Are facilities following best practices of pediatric abdominal CT scans?

Abstract

Background

Established guidelines for pediatric abdominal CT scans include reduced radiation dosage to minimize cancer risk and the use of intravenous (IV) contrast to obtain the highest-quality diagnostic images. We wish to determine if these practices are being used at nonpediatric facilities that transfer children to a pediatric facility.

Methods

Children transferred to a tertiary pediatric facility over a 16-mo period with abdominal CT scans performed for evaluation of possible appendicitis were retrospectively reviewed for demographics, diagnosis, radiation dosage, CT contrast use, and scan quality. If CT scans were repeated, the radiation dosage between facilities was compared using Student t-test.

Results

Ninety-one consecutive children transferred from 29 different facilities had retrievable CT scan images and clinical information. Half of CT scans from transferring institutions used IV contrast. Due to poor quality or inconclusive CT scans, 19 patients required a change in management. Children received significantly less radiation at our institution compared to the referring adult facility for the same body area scanned on the same child (9.7 mSv versus 19.9 mSv, P = 0.0079).

Conclusion

Pediatric facilities may be using less radiation per CT scan due to a heightened awareness of radiation risks and specific pediatric CT scanning protocols. The benefits of IV contrast for the diagnostic yield of pediatric CT scans should be considered to obtain the best possible image and to prevent additional imaging. Every facility performing pediatric CT scans should minimize radiation exposure, and pediatric facilities should provide feedback and education to other facilities scanning children.

Introduction

Seventy thousand U.S. children are diagnosed with appendicitis each year, and computed tomography (CT) is often employed to confirm the diagnosis [1], [2]. In adults, the diagnosis of appendicitis is often based solely on classic clinical features and physical examination [3]. Clinical diagnosis in children may be challenging, with features such as fever, anorexia, and migrating abdominal pain, often variable or absent and frequently present in other causes of abdominal pain [4]. Concerns about perforation due to diagnostic delay, costs of unnecessary inpatient observations, and defensive medicine to avoid a missed diagnosis have led to an increased reliance on imaging to diagnose appendicitis in children [5], [6].

If performed correctly, CT scanning approaches sensitivities of 98%; however, its use is not without risks [2]. Exposure to low-level radiation has been associated with an increased risk of malignancy, particularly when cumulative exposure resulting from repeated scanning is taken into consideration [7]. A child's growing and developing tissues are more sensitive to radiation than those of adults, and the oncogenic effects manifest over a longer latency period, since children have a longer life expectancy than adults [8]. When a fixed set of adult scanning parameters is used for children, the child receives a higher “effective” dose of radiation due to the child's smaller cross-sectional area [7].

The purpose of this study is to determine if established guidelines for CT scanning, including the use of intravenous (IV) contrast and reduced radiation exposure, are being utilized at nonpediatric facilities that transfer children to a tertiary pediatric center following initial evaluation of suspected appendicitis. We hypothesize that nonpediatric facilities are using more radiation per CT scan and not consistently following guidelines.