Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎

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Radiation Physics and Chemistry

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Evaluation of entrance surface air kerma in pediatric chest radiography

L. Porto a, N. Lunelli a, S. Paschuk a, A. Oliveira a, J.L. Ferreira a, H. Schelin a,b,n, C. Miguel a,c,
V. Denyak b,d, C. Kmiecik b,c, J. Tilly c, H. Khoury e
a
Federal University of Technology of Paraná, Curitiba, Brazil
b
Pelé Pequeno Príncipe Research Institute, Curitiba, Brazil
c
Federal University of Paraná – Clinical Hospital, Curitiba, Brazil
d
National Science Center, Kharkov Institute of Physics and Technology, Kharkiv, Ukraine
e
Federal University of Pernambuco, Recife, Brazil

H I G H L I G H T S

The entrance surface air kerma of chest X-ray examinations in pediatric patients was estimated.

The data were analyzed for patients aged up to 15 y, stratified by age.

The doses of LAT examinations were 40% higher than of AP/PA because of kV used.

An increase in kV with a decrease in mAs leads to significant dose reduction.

art ic l e i nf o a b s t r a c t

Article history: The objective of this study was to evaluate the entrance surface air kerma in pediatric chest radiography.
Received 30 June 2013 An evaluation of 301 radiographical examinations in anterior–posterior (AP) and posterior–anterior (PA)
Accepted 16 February 2014 (166 examinations) and lateral (LAT) (135 examinations) projections was performed. The analyses were
performed on patients grouped by age; the groups included ages 0–1 y, 1–5 y, 5–10 y, and 10–15 y. The
Keywords: entrance surface air kerma was determined with DoseCal software (Radiological Protection Center of
Pediatric chest radiography Saint George's Hospital, London) and thermoluminescent dosimeters. Two different exposure techniques
Entrance surface air kerma were compared. The doses received by patients who had undergone LAT examinations were 40% higher,
DoseCal on average, those in AP/PA examinations because of the difference in tube voltage. A large high-dose
“tail” was observed for children up to 5 y old. An increase in tube potential and corresponding decrease
in current lead to a significant dose reduction. The difference between the average dose values for
different age ranges was not practically observed, implying that the exposure techniques are still not
optimal. Exposure doses received using the higher tube voltage and lower current-time product
correspond to the international diagnostic reference levels.
& 2014 Elsevier Ltd. All rights reserved.

1. Introduction Significant progress in the improvement in radiographic equip-

There is growing concern about the amount of absorbed dose
in patients undergoing radiographic examinations (Azevedo et al.,
2006; Lacerda et al., 2008; Suliman and Elawed, 2013). This
concern is greater in children, who have a longer life expectancy
than adults and are more sensitive to ionizing radiation (UNSCEAR,
2013). X-ray equipment is not designed solely for pediatrics, and
consequently, the equipment is not optimized for this purpose.
n in a range of institutions and are subject to change with the
Corresponding author at: Pelé Pequeno Príncipe Research Institute – IPPPP,
Av. Silva Jardim, 1632, Curitiba-PR, 80250200, Brazil. Tel.: þ 55 41 33388052.
E-mail address: schelin2@gmail.com (H. Schelin).
ment has been achieved in the last decades (high frequency X-ray
generators, film-screen systems with high relative speeds, com-
puted and digital radiography, etc.) resulting in reduction in the
patient dose. However, one of the most significant contributions to
decrease the mean radiation dose was the implementation of
quality assurance programs to control correct usage of the radio-
graphic equipment (Huda et al., 2008).
The introduction of the concept of diagnostic reference level
(DRL) (ICRP, 2013) has established the benchmarks for achievable
doses. However the DRLs should not be considered as technical
limits. They are established by surveying an appropriate quantity
improvement of radiographic equipment and the technique used.
That is why the achievements in dose reduction are of constant

http://dx.doi.org/10.1016/j.radphyschem.2014.02.014
0969-806X & 2014 Elsevier Ltd. All rights reserved.

Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i
2 L. Porto et al. / Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎

interest especially in the developing countries that were not posterior–anterior (PA) and lateral (LAT) projection chest X-ray
covered in previous surveys. examinations in pediatric patients. The data were analyzed for
Chest radiography is the most frequent pediatric X-ray exam- patients aged up to 15 y, stratified by age.
ination. The purpose of the present study was to estimate the
entrance surface air kerma (ESAK) of anterior–posterior (AP),
2. Materials and methods
Table 1
Number of examinations by projection type in each age group. The investigation was performed at the Clinical Hospital of the
Federal University of Paraná, Brazil. Before the beginning the
0–1 y 1–5 y 5–10 y 10–15 y Total research project was submitted to the Ethical Committee of the
Hospital that is linked to the Brazilian Federal Government. All
AP/PA 48 58 34 26 166
patient's parents received instructions and gave the approval
LAT 34 47 29 25 135
about the survey.

Fig. 1. Weight and thickness of patients who underwent AP/PA examinations.

Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i
 L. Porto et al. / Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 3

Fig. 2. Weight and thickness of patients who underwent LAT examinations.

In this study, 301 X-ray examinations (166 AP/PA projections
and 135 LAT projections) of pediatric patients were acquired. Only
films that were considered diagnostic by the radiographer were
accepted for this study. The patients were divided into age groups
of 0–1 y, 1–5 y, 5–10 y, and 10–15 y. Table 1 shows the number of
examinations by projection type for each age group.
For each examination, patient characteristics important for
X-ray radiography were recorded (Figs. 1 and 2).
The radiological protocols used, including tube voltage (kV),
current-time product (mAs), and focus-surface distance (FSD), are
shown in Figs. 3 and 4.
The X-ray equipment used was a GE Medical Systems model
AL01F-Proteus XR/a, type 2261765, with 3 mm Al total beam
filtration and 400-speed screen-film receptor. A Potter– Bucky
grid was used for the 1–5 y, 5–10 y and 10–15 y children and no
grid was used for the group 0–1 y.
In order to obtain the ESAK with DoseCal software, the radiation
outputs of the X-ray tube for different tube voltages were measured
using an ionization chamber (Model 10  5–6, Radcal Corp.) with
6 cm3 of sensitive volume. The ionization chamber was connected to
an electrometer and was placed 25 cm from the table top in order to
prevent inaccurate readings caused by backscatter and 100 cm from

Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i
4 L. Porto et al. / Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Fig. 3. Tube voltage, current–time product, and focus–surface distance used for examinations in AP/PA projection.

the X-ray focus. Exposures were taken and the output recorded for
different mAs values throughout the tube potential range from 40 to
90 kV in 5 kV increments.
The doses were evaluated using a DoseCal software, developed
by the Radiological Protection Center of Saint George's Hospital,
London. The outputs from the X-ray equipment were used as input
parameters for DoseCal. The program performs a simulation of the
dose received by the patient, taking into account variations in
parameters provided by the ionization chamber and the values of
kV, mAs, the focus-skin distance used in each examination, and
the backscattering factor. The software uses the following equation
to calculate the ESAK:
   irradiated and was used to evaluate the background.
Ka kV cal dcal
ESAK ¼ mAs ðBSFtable þ 1Þ
mAscal kV d
where Ka is the air kerma value measured with the ionization
chamber at kVcal and mAscal; dcal is equal to 100 cm. The overall
uncertainty of the ESAK values was better than 15%.
In some of the examinations (26 patients) TLD-100 were also
used, placed with adhesive tape on the skin of the patient at the
center of the field. Fig. 5 shows a dosimeter attached to a child
with adhesive tape. After irradiation, the dosimeters were sent to
the Thermoluminescent Dosimetry Laboratory of the Dosimetry
and Nuclear Instrumentation Group of the Nuclear Energy Depart-
ment of the Federal University of Pernambuco (GDOIN-DEN/UFPE).
The readings of the TLDs were made in a Victoreen reader model
2800M. The results in nC were converted into μGy using the
calibration curve obtained earlier. One pair of dosimeters was used
in each examination, and the mean value and corresponding error
were calculated. One pair of dosimeters from a set was not
In addition, 2 different techniques used in the hospital were
investigated. Both the techniques were applied by the same group
of operators. Initially Technique 1 was used and then it was changed
to satisfy the recommendations of European Communities (1996).
The difference between the techniques results from a reduction in

Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i
 L. Porto et al. / Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 5

Fig. 4. Tube voltage, current–time product, and focus–surface distance used for examinations in LAT projection.

the current–time product and a corresponding increase in tube
voltage. Tables 2 and 3 show the exposure parameters for these
techniques.
In AP/PA projection, 56 and 38 examinations were performed
with Techniques 1 and 2, respectively. In LAT projection, 44
and 38 examinations were performed with Techniques 1 and 2,
respectively.
3. Results and discussion
A comparison of the ESAKs calculated with DoseCal software
and measured using TLDs showed that the difference between
them is not greater than 15%.
Figs. 6 and 7 show the ESAK of chest X-rays in pediatric
examinations performed in AP/PA and LAT projections for different
patient age ranges. The dose received by patients in LAT examina-
tions was 40% higher, on average, than in AP/PA examinations.
Figs. 3 and 4 and Table 4 show no significant difference in mAs and
FSD values between these projections. Therefore the main reason
for such result is the difference in tube potential used.
Very small differences were observed between the average
dose values for different age ranges. In the case of AP/PA projec-
tion, the maximum of the dose distribution migrates towards
higher doses with increasing age, but a large “tail” is observed in
the region of high doses for age ranges 0–1 y and 1–5 y. The same
“tail” is also observed in LAT projections, but in this case there is
no change in the position of the maximum distribution .
The obtained results triggered a detailed analysis of the
exposure parameters utilized. Tables 2 and 3 show that with
Technique 1 all age ranges in LAT projections and age ranges
0–1 y and 1–5 y in AP/PA projections had tube voltage values
somewhat lower than the values of 60–80 kV recommended
by the European Guidelines on Quality Criteria for Diagnostic
Radiographic Images in Paediatrics (European Communities,
1996). Technique 2 increases the tube voltage by 10–30% with a

Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i
6 L. Porto et al. / Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎

simultaneous decrease in the current-tube product by a factor
of 2.
Fig. 8 shows the mean ESAK values obtained in each patient
group using the 2 techniques. The higher tube voltage and lower
current–time product contributed to a reduction in ESAK values.
Usage of Technique 1 leads to the appearance of a high dose “tail”
in Figs. 6 and 7.
Although Technique 2 reduces dose, Fig. 8 shows that it
produces almost the same dose in different age ranges despite
significant differences in patient thickness (Figs. 1 and 2). These
results show that the exposure techniques are still not optimal.
The inappropriate use of anti-scatter grids may be one of the
factors that increased ESAK because it requires higher radiation
intensity. According the European Guidelines (European
Communities, 1996) a grid is not required for chest radiography
until 8 y of age because there is no significant scattering. Another
factor is that radiographic voltage can still be increased with
appropriate decreases in the current–time product.
Comparison of our results with the investigations of the screen
film radiography practice carried out earlier in Brazil (Lacerda
et al., 2008) and with the other investigations mentioned there
shows that the doses obtained in the case of Technique 2 coincide
with the best results. The same conclusion can be made by
analyzing the latter research in Brasil (Mohamadain and
Azevedo, 2009).
Recently the survey of the hospital practice in screen film
radiography has been made in eight general radiography hospitals
of Sudan (Suliman and Elawed, 2013). For all age groups except
0–1group children, the lowest doses observed in this survey are
about two times higher than ours for the Technique 2. In the case
of the 0–1 group, they are similar.
According to European Guidelines (European Communities,
1996) the ESAK reference values for AP and PA projections for
chest radiography in children are 50 μGy for neonates and 1-y-old
infants, 70 μGy for 5-y-old children, and 120 μGy for 10-y-old
children. Practically the same DRL values were established in
United Kingdom and Austria (UNSCEAR, 2013). Results obtained
using Technique 2 satisfies these requirements.

4. Conclusion

The doses received by patients undergoing LAT examinations

Fig. 5. Dosimeter attached with an adhesive tape to a child being prepared for a
radiologic examination (PA projection).
were 40% higher, on average, than in AP/PA examinations because
of the difference in tube potential used. A large high-dose “tail”
was observed for children up to 5 y of age. An increase in tube
voltage with a corresponding decrease in current leads to sig-
nificant dose reduction. A statistically significant difference was
not observed between the average dose values in different age
ranges, implying that exposure techniques are still not optimal.
Exposure doses received using the high kV and low mAs technique
correspond to the international DLRs.

Table 2
Tube potential, current–time product, and focus–surface distance used for examinations in AP/PA projections.

kVp mAs FSD

Technique 1 Technique 2 Technique 1 Technique 2 Technique 1 Technique 2

Mean Stand. dev Mean Stand. dev. Mean Stand. Dev. Mean Stand. Dev. Mean Stand. Dev. Mean Stand. Dev.

0–1 y 51.9 70.7 0.9 55.0 74.8 9.7 3.20 7 0.03 0.16 1.517 0.11 0.23 987 3 9 1087 23 45
1–5 y 53.6 70.5 2.0 62.5 72.1 9.2 3.20 7 0.03 0.16 1.577 0.03 0.12 1247 8 35 1547 10 43
5–10 y 70.1 71.8 6.5 65.6 71.9 5.3 3.20 7 0.03 0.16 1.63 7 0.02 0.07 1627 4 14 1697 5 13
10–15 y 71.5 71.2 4.5 71.7 71.8 4.4 3.20 7 0.03 0.16 1.60 7 0.03 0.08 1627 4 14 166 7 4 9

Table 3
Tube potential, current-time product, and focus-surface distance used for LAT projection examinations.

kVp mAs FSD

Technique 1 Technique 2 Technique 1 Technique 2 Technique 1 Technique 2

Mean Stand. dev. Mean Stand.dev. Mean Stand. dev. Mean Stand dev. Mean Stand.dev. Mean Stand. dev.

0–1 y 56.1 70.7 1.9 59.8 7 4.0 8.0 3.20 7 0.03 0.16 1.707 0.13 0.26 97 73 10 1077 21 42
1–5 y 60.1 71.7 5.2 71.17 2.8 12.0 3.20 7 0.03 0.16 1.647 0.03 0.14 124 713 41 1497 9 41
5–10 y 59.4 71.2 5.0 75.17 1.3 3.6 3.20 7 0.03 0.16 1.647 0.02 0.06 166 73 10 1627 5 13
10–15 y 59.7 70.8 2.9 83.9 7 1.3 3.6 3.20 7 0.03 0.16 1.60 7 0.03 0.08 165 73 11 1627 1 4

Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i
 L. Porto et al. / Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎ 7

Fig. 7. ESAK in LAT projection examinations.

Fig. 6. ESAK in AP/PA projection examinations.

Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i
8 L. Porto et al. / Radiation Physics and Chemistry ∎ (∎∎∎∎) ∎∎∎–∎∎∎

Table 4
Basic characteristics of the distributions of tube potential, current-time product, focus-surface distance and ESAK.

kVp mAs FSD ESAK

AP/PA LAT. AP/PA LAT. AP/PA LAT. AP/PA LAT.

Mean St. dev. Mean St. dev. Mean St. dev. Mean St. dev. Mean St. dev. Mean St. dev. Mean St. dev. Mean St. dev.

0–1 y 48 7 1 5 557 1 6 2.17 0.1 0.5 2.2 70.1 0.6 857 4 25 877 4 23 597 6 43 817 9 51
1–5 y 587 1 8 677 2 11 2.2 7 0.1 0.7 2.1 70.1 0.6 1377 5 38 1327 5 38 477 4 33 617 5 35
5–10 y 617 1 7 727 1 8 2.8 7 0.2 1.4 2.8 70.3 1.4 1597 3 17 153þ 4 20 417 3 17 687 6 32
10–15 y 64 7 28 9 777 2 9 2.7 7 0.2 1.0 2.8 70.2 1.2 1587 5 28 1587 3 16 55þ 11 56 807 11 53

Fig. 8. Mean ESAK values obtained in patients by age. The solid line is for Technique 1; the dashed line is for Technique 2. a and b represent AP/PA and LAT projections,
respectively.

Acknowledgments
The authors would like to thank the Radiological Protection
Center of Saint George's Hospital, in London for the DoseCal
software and CAPES, CNPq, and Fundação Araucária for financial
support.
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Please cite this article as: Porto, L., et al., Evaluation of entrance surface air kerma in pediatric chest radiography. Radiat. Phys. Chem.
(2014), http://dx.doi.org/10.1016/j.radphyschem.2014.02.014i