Pediatric x-ray techniques of chest and abdomen

1. PEDIATRIC CHEST AND ABDOMEN
XRAY TECHNIQUE, PITFALLS,
REMEDIES AND INDICATIONS
The chest radiograph is one of the most commonly requested
radiographic examinations in the assessment of the pediatric patient.
Depending on the patients' age, the difficulty of the examination will
vary, often requiring a specialist trained radiographer familiar with a
variety of distraction and immobilization techniques.

2. GRORUP 6B
• GROUP MEMBERS

3.  In the context of diagnostic imaging, childhood can be divided into six
main age groups, each of which has different needs and capabilities:
 birth to six months;
 infancy (six months to three years);
 early childhood (three to six years);
 middle childhood (six to 12 years);
 early adolescence (12–15 years);
 late adolescence (15–19 years).
Each age group requires a different level of interaction, tolerance and
understanding
CARTEGORIES OF CHILDHOOD

4.  Small AP diameter: The smaller depth of the thorax results in less
enlargement of the heart, due to magnification, on AP projections of
the chest compared to adults.
 The thymus: contributes to the cardiomediastinal shadow in young
children and its variable presentations can mimic pathology
 Multiple ossification centers at various sites can cause confusion and
reference texts should always be available, which in combination
with high quality images will aid
Children have faster heart/respiratory rates and they generally have
difficulty in staying still. Very short exposure times are required
Differences between children and adult

5.  Respiratory difficulty
 Persistent cough with fever
 Meconium aspiration
 Chronic lung disease
 Position of catheters or tubes
 Cyanosis
 Previous antenatal ultrasound abnormality suspected
 Thoracic cage anomaly
 As part of a skeletal survey for syndrome/NAI (Non accidental
injuries)
 Postoperative evaluation
General indications for pediatric chest and
abdomen x-ray.

6. Waiting area
 The reception area is the child’s and the parents’ first contact with the X-ray department. It
is essential that the staff and the environment put the child and parents at their ease as
quickly as possible.
 Working with children requires a child-friendly approach from all individuals involved.
 The waiting area should be as well-equipped as possible.
 It does not have to involve much expense, but toys and games aimed at all age groups
should be available. Even more general department could consider having
video/computer games available in the paediatric area, even if this is shared with the
paediatric outpatients.
 More specialized departments may be able to employ a play therapist.
 This is particularly useful in gaining children’s confidence for more complex procedures.
 Drawing and colouring activities are often appreciated, and children love donating their
own compositions to the department’s decor.
Special Considerations in pediatrics

7. Examples of child-friendly waiting area

8.  The room should already be prepared before the child enters.
 It is preferable to keep waiting times for examinations to a minimum,
as this will significantly reduce anxiety.
 The room must be immediately appealing, with colourful decor,
attractive posters and stickers applied to any equipment that may be
disconcerting.
 Soft toys undergoing mock examinations are also helpful.
 A fairly low ambient lighting is preferred, unless fluoroscopy
equipment, for example, can be operated in normal daytime lighting.
 This avoids darkening the room later, which may frighten a child.
Imaging room

9. Imaging room

10.  One should always introduce oneself to a child and parent in a
friendly and capable manner.
 The child’s name, age and address should be verified. It is important
to speak to the child at their level.
 A firm but kindly approach is required, and the child should be
escorted into the already prepared imaging room.
 It is preferable for the X-ray tube to be in the correct position.
 Adjusting its height over the child can be disconcerting.
 Usually only one parent is asked to accompany the child into the
room.
 This complies with radiation protection guidelines.
 However, both parents are sometimes required for holding.
Approach to a paediatric patient

12. These are devices that used in radiography to make sure the patient
stays in the correct position during the procedure. Example are;
 Tam-em-board
 Pigg-o-stat
 Tape, 4-inch ace bandage is best for small infants and young
children, whereas a 6-inch bandage works well for older children.
 Sheets or towels
 Sandbags
 Head clamps
 Compression bands
 Radiolucent sponge blocks.
Immobilization devices.

16. Standard projections,
As pediatrics vary in their level of cooperation, various projections
can be utilized to suit the patient's needs and age:
PA erect ,performed on older patients (teenage years), not
advisable for younger patients due to their attention span (looking
away from the 'camera' and everyone else can make for a very
agitated child)
 AP erect, ideal for cooperative younger children (i.e. between 3-7
years old) due to the ease of positioning and immobilization
 AP supine, performed when imaging unconscious or
uncooperative children
 AP supine (neonatal) ,performed mobile in the neonate unit
Projections

17. lateral view, not often performed in pediatrics.can be used to
highlight pathology in the mediastinum, costophrenic recess
and localize lesions 2
cross-table lateral view, utilized in patients under the age of 6
months,not often performed in pediatrics. can be used to
highlight pathology in the mediastinum,costophrenic recess and
localize lesions 2
Additional projections

18. In pediatric imaging, the anteroposterior supine chest x-ray is
beneficial for imaging unconscious or uncooperative patients.

19. Indications
This view is preferred in infant and neonate imaging, whilst AP erect and
PA erect views are ideal for children able to cooperate in sitting or standing
As radiation protection is necessary for pediatric patients, it is essential to
image the chest properly and avoid unnecessary repeats. If the pediatric
patient can only manage a supine view, this is more ideal than performing
a poor erect view.
Patient position
patient is supine,detector is placed underneath the patient, or the patient
is placed on top of the detector
head is straight and chin ideally out of the field of view
 arms are placed above the patient's head

20. Technical factors anteroposterior projection
suspended inspiration, observe breathing by watching the patient's
stomach
centering point the level of the 7th thoracic vertebra; on or above the
level of the nipple,a 10° caudal angle can be used to degrees the patient’s
lordosis
collimation superior to the 3rd cervical vertebrae, inferior to the
thoracolumbar junction, lateral to the skin margins
it is advised not to collimate too tightly at the apices as breathing may
cause the apices to move superiorly
orientation, Portrait
detector size 24 cm x 30 cm or 35 cm x 43 cm depending on the
patient’s size
exposure , 55-65 kVp,1-2 mAs
SID 110 cm
grid no

23. Image technical evaluation
 entire lung fields should be visible; post-processing
collimation is not advisable in pediatric imaging (if it is
exposed it should be examined). This is particularly
important if the clinical indications query a foreign body
as demonstrating the abdomen will also be useful in
diagnosis
 6 anterior ribs must be visible to ensure full inspiration

24.  Peak inspiration to include eight to nine posterior ribs (four to five anterior ribs).
 No rotation. Medial ends of the clavicles should overlap the transverse processes
of the spine symmetrically, or anterior rib ends should be equidistant from the
spine.
 No tilting or lordosis. Medial ends of the clavicles should overlie the lung apices.
 Superior/inferior coning should be from cervical trachea to T12/L1, including the
diaphragms.
 Lateral coning should include both shoulders and ribs but not beyond the
proximal third of the humeri.
 The trachea, major bronchi and spine should be visible
 Visually sharp reproduction of the diaphragm and costophrenic angles.
 Visualization of retrocardiac lung and mediastinum.
Image evalution

25. Case 1: normal chest radiograph Normal pediatric chest (supine)

28.  Classically, the port hole of the incubator must not overlie the chest.
 All extraneous tubes and wires should be repositioned away from the
chest area.
 Exposure should be made in inspiration. Watching for full distension
of the baby’s abdomen rather than the chest best assesses this
Expiratory images mimic parenchymal lung disease.
 Arms should not be extended fully above the head, as this will lead
to a lordotic position.
 Lordotic images show anterior rib ends pointing upwards and the
lung bases are obscured by the diaphragm.
 The head must be supported to avoid the chin rolling forward and
obscuring the upper chest.
Common faults and remedies

29.  Minimal exposures of less than 0.02 seconds should be used to
avoid motion artefact.
 Avoide rotation as much as possible as this can cause
misinterpretation of mediastinal shift and lung translucency. The
separate ossification centres of the sternum, projected over the
lungs can also cause confusion.
 In a neonatal ward where the name label is large compared to the
size of the image, the label should not obscure any of the anatomical
detail.
 Taking a radiograph when a baby is crying should be avoided as this
can cause overexpansion of the lungs, which may mimic pathology.
 Overexposure of neonatal chest radiographs results in loss of lung
detail.

30. Projections
 Basic view (Postero-anterior – erect)
 Alternative view (Antero-posterior – erect, Antero-posterior –
supine)
• Supplementary view (Lateral)
Radiographic technique for the post
neonatal chest

31.  The key to erect chest radiography is a specifically designed
paediatric chest stand. The cassette holder should be in such a
position that a parent or carer is able to hold the child easily. A
cassette is selected relative to the size of the child.
 Indications Congenital heart disease, Inhaled foreign body,
Oesophageal pH probe for reflux study
 Technical factors
• Cassete size 18 × 24cm
• IR (nongrid) or grid with systems when it can’t be removed
• SID Minimum of 183cm
 Positioning
Postero-anterior – erect

32.  Set upper border of lead shield with R and L markers 1-2″
 Depending on the child’s age, the child is seated or stood facing the
cassette, with the chest pressed against it.
 The arms should be raised gently, bringing the elbows forward. The arms
should not be extended fully.
 The parent or carer should hold the flexed elbows and head together and
pull the arms gently upwards and slightly forward to prevent the child from
slumping backwards.
 The horizontal central beam is directed at right-angles to the midline of the
cassette at the level of the eighth thoracic vertebra.
 Center the CR to midlung fields, mammillary (nipple) line
 Collimate the beam closely on four sides to outer chest margins.
 Exposure is done on Full inspiration; if crying, expose at full inhalation
Patient positioning

34.  Peak inspiration six anterior ribs and nine posterior ribs above the
diaphragm).
 Whole chest from just above the lung apices to include the
diaphragms and ribs.
 No rotation (medial ends of clavicles or first ribs should be
equidistant from the spine).
 No tilting (clavicles should overlie lung apices). Anterior ribs should
point downwards.
 The trachea, proximal bronchi, diaphragm and costophrenic angles
should be clearly visible
 Visually sharp retrocardiac lung and mediastinum.
Image evalution

36.  Indication
 Technical factors 18 × 24cm
 IR (nongrid) or grid with systems when it can’t be removed
• Cassete 8 x 10″
• kVp 65 – 80kVp
• mAs 1 – 2 mAs
• Ffd 110cm
Antero-posterior – erect

37.  This is done when the postero-anterior projection is not possible.
 The child is seated with their back against the cassette, which is supported vertically, with the upper
edge of the cassette above the lung apices.
 The arms should be raised gently, bringing the elbows forward.
 The arms should not be extended fully.
 The parent or carer should hold the flexed elbows and head together with their fingers on the
forehead, to prevent the child’s chin from obscuring the upper chest.
 The holder should pull gently upwards to prevent the child from slumping forward.
 Place a foam wedge behind the shoulders to prevent the child from adopting a lordotic position.
 The horizontal central beam is angled 5-10 degrees caudally to the middle of the cassette
 CR is centered at the level of the eighth thoracic vertebra, approximately at the midpoint of the body
of the sternum
 Collimate the beam to area of interest to avoid exposure of the eyes, thyroid and upper abdomen
Patient positioning

39.  Anatomy Entire lungs from apices to costophrenic angles should be visible
 Peak inspiration - five or six anterior ribs and nine posterior ribs
 Collimation - whole chest from just above the lung apices to include the diaphragms and
ribs.
 No rotation - medial ends of clavicles or first ribs should be equidistant from the spine or
equal distance from lateral rib margins to spine
 Exposure quality – vertebral bodies should be visible through the heart.
 No motion, sharp outlines of rib margins and diaphragm
 Faint outline of ribs and vertebrae through mediastinal structure
Image evaluation

41.  Indications Respiratory difficulty, Chronic lung disease, Chest
pain
 Technical factors
• Cassette size 8 x 10
• No grid
• FFD 128 to 180
• Shortest exposure time possible
• Kvp 75-80
Anterior posterior supine

42.  A cassette size is selected depending on the size of the child.
 The child is positioned supine on the cassette, with the upper edge positioned
above the lung apices.
 A foam pad is places between the thorax and the cassette to avoid a lordotic
projection. A small foam pad is also placed under the child’s head for comfort.
 The median sagittal plane is adjusted at right-angles to the middle of the
cassette. To avoid rotation the head, chest and pelvis are straight.
 The child’s arms are held, with the elbows flexed, on eachside of the head.
 A suitable appliance, e.g. Bucky band or Velcro band, is securedover the baby’s
abdomen and sandbags are placed next to the thighs to prevent rotation.
 The vertical central beam is directed at right-angles to the middle of the cassette
and CR is centered at the level of T8 (mid-sternum).
 For babies with a very hyperinflated barrel chest (due to bronchiolitis or asthma),
the tube is also angled five to 10 degrees caudally to avoid a lordotic projection
Positioning

44.  Full Inspiration; visualization of 8-9 posterior and 4-5 anterior
ribs
 Rotation; medial ends of the clavicle should be equidistant
from the spinous process
 Exposure; visualization of the vertebral bones through the
heart
 Collimation; whole chest from the lung apices to the
diaphgram.
Image evaluation

46.  This is a supplementary projection wich is undertaken to locate the
position of an inhaled or swallowed foreign body, to evaluate middle
lobe pathology or to localize opacities demonstrated on the postero-
anterior/antero-posterior projection.
 Particularly useful in assessing retrosternal and retrocardiac
airspaces.
 Technical fators
• Cassette sie 24x30cm
• Exposure: 80-90 kVp and 1-3 mAs
• SID: 180cm
• Grid: not often used
Lateral projection

47.  The patient is standing on either side of the body towards the cassette so
that he median sagittal plane is adjusted parallel to the cassette.
 The arms are raised above the head and supported.
 Chin and arms elevated sufficiently
 The mid-axillary line is coincident with the middle of the cassette, and the
cassette is adjusted to include the apices and the inferior lobes.
 Direct the vertical central ray at right-angles to the middle of the cassette in
the mid-axillary line.
 Central Ray CR is centered to midlung fields, mammillary (nipple) line
 SID 183-307cm
 Collimation: Closely collimate on four sides to outer chest margins.
 Respiration: Full inspiration; if crying, time exposure at full inhalation
Positioning

49.  Whole chest from C7 to L1, Sternum and spine to be included
and to be true lateral.
 Entire lungs from apices to costophrenic angles
 Visualization of whole trachea, major bronchi, both domes of
the diaphragm and hilar vessels.
 No rotation, bilateral posterior ribs superimposed
 No motion; sharp outline of diaphragm, rib borders, and lung
markings
 Sufficient exposure to faintly visualize ribs and lung markings
through heart shadow
Image evaluation

51.  Tilted with clavicles high above the lung apices.
 This lordotic projection results in the lower lobes of the lungs
being obscured by the diaphragms.
 Pneumonia and other lung pathology can be missed.
Common faults and remedies

52. Recommended projections
 Basic view (Antero-posterior – supine)
 Alternative view (Postero-anterior – prone)
 Supplementary (Lateral, Postero-anterior – left lateral
decubitus, Antero-posterior – erect)
Abdominal pediatric radiography

53.  Indications Evaluate gas patterns, soft tissue and possible
calcification
 Technical factors
• SID-100cm
• IR size determined by size of the patient length wise
• Grid, if 10cm larger
• Shortest exposure time
Antero-posterior supine view

54.  Lie the baby in supine, align long axis of the baby to that of the IR.
The midline of the baby should be perpendicular to the IR
 If parental assistance is necessary, provide a lead gown or an
immobilizer if necessary
 To ensure that the child is not rotated, the anterior superior iliac
spines should be equidistant from the cassette.
 The cassette should be large enough to include the symphysis pubis
and the diaphragm.
 The vertical central ray is directed to the centre of the cassette.
 The CR is centered in the midline at the level of iliac crest
 Collimate to the area of interest including the xiphiod process
Positioning

56.  Anatomy demonstrated; Entire contents of the abdomen include
diaphragm, lateral abdominal walls ischial tuberosities, gas
patterns, air-fliud levels and soft tissue if not obscured by
excess fluid. Pelvis and spine should be straight, with no
rotation.
 Visualization of kidney and psoas outlines consistent with age
and bowel content and sharp bony margins
 Rotation; Evidenced by the ASIS being equidistant the IR
 Exposure; No motion is evidenced and diaphragm gas patterns
appear sharp.
Image evaluation

58.  Usually inadequate coning but occasionally too tight coning
excludes the diaphragm.
 Male gonads not protected.
 Careful technique is needed to address these problems.
Common faults and remedies

59.  Indications: Evaluate gas patterns, soft tissue and possible
calcification
 Technical factors
• SID-100cm
• IR size determined by size of the patient length wise mostly
18×24,
• Grid, if 10cm larger
• Shortest exposure time
Anterior Posterior ERECT

60.  Patient is standing erect facing away from the IR with legs
thoroughly openings
 Arms above head, side body clamps firmly in place
 Lead shield at level of symphysis pubis.
 If necessary, have parent hold arms overhead with one hand, and
with other hand hold legs to prevent rotation of pelvis or thorax
(provide with lead apron and gloves).
 Center the CR at the level of umbilicus.
 Collimation the beam On four sides to abdominal borders
 Expose is made on expiration, or during least movement.
Positioning

62.  Anatomy Demonstrated: Soft tissue and gas-filled structures;
air-fluidlevels on erect, Diaphragm to symphysis pubis included
if possible
• Exposure:
• • Optimal density (brightness) and contrast to visualize soft
tissuestructures and skeletal structures; no motion
Image evaluation

64.  Usually inadequate coning but occasionally too tight coning
excludes the diaphragm.
 Male gonads not protected.
 Careful technique is needed to address these problems.
Common faults and remedies

65. Constipation
 A very fast film/screen system should be used in chronic cases. A study of colonic
transit time may also be requested.
 The patient swallows 30 radio-opaque plastic pellets and an antero-posterior
radiograph with the child in the supine position is performed at day 5 following
ingestion.
 If pellets are not present on day 5, this is normal.
 If there is a general delay in colonic transit, then the pellets will be distributed
throughout the colon.
 If the pellets are grouped in the sigmoid/rectum, then there is poor evacuation.
 A medium-speed screen/film system is used in children under two years of age
when Hirschprung’s disease is suspected.
 All images should allow adequate assessment of the spine
Modification technique

67. Suspected swallowed foreign body
 Carry out AP chest and AP abdominal to include the neck and
upper abdomen.
 The radiograph should demonstrate the mandible to iliac crests.
 If a foreign body is demonstrated in the neck or chest, a lateral
radiograph should be taken to confirm position.
 If the swallowed foreign body is suspected be radiolucent then a
contrast study may be indicated.

69. Imperforation anus
 In this case, prone invertogram is commonly use as the main projection using horizontal beam
 This allow the intraluminal air to rise and fill the most distal bowel to assess the level of atresia
Position of patient and cassette
 The infant should be place in the prone position, with the pelvis and buttocks raised on a triangulat
covered foam pad.
 The infant should be kept in this position for approximately 10-15 minutes.
 The cassette is supported vertically against the lateral aspect of the infants pelvis and adjusted
parallel to the median sagittal plane.
 The horizontal centeral ray is directed to the center of the cassette and vertical ray below the iliac
crest.
Note; A lead marker is taped to the skin in the anatomical area where the anus would normally be
sited . The distance btn this and the most distal air filled bowel can then be measured.