American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Minimizing radiation exposure in children

OCTOBER 23, 2018
Clinical Congress Daily Highlights, Tuesday First Edition


Children are especially at risk of radiation exposure; the effects can include malformation or growth restriction, and may manifest later in life as cognitive deficits or cancer. To prevent these outcomes, surgeons are increasingly seeking ways to minimize the amount of ionizing radiation that children receive from diagnostic procedures such as computed tomography (CT). In 2010, the FDA launched an initiative to reduce unnecessary radiation exposure from medical imaging, and other programs such as the Image Gently Alliance are dedicated to improving the safety of pediatric imaging.

A Tuesday panel provided varying perspectives on the use of selective or whole-body CT scanning, Focused Assessment Sonography for Trauma (FAST), and on guidelines for the management of pediatric cervical and spinal cord injuries.

Kevin W. Sexton, MD, FACS, University of Arkansas for Medical Sciences, Little Rock, AR, made the case for use of whole-body CT, or pan-CT, showing data that it reduces mortality in adult patients. Pediatric studies, however, have found little difference in outcomes. More importantly, Dr. Sexton noted that the low cancer risk due to radiation may justify use of a pan-CT approach.

In contrast, Regan F. Williams, MD, FACS, University of Tennessee Health Science Center, Memphis, TN, argued for selective use of CT, highlighting that an abdominal CT is roughly the equivalent of 250 chest X-rays, and that radiation’s effects are cumulative. “So just because you see the kid at ten [years old] … at other time points it’s going to be someone else ordering the imaging, so we have to control what we can control, which is using this selectively.” She highlighted several studies that have developed rules for more selective use of CT.

The utility of the FAST approach as an alternative method to identify abdominal injury has been controversial. Eric R. Scaife, MD, chief, division of pediatric surgery, University of Utah Health, Salt Lake City, UT, presented a study that evaluated the ability of FAST to decrease use of CT. The data showed that the sensitivity of FAST remains limited and does not effectively decrease CT rate, with one study finding that the technique failed to identify 56 percent of patients who required an acute intervention. In addition, Dr. Scaife noted that appropriate training requires a significant time commitment from pediatric trauma surgeons.

Andrew F. Miller, MD, Boston Children’s Hospital, advocated for FAST, arguing that it can be helpful in certain subsets of patients and provides information beyond abdomen. However, he too stressed the importance of knowing the technique’s limitations and training requirements: “If you only perform the FAST examination on the most critically ill patients, it is unlikely to be useful given that you won’t be proficient in it. It does take quite a bit of practice.” 

To conclude the panel, Maya A. Babu, MD, director, adult neurotrauma, Massachusetts General Hospital, Boston , summarized clinical guidelines for the management of pediatric cervical and spinal cord injuries. While the data are still emerging, some studies show that although minimizing radiation exposure is essential, high-resolution CT could allow for earlier cervical spine clearance where MRI is not available or in situations when the patient’s clinical stability precludes obtaining an MRI.

Additional Information:

The panel session, Imaging the Injured Child: Who, When and How?, was held October 23, at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast and audio information is available at facs.org/clincon2018.


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