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.

• The technologist's attitude and approach to a child.• The technical preparation in the room.

Successful radiographic studies are dependent on two things:

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.

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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 seatB.Side body clampsC.Film holder mountD.Swivel baseE.Adjustable lead shield with markersF.Mounting stand on wheelsG.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.

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

Sandbags

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 or retention bands are valuable aids for immobilization. Compression bands, however, are more effective with pediatric patients when used in combination with sandbags,

COMPRESSION BANDS AND 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,

WEIGHTED ANGLE BLOCKS AS HEAD CLAMPS

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.

AsthmaAsthma 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.)

PATHOLOGIC INDICATIONS FOR THE PEDIATRIC RESPIRATORY SYSTEM

AtelectasisThis 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.

BronchiectasisIn 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.

CroupThis 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 DISEASERADIOGRAPHIC EXAM AND (+) OR (−) EXPOSURE ADJUSTMENT

1. Aspiration (mechanical )AP and lateral chest or AP and lateral upper airway for obstruction

2. Asthma (in children) PA and lateral chest

3. Atelectasis (lung collapse) 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. HydrocephalusHydrocephalus 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 OsteoporosisThis type of osteoporosis (in which bone becomes less dense and more fragile) occurs in children and young adults.

5. OsteochondrodysplasiaIn 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. OsteochondrosisThis 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 BifidaThe 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 DISEASERADIOGRAPHIC EXAM AND (+) OR (−) EXPOSURE ADJUSTMENTS

Craniostenosis (craniosynostosis) AP and lateral skull

Developmental dysplasia of hip (DDH), or congenital dislocation of hip (CDH) Ultrasound, AP hip

Hydrocephalus Prebirth, ultrasound, or AP lateral skull (+) increase based on size

Idiopathic juvenile osteoporosis Bone survey study or AP of bilateral upper or lower limbs (−) slight decrease

Osteochondrodysplasias •Achondroplasia

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 DiseaseIn 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.

HepatomegalyHepatomegaly, 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 KidneyIn 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.

HydronephrosisHydronephrosis, 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 ObstructionIn 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 StenosisThis 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 DISEASERADIOGRAPHIC EXAM AND (+) OR (−) EXPOSURE ADJUSTMENTS

Celiac disease Erect or decubitus abdomen and/or GI series

Hepatomegaly AP abdomen

Hirschsprung's disease (congenital megacolon)

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•VolvulusNonmechanical:•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