Pediatric Radiology Updates

Pediatric emergency imaging should minimize ionizing radiation while preserving diagnostic accuracy. In children, ultrasound is often the preferred first test, CT use should follow pediatric-specific protocols and decision rules like PECARN, and many complex studies are better deferred to pediatric referral centers.

Pediatric Imaging Readiness and Strategy

• ALARA radiation framework: ALARA should drive every pediatric imaging decision, with pediatric-specific CT settings, limited fields of view, and radiation-sparing equipment used to reduce unnecessary exposure.
• Pediatric-ready imaging systems: A pediatric-ready ED needs protocols, trained technologists, and access to pediatric radiology expertise so advanced imaging is safer and less likely to trigger repeat studies.
• Referral center coordination: Early consultation with a pediatric referral center can make transfer without local imaging the better choice when pediatric protocols, specialists, or comparison studies will change management.
• Image-sharing infrastructure: Reliable image sharing with children's hospitals helps prevent duplicate scans, a practical systems fix that matters most for transfers and serial imaging.
• Shared decision conversations: When more than one imaging path is reasonable, shared decision-making helps families weigh ultrasound, MRI, CT, or deferral. We get into the bedside framing in the episode.

High-Yield Pediatric Imaging Scenarios

• Trauma decision rules: For pediatric head and abdominal trauma, validated tools such as PECARN reduce unnecessary CT use without increasing missed injuries.
• Seizure and headache restraint: In nonfocal seizure or headache patients who have returned to baseline, CT is often unnecessary, and simple febrile seizures should not trigger routine imaging.
• Shunt and stroke transfer: Ventricular shunt evaluation and suspected pediatric stroke usually warrant coordination with the child's specialty center, where prior imaging and pediatric protocols change the workup.
• Appendicitis first-line ultrasound: Ultrasound is the preferred initial study for pediatric appendicitis, with PAS and pARC helping risk-stratify patients before CT enters the picture.
• NAT and infection pathways: Non-accidental trauma is best handled at pediatric centers with child abuse teams, while osteomyelitis and neck infections often favor MRI or ultrasound over CT depending on anatomy.
• Stone and thromboembolism imaging: Ultrasound is also the starting point for pediatric nephrolithiasis and DVT evaluation; the transfer-versus-image choice comes up more often than many community clinicians expect, and we walk through that in the chapter.

References:

1. American Academy of Pediatrics Committee on Pediatric Emergency Medicine; Section on Radiology; American College of Emergency Physicians Pediatric Emergency Medicine Committee; American College of Radiology; Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement. Ann Emerg Med. 2024 Aug;84(2):e13-e23. PMID: 39032991