This document discusses pediatric radiology and focuses on proper techniques and positioning for imaging the chest and abdomen in children. Key points include: - Obtaining chest x-rays requires proper inspiration, positioning without rotation, and ensuring adequate exposure. Positioning the child comfortably can help reduce movement. - Abdominal exams should include supine, prone, and erect views to visualize the maximum amount of bowel by moving gas into different loops. - Children are more vulnerable to radiation due to faster cell growth and their longer remaining lifespan after exposure. Proper techniques help minimize unnecessary radiation dose.

1. Pediatric Radiology
Imarzen V. Elepaño MD FPCR FUSP FCTMRISP CCD
Dept Of Radiology
UP-PGH

2. Consent, immobilisation and
health care law

3. • Children’s rights
• Perceptions of children‟s rights are not
universally consistent and it was the goal
of the United Nations Convention on the
Rights of the Child 1989 to clarify
children‟s rights.
• Three important articles for health care
workers within this convention are
identified

4. • From the United Nations Convention on the Rights of the
Child.
• Article 3: In all actions concerning children, the best
interests of the child shall be a primary consideration.
• Article 12: Parties shall assure to the child who is capable
of forming his/her own views the right to express those
views freely in all matters affecting the child, the views of
the child being given due weight in accordance with age and
maturity of the child.
• Article 24: Parties shall take all effective and appropriate
measures with a view to abolishing traditional practices
prejudicial to the health of children.

5. • Immobilisation versus restraint
• The term „restraint‟ is generally
reserved for use within the mental
health setting.
• The more general terminology used
within health care is „immobilization‟.

6. • To immobilize a person is to render
them fixed or incapable of moving
• whereas restraint is the forcible
confinement, limitation or restriction

7. • European Guidelines on Quality Criteria for Diagnostic
Radiographic Images in Paediatrics were issued.
• These guidelines state that patient positioning, prior to
exposure to radiation, must be exact whether or not the
patient co-operates.
• The guidelines advocate the use of physical restraints in
the immobilization of young children and state that for
infants, toddlers and young children, immobilization devices,
properly applied, must ensure that the patient does not
move and the correct projection is achieved

8. • Holding children still – a five-point
model

9. • (1) Prepare child and guardian for
procedure and explain their role
• (2) Invite guardian to be present
• (3) Use a specific room for painful
procedures
• (4) Position child in a comforting manner
• (5) Maintain a calm and positive
atmosphere

10. • Little research has been published
that evaluates techniques in holding
and comforting children, even though
it is generally agreed that all health
professionals working with children
need education and training into the
immobilization and distraction of
children

11. • Prepare child and guardian
• Before the radiographic examination
commences, both the child and guardian
need to know why the examination is
necessary, what the procedure will be and
essentially what their role will be (i.e. what
is expected of them).

12. • Invite guardian to be present
• The presence of a guardian within the
examination room provides the child with
security and it has been found that 99%
of 5–12 year-olds believe that the
presence of their guardian will help reduce
pain and anxiety.

13. • Guardians are also able to :
• comfort the child in a familiar manner
• implement appropriate distraction
techniques that can reduce the child‟s fear
and anxiety,
• increase the child‟s co-operation and
• minimize the need for restraining devices.

14. • Position child in a comforting manner
• Lying supine within an unfamiliar
environment increases the feeling of
helplessness and loss of control in
adults and children alike and
increases patient anxiety.

15. • The need for „cuddles‟ and comfort
throughout an imaging examination is
not restricted to very young children
and children as old as 7 or 8 years
will prefer to sit across a guardian‟s
lap or next to a guardian to gain
comfort from their presence

16. • a) and (b) Sitting an
older child next to the
guardian allows them
to feel comforted
while still respecting
their „older‟ status.
• The guardian can also
assist with
immobilization.

17. • a) and (b) Sitting the child
across the guardian‟s lap is
a natural and comforting
position for older children
and permits some adult
assistance with positioning
and immobilization.
• Note the guardian and
child are seated to the
side of the table.

18. • Seating a young child
at the end of the
table where they can
„lean in‟ to the
guardian is more
comforting than being
laid in the supine
position and may be
useful for
examinations of the
lower limb.

19. • a) and (b) The
straddle hold is a
natural, comforting
position for young
children and naturally
allows the guardian to
successfully
immobilize the child
and assist in
positioning.

20. • (a) and (b) Projectors
may be useful
distraction tools
within the x-ray room
but care needs to be
taken to ensure that
they are positioned in
a safe and appropriate
place without
electrical leads
trailing across the
room.

21. • Maintain a calm, positive atmosphere
• If you talk to a screaming child quietly and
positively then eventually they will calm
down.
• Anxiety levels in children and adults
increase with the level of surrounding
noise and therefore focusing on a calm and
quiet voice can help reduce this anxiety.

22. • Distraction tools
• The use of distraction techniques within health care is
growing greater in prominence and the experts in the use of
distraction and play are play specialists.
• Alternatively, various pieces of equipment designed to
distract children are available but care must be taken
before purchase to ensure that they are easy to use and
operate.
• Whatever the distraction tools used, it is essential that
they be used only within the examination room to maintain
their novelty value and maximize their effectiveness.

23. Radiation protection
• Radiation protection in diagnostic
radiography is essential if medical
exposure to ionizing radiation is to be
maintained at a level of minimal acceptable
risk.
• The concept of risk is an important one
and it is essential that we reduce risks to
patient and staff through the
justification, optimization and limitation of
radiation exposures

24. • Patient positioning
• Incorrect positioning is the most
frequent cause of inadequate
radiographic image quality in
paediatrics and should not be used
as an excuse for substandard image
quality

25. • Field size and beam limitation
• Inappropriate field size is a common fault in paediatric
radiographic technique and its correction is an effective
method of reducing unnecessary dose to the patient.
• Correct beam limitation requires the radiographer to apply
precise knowledge of external anatomical landmarks to the
paediatric patient being examined.
• Reiterate the importance of accurate collimation to the
area of interest as a method of reducing dose

26. • Protective shielding
• For all paediatric examinations, the
consistent use of lead rubber to
shield that part of the body in
immediate proximity to the
diagnostic field is essential.

27. Understanding Radiation
and Its Effect on Children

28. • Every day each of us receives 1 millirad of
radiation from environmental sources. The
biggest contribution to environmental
radiation comes from radon gas, which is a
decay product in the uranium series.
• However, the largest source of radiation
exposure resulting from human activity is
diagnostic X-rays.

29. • Since radiation is ubiquitous in our
environment, why are we concerned about
medical radiation?
• Firstly, the background dose is much lower
than that of CT. There have never been
proven deleterious effects secondary to
“normal” background radiation.

30. • Of those effects caused by radiation
(genetic mutations, carcinogenesis,
and cell death), the one we are most
concerned about is carcinogenesis.
• There are a lot of data for radiationinduced cancer, both incidence and
mortality

31. • The incidence of cancer is 2–2.5 times
greater than the mortality.
• The biological effects of radiation are
greatest on the faster-growing organisms
– the fetus, infant, and young child.
• The thyroid gland, breast tissue, and
gonads are organs with increased
sensitivity in growing children.

32. • A second factor in children‟s vulnerability
to radiation carcinogenesis is the life-long
cumulative effect of radiation.
• The younger the patient and the more
times he/she is exposed to radiation, the
higher the probability of cancer.

33. • The third factor which explains why
children are at the greatest risk of
radiation carcinogenesis is the fact
that it takes a long time to develop a
cancer and that children have the
longest life span remaining after
exposure.

34. The chest and upper
respiratory tract
• Chest radiography is the most frequently
performed paediatric plain film
examination1 and may be requested to :
• assist in establishing a preliminary
diagnosis, or
• to monitor the progression of a
respiratory condition and assess the
effectiveness of any implemented
treatment.

35. • Despite the relative frequency , it is
still regarded as one of the most
clinically challenging examinations to
perform adequately and, as a
result, many chest radiographs are of
reduced image quality, in particular
those undertaken on children under 6
years of age3

36. Chest Examinations in
Children
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Normal inspiratory chest
a Frontal examination reveals
a normal lung volume.
The criteria for a normal lung
volume are:
(a) less than one-third of the
heart is projected below the
hemidiaphragm;
(b) the diaphragm is
rounded, and the sixth or
seventh anterior rib (ar)
intersects the diaphragm; and
(c) the lungs are air-filled
(black).

37. •
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This is a properly positioned, nonrotated film as evidenced by
(1) comparative anterior ribs
equidistant from the pedicles (p),
(2) medial aspects of the clavicles
(cl) symmetrically positioned,
(3) the carina approximates the
right pedicles (arrow), and
(4) no difference in aeration
between the two sides.
The film was taken with the
patient erect, as shown by the
air–fluid level in the stomach
(arrowhead)

38. • b Lateral examination
confirms normal aeration
of the lungs.
• Note that the vertebral
bodies (vb) get blacker as
we go from superior to
inferior.
• The patient is slightly
rotated as you can see the
ribs on each side (arrows)

39. • Technical Factors
• Technical problems in pediatric radiology
are caused by:
• A largely by uncooperative children.
• The young patients are not feeling well,
• the environment is strange, and
• they may as a result be quite frightened.

40. • Preliminary evaluation of the chest
radiograph should assess these technical
factors:
• ● The degree of inspiration: lung volume
• ● The position of the patient: extent of
rotation and posture of the patient
• ● How the film was obtained
• ● Adequacy of the exposure

41. • Lung Volume
• The radiographic examination of the
chest begins with frontal and lateral
roentgenographs taken after deep
inspiration

42. • If the child has taken a shallow breath:
• the heart may appear enlarged,
• the vessels may coalesce to give a false
impression of an opacity, especially in the
region of the bases and hila, and
• sometimes the radiograph has a hazy
quality due to the influx of blood and lack
of aerated lung.

43. • Position of the Patient
• The position of the patient is
determined by rotation and posture
(lying, sitting, or standing).
• The child‟s posture is important.

44. • When the patient is supine, the vascular
supply to the upper and lower lobes is
equal since gravity has no effect.
• When the child is sitting or standing,
gravity plays a significant role, and the
upper-lobe vessels are less distended than
the lower-lobe vessels (one-third to twothirds size).

45. • One can determine an erect film by
looking at the air–fluid level in the
stomach and at changes in the
pulmonary vasculature.

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c–e These three films are in
varying degrees of inspiration:
c is an optimal inspiration;
d is acceptable but less than
average with the 5th anterior rib
at the diaphragm;
e shows complete expiration with
almost a white-out of the lungs.
It is important to appreciate the
degree of inspiration so one can
make an accurate determination
of any pathology

47. • The rotated chest
• – asymmetric clavicles,
differences in aeration ,
heart projected over one
hemithorax and not the
other, asymmetric ribs
when relating the anterior
rib to the pedicle
• The ribs are visible and
not the spinous process

48. • How the Film Was Obtained
• The third major technical factor to keep in mind
is how the film was obtained.
• Greater magnification occurs when
structures, such as the heart, are farther from
the film.
• When the X-ray beam passes through the patient
from back to front [a posterior–anterior (PA)
projection], the heart is closer to the film and is
less magnified.

49. • Conversely, if the X-ray beam enters
the front of the patient‟s
chest, passes through the back and
onto the film [an anterior– posterior
(AP) projection], the magnified heart
and great vessels may give the
impression of cardiomegaly.

50. •
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Effect of patient position and the
tube target distance
a Patient in supine position, with
approximately 46 in. (ca 1.2 m)
between the X-ray tube and the
film. Upper-lobe vessels (arrow)
are equal in size to those of the
lower lobe (arrow). The heart is
magnified. There is a central
venous catheter in place
b Patient is erect and 6 ft (ca 1.8
m) from the X-ray tube. It is
difficult to see the upper lobe
vessels, but the lower lobe
vessels are easily seen

51. • Adequacy of Exposure
• Be sure that the film is properly exposed or the
digital image is windowed and leveled properly
• You can tell this on the frontal film by examining
the vertebral column behind the heart.
• If you can see the detailed spine and pedicle
through the heart and can also see the pulmonary
vessels in the peripheral lung, the exposure is
correct.
• If you see only the spine but not the pulmonary
vessels, the film is too dark (overexposed).

52. •
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Adequacy of exposure
b This is an underexposed
examination. The film is
white, and you can barely see
the surgical sutures (arrow) in
the sternum and cannot see
the spine at all
c This is a (overexposed)
frontal examination;
Note how on the poorly
exposed film the pedicles can
be seen (arrow), but you
cannot see peripheral lung
markings

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Summary
A thorough radiographic work-up should include the
following, in order of priority:
● Good erect, nonrotated inspiratory frontal and lateral chest films
● Inspiratory and expiratory films (if foreign body is suspected, there is
persistent hyperexpansion or atelectasis ) and/or fluoroscopy of the chest
to observe mediastinal shift and diaphragmatic excursion (decubitus films
may help)
● Specialized magnification high-kV films of the airway, if the air passage
itself needs evaluation
● An esophagram in any unexplained airway disease
● MR or CT for mediastinal masses
● High-resolution CT for complete work-up of unusual or questionable
pulmonary parenchymal abnormalities

54. Respiratory system
Airway abnormalities

58. Respiratory distress in the newborn

63. Pulmonary infection

65. Thoracic tumours

68. Abdominal Imaging

69. • The abdominal examination should include
a minimum of three views: supine, prone,
and erect.
• One can think of the air in the abdomen as
contrast medium; the purpose of obtaining
three views is to move air into different
loops of bowel so that the maximal
quantity of bowel can be visualized.

70. •
The value of air as contrast medium by
utilizing three views
•
a Supine roentgenograph in this 15year-old girl with abdominal pain
reveals multiple air-filled loops of
bowel in the midabdomen but little gas
within the rectum
b An erect film reveals that the base
of the lungs is clear, and there is no
free air under the diaphragm. There is
gas in the hepatic flexure, transverse
colon, and splenic flexure
c Prone examination reveals gas in the
rectum (R), ascending (A), and
descending (D) colon. The predominant
pattern is that of colonic gas. The
small bowel is not distended, and there
is no evidence of obstruction
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71. •
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The upper gastrointestinal series
a The stomach is visualized in multiple
positions so that contrast agent moves
through the fundus (F), body (B), and antrum
(A). The mucosal pattern is smooth and
regular without any disruption. Peristaltic
waves can be deduced by the various shapes
of the stomach, noted on multiple films as
well as at fluoroscopy
b Oblique view shows to advantage the
contraction at the antrum (A) and the pyloric
channel (P). The duodenal bulb (D) is
triangular and smooth. The duodenum is
partially filled
c Further along in the study, the duodenum
is entirely visualized, and the ligament of
Treitz (arrow), behind the stomach, is at the
level of the duodenal bulb. Note the four
portions of the duodenum (1, 2, 3, 4). The
jejunal mucosal pattern appears feathery and
unobstructed
d Drawing of the frontal view of the
proximal stomach to the jejunum
e Drawing of the lateral projection.
Duodenum parts 1–4. E, esophagus; F, fundus;
B, body; A, antrum

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Small bowel follow-through
a A film taken 30 min after the upper
portion of the gastrointestinal tract was
viewed reveals that the proximal half of the
small bowel is now filled.
The demarcation between the jejunum and
ileum is difficult to see, but bowel is filled on
both the right and left sides of the midline.
The loops are not significantly separated
b, c A 1.5-h film
(b) shows that contrast has advanced into
the right ascending colon (C); the feathery
pattern of the jejunum is still visible.
In c the terminal ileum is demonstrated by
compressing it with a balloon paddle and
taking a spot film.
This method helps evaluate the
cecum,ileocecal valve, and terminal ileum. CE,
cecum

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Normal barium enema
a Frontal view of the barium-filled colon
shows the midline rectum (R), tortuous
sigmoid (S), and rather smoothwalled
descending colon (D).
The haustrated transverse colon
(T), ascending colon (A), and the cecum (C)
are also identified.
Reflux into the terminal ileum (TI) is present
•
b Lateral projection affords a good view of
the rectum and its proximity to the sacrum
•
c Postevacuation films show the bowel almost
totally collapsed, with no filling defects. The
thin, tubular, bariumfilled appendix is seen in
the right lower quadrant (arrow)

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The female urethra
a Filled bladder with catheter in
place again reveals the central
position of the bladder without
any mass impinging on its wall
b, c On voiding, as seen on this
oblique view, the posterior aspect
of the bladder becomes slightly
irregular.
The urethra is much shorter in a
female and often displays a
“carrot-top”or “spinningtop”deformity (C). There is often
reflux into the vagina when the
patient voids in the recumbent
position (asterisk)
d The female urethra

75. •
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The normal excretory urogram (EU)
a Prone coned-down view shows the
nephrogram effect. The kidneys are
homogeneous, and there is little contrast
material in the collecting systems.
Occasionally such a film is taken 1–2 min
after injection; the collecting systems are
then seen to better advantage.
On this initial film the renal axis is noted
with the upper pole being closer to the spine
than the lower pole.The renal contours are
evaluated and should be smooth without
scarring or indentations
b This 5-min film reveals the renal collecting
system – the calyces and infundibula leading
to the renal pelvis and ureter. Any deviation
or blunting of the collecting system is seen
at this time. The renal pelvis then tapers into
the ureter. The ureters pass inferiorly,
crossing the margins of the transverse
processes of the vertebrae. The bladder is
separate from the pubic bones because it is
partially filled. A 10-min frontal film is
usually obtained to view the entire system to
see if there has been any change secondary
to osmotic load
c The normal intrarenal anatomy as see on
the EU

76. Signs or symptoms which may lead to imaging
(listed alphabetically)
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Abdominal mass (Chap. 6)
Abdominal–pelvic pain
Acute (particularly right lower quadrant)
Chronic (imaging only after clinical
observation)
Bowel obstruction
Child abuse
Constipation (chronic and severe except in
neonates)
Enuresis (imaging usually not necessary)
Failure to thrive
Gastrointestinal bleeding
Gastrointestinal perforation
Hematuria
Jaundice of uncertain etiology
Lymphadenopathy (systemic)
Malformations including meningomyelocele
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Anorectal abnormalities
Genital abnormalities
Renal transplant
Screen for monitoring spread of known tumor
Screen for conditions/syndromes with
abdominal
components
Aniridia (Wilms‟)
Beckwith‟s syndrome (Wilms‟)
Sickle cell disease (gallstones)
Tuberous sclerosis
(renal cysts and renal angiomyolipoma)
Scrotal pain
Systemic infection
Trauma (with appropriate history
and/or significant physical or laboratory
findings)
Urinary tract infection
Vomiting

77. Gastrointestinal tract

78. Oesophagus

80. Stomach and duodenum

82. Small bowel

84. (+) freeair, wriggler sign

85. Colon

88. Genitourinary tract

89. Renal abnormalities
Congenital

92. Lower urinary tract
abnormalities

94. Genitourinary tumors

96. Skeleton

97. • The second most frequent
radiographic study, after the chest
film, is that of the pediatric
skeleton.
• The most common indication for such
studies is of course trauma.

98. •
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Unique Features
The skeleton of children is quite different from that
of adults.
The child‟s bones are obviously still growing, developing, and
modeling; therefore, many ossification centers are
constantly appearing and fusing with the main skeleton
• Because these ossification centers may appear
fragmentedand may ossify in a multicentric fashion, they
can easily simulate chip fractures. One should therefore
obtain comparison views of the contralateral extremity if
there is any question.

99. • Another unique difference between the child‟s
and the adult‟s skeleton is the low incidence of
dislocations (complete disruption of the joints
with loss of contact between articulating
surfaces) of otherwise normal joints
• Because of this resiliency children are more likely
to have “incomplete fractures,” two of which have
characteristic names – the greenstick fracture
and the torus fracture.

100. •
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The normal elbow at different
stages of development
Note the appearance of the
various ossification centers as
the child matures (see Table 7.1)
a A 6-month-old. Capitellum (C) is
ossified
b A 4-year-old. Radial head
(arrow) and medial epicondyle
(asterisk) have begun to ossify
c An 8-year-old. Secondary
centers of ossification are larger
d A 15-year-old.Mature elbow
with closure of the growth plates

101. •
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Common pediatric
fractures
a Greenstick fracture.
The fracture appears to
extend halfway through the
diaphysis (arrow).Note the
bowing of the radius and
ulna
b Torus fracture.Note the
buckling at the medial aspect
of the distal radius (arrow).
Microscopic examination
of both greenstick and torus
fractures show trabecular
disruption across the entire
horizontal width of the bone

102. Common Pediatric
Problems
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Trauma
Nonaccidental Injury(Child Abuse, Battered Child)
Developmental Dysplasia of the Hip
Osteomyelitis
Bone Infarct
Metabolic Disorders
Bone Tumors- Benign Lesions vs Malignant Lesions
Arthritides
Congenital Abnormalities