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BACKGROUND

The purpose of this chapter is to familiarize hospitalists with common pediatric imaging examinations so that they can order the most appropriate test for the patient and be able to properly inform and prepare the patient and family before the study. The techniques, indications, and patient preparation for common pediatric imaging examinations are described here.

Given the wide array of choices, it is sometimes difficult for clinicians to determine the best exam for a particular clinical situation. Discussion with a radiologist regarding available options is strongly encouraged. Many common clinical scenarios are addressed in the American College of Radiology Appropriateness Criteria, a regularly updated, evidence-based internet resource designed to assist clinicians in choosing the best test to answer their clinical question.

Following a discussion of radiation safety and contrast agents (for non-nuclear medicine studies), the chapter is divided into imaging studies that require ionizing radiation (conventional radiographs, fluoroscopy, computed tomography [CT], and nuclear medicine examinations) and those that do not (ultrasound [US] and magnetic resonance imaging [MRI]). Vascular and nonvascular interventional procedures are described at the end of the chapter.

With the exception of some interventional procedures, parents may remain with their child when any of these examinations are performed. Pregnant mothers and siblings under the age of 18 will be asked to wait in a separate area for studies utilizing radiation. Ionizing radiation exposure in the fetus is known to cause miscarriages and malformations and carries a small but real risk for the development of childhood cancers.1 Parents and other personnel who remain in the same room during x-ray or CT examinations must wear lead shielding for protection. For patients who are pregnant, studies with ionizing radiation are contraindicated unless the medical need (such as a ventilation-perfusion [V/Q] scan in a patient at high risk for pulmonary embolis) outweighs the medical risk. MRI is avoided in early pregnancy but has increasing utility for fetal assessment later in pregnancy.

RADIATION SAFETY

Whenever considering a radiographic examination for any patient, one must be cognizant of the amount of radiation that the patient will receive, especially if the patient has a chronic condition. The guiding principle behind radiation protection is that radiation exposures should be kept “as low as reasonably achievable (ALARA).” This principle must be especially adhered to in children because for the same dose, children are more susceptible to radiation effects than adults.2 As knowledge of the risks of medical radiation has grown in recent years, radiologists have responded by lowering the doses of common medical tests. Referring physicians have also responded by ordering fewer tests with ionizing radiation.

The clinician may find himself or herself confronted by a concerned parent regarding the necessity of a test that uses ionizing radiation. Table 185-1 provides a real-world reference for clinicians and parents when discussing these risks. While appropriate indications for evaluation of a ...

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