A, Cattaneo A, Ronfani L, Minisini S, Ventura A. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomised, controlled trial. Paediatrics. 2008 [cited 2017 Oct 19]; 121(6):e1489-1494. Available from: https://www.medscape.com/medline/abstract/18490378
4.6 Imaging Guidelines
x Government of Western Australia. Diagnostic Imaging Pathways (Aus); 2017 [cited 2017 Oct 19]. Available from: www.imagingpathways.health.wa.gov.au
Recommendations for Imaging in Children in Non-Dedicated Paediatric Centres Version 2 © The Royal Australian and New Zealand College of Radiologists® May 2021 Page 7 of 8 5. ACKNOWLEDGEMENTS
This guideline was reviewed by the Australian and New Zealand Society for Paediatric Radiology Executive Committee 2021.
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