After I saw reports of the 5-fold increase in CT scans in children, I asked for “The Husband’s” take. I worry about a rise in the use of pediatric CT scans in the US because when a child gets scanned, they are being exposed to radiation. A CT scan is a series of x-rays taken in quick succession that form a more composite view of the body. Although x-rays and CT scans save lives and improve diagnosis, the radiation given to children when obtaining these studies must be minimized. Children are more sensitive to radiation than adults; their bodies are still developing. And as the Society for Pediatric Radiology reminds, “What we do now lasts their lifetimes.” Here’s a post about why it may matter where your child gets a CT scan by Dr. Jonathan Swanson:

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Pardon the interruption…I’m chiming in again on a similar topic as my last guest post (I am kind of a one trick pony) – radiation exposure in children. SMD has asked me to talk about a recent radiology-based study and what it might mean for how we take care of our children.  My take:

If it were my child, and F or O needed to go to an emergency room, I would go to the nearest children’s hospital…to spare my children unnecessarily high radiation exposure. Bias alert, I am a pediatric radiologist working at a children’s hospital. However, I think the literature supports my position.

Recently, David Larson and his colleagues published a paper in the journal Radiology that confirmed a trend that those of us in the pediatric world have long suspected – the use of computed tomography, or CT scans, in children who visit the ER has increased substantially over the last 10 to 15 years.  According to their research, from 1995 to 2008, the number of pediatric ED visits that included CT examination increased from 330,000 to 1.65 million, a fivefold increase. In other words, if your child were to go to the ER today, he/she would be five times more likely to have a CT than if he/she were to be ill back in 1995. Amazing. The older generation of doctors are groaning somewhere, mumbling “whatever happened to the physical exam.”

What I find fascinating is that, according to this study, 90% of these emergent CT scans occur at adult-focused hospitals and only 10% occur in children’s hospitals. Really? Sure, children’s hospitals are not ubiquitous, but I would have thought that more than 10% of families have relatively easy access to a children’s hospital. Maybe I am wrong, but my guess is that some of those families that ended up at a community hospital had a choice of a children’s hospital, and, for whatever reason– proximity, ER wait time, advertisement – they chose the community hospital.

According to this study, both the adult-focused hospitals and the children’s hospitals showed a similar alarming rate in the increased use of CT scans. So choosing a children’s hospital may not avoid the CT scan. But this paper suggests, and I agree, that going to an adult-focused hospital when your child needs a CT scan may expose your children to a higher dose of radiation.

Dose of Pediatric CT Varies Between Hospitals:

  • Dr Larson writes, “Adult-focused facilities may have many competing priorities; focus on pediatric CT may be hard to achieve because of the relatively small volume that pediatric CT represents at such institutions.”
  • Larson cites a 2001 study (Paterson et al) of mostly community-based hospitals that found that CT radiation doses were not typically adjusted for children’s smaller body size. In other words, even though lower dose CT scans on children can provide equal quality images as full dose scans on adults, community hospitals did not tend to make the adjustment to the lower dose.
  • On the flip side, another study found that CT protocols and scans supervised by pediatric radiologists are routinely adjusted to an appropriate dose for children.
  • Even if a pediatric radiologist is in the radiology group at an adult-focused community hospital, it is unlikely, if not impossible for that individual to be involved in all of the pediatric scans.

Why children may get a higher dose at an adult-focused hospital:

  • Pediatric hospitals are more comfortable with alternative, lower dose approaches to common diagnoses. Take appendicitis, for example. At a children’s hospital, the first line of imaging for appendicitis is abdominal ultrasound. Ionizing radiation in an ultrasound is zero. In an adult-focused hospital, CT is often the first imaging tool. The reasons is that it can be very difficult to visualize the appendix by ultrasound in young children. If an ultrasound technologist isn’t accustomed to working with children, CT may be a more reliable choice.
  • When adult-focused facilities take care of children, there can be a level of discomfort. Kids are the exception in the ER department, not the rule. From my experience as a radiologist, when physicians are uncomfortable, they tend to order more tests or order a test that will give them the most information, some of which may be more than they need to make the diagnosis. In the world of radiology, this can translate into a higher-than-necessary-dose of CT because higher dose can translate into sharper images. We radiologists like our sharper images. The problem is that sharper images don’t always translate into improved diagnostic accuracy.

If you don’t have a children’s hospital nearby, then I recommend that you read my earlier post on how best to inform yourself, your doctor, and your local radiology department about reducing the radiation to which your child is exposed. The Image Gently site is mentioned in my prior post and remains an excellent toolkit for working with your community hospital to lower the pediatric CT dose.

We pediatric radiologists need to continue to work with community hospitals to help remove barriers to decreasing the dose for children. We also need to work with manufacturers of CT scanners to make it near impossible to scan a child with an adult-dose of radiation. So, back to work…