Pediatric Radiography
Children do not all reach a sense of understanding at the
same predictable age. This ability varies from child to child,
and the pediatric technologist must not assume that children
will comprehend what is occurring. Generally, however, by
the age of 2 or 3 years, most children can be talked through
a diagnostic radiographic study without immobilization or
parental aid. Most important is a sense of trust, which begins
at the first meeting between the patient and the technologist;
the first impression that the child has of the technologist is
everlasting and forges the bond of a successful relationship.
Successful radiographic studies are
dependent on two things:
• The technologist's attitude and approach to a child.
• The technical preparation in the room.
At the first meeting, most children are accompanied by
at least one parent or caregiver. The following steps
are important:
• Introduce yourself as the technologist who will be working
with this child.
• Find out what information the attending physician has given
to the parent and patient.
• Explain what you are going to do and what your needs will
be.
Tears, fear, and combative resistance are common
reactions for a young child. The technologist must take
the time to communicate to the parent and the child, in
language they can understand, exactly what he or she is
going to do. The technologist must try to build an
atmosphere of trust in the waiting room before the patient
is taken into the radiographic room. This includes
discussing the necessity of immobilization as a last resort
if the child's cooperation is unattainable.
Evaluate Parent's (or Caregiver's) Role
• Parent is in room as an observer, lending support
and comfort by his or her presence.
• Parent serves as a participator, assisting with
immobilization.
• Parent is asked to remain in the waiting area and
not accompany the child into the radiography
room.
.
Sometimes children who act fearful and
combative in the waiting room with the parent
present will be more cooperative without their
presence. This is the time when the
technologist's communication skills are tested
REPORTING SUSPECTED CHILD ABUSE
Most medical facilities have a procedure in place to report
suspected child abuse. In the past, the term used for this
was battered child syndrome (BCS). The current
acceptable term is nonaccidental trauma (NAT).
Generally, it is not the responsibility of the technologist to
make a judgment as to whether child abuse has occurred,
but rather to report the facts as they are seen or
suspected. If NAT is suspected, the technologist should
discuss this with the radiologist or other supervisor as
determined by departmental protocol. Laws vary on
technologists' responsibilities, and it is most important that
all technologists know what their responsibilities are
concerning this in the state or province in which they
are working.
Pediatric patients in general can include infants through
children up to ages 12 to 14. However, older children can be
treated more like adults, except for special care in gonadal
shielding and reduced exposure factors because of their
smaller size. In general, pediatric radiography should always
use as short exposure times and as high mA as possible
to minimize image blurring that may result from patient
motion. However, even with short exposure times, preventing
motion during exposures is a constant challenge in pediatric
radiography, and effective methods of immobilization are
essential.
Immobilization devices:
• Tam-em board
• Pigg-O-Stat
Tam-em board
Pigg-O-Stat
Pigg-O-Stat (set for PA chest).
A.Bicycle-type seat
B.Side body clamps
C.Film holder mount
D.Swivel base
E.Adjustable lead shield with markers
F.Mounting stand on wheels
G.Extra set of smaller body clamps
The simplest and least expensive form of immobilization
involves the use of equipment and supplies that are
commonly found in most departments. Tape, sheets or
towels, sandbags, covered radiolucent sponge blocks,
compression bands, stockinettes, and ace bandages, if
used correctly, are effective in immobilization.
Sandbags
Strong canvas-type material and children's coarse sterilized
playing sand should be used. Coarse sand is recommended
because if the bag should break open, the sand is more easily
cleaned up, and the chance of causing artifacts on
radiographs is minimized
Tape and bandage
Various types of “gentle” tape are used for surgical procedures and sensitive
skin. Adhesive tape may show on the radiograph and create an artifact that
could obscure the anatomic part of interest. Also, some patients have an
allergic reaction to adhesive tape. The fragile skin of infants can be injured
by adhesive tape, unless the tape is twisted so that the adhesive surface is
not against the skin. Gauze pads placed between skin and adhesive tape
also can be used effectively
A 4-inch ace bandage is best for small infants and
young children, whereas a 6-inch bandage works
well for older children. These are best used for
immobilizing the legs. When starting the wrapping
process, begin at the patient's hips and wrap down to
the patient's midcalf. Do not wrap too tightly; this
would cut off circulation.
COMPRESSION BANDS AND HEAD CLAMPS
Compression or retention bands are valuable aids for
immobilization. Compression bands, however, are more
effective with pediatric patients when used in combination
with sandbags,
WEIGHTED ANGLE BLOCKS AS HEAD CLAMPS
These are heavy steel angle blocks with thick, radiolucent
sponge pads attached. They are relatively inexpensive to
have made compared with the cost of commercially available
head clamps. They are very effective and versatile in
immobilization, especially when used in combination with
sandbags and/or tape, or if the patient is mummified,
MUMMIFYING,” OR WRAPPING WITH SHEETS OR
TOWELS
BONE DEVELOPMENT (OSSIFICATION)
The bones of infants and small children go through various growth
changes from birth through adolescence. The pelvis is an example of
ossification changes that are apparent in children. As shown in, the
divisions of the hip bone between the ilium, the ischium, and the pubis are
evident. They appear as individual bones separated by a joint space,
which is the cartilaginous growth region in the area of the acetabulum.
The heads of the femora also appear to be separated by a joint space that
should not be confused with fracture sites or other abnormalities. These
are normal cartilaginous growth regions.
MINIMAL REPEATS
Reduction of repeat exposures is critical, especially in young children,
whose developing cells are particularly sensitive to the effects of
radiation. Proper immobilization and high mA, short exposure time
techniques will reduce the incidence of motion unsharpness. Accurate
manual technique charts with patient body weights should be used.
Radiographic grids should be used only when the body part examined is
greater than 10 centimeters in thickness. Each radiology department
should keep a list of specific routines for pediatric imaging exams,
including specialized views and limited examination series, to ensure that
appropriate projections are obtained and no unnecessary exposures are
made.
GONADAL PROTECTION
Gonads of the child should always be shielded with
contact-type shields, unless such shields obscure the
essential anatomy of the lower abdomen or pelvic area.
Pre-exam Preparation
The following should be completed before the patient is brought into the room:
•The necessary immobilization and shielding paraphernalia should be in place
(sandbags, tape, Tam-em board if used, sheets or towels, stockinette, ace
bandages, and shielding devices for patient and for parents if assisting).
•Image receptors and markers should be in place and techniques set (if a solo
technologist is performing the exam).
•Specific projections should have been determined, which may require
consultation with the radiologist.
•If two technologists are working together, they should clarify the role that each will
play during the procedure. A suggested division of responsibilities is to have the
assisting technologist set techniques, make exposures, change the IRs, and
process the images while the primary technologist positions the patient, instructs
the parents (if assisting), and positions the tube, collimation, and required
shielding.
CHILD PREPARATION
After the child is brought into the room and the procedure is
explained to the child's and parent's satisfaction, the parent or
technologist must remove any clothing, bandages, and/or diapers
from the body parts to be radiographed. This is necessary to
prevent these items from casting shadows and creating artifacts
on the radiographic image because of low exposure factors used
for the patient's small size.
PATHOLOGIC INDICATIONS FOR THE PEDIATRIC RESPIRATORY SYSTEM
Asthma
Asthma is most common in children and generally is caused by anxiety or
allergies. Airways are narrowed by stimuli that do not affect the airways in normal
lungs. Breathing is labored, and increased mucus in the lungs may result in some
increase in the radiodensity of lung fields. (Chest radiographs frequently appear
normal, however.)
Atelectasis
This is a condition, rather than a disease, in which collapse of all or a portion of a
lung occurs because of obstruction of the bronchus or puncture or “blowout” of an
air passageway. With less than normal air in the lung, this region appears more
radiodense, which may cause the trachea and heart to shift to the affected side.
Bronchiectasis
In this condition, irreversible widening (dilation) of bronchi results from acute
infection or from congenital structural abnormalities of portions of airways,
eventually creating obstruction. This may develop at any age but most often begins
in early childhood. Severe conditions may require a slight increase in exposure
factors.
Croup
This condition (primarily seen in children from ages 1 to 3) is caused by a
viral infection. It is made evident by labored breathing and a harsh dry cough
that frequently (but not always) is accompanied by fever. It is treated most
commonly with antibiotics, but AP and lateral radiographs of the neck and
upper airway may be requested to demonstrate characteristically smooth but
tapered narrowing of the upper airway, which is most obvious on the AP
projection.
Epiglottitis (supraglottitis)
This bacterial infection of the epiglottis is most common in children from ages 2
to 5 but may also affect adults. Epiglottitis is a serious condition that can
rapidly become fatal (within hours of onset); it results from blockage of the
airway caused by swelling. Examination usually must be performed in an
emergency room by a specialist who is using a laryngoscope; the airway can
be reopened by inserting an endotracheal tube or by performing a
tracheostomy (opening through the front of the neck).
A physician or other attendant should accompany the patient during any
radiographic procedure to ensure that the airway remains open.
CONDITION OR DISEASE
RADIOGRAPHIC EXAM AND (+) OR (−)
EXPOSURE ADJUSTMENT
1. Aspiration (mechanical )
AP and lateral chest or AP and lateral
upper airway for obstruction
2. Asthma (in children)
3. Atelectasis (lung collapse)
PA and lateral chest
PA and lateral chest (+) slight increase
4. Bronchiectasis
PA and lateral chest (+) slight increase
5. Croup (viral infection)
PA and lateral chest and AP and lateral
upper airway
6. Epiglottitis (acute respiratory
obstruction)
AP and lateral chest and lateral upper
airway
PATHOLOGIC INDICATIONS FOR THE PEDIATRIC SKELETAL SYSTEM
1. Craniostenosis (craniosynostosis)
A deformity of the skull caused by premature closure of skull sutures. The type of
deformity is dependent on which sutures are involved. The most common type
involves the sagittal suture and results in AP (front to back) elongation of the
skull.
2. Developmental Dysplasia of the Hip (DDH)
An older term is congenital dislocation of the hip (CDH). In this condition, the
femoral head is separated by the acetabulum in the newborn (see Fig. 19-59). The
cause of this defect is unknown; it is more common in girls, in infants born in
breech (buttocks first), and in infants who have close relatives with this disorder.
Ultrasound is commonly used to confirm dysplasia in newborns. It may require
frequent hip radiographs later; thus gonadal shielding is important when x-rays are
used.
3. Hydrocephalus
Hydrocephalus involves enlarged ventricles from which the cerebrospinal fluid
produced in the ventricles cannot drain, resulting in a pressure buildup and
overall enlargement of the head.
4. Idiopathic Juvenile Osteoporosis
This type of osteoporosis (in which bone becomes less dense and more fragile)
occurs in children and young adults.
5. Osteochondrodysplasia
In this group of hereditary disorders, the bones grow abnormally, most often
causing dwarfism or short stature.
•Achondroplasia: Achondroplasia is the most common form of short-limbed
dwarfism. Because this condition results in decreased bone formation in the
growth plates of long bones, the upper and lower limbs usually are short with a
near-normal torso length.
6. Osteochondrosis
This group of diseases primarily affects the epiphyseal or growth plates of long
bones, resulting in pain, deformity, and abnormal bone growth.
•Kohler's bone disease: This disease causes inflammation of bone and cartilage
of the navicular bone of the foot. It is most common in males, beginning at ages 3
to 5 years, and rarely lasts more than 2 years.
•Legg-Calvé-Perthes disease: This condition leads to abnormal bone growth at
the hip (head and neck of femur). It affects children at ages 5 to 10 years (head of
femur first appears flattened, then later appears fragmented). It usually affects
only one hip and is more common in males.
•Osgood-Schlatter disease: This condition causes inflammation at the tibial
tuberosity (tendon attachment). It is most common in 5- to 10-year-old males and
usually affects only one leg.
•Scheuermann's disease: In this relatively common condition, bone
development changes of the vertebrae result in kyphosis (humpback).
Scheuermann's disease is more common in boys, beginning in early
adolescence.
7. Osteogenesis Imperfecta (OI)
In this hereditary disorder, the bones are abnormally soft and fragile. Infants with
this condition may be born with many fractures, which can result in deformity
and/or dwarfism. Sutures of the skull are unusually wide, containing many small
wormian bones.
8. Osteopetrosis (marble bones)
In this hereditary condition, the density of the bones is increased. It may include
skull abnormalities. This can be a mild condition, causing little disability, or it can
be severe, beginning in infancy and often becoming fatal.
Osteopetrosis may be demonstrated prenatally with ultrasound or radiographically
with bone survey exams in children and adults. Radiodense bones require an
increase in exposure factors.
9. Spina Bifida
The posterior aspects of the vertebrae fail to develop,
exposing part of the spinal cord. Spina bifida can be
discovered before birth by ultrasound and/or by clinical tests
of the amniotic fluid. Various degrees of severity exist. Spina
bifida now can be demonstrated before birth with the use of
prenatal ultrasound.
10. Talipes (Clubfoot)
Talipes is a congenital deformity of the foot that can be diagnosed
prenatally with the use of real-time ultrasound. It also is commonly
evaluated radiographically in an infant with frontal and lateral projections
of each foot.
CONDITION OR DISEASE
Craniostenosis (craniosynostosis)
Developmental dysplasia of hip (DDH),
or congenital dislocation of hip (CDH)
Hydrocephalus
Idiopathic juvenile osteoporosis
Osteochondrodysplasias
•Achondroplasia
RADIOGRAPHIC EXAM AND (+) OR (−)
EXPOSURE ADJUSTMENTS*
AP and lateral skull
Ultrasound, AP hip
Prebirth, ultrasound, or AP lateral skull
(+) increase based on size
Bone survey study or AP of bilateral
upper or lower limbs (−) slight decrease
AP survey of long bones (for possible
dwarfism)
Osteochondroses
•Kohler's
•Legg-Calvé-Perthes
•Osgood-Schlatter
•Scheuermann's
AP and lateral of affected parts
- Foot
– Hip
– Tibia (proximal)
– Spine (kyphosis)
Osteogenesis imperfecta (OI)
Bone survey, including AP and lateral
skull (−), significant decrease, up to 50%
Osteomyelitis
AP and lateral of affected limbs and/or
radionuclide bone scans, CT/MRI
Osteopetrosis (marble bones)
Bone survey, including skull (+)
moderate increas
Talipes (clubfoot)
AP and lateral foot (Kite method)
Celiac Disease
In this hereditary disorder, a certain protein found in wheat (gluten) causes an
allergic reaction of the intestinal lining, resulting in improper absorption of fats from
the diet.
Hepatomegaly
Hepatomegaly, or enlargement of the liver, indicates a liver disease such as acute
hepatitis, cirrhosis, or bile duct obstruction.
Hirschsprung's Disease (Congenital Megacolon)
In this congenital condition of the large intestine, nerves that control rhythmic
contractions are missing. This serious condition results in severe constipation or
vomiting. It usually is corrected surgically by connecting the distal portion of the
normal part of the large intestine to an opening in the abdominal wall (colostomy).
Horseshoe Kidney
In this congenital condition, the two kidneys are joined
together at their lower pelves. The kidneys are malrotated,
facing anteriorly, and the ureters attach the kidneys at the
anterior rather than the normal medial aspect. This is the
most common type of kidney fusion anomaly.
Hydronephrosis
Hydronephrosis, or an enlarged kidney distended with urine, is caused by
obstruction of urine. It may result from tumors, kidney stones, severe urinary tract
infections, or congenital structural abnormalities.
Inflammatory Bowel Disease (IBD)
IBD includes chronic disorders of inflammation of the intestines. The two most
common are Crohn's disease and ulcerative colitis, which have similar
symptoms. These may occur at any age but usually occur first at ages 14 to 30.
•Crohn's disease: Crohn disease is an infection of the intestinal wall that may
occur in the small or the large intestine or both.
•Ulcerative colitis: Ulcerative colitis involves only the large intestine and usually
starts in the rectum or sigmoid.
Intestinal Obstruction
In adults, intestinal obstruction is caused most frequently by fibrous adhesions from
previous surgery. In newborns and infants, it is caused most often by birth defects
such as intussusception, volvulus, or meconium ileus.
•Ileus: Ileus, which also is called paralytic ileus or adynamic ileus, is an intestinal
obstruction that is not a mechanical obstruction (such as a volvulus or an
intussusception) but rather an obstruction caused by lack of contractile movement of
the intestinal wall.
•Intussusception: Intussusception is a mechanical obstruction that is caused by the
telescoping of a loop of intestine into another loop. It is most common in the region
of the distal small bowel (ileus).
•Meconium ileus: Meconium ileus is a mechanical obstruction whereby the
intestinal contents (meconium) become hardened, creating a blockage.
•Volvulus: Volvulus is a mechanical obstruction that is caused by twisting of the
intestine itself.
Pyloric Stenosis
This narrowing or blockage at the pylorus or stomach
outlet occurs in infants, frequently resulting in repeated,
forceful vomiting.
Tumors (Neoplasms)
Malignant tumors (cancer) occur less frequently in children than in adults and
are more curable in children.
•Neuroblastoma: Neuroblastomas are associated with childhood cancer
(generally younger than age 5). They occur in parts of the nervous system, most
frequently the adrenal glands. This cancer is the second most common type in
children.
•Wilms' tumor: Wilms' tumor indicates a cancer of the kidneys of embryonal
origin. It usually occurs in children younger than age 5. The most common of
abdominal cancers in infants or children, it typically involves only one kidney.
CONDITION OR DISEASE
Celiac disease
Hepatomegaly
Hirschsprung's disease
(congenital megacolon)
RADIOGRAPHIC EXAM AND (+) OR (−)
EXPOSURE ADJUSTMENTS
Erect or decubitus abdomen and/or GI
series
AP abdomen
AP abdomen and/or GI series (frequently
requires a colostomy)
Hydronephrosis
Ultrasound
Inflammatory bowel disease (IBD)
•Crohn's disease
•Ulcerative colitis
Acute abdomen and/or small bowel and GI
series (helical CT and/or MRI can detect
early stages of IBD)
Intestinal obstructions Mechanical:
•Intussusception
•Meconium ileus
•Volvulus
Nonmechanical:
•Ileus (paralytic or adynamic ileus)
Acute abdomen series and small
bowel series or barium enema (BE);
(−) moderate decrease in exposure
depending on severity of bowel
distention
Pyloric stenosis
Upper GI series and/or ultrasound
Tumors
•Neuroblastoma
•Wilms' tumor
Radiographic studies of affected body
part, CT, ultrasound