Introduction

Paediatric patients presenting for radiographic imaging range from the very small, such as neonates and premature babies, to teenagers and young adults. Regardless of age, each group has unique differences and presents separate challenges to the examining radiographer. Most children will first encounter the hospital environment through an attendance at the emergency department of a local general hospital, despite the presence of specialist paediatric units throughout the country. As a consequence, children are likely to meet radiographers who are more at home examining adults, using equipment and surroundings designed for that purpose.

It has been decided to include key examinations likely to be encountered in independent practice as opposed to those regularly carried out in paediatric radiology departments. Some of the radiographic techniques explored will need to be cross-referenced with the relevant chapter elsewhere in this book. Details of invasive procedures and specialised examinations are therefore not included, and readers are encouraged to refer to specialist paediatric texts for in-depth information. This chapter is not designed to be definitive or exhaustive, but provides a general overview of techniques which from the authors’ experience have been shown to work well. It is recognised that alternative methods may be used which can also achieve desired results.

Radiographers are encouraged to formulate collaborative approaches through interprofessional working with other healthcare professionals and contact with colleagues at dedicated paediatric units throughout the country. The Association of Paediatric Radiographers (APR) is an excellent initial contact.¹ Not only will this be of direct benefit to patients but it will also contribute to the radiographer’s continuing professional development. The specialty of paediatric imaging provides potential scope for the introduction of advanced and consultant radiographer practitioners for those aspiring to a career in this area.

Special considerations when imaging children

The key factor in obtaining a high-quality diagnostic image is undoubtedly the gaining of the child’s trust prior to the commencement of the examination.² With such trust follows the development of the patient–radiographer relationship that will result in compliance by the child and positive feelings about the imaging experience. Positive feelings are invaluable in the paediatric age group, as a large proportion of children are likely to return for X-rays in their formative years.

The Kennedy Report,³ in the context of heart surgery, advises that all children should be treated in a paediatric environment by paediatric specialists and healthcare professionals. Clearly this is unachievable in many general hospitals. It is likely that most will agree that radiology departments should have at the very least a named lead radiographer and a core team of staff that are specially trained, competent and keen to examine children.⁴ It is not unreasonable to strongly suggest that all undergraduate diagnostic radiography students should be provided with learning opportunities in dedicated paediatric departments. Most radiographers will examine children as early as their first appointment as a radiographer. Therefore, a sound knowledge and understanding of the paediatric specialty gained during placement will be of great benefit to all radiographers commencing their careers.

Anxiety is a common emotion in patients of any age, but is often heightened in children due to unfamiliar surroundings, adults, and sometimes the reactions of their parents/carers. The radiographer needs to appear friendly, positive and self-assured and able to instil a sense of confidence in both the child and the parent/carer (Fig. 27.1).

Figure 27.1 An explanation of the examination to take place.

Ensuring that the physical environment is favourable to imaging children is an important factor, although this is often dependent upon additional funds and the backing of management. Child-friendly decor and furnishings with toys and books, ideally away from the adult waiting area, helps to achieve a welcoming, relaxed and warm atmosphere (Fig. 27.2).

Figure 27.2 A typical paediatric examination room for imaging children.

Understanding the different stages of child development is vital in order to tailor the examination for the individual: make the examination fit the child rather than vice versa. Some helpful tips are as follows:

Parents/carers play a pivotal role in the imaging of the young child, particularly the preschool age group. Babies and toddlers have very strong attachments to family members and resent any form of separation. When examining older children the radiographer may need to make a decision regarding the degree of involvement of the parent/carer and their location in the room. In addition to any anxieties, the older child is more aware of him/herself and understands how refusal to cooperate can control a situation to their liking. With regard to parental role, there is a risk that some parents will assert themselves and attempt to orchestrate the proceedings. It is therefore important that the radiographer carefully manages the imaging environment and the examination.

Radiation protection and dose limitation

Radiation exposure in the first 10 years of life may have an attributable lifetime risk three to four times greater than that after 30 years of age.⁵ As such, there is a greater opportunity for potential harmful effects to manifest themselves. The rationale in this chapter is to offer suggestions for radiation dose reductions; however, optimisation of the exposure factors may be more realistic. The choice of radiographic exposures should be in accordance with the 1996 CEC guidelines,⁵ taking weight, age and size into account. For examinations conducted using the X-ray table or bucky, automatic exposure devices may be used. The radiographer needs to consider the size of the selected chamber in comparison with the child’s anatomical size. In these instances it is important that the correct ionisation chamber and X-ray tube potentials are selected. Information on exposure factors should be readily available throughout the department, including mobile apparatus. It is essential that there is close working alongside clinical scientists to ensure that the appropriate balance between dose and image quality are maintained. Although practitioners may become involved in the evaluation of computed/digital radiography systems, it is important that consideration is given to dose, particularly when used for imaging children.⁶ Added consideration may need to be given to the optimisation of paediatric doses in non-specialist centres where digital imaging is already in place.

In keeping with the Ionising Radiation (Medical Exposure) Regulations⁷ prior to carrying out a diagnostic radiographic examination, all requests must be clinically justified. It is not uncommon for junior clinicians to over-request X-rays on children through inexperience with image interpretation or difficulties encountered during the initial assessment. Radiographers need to fully understand the RCR guidelines⁸ and enlist the assistance of a radiologist colleague if necessary.

Checking previous images is an essential part of any radiographer’s role. In paediatrics, such an assessment can provide useful information regarding the technique employed, in addition to the exposure used and the exact image series obtained.

Radiographers will need to confirm the pregnancy status of any female of child-bearing age before undertaking a radiographic examination.⁷ The lower age limit for pregnancy status is considered to be 12 years; however, some girls commence menstruation as young as 10. The issue of ascertaining pregnancy status is complex and delicate. A simple and uncomplicated approach is recommended as one that is likely to achieve an honest answer. First, the radiographer should ask whether the patient has started her monthly periods. If the answer is confirmatory, the radiographer needs to ask whether there is any possibility that the patient could be pregnant. Ideally this conversation should take place away from the parent/carer, and make clear to the patient that it is an important part of the radiographer’s responsibility to ask such questions. Proof of pregnancy status should be retained permanently, either electronically or on paper.

A common error by radiographers who do not undertake X-ray examinations on children regularly is the failure to tightly collimate the primary beam. This may be through fear of missing the area of interest off the image. The use of effective immobilisation, be it with devices or a holder, coupled with ongoing learning and skill development, should enable the radiographer to feel confident about collimating more appropriately and thereby limiting radiation. A holder can be defined as anyone who supports and immobilises a patient during a radiographic exposure.² Different centres may use varying approaches in their recommended choice or preference of holder, be it the child’s parent, carer or healthcare worker. Debate and appropriate recommendations on this subject should be encouraged, but the radiographer must be aware that immobilisation is a potentially contentious issue, in that there is a difference between immobilisation and restraint. It is therefore recommended that radiographers are fully conversant with the hospital’s holding policy.

Care should be taken to ensure that any parent/carer remaining within the X-ray room and/or providing immobilisation is adequately protected (lead or equivalent apron). There must also be clear instruction by the radiographer how to put the apron on properly and the importance of good posture to avoid injury. Before enlisting the assistance of any female parent/carer, the radiographer should consider the possibility of pregnancy. Radiographers should provide the holder with clear instructions to avoid the need for repeat exposures.

The holder’s fingers should always be excluded from the primary beam. Should the fingers be close to the primary beam, lead gloves/mittens should always be worn, although they will not provide complete protection at higher beam energies (Fig. 27.3). It is recommended that records are kept of any radiographers or healthcare personnel who hold children for X-ray examinations to avoid the same individual regularly undertaking this role.¹

Figure 27.3 Lead rubber mittens for use when immobilising patients.

Radiographic examinations in this chapter

This chapter will examine standard imaging requested on paediatric patients. It will provide the undergraduate and less experienced radiographer with a fundamental understanding using a commonsense approach. Depending upon the area examined, it will be necessary to offer specific descriptions of techniques that differ in their approach from that of adult examinations of the same area. Other examinations may require only an observation on possible differences that may be relevant to immobilisation strategies and positioning that requires a supine approach for babies and very young children.

Subjects included in this chapter are as follows:

Facilitating the radiographic examination

Before commencing any imaging examination the radiographer must undertake a holistic assessment, considering the child’s physical state, and their emotional, cognitive and educational needs. Often talking to the child is sufficient in itself as a distraction technique.

As previously mentioned, immobilisation or clinical holding is sometimes unavoidable to obtain diagnostic images in a safe and controlled manner. Most hospitals will have a patient restraint policy document, often called a ‘clinical holding policy’. It is important that a copy is kept in the radiology department. It is essential that all radiographers likely to be involved in immobilising children are adequately trained and aware of alternative approaches to gaining a child’s cooperation. This may include distraction techniques (Fig. 27.4), play therapy, improved explanations or simple persuasion. Non-cooperation may be due to the child having a bad day or sensing their parent/carer’s anxieties. On occasions having a break or time out can work wonders. Children who have undergone a seemingly endless series of examinations may benefit from returning on another day, provided this does not jeopardise their clinical management.

Figure 27.4 Image projector in an imaging room used as distraction.

Samples of tried and tested techniques are as follows:

Common mistakes and errors in paediatric radiographic examination

General errors that can occur during paediatric examinations, and the reasons for them, are detailed in Table 27.1. Common errors are also identified for some individual projections, when there may be additional considerations or common faults associated particularly with paediatric examinations; otherwise errors and their correction can be assumed to be the same as those for adults.

Table 27.1 Common errors noted in paediatric radiography

Chest

The chest X-ray is one of the most commonly requested radiographic images in children but is often difficult to obtain and can be of poor quality, particularly in the younger age group.¹⁰

It is imperative that any clothing is removed so as to avoid the presence of artefact (embroidery, transfers on garments) on the resulting image. We strongly advise that long hair should be moved away from the area of interest, as should any monitors or leads, providing it is not detrimental to the patient to do so.

The posteroanterior (PA) erect projection is preferred by radiologists, although in practice the anteroposterior (AP) is more readily performed in infants and young children as they are more likely to cooperate with this style of examination. This patient preference can be attributed to the need of the child to see their surroundings and their parent/carer. Unfortunately, the choice of technique often relies heavily upon the confidence of the radiographer: the less capable individual may elect to use the AP projection when careful assessment and communication might have established that a PA could have been achievable. In other words, it may be more ‘convenient’ for the radiographer to undertake a supine AP projection in preference to an erect AP. It should be remembered that the majority of children reach their sitting milestone at approximately 6 months of age. The implication here is that at the very least erect projections should be performed from this age, or before.²

Abdomen

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