Issue 2 Autumn 2010
APR News & Views
Association of Paediatric Radiographers
Individual
Highlights:
What is APR
1
RCR meeting
2
APR Study Day
2
Bristol Study Day Report
3
New committee member
4
Chest & Abdos on SCBU
5
Practice standards
6
Agenda for Change
6
• Meetings
• Your Committee
• Best Practice
 Reports
 Innovations in practice
Superheros For Sick Children
Medikidz, the world’s first multimedia medical education publishing
company for children was launched at Evelina Children’s Hospital on
Wednesday 16th September. Founded by two doctors – Kim Chilman-Blair
and Kate Hersov, Medikidz aims to give young people access to child
friendly information about their illness and treatment.
After working in paediatrics, the doctors became frustrated that there
was very little available to help educate young people about their
conditions and medicines.
Medikidz will be a one stop destination to explain often complex
information in an entertaining, exciting and novel way. It will introduce
young people and their parents to the Medikidz gang of five superheroes
and educate through a wide range of media. These will include comic
books, pamphlets, brochures and an interactive website consisting of a
virtual world of the human body, a child friendly medical encyclopaedia
and an integrated global social network to enable children to connect
and discuss their illness.
With 350 million 5-15 year olds diagnosed with a childhood illness every
year in the top seven English speaking countries, the founders saw a
gaping need for support. They have identified 300 conditions they want
to explain through the comic book approach and this week will launch
the first ten titles on the website. These include Type 1 Diabetes,
Epilepsy and Leukaemia with further titles available later in the year.
Children’s Workforce Development Council refreshes common core
of skills and knowledge
The refreshed common core is available at www.cwdcouncil.org.uk/common-core, detailing
the six areas of expertise required by everyone working in the children and young people’s
workforce: effective communication and engagement with children, young people and
families; child and young person development; safeguarding and promoting the welfare of
the child or young person; supporting transitions; multi-agency and integrated working and
information sharing.
Page 2 Autumn 2010
Incubator trays or directly under the babe??
Our neonatal unit has just replaced their incubators
with new ones -Drager Incubators Isolette 8000and the unit has asked us to use the x-ray trays on
the incubator rather than our current practice of
having the plate directly under the baby. I was
wondering what other hospitals do and what they
find are the pros and cons of whichever method.
Obviously we don’t want to disturb the baby if
possible but are there artefact problems, an
increase in dose, image quality issues or anything
else if using the tray.
We are a DGH and have a rotating rota and shift
system so a large pool of radiographers perform
these examinations. Any advice or information
from others in the same position would be helpful
and very welcome.
Rosie Langridge
We were asked to use the tray but gave the
attached reasons against using it We were
prepared to work with Radiation Physics to look at
the dose but it didn't come to that, would have
been an interesting project though.
Also the abstract: Imaging the neonate in the
incubator: an investigation of the technical,
radiological and nursing issues. Mutch SJ,
Wentworth SD demonstrates the dose absorption of
the mattress when using the incubator tray.
Sheila Cameron
Hi Liz
I just wanted to feedback how helpful it has been
being a member of the APR, and how the newsletter
and the various emails have helped me improve our
practice at The Royal United Hospital Bath. There is so
much negative at the moment.
From an article in the newsletter ,and a lot of time
and energy we have been able to reduce the dose for
our neonates,( fortunately we have a very good
medical physics team who are very supportive) and
this has been recognized in the RUH quality
accounts(see attached).
From the e-mail about the use of the incubator trays
,which came at the same time as we were being asked
to use them, we did some testing, and in our case with
our equipment, it wasn't a good idea.(see attached)
My next project is to try and reduce dose to all
children receiving plain x-rays ,do any of your
members have any top tips/ideas they could share
with me?
Keep up the good work the APR do.
Kind Regards
Cheryl Makepeace Specialist Radiographer
Royal United Hospital Bath
We have been using the trays on Neocribs since the middle
of the 1990's and did have serious doubts about them.
However in practice we have not increase our exposure to
compensate for them, the babies are normally very sick or
post cardiac/hepatic surgery and the intensivists are
adamant that minimal handling is used especially when they
are oscillated or nursed with their chest/abdomen open
(sternum not wired and chest/abdomen just dressed post
cardiac or liver surgery). The children are also not dressed
except for a thin item of clothing hence can be imaged
with minimal/no disturbance.
The images are slightly magnified however this is
compensated by standardisation of technique ffd/film size
and it can be tricky to image the lower abdomen due to the
overhead heater but this would also be the case with the
film placed directly under the patient. The downside is the
tray can act as a bin for needles blood etc but
with the hygiene of our unit this is not an issue - we have
more of a problem with hidden apnoea mattresses. We
image directly under the limbs and skull for portable
skeletal surveys but the children undergo significant
handling for this examination. We use kVs of 70 even for
premature babies and drop the mAs to the limit of the
machine.
We tried incubators with trays but the ones on trial had
no room to move the plate laterally or sup/inferiorly hence
the Trust did not purchase them.
Our radiographers prefer the trays but please feel free
to discuss if you want any more information.
Kate Parkes
In Edinburgh Sick Kids and Edinburgh Royal Infirmary the xray cassettes are placed directly below the patient.
Regards
Freya Johnson
Specialist Radiographer
RHSC
It does appear that there is a wide range of opinions and
practice around the country.
It would also be interesting to see if the some of the
reasons have to do with your imaging system DR or CR etc.
Any other advice or information would be appreciated.
Many thanks again
Rosie
If anyone has useful information and or has
carried out recent dosimetry using these trays
perhaps you could also forward it to me for
inclusion in our Newsletter.
Page 3 Autumn 2010
Report on potential use of incubator x-ray trays in NICU
Summary The use of incubator trays for performing x-rays in NICU provides the opportunity for reduced disturbance of
the neonate, and improved infection control. However, the following radiological concerns should be noted:


radiation doses may doubled, or image quality may be adversely affected due to reduced cassette doses
alignment of the x-ray cassette in the trays is difficult, and repeat x-rays may be required if alignment is poor:
alignment markers on the incubators may reduce these risks


some babies may still require movement if they are not lying in the correct part of the incubator
artefacts may be present in the image due to items under the mattress and mattress creasing, particularly when
using the softer top mattress

Responses at UKRC were negative, although the drager incubators are used successfully at Sheffield
Details Radiation Dose
If the x-ray cassette is placed in the tray instead of directly under the neonate, radiation reaching the cassette is halved.
to maintain dose to the cassette, radiation dose to the neonate would double
Or, maintaining neonate dose and halving cassette dose may adversely affect image quality: Doses have recently
been reduced to point where a slight decrease in image quality was perceived for smallest weight groups (<4kg)
Alignment
The trays do not have any positioning aids for the x-ray cassette. Without proper alignment of x-ray tube, neonate and
cassette, there is a risk that the image will not contain the required anatomy and a repeat will be therefore be required,
doubling radiation dose.
alignment aids are required to be permanently marked on the incubator
24x30cm cassettes should be used, as 18x24 cassettes do not allow sufficient margin of error in alignment. However
the smallest cassettes produce images with best resolution
The trays do not allow cassettes to be placed at the corners of the incubator
if the baby if not lying over the correct part of the tray, it will need to be moved
Artefacts
Any items underneath the mattress will appear on the image as artifacts, including the mattress itself.
the main mattress was found to produce acceptable uniform images
however, the softer top mattress, used for the smallest babies, produced noticeable crease lines on a uniform image
At UKRC, the following comments were received about the use of incubator trays:
“altered magnification made the images unacceptable”/ “image quality was poor”
If the RUH is considering purchasing new incubators, MEMS have agreed that Medical Physics will be involved in their
evaluation with respect to the use of x-ray cassette trays.
Laura Sawyer/ Hazel Starritt Royal United Hospitals, Bath 2/7/10
Reduction of radiation exposure to babies receiving X-rays on the Neonatal Intensive Care Unit
The babies in our NICU need a range of treatments and therapies during the time they spend with us. One such
diagnostic treatment is an X-ray. Whilst it is important the X-ray image is sufficient for the radiologist to diagnose a
potential problem, it is vital that the radiation dose the baby receives is as low and as safe as possible. We know that
infants, because they are still developing, are at greater risk of the harm associated with radiation exposure. To perform Xrays on such tiny babies requires a significant amount of handling, which in turn, can affect their stability.
During 2009/10, a team of specialists from the RUH undertook research to see if the amount of radiation a premature baby
was exposed to could be reduced without compromising image quality. This was a joint project involving medical
physicists, radiologists, and paediatricians from NICU. Their premise was that the dose of radiation received by these
babies could be reduced without any reduction in quality of the exposed films, or adverse impact on clinical effectiveness.
This would enable the continuance of good medical care but improve the safety of the procedure for the babies.
Over a period of a few months the radiation doses being used on our premature babies was gradually reduced. The
clinicians on NICU were not told which X-rays were being exposed at the reduced dosage. They looked at each X-ray on
merit and commented on whether the quality was adequate to give the appropriate level of clinical information requested.
The X-rays were further quality assured by consultant radiologists. The result at the end of the project time frame was that
the target dose was achieved with no discernible reduction in image quality. The dose of radiation given to a baby
receiving an X-ray reduced by an average of 33%; more specifically, it was reduced by 40% in our most vulnerable, small
and immature babies and 26% in the largest babies.
This project is an excellent example of how teams from different disciplines can work together to improve quality of care
and patient safety in an organised and comprehensively evaluated way
CONCERNS FOR USING NEW TRAY SYSTEM IN NNU
 Babies still have to be moved in order to achieve straight and well positioned images, correctly positioned images are
critical for line positions etc.
 Radiation doses are very critical in neonates, anything which may cause an increased dose or an alteration in image
quality needs to be assessed and accounted for. Radiation Protection Dept need to be involved to check viability. Any
distance between patient and cassette can cause :Magnification; Increase in radiation dose; Possible artefacts
 Digital imaging systems require the area of investigation accurately positioned to the centre of the cassette to obtain
optimum images.


There is a possibility of an increase in repeats if the tray is not positioned correctly, causing an increase in dose.
Discussion with the radiology department is imperative prior to changes being made to x-ray procedures. A practical
trial of equipment should be done prior to usage. For the tray to be utilised the baby would still have to be moved and
positioned accurately in the incubator above the tray, to obtain a diagnostic image
Report:
Study2010
Day January, Page 4. Summer 2010
Page 4APR
Autumn
Page 3 January 2009
2010
2009
Strictly Children!
The Association of Paediatric Radiographers (APR)
latest study day was held at the Tower Hotel in the
heart of London. At least one hundred and twenty
delegates enjoyed not only the excellent facilities of
this river-side hotel, but also a full day of very
informative lectures.
The APR recognises that children are not only imaged
in specialised paediatric hospitals, but also provision of
child friendly environments should be provided in all
hospitals that treat children. It is important that
radiographers working in these non-specialist hospitals
are educated to a high standard to enable them to
image children well. The study day attracted
radiographers from all types of hospitals as well as not
only newly qualified staff, but also those that were
eager to learn new ideas.
Faith Constantine, from Derriford Hospital, Plymouth
was chair for the morning’s programme. The first
lecture was “Brain scanning – a real headache!”. Dr
Steven McKinstry, Consultant Neuroradiologist from the
Royal Victoria Hospital, Belfast, gave an excellent
presentation that attempted to help determine
whether or not a child presenting with “a headache”
should or should not have CT imaging. Not an easy
question to answer all the time but the lecture
provided sensible and logical steps to take.
Martin Churchill Coleman, Superintendent Paediatric
Radiographer at the Royal London Hospital and Dr Sam
Chippington, Interventional Radiologist at The Hospital
for Sick Children, Great Ormond Street got together to
present an in-depth talk entitled “TOF and
Oesophageal Atresia”. Martin gave us all the facts on
these conditions and Sam told us of the latest advances
in treatment that are being carried out at GOS
hospital.
Dr Rob Hawkes, Consultant Radiologist, travelled all
the way from Bristol Royal Hospital for Children to
present the next lecture – “Locating the Lines”. He
gave a very clear interpretation of all the “lines” that
can be visualised on images and a clear explanation of
their purpose and where their correct position should
be. How important it is to produce a non-rotated x-ray
for the radiologist to be able to interpret correctly; a
lesson for all of us!
“Lumps and Bumps” was a presentation packed with
interesting images. Donna Dimond, Superintendent
Radiographer from Bristol Royal Hospital for Children
gave an excellent presentation to help us identify what
could possibly be a tumour – and what probably is not.
Donna gave us very clear advice about how to interpret
focal lesions that we come across on images.
Before breaking for lunch the APR held its annual
general meeting. The Chairman, Mike Scriven,
informed members of the APR’s continuing work to
ensure that the needs of children are recognised, and
how the APR works closely with the Society of
Radiographers and other specialist interest groups to
Page 4 of 7
keep at the forefront of new developments. Delegates
enjoyed an excellent lunch where not only were the
views of the Thames and Tower of London enjoyed,
but also a lot of networking was done and old
colleagues caught up with!
Jude Hardwick chaired the afternoon session – the
APR is grateful to Dr Sapna Verma who stood in at the
last minute. Sapna, a Consultant in Paediatric
Emergency Medicine at Birmingham Children’s
Hospital, talked on “The Recognition of Serious Illness
in Children”. She provided the audience with very
clear and concise instructions on what to do when a
child looses levels of consciousness in the imaging
department. This situation could happen to any of us
and it is really important to take the correct steps to
ensure that life support is delivered quickly and
efficiently.
Mike Scriven, Superintendent Paediatric radiographer
from Southampton General Hospital took to the floor
again – this time to talk about “Paediatric Gastro
Intestinal Emergencies”. He reminded us of how
children’s pathology differs from that of an adult –
and what is required surgically to correct it. Excellent
images accompanied a very informative presentation.
Jenny McKinstry, Superintendent Radiographer at the
Royal Belfast Hospital for Sick Children told us all
about “Urinary Tract Infection”. We had a re-cap on
anatomy, symptoms and appropriate tests that the
child should undergo. The NICE guidelines have been
recently revised, so Jenny updated us on the new
guidelines for investigation.
Kate Parkes, Clinical Systems Manager from
Birmingham Children’s Hospital rounded up the day
with an “Overview of Cystic Fibrosis”. This in depth
presentation went into the history of cystic fibrosis
and also told us what it is like to live with a child with
CF. Advances in treatment have meant that more
children are surviving into adulthood – an inspiring
fact for all those that are involved medically with
children that suffer from long term conditions.
The “Strictly Children” study day was a great success
and the APR Committee would like to thank all the
speakers who provided us with varied and interesting
topics; also thanks to the Tower Hotel for the
excellent facilities and food. Paula Smith helped with
all the administration and registering of attendees –
thanks for all the hard work Paula. Finally we would
like to thank all the delegates who attended and
made the day so enjoyable.
Future study days are planned in Belfast and
Nottingham. To keep in touch with these events and
with latest developments in paediatric imaging you
can find the APR website on line via the Society of
Radiographers “special interest groups – or contact
any committee member.
Faith Constantine
Page 5 Autumn 2010
Your Committee
Committee members;
The APR committee
consists of a maximum 10
elected members from
throughout the UK & a
Council representative
from the Society of
radiographers.
Committee meet twice a
year, in Spring and
Autumn.
Study days are arranged,
usually twice a year in
the Spring and Autumn.
It is getting increasingly
difficult to find suitable
venues. If you think that
you would be able to host
a Study Day (with help
from the APR) then
please contact a member
of the committee
Chair: Michael Scriven: Supt Radiographer, Paediatric Xray Department at Southampton General Hospital.
E-mail Michael.scriven@suht.swest.nhs.uk
Vice-chair: Faith Constantine: Lead Paediatric
Radiographer at Derriford Hospital, Plymouth
E-mail Faith.constantine@phnt.swest.nhs.uk
Secretary: Jenny McKinstry: Supt Radiographer, Royal
Belfast Hospital for Sick Children.
E-mail Jenny.mckinstry@royalhospitals.n-i.nhs.uk
Treasurer: Barrie Pilkington: Working freelance
Barrie_pilkington@hotmail.com
Membership secretary: Elizabeth Hunter: Supt
Radiographer, Paediatric X-ray Department at the Royal
Victoria Infirmary, Newcastle-upon-Tyne
E-mail Elizabeth.hunter@nuth.nhs.uk
Newsletter: Jude Hardwick: Former Superintendent
Radiographer, Great Ormond Street Hospital for Children
E-mail judith.hardwick@btinternet.com
Sheila Cameron: Supt. Radiographer, The Royal Aberdeen
Children’s Hospital
E-mail Sheila.mcdonald@nhs.net
Martin Churchill-Coleman: Supt Radiographer, Paediatric
X-ray Department the Royal London Hospital
E-mail martin.churchillcoleman@bartsandthelondon.nhs.uk
Kate Parkes: Clinical Systems Manager at Birmingham
Children’s Hospital
E-mail kate.parkes@bch.nhs.uk
Judith Hobson: Senior Paediatric Radiographer, X-ray
Dept. Royal Victoria Infirmary, Newcastle-upon-Tyne
E-mail Judith.hobson@nuth.nhs.uk
SOR Representative: Sandie Mathers
E-mail s.mathers@rgu.ac.uk
Trampoline Injuries
Page 6 Autumn 2010
Trampoline Injuries
The result of the latest craze!
Are you like most of us at the Children’s
hospital thinking that trampolines should be
banned?
The Clocks are about to go forward next week,
the light evenings will be here and the A&E
departments are going to get busier! In the
summer months we see about 2 children per day
who have suffered injuries as a result of falling
off a trampoline. Most of these occur when
there was no safety net in place, no parental
supervision and when more than one child was
jumping on the trampoline at the same time.
If trampolines are used according to the
manufacturer’s instructions there are relatively
few injuries so maybe we are just turning into
grumpy old radiographers wanting to spoil the
fun they provide!
The injuries we see are varied but having
looked at our records here the most common
are lower limb injuries (especially in the
younger age group) followed by the upper limb
and then the head and neck.
Taking x rays of these injuries can be stressful
as the children are quite shocked, in
considerable pain and the parents can be very
upset. Falling off a trampoline involves falling
from a significant height and some of these
injuries can be quite severe. In obvious
deformities pain relief should always be given
BEFORE any x rays are attempted and the child
should be accompanied by a nurse from the A&E
department. Please remember that this may be
the child’s first experience of hospital and if
that is a painful one the follow up visits will not
be easy. If possible, move the affected limb as
little as possible and use a horizontal beam
where necessary, this is your chance to be
creative and use your skill as a radiographer! In
gross deformities the child will be taken to
threatre for reduction under general
anaesthetic. If only one view is possible, leave
the other until the child is unconscious it
is not worth causing more pain just for
the sake of perfect pictures.
Head injuries are usually sustained by
striking the head on the side of the
trampoline, clashing with another child or
hitting the ground. If the referring A&E
officer is sufficiently worried that about
the injury a CT scan is indicated as a
skull X ray will only demonstrate a
fracture and not brain injury.
Neck injuries simply require a lateral
cervical spine view to demonstrate the
alignment or fracture of the cervical
vertebrae. It is not necessary to
demonstrate T1 in a child, as long as the
body of C7 is demonstrated, this will be
adequate. The reason for this is that the
head of a child is much heavier in relation
to the body and most injuries occur in the
upper region of the cervical spine. If,
however, there are neurological signs
pain or bruising lower down further views
or CT may be necessary.
In conclusion trampoline injuries still only
form a small percentage of childhood
injuries compared to bikes and playing
football and no one would suggest
banning either of these activities!
As radiographers it is simply important for
us to remember that children and their
parents are often shocked and frightened
by these injuries and they need us to be
calm confident and creative.
Jennifer McKinstry
Superintendent Radiographer
Royal Belfast Hospital for Sick Children
Postbag
Postbag
From Jo French, West Suffolk Hospital:
I took on the role as departmental Paediatric
radiographer a few years back and joined a
colleague who had a wealth of knowledge from
her days at Liverpool's children's hospital prior to
her joining West Suffolk many years ago ( Di
Mungo, she has since emigrated to New Zealand!)
So it is just me now! I am partime but there is a
superintendent rad who use to work along side of
Di as the Paed rads, so she is in the dept when I'm
not and that works well.
We already had set Paed protocols and
exposure charts, and we are starting to audit for
Paed DRL's. We have just finished PA CXR's, so it
will be a slow process but worth while.
I am given admin time to update the protocols
and give tutorials on any issues that crop up or
are requested. I have given them on Skull x-rays,
foreign bodies protocol, paediatric pelvis imaging,
using the Wolverson Paed chest stand (which is
great), immobilisation and holding a child still
and 'what to do if you feel a child is at risk'.
In the light of the baby P case, I formalised a
departmental guideline/policy, liaising with our
Named nurse for safeguarding children at our
trust, so that all radiographers and radiologists
new what to do if they felt a child was at risk and
who to contact for advise and where to access the
correct paperwork etc.
Another member writes:
I don't know when your next APR newsletter
comes out, but could you put a thank you note in
from me from to all yours members who have sent
information on their NICU exposures. This
information made our work easier in changing our
exposure factors as Physics were able to show
the exposure factors we wanted to use were
accepted practice across the country. Saved a lot
of red tape! We have been able to reduce our
exposure factors by 25% already and are working
towards a 50% dose reduction, but as you know it
all takes time.
My next project is to reduce our other
paediatric doses as we have proved that you can
reduce dose and not affect image quality.
Do you have any members who use the Kodak CR
system we would be willing to share their
exposure charts with me and our physics
department, particularly exposures for chest,
abdomen, pelvis and skulls, to help reduce the red
tape we need to go through!
Many thanks
Cheryl Makepeace Specialist Radiographer
/Paediatric Lead RUH Bath
Page 7 Autumn 2010
I don't profess to know more than my colleagues
but I have been trying to gleen further knowledge
through attendance at our Paed outpatient
orthopaedic clinic, a local child development centre,
two days at GOSSH and the RCR accidental and
Non accidental injury study day.
We have a Paed information folder in the
department which I put in regular articles (synergy
etc) for CPD, there's a section on abbreviations and
relevant conditions/syndromes for reference,
relevant SOR docs and other pieces of information
that could be useful on a day to day basis. I was
also able to purchase a couple of text books on
general paediatric radiography and paediatric
orthopaedics for the department with funding from
a hosp charity.
Although I am a BAND 6 rad and do not get any
further recompense under AFC for my job title and
role, each senior rad in our department has extra
roles i.e. Theatre and Orthopaedics, COSHH,
infection control, CR and PACS, I do have a
separate job description and KSF along with the
Theatre and Orthopaedic rad.
I have tried to contact a couple of universities that
did offer a Paediatric elements or modules to further
my studies and help to give my role some more
sustenance, but they no longer offer these
courses. I enjoy my role as a Paediatric
Radiographer Practitioner which can be challenging
and rewarding. Working within a DGH rather than a
specialist hosp you have to be able to cover all
areas; Geriatric to Paediatric and any help that you
can give colleagues, staff and patients is of great
benefit. Regards Jo
Parental Responsibility:
Throughout the UK a mother automatically has
parental responsibility for a child.
Pre 2003
A father has parental responsibility if married to the
mother at the time of birth or subsequently, or if they
have jointly adopted the child.
An unmarried father can acquire parental
responsibility by obtaining a court registered
agreement with the mother, or a court responsibility
order.
Post 2003
England and Wales - a father has parental
responsibility if married to the mother at the time of
birth or subsequently. An unmarried father acquires
responsibility if registered on the child’s birth
certificate.
Scotland this applies to births registered from May
2006
Northern Ireland this applies to births registered from
April 2002.
Parents do not loose responsibility if they divorce.
Consent may be implied or oral, but written consent
must be given by the Child (if competent) or the
parent/guardian for invasive procedures. These
procedures may vary according to individual Hospital
Trust’s Policies.