Reducing radiation exposure in pediatric CT imaging: strategies and alternatives in emergency medicine—a narrative review

Introduction

Computed tomography (CT) scan is a pivotal tool in pediatric emergency medicine. It offers rapid, precise diagnosis and insight into various medical conditions, aiding healthcare providers in making informed decisions for effective treatment strategies (1-4).

Traditionally, CT scans have been chosen as the predominant choice among advanced imaging modalities in the emergency department (PED) realm due to their rapidity, precision, and widespread availability (1,5). Also, newer versions scan faster making the scan time from few seconds to few minutes thus reducing the need for sedation avoiding their side effect (1,5,6).

According to Larson [2011] from 1995 to 2008 there has been an increase in CT use among children visiting emergency departments despite the relatively similar number of visits with the records showing that 89.4% took place at non-pediatric-focused facilities while 10.6% in pediatric emergency department (PED) raising the concern of overuse and the long-term radiation induced harm (7).

Because despite their undeniable benefits, CT scans also present inherent risks, notably concerning radiation exposure, especially concerning pediatric patients due to early childhood exposure (1,2,8). Due to their smaller size, developing organs and tissue with a higher cell proliferation rate and the more radiosensitive compared to adults, pediatrics are at a heightened susceptibility to the radiation associated risks, the pediatric population is more susceptible to the detrimental effects of radiation (1,2,9). Prolonged or excessive exposure to radiation from multiple CT scans can significantly elevate the risk of developing cancer and other long-term health complications (1). Consequently, medical professionals must use instruments such as CT with great care due to the potential risks associated with radiation exposure (1,2).

This project aims to address the challenges of minimizing radiation exposure from CT scans in PED while ensuring optimal patient care all while upholding the standards of quality care. Through comprehensive exploration and analysis, this paper sheds light on the vulnerability of pediatric patients to radiation, exploring the quality improvement initiatives aimed at reducing unnecessary CT scans and optimizing radiation doses in pediatric emergencies, reducing potential long-term risks, including cancer development (1,2,10). Furthermore, the study also evaluates alternative imaging modalities such as ultrasound (US) and magnetic resonance imaging (MRI), examining their role as first-line options in specific clinical scenarios. We present this article in accordance with the Narrative Review reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-102/rc).

Methods

This narrative review was conducted by systematically searching the literature for articles related to minimizing radiation exposure from CT scans in PED settings. The focus was on understanding the risks, exploring effective dose-reduction strategies, and evaluating alternative imaging modalities, with particular attention to low-resource settings.

Literature search

Databases such as PubMed and Google Scholar were used to identify relevant studies, guidelines, and reviews. We used relevant keywords and terms for the literature search. The last search was conducted in July 2024. Please refer to Table 1 for the detailed research strategy. Key findings related to radiation risks, dose reduction strategies, and the effectiveness of alternative imaging modalities were summarized and synthesized to provide a coherent narrative.

Radiation risks in pediatric CT imaging

Children are more inherently susceptible to the harmful effects of ionizing radiation and developing radiation-associated cancer compared to adults due to Their developing, having a higher cell proliferation rate and rapidly dividing cells and growing tissues and organs that are inherently more radiosensitive (1,3). According to The National Research Council Committee on the Biological Effects of Ionizing Radiation, it has been estimated that children younger than 10 years are several times more sensitive to radiation than are adults and They are more likely to live longer so a radiation-induced cancer could develop (11). They are also susceptible to sedation side effects that can lead to respiratory depression, psychological effects and financial burden (6,11,12).

Historically, CT scans are often not adjusted for the smaller size of pediatric patients, resulting in higher radiation exposure for their body size. This discrepancy in radiation exposure is exacerbated by the reduced radiation filtering effect of a child’s thin body walls, which exposes deeper organs to higher radiation doses compared to adults (1).

One of the primary concerns that studies have documented is that children are at an increased risk of potentially developing cancer later in life in relation with radiation exposure from medical imaging, particularly CT scans (2).

For example, a cohort using data of 11 million Australians by Mathews et al. [2013] evaluated cancer risks in 680,000 young individuals who were exposed to CT scans in their childhood or adolescence (2). The cohort concluded that those exposed to CT scans in childhood or adolescence have a 24% increased risk of developing cancer in comparison to those not exposed to CT scans and that the cumulative effect of the rate of use of CT scans during childhood can significantly elevate the lifetime attributable risk of cancer as each additional CT scan increases the risk by 16% (2). The risks for a variety of cancers, with the highest risks for brain tumors and leukemia, which are more common in younger populations (2).

Similarly, a landmark retrospective cohort study by Pearce et al. [2012] analyzed the data of 178,604 pediatric patients undergoing CT scans and estimating the cumulative radiation doses and associated cancer risks finding that they are at an increased risk of developing both leukemia and brain tumors (3). Higher doses of radiation increased the malignancy risk as a cumulative dose of about 50 mGy, 60 mGy had three times the risk for leukemia and brain tumor respectively with the risks persisting for years after the exposure (3). The study found that the excess relative risk (ERR) of developing cancer was highest among children younger than five years old, emphasizing the need for extra caution for this age group (3).

Another example, Hauptmann et al. [2022] in the EPI-CT cohort study where he assessed the correlation between radiation dose from CT scans in pediatrics and young adults and the potential to develop long term health risks especially cancer (13). The study concluded that with each additional mGy of radiation absorbed by sensitive tissues. The ERR for brain tumors and leukemia rises so the greater number of CT done or the higher the radiation dose, the higher the risk of developing brain tumors and leukemia (13).

These findings highlight the importance of weighing the risks and benefits of CT imaging in pediatric patients ensuring that imaging studies are justified based on clinical indications reducing unnecessary radiation exposure in pediatric patients while (2,3,13) (Table 2).

Low-dose CT protocols: reducing risk without compromising care

By 2017, more than 6 million CT scans were performed in hospitals throughout the UK making a notable and extensive rise in their use (13). The global increase in CT scans for pediatric patients and awareness and concerns about the hazards of ionizing radiation have heightened the demand for reducing radiation doses (5,8).

While the long-term risk from a single CT scan (1–12 mSv) is uncertain, Repeated CT scans pose a particular risk to children, who are more sensitive to radiation’s carcinogenic effects and have longer lifespans than adults (5,9). Hence, guidelines like As Low as Reasonably Achievable (ALARA) and the Image Gently Campaign aim to minimize these risks (5,10).

The Image Gently Campaign offers tools to reduce radiation by following four simple steps (10):

• Decrease or “child-size” the radiation dosage.
• Conduct scans only when essential.
• Limit the scan area to the indicated region.
• opt for single-phase scanning; multiphase scans are typically unnecessary in children (5).

Over the past decade, advancements in technology and various strategies have successfully reduced the radiation doses in CT scans, allowing for low-dose and even ultra-low-dose CT imaging (5,10).

CT scanners have parameters that affect the dose received by the patients and the image quality (6,14). Zacharias et al. [2013] have highlighted the importance of managing radiation dose by adjusting key scan parameters such as kVp, mAs, and pitch (6). The kVp is the tube voltage that controls the energy of the beam. For instance, lowering kVp, which controls the energy of the X-ray beam, can significantly reduce radiation dose, although it may also increase image noise (6,14). The mA or mAs is the tube current in milliamperes and the exposure time in seconds dictating the number of x rays produced. Conversely, adjusting mAs affects radiation dose linearly: higher mAs result in a higher dose and vice versa (6,14). The pitch is the table distance per one 360° gantry rotation divided by the beam width. It inversely correlates with radiation dose the higher the pitch, the lesser the scan time and the dose (6,14). Other critical considerations include collimation (section thickness), which determines the width of the X-ray beam, and patient positioning within the gantry. Narrower collimated beams and placing the patient centrally in the gantry help minimize unnecessary radiation exposure (6). Furthermore, restricting the scan length to the area of interest and adjusting the orientation of the scout scan also contributes to dose reduction strategies (6).

Additionally, there are also the concepts of diagnostic reference levels (DRLs) and achievable dose (AD). They are set at the 75^th and 50^th percentile of dose distribution respectively where DRLs are mainly the benchmarks for the doses that shouldn’t be exceeded during standard procedures having a regulatory role to prevent excessive exposure and AD aim to improve the guidelines followed by facilities improving imaging practices and aiming at lower doses without compromising the imaging outcomes (14-16).

Bhargavan-Chatfield et al. [2013] in The ACR Computed Tomography Dose Index Registry reported the need for establishing DRLs due to the variability in radiation doses across facilities collecting a comprehensive data on the pediatric population and reporting benchmark for CT examinations (16). The Computed Tomography Dose Index volume (CTDLvol) measures the radiation dose output in a standardized way, accounting for variations in scan length and patient size (16). The outcomes for CTDLvol for head CT without contrast, chest CT without contrast and abdomen and pelvis CT without contrast were 45–60, 5–12 and 10–25 mGy respectively (16). The study also highlighted the need for variant doses for variant age groups as smaller children or infants might have lower doses than older children or adolescences (16).

The European EPI-CT cohort studies study also stressed on the importance of dose optimization by adapting CT imaging advanced technique by adjusting scan parameters based on patient size and diagnostic needs and Shielding Sensitive Organs like shielding the thyroid and reproductive organs limiting radiation exposure to non-target tissues ensuring the lowest possible radiation dose for an effective scan (13). It also gives an insight to ethical consideration that each CT scan should be justified, and parental informed consent should be obtained with long term follow up of the children who were exposed to multiple scan or large radiation doses for any potential long-term risk (13).

In Kanal et al. [2021], they collected data from various hospitals across the united state regarding different pediatric age groups infants (0–1 year), children (5–10 years), and adolescents (14–18 years) to establish DRLs and ADs for pediatric CT examinations for 10 different regions (15). ADs are consistently 20–30% lower than the DRLs, demonstrating the possibility of reducing radiation exposure with optimization. Head CT has the highest radiation doses in comparison to chest and abdomen/pelvis CT doses whose doses are generally lower as it requires more details (15). The median volume CT dose index (CTDIvol) DRLs for head CT without contrast for pediatrics depending on their age and size ranged from 23 to 55 mGy. The CTDIvol DRLs for abdomen and pelvis with contrast CT examination for age-based pediatric populations and for size-based pediatric populations ranged from 2.4 to 11 mGy and 2.7 to 26 mGy respectively (15).

Similarly, a study on pediatric single-photon emission computed tomography/CT (SPECT/CT) imaging demonstrates the feasibility of significantly reducing radiation doses without compromising detector signal quality. Optimizing scanning parameters such as adjusting voltage and current can result in substantial dose reductions for children, especially those with smaller body sizes. For instance, infants under 150 mm in diameter can be imaged using the lowest settings of 120 kV and 1 mA, yielding a dose reduction from 7.23 to 2.01 mGy. These findings emphasize the importance of dose modulation and parameter optimization to enhance safety and efficacy in pediatric imaging, underscoring the potential for manufacturers to improve SPECT/CT systems with adjustable settings tailored to patient size (17).

Another study highlighted that automatic tube current modulation (ATCM) could significantly reduce CT dose by adjusting the tube current in real time based on the patient’s size and density. ATCM tailors the radiation dose to the individual patient, ensuring adequate image quality while minimizing exposure. This technique effectively balances diagnostic needs with radiation safety. Data from their research indicated that the median values of tube current and CTDIvol increased from the youngest to the oldest age groups. For the baseline data, the median tube current ranged from 150 to 266 mAs, representing a 1.8-fold increase, while CTDIvol rose from 7 to 20 mGy, a 3-fold increase, across age groups. In the follow-up data, these parameters showed less variation, with tube current ranging from 128 to 165 mAs (a 1.3-fold increase) and CTDIvol from 4.4 to 7 mGy (a 1.6-fold increase) (17,18).

Joyce et al. [2020] also discussed developments such as ATCM, adaptive section collimation, and organ-based dose modulation, which have significantly reduced radiation doses (4). ATCM adjusts current based on body size, reducing doses by up to 31% for abdominal imaging, while adaptive collimation reduces radiation by up to 38% for young children (4).

Moreover, recent innovations in CT technology have introduced commercial iterative reconstruction (IR) techniques, such as adaptive statistical iterative reconstruction (ASIR) and model-based iterative reconstruction (MBIR), showing promise in enhancing image quality from low-dose scans (5,7). Unlike traditional filtered back projection (FBP), which can produce images with significant noise, ASIR and MBIR iteratively refine image quality by incorporating raw data and image space, resulting in higher-quality images with reduced noise (5,7). ASIR allows for a 40–50% reduction in CT dose, while MBIR offers even further dose reduction with preserved image quality. MBIR shows promise for pediatric chest CT, where minimizing cumulative radiation exposure is crucial (5,7). Initial experiences with ultra-low-dose chest CT using MBIR have shown acceptable image quality, expanding its application for various clinical scenarios (5,7).

We can see that recent advancements in CT imaging have focused on reducing radiation exposure while maintaining diagnostic quality Using low-dose radiation in pediatric CT during emergencies is crucial for balancing the urgency of accurate diagnosis with the long-term safety of the child. By minimizing unnecessary radiation exposure, healthcare providers can reduce future health risks while obtaining critical information for timely, life-saving decisions (4,15,17,18).

Utilization of alternative imaging modalities

US and MRI are increasingly utilized as first-line imaging modalities in specific clinical scenarios, offering significant advantages and certain limitations. US, which avoids ionizing radiation, uses sound waves rather than ionizing radiation, making them a safer option, especially for vulnerable populations like children and pregnant women making it valuable in obstetrics, gynecology, and pediatric care, effectively diagnosing conditions like appendicitis, gallstones, and deep vein thrombosis (19). This lack of radiation exposure significantly reduces the long-term health risks associated with repeated imaging, such as increased cancer risk (19).

One of US’s greatest strengths is its ability to provide real-time imaging, allowing clinicians to assess organ function, blood flow, and movement immediately (19). This is especially valuable in procedures like central line placements or during trauma evaluations with a Focused Assessment with Sonography for Trauma (FAST) exam. Its real-time imaging capability is crucial in emergency settings, especially for pediatric abdominal pain and trauma, with studies showing high diagnostic accuracy (19).

Additionally, USs are more cost-effective and widely accessible, often available at the bedside, making them ideal for use in emergency and resource-limited settings. Although CT scans offer higher resolution and better visualization of bone and air-filled structures, the portability, safety, and dynamic capabilities of US make it a worthy alternative (19).

MRI provides superior soft tissue contrast and detailed imaging of the brain, spinal cord, joints, and internal organs, making it ideal for diagnosing neurological conditions, musculoskeletal injuries, and certain cancers without ionizing radiation (19,20). In pediatric emergencies, MRI is effective in detecting clinically important traumatic brain injuries (ci-TBI), offering a safer alternative to CT scans. Notably, studies have demonstrated the effectiveness of MRI in accurately diagnosing ci-TBI in pediatric patients, potentially avoiding unnecessary radiation exposure (19,20). Additionally, MRI excels in visualizing areas where fine anatomical details are essential, such as the nervous system or joint structures, where CT might be less detailed. It can provide clearer images in multiple planes (sagittal, coronal, axial) without needing to reposition the patient. However, the US is highly operator-dependent, and certain conditions may require complementary imaging techniques for definitive diagnosis (19,20).

MRI, while offering excellent image quality, is expensive, time-consuming, and often necessitates sedation for young children, introducing risks such as respiratory complications and neurological effects. Additionally, MRI’s use of gadolinium-based contrast agents poses risks for patients with renal impairment. Furthermore, interpreting MRI results in pediatric patients, need radiologists to be aware of age-related variations in anatomy and pathology which can be challenging (9,19,20).

Despite these limitations, the benefits of avoiding ionizing radiation, particularly in pediatric patients, make US and MRI valuable alternatives. Evidence supports their efficacy and safety, with US’s point-of-care applications reducing unnecessary CT scans and MRI providing critical diagnostic information in neurological assessments (19,20). Careful selection and appropriate application of these modalities, considering clinical scenarios and patient-specific factors, can enhance diagnostic accuracy and patient safety. Thus, while traditional radiographic methods remain essential, the judicious use of US and MRI offers a balanced approach to medical imaging, prioritizing patient safety and diagnostic effectiveness (19,20).

Risks and benefits of CT scan radiation in pediatric emergency care

Pediatric CT scans play a critical role in modern emergency medical care, offering significant benefits for diagnosing and managing complex medical conditions (21-24). However, the use of CT scans in children also raises concerns about radiation exposure and associated risks. Pediatric CT scans provide detailed cross-sectional images that enable healthcare professionals to identify and assess various medical conditions with high precision (21-24). This accuracy is particularly crucial in emergencies and complex cases, allowing for prompt and effective medical intervention (21-24). In emergency settings, where timely diagnosis is essential, CT scans offer rapid imaging results. This enables healthcare providers to make quick and informed treatment decisions, which can be lifesaving in critical situations. CT scans are invaluable for evaluating pediatric intracranial hemorrhage, trauma, and abdominal injuries in emergent conditions (21-24).

The detailed images help in planning appropriate treatment strategies and surgical interventions, thereby improving patient outcomes (17,25). For children with chronic or progressive conditions, CT scans are used to monitor disease progression and evaluate treatment effectiveness over time (16,25). This ongoing assessment is crucial for adjusting treatment plans to meet the changing needs of pediatric patients. Regular imaging allows for the adjustment of treatment plans based on the child’s evolving medical needs (22,25).

Children are more sensitive to radiation than adults, making them more vulnerable to the potential risks of radiation exposure, such as the increased risk of developing cancer later in life. It is imperative for healthcare providers to carefully consider the necessity of each scan and to implement measures to minimize radiation exposure. It is better to use the lowest possible radiation dose that achieves the necessary diagnostic quality (23,24).

Some pediatric CT scans require sedation or general anesthesia to ensure that the child remains still during the procedure. While these measures are necessary to obtain clear images, they carry inherent risks, including potential adverse reactions to anesthesia (23). It is crucial to carefully evaluate the need for sedation or anesthesia based on the child’s age, condition, and the complexity of the scan. It is better to ensure continuous monitoring of the child during and after the procedure to promptly address any adverse reactions (23). Pediatric CT scans offer significant benefits in emergency medical care, providing accurate and rapid diagnosis, aiding in the evaluation of complex conditions, and monitoring disease progression. However, the risks associated with radiation exposure and sedation must be carefully managed (23). Advances in radiation risk estimation methodologies—such as Monte Carlo simulations, IR techniques, personalized risk profiling, size-specific dose estimations, and the use of Bayesian risk models and machine learning to provide accurate dose estimates and risk indices—offer a more nuanced understanding of the potential risks. These developments help balance the benefits and risks of CT scans, particularly in pediatric patients (8,21,26-29).

A Risk Index is a quantitative measure used to assess the potential health hazards associated with exposure to ionizing radiation. It integrates several factors to estimate the likelihood or severity of adverse health effects, such as cancer or tissue damage, resulting from such exposure. The key components of a radiation risk index typically include the radiation dose, type of radiation, exposure duration, and frequency (21,30). The ongoing efforts to optimize CT protocols and minimize radiation exposure are essential to ensure the safe and effective use of this diagnostic tool in pediatric emergency care, as shown in Figure 1. It is crucial to employ personalized risk estimates for a more accurate representation of the radiation burden and potential risks (29). Furthermore, the use of advanced simulation techniques to estimate organ-specific doses and normalize effective doses by dose-length product (DLP) can lead to the development of comprehensive risk assessment tools (29).

Figure 1 Flowchart showing how to avoid and reduce CT scans in pediatric population and illustrating the process of ordering imaging in the PED. MRI, magnetic resonance imaging; CT, computed tomography; PED, Pediatric Emergency Department.

Navigating the risks and benefits of pediatric CT scans involves a careful balance between the immediate need for rapid, accurate diagnosis and the long-term risks of radiation exposure. By justifying and optimizing the use of CT scans, exploring alternative imaging methods, and employing advanced risk estimation techniques, healthcare providers can minimize potential risks while maximizing the benefits. Continuous advancements in imaging technology and risk assessment methodologies will further enhance the safe and effective use of CT scans in pediatric emergency care (23,31).

Quality Improvement and Initiative: Driving Change in Pediatric Emergency Care Managing the balance between diagnostic image quality and radiation dose reduction in CT imaging is inherently challenging. Achieving dose reductions often compromises image quality (32-35). This balance is particularly complex in pediatric populations due to the wide range of variables, including body habitus, body and lesion sizes, and baseline tissue separation, which varies from soft-tissue structures with minimal intervening fat to structures separated by well-defined fat planes (32-35). During the era of FBP reconstruction, reducing the dose while maintaining image quality was difficult. However, modern CT reconstruction techniques, such as statistical-based iterative reconstruction (SBIR) and MBIR, primarily focus on reducing quantum noise. This improvement enhances signal-to-noise and contrast-to-noise ratios, thereby aiding in dose reduction without compromising image quality (32-35). Additionally, some SBIR and MBIR algorithms demonstrate improved spatial resolution. However, these algorithms may alter the image noise properties in the reconstructed image, limiting their clinical adoption. Furthermore, MBIR algorithms have not fully replaced SBIR algorithms, due to lengthy reconstruction times and changes in noise texture that reduce radiologist confidence in the images (35-37).

Recent advances in artificial intelligence have led to investigations into the use of deep learning reconstruction (DLR) for CT imaging. These studies have shown potential for improved image quality and dose reduction, without causing detrimental changes in noise texture. The purpose of this study was to compare a new DLR algorithm with existing FBP, SBIR, and MBIR algorithms in a pediatric patient sample. To achieve this, they used a mathematical observer model to minimize bias and provide an objective assessment of image quality, although this model is limited to a simple metric of object detectability. To reflect the complexities of clinical practice more accurately, real observers performed subjective image quality assessments related to clinical diagnostic tasks (38-45) (Table 3, Figure 1).

Challenges and opportunities in developing countries

Given the increased adoption of CT among the pediatric population in developing countries (28), minimizing CT scan radiation exposure in PED is a critical issue. Although developing countries often lack the infrastructure found in more developed regions, addressing this issue is still essential because children in these areas are particularly vulnerable to higher radiation exposure due to outdated technology and lack of safety protocols (48,49).

Developing countries have unique challenges that complicate the implementation of effective radiation safety measures. These challenges are multifaceted, involving technological, educational, regulatory, and socio-economic factors. A significant challenge is the reliance on outdated CT scan machines, which emit higher levels of radiation compared to newer models with dose-reduction technologies. The use of newer models of radiology equipment is one of the keyways’ developed nations have used to reduce radiation from CT scans (48,49). Yet many healthcare facilities in developing countries rely on outdated CT scan machines, which typically emit higher levels of radiation compared to newer models equipped with dose-reduction technologies (22). Additionally, many healthcare facilities in developing countries also lack pediatric-specific equipment, and adult CT scanners, which lack pediatric protocols, are often used, leading to unnecessarily high radiation doses (50). This issue is exacerbated by financial constraints that prevent the acquisition of newer, safer imaging technology and the implementation of protocols designed to reduce radiation exposure. Insufficient training and awareness among medical professionals, especially pediatricians, further complicates the situation (51,52).

Studies have shown that in many centers, adult CT exposure parameters are still used for children, increasing the radiation burden unnecessarily (51). For example, a study in Saudi Arabia revealed that pediatricians underestimated the risks associated with radiation exposure in children (52). Training initiatives aimed at optimizing CT dose radiation for pediatric patients can make a substantial impact even without immediate access to newer equipment. Resource constraints are a pervasive issue. Financial limitations restrict not only the purchase of advanced equipment but also the ability to hire and retain adequately trained radiologists and technicians (51,52).

Cultural and socio-economic factors also play a role. There is often limited parental awareness of the risks associated with radiation from CT scans, and disparities in healthcare access can result in delayed medical presentations (53). This delay can lead to the progression of more severe conditions, such as traumatic brain injury, acute appendicitis, or non-accidental trauma, that necessitate the use of CT scans for rapid assessment and intervention (54). In these critical cases, CT imaging provides a quick and accurate diagnosis, which is essential for guiding lifesaving treatments. Although radiation exposure is a concern, the immediate need for precise imaging to manage potentially life-threatening conditions often justifies the use of CT, especially when weighed against the risk of clinical deterioration due to delayed intervention (55).

Despite the peculiar challenges faced by developing countries in minimizing CT scan radiation exposure in PED, there are numerous opportunities for collaboration and capacity-building initiatives aimed at improving radiation safety and access to appropriate imaging modalities. Initiatives and partnerships have demonstrated success in enhancing radiation safety and access to imaging in developing countries. Several initiatives and partnerships have demonstrated success in enhancing radiation safety and access to imaging in developing countries (53-55).

The World Health Organization (WHO) has been instrumental in these efforts. In 2019, the WHO organized a consultative meeting to address medical imaging in developing countries, resulting in a comprehensive report that highlighted the importance of strengthening health systems and enhancing the capacity of healthcare providers through training and education (54).

Another noteworthy example is the International Atomic Energy Agency (IAEA), which launched programs to improve radiation protection in medicine (55). The IAEA’s 2017 report emphasized the need for action to strengthen radiation protection measures and provided guidelines for implementing effective radiation safety protocols. In a study in Cameroon, training of personnel on optimization protocols contributed by the IAEA led to a reduction of doses in pediatric CT examination, even without the acquisition of new machines (50,55). These initiatives show that pediatric CT dose reduction can be realized in developing nations despite the financial hurdles that are harder to overcome (53-55).

Beyond technology, training and education to increase awareness are also cost-effective and sustainable solutions. For instance, use of clinical decision-making tools offers a crucial, low-cost strategy for reducing unnecessary CT scans. One such tool is the PECARN (Pediatric Emergency Care Applied Research Network) clinical decision rule and guidelines. It can be used to determine whether a child with minor head trauma needs a CT scan, identifying pediatric patients with low risk of ciTBI thus helping to avoid unnecessary scans while ensuring that those with severe injuries receive timely imaging (55). Implementing such guidelines, even in resource-limited settings, can significantly reduce radiation exposure while maintaining diagnostic accuracy relying more on clinical observation in emergency settings rather than immediate CT scan (56).

In conclusion, while challenges persist, the opportunities for improving radiation safety in pediatric imaging through collaboration and capacity-building are substantial. By leveraging successful initiatives, tailoring strategies to local contexts, and fostering a global commitment to radiation safety, we can protect the health and future of children in developing countries (53-56) (Table 4).

Future directions

Addressing pediatric CT use challenges requires a tailored approach involving infrastructure, education, and research investments. Collaborative efforts among health centers, government agencies, and international organizations are crucial for implementing sustainable solutions prioritizing patient safety. In developing countries, limited resources, outdated equipment, and reliance on adult protocols expose children to high radiation levels (59). Inadequate education and financial constraints further impede dose-reduction strategies (60).

Progressive adverse effects can be minimized by properly implementing pediatric CT protocols and reducing acquisition parameters according to age. Reducing scan lengths and choosing appropriate diagnostic criteria are vital (50). Wu et al. reported a 50% decrease in CT scan orders for pediatric trauma cases following a three-month evidence-based imaging education initiative (60).

Blumfield et al. showed a 62.7% decrease in abdominal CT phases per visit by highlighting the “As Low as Reasonably Achievable” (ALARA) principle and increasing abdominal US use (61). Programs like the IAEA and the Image Gently campaign promote radiation safety through education and alternative imaging methods (62). Although MRI risks, such as increased sedation time, should be considered, MRI may be preferable over CT in some situations (62,63).

Ongoing research and initiatives aim to provide guidelines, resources, and education to optimize radiation doses in pediatric imaging. Collaborative efforts and investments in training and technology are essential to prioritize pediatric health and welfare.

Conclusions

The utilization of CT scans in pediatric emergency medicine presents indispensable diagnostic benefits and inherent risks associated with radiation exposure. Several key strategies have emerged to mitigate these risks effectively.

Firstly, technical innovations, such as specifying an anatomical definition of the area to be scanned and configuring the CT machine for image quality, have proven beneficial. Additionally, using low-dose CT protocols and advancements in imaging technology, such as ASIR and MBIR, has shown promising results in reducing radiation doses while maintaining diagnostic accuracy. These approaches underscore the importance of balancing diagnostic needs with patient safety, adhering to principles like ALARA.

Secondly, interdepartmental cooperation between radiologists, pediatricians, and other physicians is crucial. This collaboration can help minimize or avoid exposure to ionizing radiation by utilizing alternative imaging modalities, such as US or MRI, particularly when ionizing radiation can be avoided altogether. These modalities eliminate radiation risks and provide valuable diagnostic information, enhancing patient care outcomes.

Furthermore, initiatives like the Image Gently Campaign and international collaborations by the IAEA and the WHO promote radiation safety awareness and optimize imaging practices globally. These efforts emphasize continuous education and training among healthcare providers to ensure the implementation of evidence-based practices in pediatric imaging. Studies show that applying these strategies does not compromise CT scan detection. Healthcare providers are called upon to prioritize radiation safety as a fundamental aspect of patient care. This proactive approach safeguards pediatric patients from potential long-term health risks associated with radiation and aligns with the overarching goal of improving healthcare outcomes through safe and effective diagnostic imaging practices.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-102/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-102/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-102/coif). I.B. is employed by Visavis Health. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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