Balancing Imaging Risks, Benefits for Pediatric ED Patients

When an ill or injured child arrives at an emergency department, clinicians face a balancing act when considering how advanced imaging can assist with a diagnosis, particularly if their facility does not have a focus on pediatric care.

Should a clinician order a CT scan, which may raise concerns regarding radiation dosing? For which conditions are ultrasounds or MRIs better? And is any imaging necessary if the child will be transferred soon to a pediatric hospital?

To assist with the decision-making process and to weigh risks like radiation exposure and incidental findings , the American Academy Of Pediatrics (AAP), the American College of Emergency Physicians, and the American College Of Radiology issued a joint policy statement and technical report published online on June 27 in Pediatrics, as well as in the Journal of the American College of Radiology.

The organizations present several considerations for clinicians, including weighing potential false-positive results, downstream testing, and the resulting unnecessary, prolonged stays in the emergency department. The guidance is based on evidence-based examples from children’s hospitals around the country.

“More imaging doesn’t necessarily mean better care,” said lead author Jennifer R. Marin, MD, MSc, a member of the AAP Committee on Pediatric Emergency Medicine and a professor of pediatrics, emergency medicine, and radiology at the University of Pittsburgh School of Medicine, Pittsburgh.

The policy statement recommends hospitals adopt protocols and conditions for the use of CT scans on children, including using ultrasound first when possible and establishing consultation services with a radiologist with expertise in pediatric imaging in order to minimize patient transfers to other facilities if only a review of a scan is needed.

“At the end of the day we know that not every kid is going to be evaluated and imaged at a children’s hospital, and that’s perfectly fine; we just want to empower everybody to weigh the risks and benefits,” Marin said.

The statement also provides guidance for primary care clinicians, Marin said. For suspected appendicitis or kidney stones, ultrasound is recommended as the first-line imaging modality. When possible, clinicians should refer families to emergency departments with the capacity to perform pediatric ultrasounds.

“Depending on where you practice, you may not have an option of where to send your patient with abdominal pain,” Marin said. “A sense of what resources are and are not available at those departments can be helpful in deciding where to send the patient.”

Pediatric-Friendly Referrals

Marin said some clinicians working in the emergency department may order imaging even if a child will be transferred to a facility with advanced pediatric care. The recommendations advise against this practice.

“If you’re going to transfer this patient regardless of what the imaging shows because they require a higher level of care that you can’t provide…there’s no real good reason to waste time doing the imaging before they get transferred,” she said.

Concerns about exposure to radiation from CT scans is often raised when families are talking with emergency clinicians, according to Cynthia K Rigsby, MD, a pediatric radiologist at the Ann & Robert H. Lurie Children’s Hospital of Chicago, who was not involved in the creation of the recommendations.

“Patients and families have become very savvy about this and are going into scenarios — even where it’s urgent — with questions about what studies they are going to be having and the appropriateness,” Rigsby said.

She said clinicians can use the new guidelines when talking with families about various imaging options. The groups also recommended emergency departments develop protocols for reduced-dose radiation for CT and radiographic imaging for children, which roughly 25% of these departments lack.

Rigsby added adopting imaging protocols for children “would be a huge leap forward because we know now that that’s not the case for all places.” 

Statement authors reported no relevant financial disclosures.

Maura C. Ciccarelli is longtime freelance journalist now based in New Mexico who covers healthcare, medicine, education, and more.