Role of Pediatric Health Care Professionals in Radiation Risk

PEDIATRIC HEALTH CARE PROFESSIONALS HAVE AN IMPORTANT ROLE IN THE USE OF CT ON CHILDREN.¹⁰ THE HEALTH CARE PROFESSIONAL ULTIMATELY DECIDES WHETHER A CT EXAMINATION IS NECESSARY. WITH THIS IMPORTANT ROLE COMES A RESPONSIBILITY TO RECOGNIZE BOTH THE VALUE OF CT AND ITS RISKS, WHICH, AS DESCRIBED PREVIOUSLY, IT IS REASONABLE TO ASSUME ARE VERY SMALL BUT REAL. THE HEALTH CARE PROFESSIONAL SHOULD ALSO BE ABLE TO DISCUSS THESE RISKS IN A MANNER THAT IS INFORMATIVE AND UNDERSTANDABLE TO PATIENTS AND FAMILIES. ONE MUST RECOGNIZE THAT THE DECISION REGARDING A CT EXAMINATION WILL OFTEN DEPEND ON THE COMBINATION OF THE INTERACTION WITH CONSULTANTS, SUCH AS RADIOLOGISTS, AND THE FAMILY. THERE IS A VAST POOL OF INFORMATION AVAILABLE ON THE INTERNET, MUCH OF WHICH MAY BE CONFUSING WITH RESPECT TO CT, RADIATION, AND CANCER. THE PEDIATRIC HEALTH CARE PROFESSIONAL SHOULD BE IN A POSITION TO BE ABLE TO ANSWER QUESTIONS AND ADDRESS CONCERNS.

The pediatric health care professional is usually the first, and often the only, source of direct communication with the child and the family. This relationship carries with it an opportunity to inform and educate the family. Recent reviews that covered CT technology and its role in the imaging armamentarium^11,12 are salient for pediatric health care professionals. CT has an increasingly recognized role as the first, if not only, imaging examination for a wide variety of disorders that affect infants and children. What is most important to realize is that the use of CT is not infrequent in children and that the frequency of CT examinations is increasing. A recent review summarized investigations indicating that CT use has increased substantially over the last 1 to 2 decades, including estimates of at least 10% growth per year.¹³Currently, approximately 11% of CT examinations are performed on children,⁴which could account for more than 7 million pediatric CT examinations per year in the United States.^13,14 The use of CT for common problems such as trauma (closed head injury, skeletal evaluation including cervical spine assessment, and blunt abdominal trauma), appendicitis, and renal calculi has increased the frequency of CT examinations in adult and pediatric populations. Most clinicians believe that CT studies on children prevent hospitalization for head injuries and that negative findings in patients with acute onset of abdominal pain can obviate surgical explorations. These studies provide information that leads to earlier and more definitive diagnosis.

This increased use, however, must be based on a firm understanding that the CT study is the best study for the clinical situation being evaluated and that the possibility of a very small risk of cancer is considered when making the decision to order the study. The possible cancer risk is not clearly understood by many health care professionals, as concluded by 2 recent investigations. In the first investigation, Lee et al¹⁵ surveyed emergency department patients, physicians, and radiologists. The results indicated that only 7% of patients indicated that there was any discussion outlining the radiation risks and benefits from an abdominal CT examination. In addition, only 9% of emergency department physicians believed that the lifetime risk of cancer was potentially increased by CT scanning. Moreover, 75% of physicians surveyed underestimated the accurate range for the equivalent number of chest radiographs for a CT examination (Table 1). In another recent investigation, Jacob et al¹⁶ surveyed physicians in the United Kingdom and found that only 12.5% were aware of the potential association of CT radiation and cancer. Less than 20% correctly identified the relative radiation dose of CT examinations.¹⁶These studies support a continued and compelling need for radiation safety education for health care professionals and the public.

The pediatric health care professional should also be able to provide summary information to families on local practice patterns of radiology colleagues. It is reasonable to have information immediately available from the radiology practice in addition to that stated above. This information should include:

• additional expertise of the practice (pediatric radiology fellowship training, American Board of Radiology Certificate of Added Qualification, and current Maintenance of Certification in pediatric radiology);
• appropriate pediatric head and body CT protocols consisting of size- or age-based adjustments in scanner settings; and
• American College of Radiology accreditation of the CT scanners and the radiologists who interpret those studies in the practice.

An important role of the pediatric health care professional is to communicate with the radiologist to decide whether CT is the best study to perform. This consultation will vary from practice to practice, but it should be the goal of both parties to facilitate discussions on imaging strategies. These discussions provide an opportunity to share information, such as the number of studies using ionizing radiation to which the patient has been exposed. In addition to the pediatric health care professionals and radiologists, the integration of other care providers, such as surgical consultants or emergency department physicians, in decisions regarding pediatric CT policy or practice should also be fostered. Other imaging techniques such as ultrasonography or MRI may be suitable alternatives to CT examination, and they do not use ionizing radiation. If the CT examination is indicated and the radiology department uses a low-dose technique, another way to reduce CT dose is to limit the number of times (or phases) the child is scanned for the individual examination. It is very common for adult CT protocols to involve multiple scans through the same body part, which can double or triple the radiation dose to the patient. For most indications for pediatric CT scans, a single pass through the body part of interest is usually sufficient for diagnostic purposes.