Rachelle Danya M.

Dela Rosa April 14, 2021

RT 301-B LAB BSRT 3-A

Introduction to Pediatric Radiography:

Pediatric radiography is a subset within general
radiography specializing in the radiographic imaging of the pediatric
population. The general principles of radiography remain the same.
However, additional consideration needs to be taken into account
when determining patient-specific exposure factors, immobilization
techniques and appropriateness of examinations.

The child is not a small adult – it might seem as a cliché, but in fact
it is the basic truth. Children and adolescent suffer from different
diseases than adults and require different therapies as well as altered
imaging approaches. The strategies for diagnostic imaging are
different, although the modalities are the same or similar to those used in adult radiology. The sequence of modality
choice, some of the technical parameters and the follow‐up protocols are different in pediatric radiology. The
number one difference is radiation safety. Children are especially sensitive to ionizing radiation. Immature tissues
are extremely sensitive to radiation and there is no minimal safety dosage that is considered absolutely harmless.

APPROACH TO CHILD:  One who wishes to have successful relationship with children
must like children & not only happy with well children but also
with the sick children who often tired, cranky & frightened.

 One must understand the fears, needs & desires of children.

 Medical personnel who deals with children should develop a
sensitivity against child reaction.

 By the help of parents, technologists & nurses prepare the child.

Our hospital has posters & toys to prepare the children.
 Technologists need to learn to observe & quickly evaluate the
children, their level of maturity & ability to communicate.
YOUNG INFANTS (ABOUT 6  They often are playful or sleepy.
MONTH - 2YEARS):
 Reacting to pain stimulates total body movements & loud crying
may cease upon distraction.

 Ask the parent to hold the child, speak softly & smoothly & offer
a bottle of milk.

 Ask to bring his/her favorite Toy.

PRESCHOOLERS (3 – 5  Preschooler can understand instructions & explanations if they

YEARS): are offered with an understanding of child likely precaution.

 Preschooler are eager to please & a game like atmosphere can

facilitate our work.

 Praise must be given when the child tries to cooperate.

MENTALLY RETARDED  Some mentally retarded children can be examined without

CHILDREN: problem.

 Some examined with the help of their Parents, Teachers or

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Hospital attendants.

 But some can examine only after sedation.

PARENTS IN RADIOGRAPHIC  Pediatric radiologists & technologists believed that parents who
ROOM: wish to accompany their child should be permitted to do so.

 Most parents can give their child important support, so should be

encouraged to accompany the child.

 Parents should be given lead gloves, lead apron to protect from

scattered radiation.

Pediatric Immobilization:
• Communication

• Sheets

• Tape

• Velcro straps

• Octa stop board

• Pigg-O-Stat

PRECAUTIONS:
• An immobilized child must never be left alone in room except for the moment the exposure is made.

• An infant or child must never be immobilized so tightly that small movements are impossible.

• Frequently the child will ask for the description of the procedure a number of times, such repetition may
indeed test one’ patience

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.
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RADIATION PROTECTION:
1) Keeping the number of radiograph examination to a minimum consistent with health and welfare.

2) Avoid repeat.

3) Use of high-speed intensifying screen, I P plates & reduced exposure time.

4) Proper shielding of gonad, hip, pelvis & abdomen according to examination.

5) Proper collimation.

6) Follow ALARA Principle (as low as reasonably achievable)

- Distance

- Time

- Shielding

7) Use of lead gloves & apron by technologist & attendant if present.

8) Pregnant woman is not allowed to accompany the child.

9) During radiography of upper limbs protect the upper torso of all children.

Differences children and adults:

• Mental development
• Chest and abdomen the same circumference in NB
• Pelvis - mostly cartilage
• Abdominal organs higher in infants than older children
• Hard to find ASIS or Iliac Crest in young child, can center 1 inch above umbilicus (bellybutton)
• Exposure made as baby takes a breath to let out a cry

Common Pediatric Examinations:

CHEST RADIOGRAPHY
The most common radiographic procedure performed in hospitals and clinics is of the chest.
Radiologists agree that for most diagnostic chest radiographs in pediatric patients, upright images yield a
great deal more information than supine radiographs. It is, however, important to know the way to
achieve diagnostic quality in both positions. Regardless of body position, accurate diagnosis depends on
high-quality images made with short exposure times to reduce motion.
Upright radiograph on the newborn to 3- Various methods of immobilization are used to achieve
year-old these images, often with somewhat mixed results.
Fortunately, these challenges are easily met with the
use of a pediatric positioner and immobilization tool
called the Pigg-o-stat.

Communication with parents:

A complete explanation is worthwhile and essential.
The parent can be shown how to help place the child
on the seat by guiding the feet in. Then the parent can
assist by holding the arm above the child's head.
Radiographers should realize that positioning a child in
a Pigg-o-stat is a two-person job. Radiographers can
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Upright radiograph on the 3- to 1 8-year-old
April 14, 2021
BSRT 3-A
safely take children out of the Pigg-o-stat without
assistance, but an extra pair of hand is needed in the
initial positioning. The properly instructed parent is
generally willing and able to assist.
Method:
The following steps are observed:
• Have the patients undress completely from the waist
up, so that after the patient is positioned, the ribs are
visible on inspiration.
• Choose the appropriate sleeve size. Sleeves should fit
snugly, which often requires Velcro strips or adhesive
tape wrapped around the base of the sleeves.
• Adjust the seat height to approximately the correct
level. The seat is at the correct height if, when the
patient is sitting up straight, the face fits in the contours
or cutout portions of the sleeves.
The radiographer can detect inspiration by doing the
following (listed in decreasing order of reliability):
I. Waiting for the end of a cry-the child will take a big
gasp of air
2. Watching the abdomen-the child's abdomen will
extend on inspiration
3. Watching the chest wall-the ribs will be outlined on
inspiration
4. Watching the rise and fall of the sternum
Centering and collimation:
The central ray for both PA and lateral projections is
directed to the level of T6-T7, but the collimated field
should extend from and include the mastoid tips to just
above the iliac crests.
Upright radiographs on 3- to 1 8-year-olds are easily
obtained by observing the following steps:
• Help the child it on a large wooden box, a wide-based
trolley with brakes, or a stool, with the IR supported
using a metal extension stand. Children of this age are
very curious and have short attention span. By having
them sit, the radiographer can prevent them from
wiggling from the waist down.
• For the PA radiograph, have the child hold on to the
ide supports of the extension stand, with the chin on
top of or next to the IR. This prevents upper body
movement.
• When positioning for the lateral radiograph, have the
parent (if presence is permitted) assist by raising the
child's arm above the head and holding the head
between the arms.
Supine radiograph
Infants needing supine and cross-table lateral
radiographs can be immobilized using Velcro straps
around the knees and Velcro band across the legs.
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Evaluating the image

As in adult chest radiography, the use of kVp is also
desirable in pediatric chest work; however, this is
relative. In adult work, high kVp generally ranges
between 110 and 130 but for pediatric PA projections
ranges between 80 and 90. Practically speaking, the use
of a higher kVp is impossible because the
corresponding mAs are too low to produce a diagnostic
image. Relatively high kVp helps to provide images
with long-scale contrast.
HIP RADIOGRAPHY
The hip and pelvis are commonly examined radiographically in both the pediatric and adult population.
However, the clinical rationale for ordering these examinations varies tremendously. The informed
radiographer who understands these differences can be of great assistance. With a basic comprehension
of some of the common pediatric pathologies and disease processes, the radiographer is better able to
appreciate the skills required of the radiologist to make an accurate diagnosis.
General Principles:
Despite the importance of radiation protection, little
written literature is available to guide radiographers on
the placement of gonadal shields and when to use
shielding. The radiographer should observe the
following guidelines:
• Always use gonadal shielding on males. However,
take care to prevent potential lesions of the pubic
symphysis from being obscured.
• In female, use gonadal protection on all radiographs
except the fir t AP projection of the initial examination
of the hips and pelvis.
• After sacral abnormality or acral involvement has
been ruled out, use shielding on subsequent images in
females.
• Before proceeding, check the girl's records or seek
clarification from the parents regarding whether this is
the child's first examination.
• Because the female reproductive organs are located in
the mid-pelvis with their exact position varying, ensure
that the shield covers the sacrum and part or all of the
sacroiliac joints.

Positioning and immobilization:

The radiographer should observe the following steps
when positioning the patient:
• As with hip examinations on any patient, check that
the ASISs are equidistant from the table.
• After carefully observing and communicating with
the patient to discover the location of pain, the
radiographer can use sponges to compensate for
rotation. Sponges should routinely be used to support
the thighs in the frog leg position. This can help
prevent motion artifacts.
• Do not accept poorly positioned images. Expend
considerable effort in attempting to achieve optimal
positioning. This effort may include giving
instructions, or repeating instructions to the novice
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pediatric radiographer.
SKULL RADIOGRAPHY
Along with radiography of the limbs, skull radiography presents some of the greatest challenges to the
radiographer. Indeed, cranial radiography is usually one of the last areas students become comfortable
with during their clinical education.
Immobilization
All patients 3 years old and younger should be
immobilized using the "bunny" technique. (An
exception to this rule is the sleeping child.) A well-
wrapped child remains that way through five to seven
images. Mastering this technique is clearly one of
the secrets to successful immobilization.

Positioning
The skull grows rapidly in the first 2 years of life,
approaching the 75th percentile of adult size by that
age. The radiographer must understand the way this
growth and the rate at which the cranium grows
relative to the facial bones alter the position of the
various radiographic landmark and angles.

Routines and protocols

Physicians order skull radiograph to assess neurologic
problems and evaluate the extent of trauma or injury.
For these reasons, many departments develop two
routines: neurologic and trauma.

LIMB RADIOGRAPHY
Limb radiography, which accounts for a high percentage of pediatric general radiographic procedures in
most clinics and hospitals, requires some explanation. The child's age and demeanor determine the
method of immobilization to be employed. The immobilization methods are described here according to
age group. In planning the approach, the radiographer should consider the chronologic age and
psychologic outlook of the patient. For example, a very active 3-year-old may be better managed using
the approach for newborns to 2-year-olds.
Immobilization:
Newborn to 2-year-old:
Limb radiography on the newborn to 2-year-old is
probably the most challenging; however, it is made
easier when the patient is wrapped in a towel. (A
pillow case will suffice if a towel is not available.)

Preschoolers
The upper limbs of preschoolers are best examined
radiographically with the child sitting on the parent's
lap as shown in. If the parent is unable to participate,
these children can be immobilized as described
previously.
School-age children
School-age children can generally be managed in the
same way adult patients are for both upper and lower
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limb examinations.

Radiation protection:
The upper body should be protected in all examinations
of the upper limbs, because of the close proximity of
the thymus, sternum, and breast tissue to the scatter of
the primary beam. Child-sized lead aprons with cartoon
characters are both popular and practical.

Management of fractures:
Patients with fractures often arrive in the imaging
department on a stretcher. The radiographer skilled at
adapting routines can often obtain the necessary
radiographs without moving the patient onto the table.
ABDOMINAL RADIOGRAPHY
Abdominal radiography for children is requested for different reasons than it is for adults. Consequently,
the initial procedure or protocol differs significantly. In addition to the supine and upright images, the
assessment for acute abdomen conditions or the abdominal series in adult radiography usually includes
radiographs obtained in the left lateral decubitus position. Often the series is not considered complete
without a PA projection of the chest. To keep radiation exposure to a minimum, the pediatric abdominal
series need only include two images: the supine abdomen and an image to demonstrate air-fluid levels.
Positioning and immobilization:
The radiographer should observe the following
guidelines for upright abdominal imaging:
• Effectively immobilize newborns and children as old
as 3 years for the upright image using the Pigg-o-stat.
• Raise the seat of the Pigg-o-stat to avoid projecting
artifacts from the bases of the sleeves over the lower
abdomen.
• For the best results in the older child, have the child
sit on a large box, trolley, or stool and spread the legs
apart to prevent superimposition of the upper femora
over the pelvis.

The radiographer should observe the following steps

for lateral abdominal imaging:
• Remember that the parent can do only one job.
• Ask the parent to stand on the opposite side of the
table and hold the child's head and arms.
• Immobilize the rest of the child's body using available
immobilization tools. These tools include large 45-
degree sponges, sandbags (large and small), a
"bookend," and a Velcro band.
• Accomplish immobilization by rolling the child on
the side and placing a small sponge or sandbag
between the knees.
• Snugly wrap the Velcro band over the hips; to prevent
backward arching, place the "bookend" against the
child's back with the 45-degree sponge and sandbag
positioned anteriorly.
GASTROINTESTINAL AND GENITOURINARY PROCEDURES
In the interest of limiting radiation exposure to the GI and genitourinary systems, examinations are
tailored to the individual patient. After a brief introduction, the radiographer should explain the
procedure and check that the patient has undergone proper bowel preparation. The radiographer can then
proceed with preparation (e.g., enema tip insertion) and immobilization of the patient.
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Immobilization for gastrointestinal procedures:
As with other immobilization techniques, various
beliefs exist regarding immobilization methods for the
fluoroscopic portion of GJ procedures; two method are
described. (The child may be immobilized for the
"overhead" images as per the method outlined for the
supine abdomen examination.)

Modified "bunny" method

The child's torso and legs are wrapped in a small
blanket or towel and secured with a Velcro strip or
tape. The arms are left free, raised above the head, and
held by the parent (if present).

Method
The patient is catheterized, a procedure that often
requires two people--one to perform the catheterization
and one to immobilize the legs in a frog leg position.
The catheter is connected via tubing to a 500-ml bottle
of contrast medium hung about 3 feet above the table.
Under fluoroscopic guidance, contrast medium is
dripped into the bladder until the bladder is full.
Images are then taken while the patient is voiding to
demonstrate reflux.

Positioning
The female patient remains in the supine position, but
the male patient must be placed in an oblique position
during voiding to prevent the urethra from being
superimposed over the pubic symphysis. After placing
the male in an oblique position, the radiographer
should take care to ensure the urethra is not
superimposed over the femur.
RADIOGRAPHY FOR SUSPECTED Aspirated foreign body
FOREIGN BODIES A significant number of pediatric patients examined in
emergency departments have a history that leads the
physician to suspect a foreign body has been aspirated
into the bronchial tree. This is a common cause of
respiratory distress in children between the ages of 6
months and 3 years. In many cases the foreign body is
nonopaque or radiolucent.

Method
The radiographer observes the following guidelines:
• Have the child be undressed from the waist up. Then
position the child with the head in the contoured/cut
out portion, the neck over the raised portion, and the
chest on the sloped portion of the immobility device
• Lower and immobilize the shoulders using the
provided towelette; then immobilize the head and
upper thorax using the foam-lined Velcro strips. The
neck extension helps to keep the trachea from
appearing buckled, and the towelette and foam-lined
Velcro shoulder straps keep the shoulders from being
superimposed on the airway.
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Ingested foreign body

Children frequently put objects in their mouths. If
swallowed, these objects can cause obstruction or
respiratory distress. Coins are the most commonly
ingested foreign body, and, being radiopaque, they are
easily identified. When ingested foreign body is known
or suspected, the first imaging examination should be
radiographs of the neck and chest or radiographs of the
nasopharynx, chest, and abdomen.
SCOLIOSIS
Scoliosis has been defined as "the presence of one or more lateral-rotatory curvatures of the spine.
The radiographer should observe the following
guidelines for obtaining the easiest and potentially
most accurate method of accomplishing the bending
images:
• Place the patient in the supine position on the
radiographic table.
• Ask the patient to bend sideways as if reaching for
the knees.
• Ensure that the ASlS remain equidistant to the table
as the patient bends.
• Collimation and centering are crucial because the
resultant image must include the first "normal" shaped
(i.e., non-wedge-shaped) cervical or thoracic vertebra
down to the crests of the ilia. (Experience has shown
that curve progression usually stops coincident with the
fusing of the epiphyses of the iliac crests.)
• The geometric measurements determine the degree of
curvature. The selected method of treatment is
determined in part by the measurement of the angles
outlined.

Radiation protection
Because scoliosis images are obtained relatively
frequently to assess the progression of the curves,
effective methods of radiation protection must be used:
• Obtain the 3-foot AP projection using breast shields
(the AP is used as it allows for more stability of patient
especially after surgery); alternatively, position the
patient for the PA projection, with very careful
placement of breast shields.
• Ensure that lead is draped over the patient's right
breast tissue for the AP left-bending image, and vice
versa.
• Protect gonads by placing a small lead apron at the
level of the ASIS.

Conclusion:
Imaging in the pediatric population is unique, and it is essential for physicians to limit patient exposure to ionizing
radiation in the medical workup due to increased risk of cancer development. Children are at higher risk of cancer
development because they are more radiosensitive and live more years than adults. The use of nonionizing radiation
in children with ultrasound and MRI is recommended when possible. Also, as demonstrated in the case presentations
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in this chapter, the initial imaging modalities of choice in the evaluation of the majority of pediatric patients include
radiographs, which have a low amount of ionizing radiation, and ultrasound. Therefore, it is important to be aware
of the imaging modalities and techniques available to promote radiation protection in the imaging of children and to
take a conscientious approach to imaging this population.