ORIGINAL RESEARCH • PEDIATRIC IMAGING

Radiation Dose for Pediatric CT: Comparison of

Pediatric versus Adult Imaging Facilities
Keith J. Strauss, MSc • Elanchezhian Somasundaram, PhD • Debapriya Sengupta, MBBS, MPH •
Jennifer R. Marin, MD, MSc • Samuel L. Brady, PhD
From the Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229-3026 (K.J.S., E.S., S.L.B.);
University of Cincinnati School of Medicine, Cincinnati, Ohio (K.J.S., E.S., S.L.B.); National Radiology Data Registries, American College of Radiology, Reston, Va (D.S.);
and Department of Pediatrics and Emergency Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pa (J.R.M.). Received
August 13, 2018; revision requested October 8; revision received December 11; accepted December 18. Address correspondence to K.J.S. (e-mail: Keith.Strauss@cchmc.org).
Conflicts of interest are listed at the end of this article.
See also the editorial by Strouse in this issue.

Radiology 2019; 291:158–167 • https://doi.org/10.1148/radiol.2019181753 • Content code:

Background: The American College of Radiology Dose Index Registry for CT enables evaluation of radiation dose as a function of
patient characteristics and examination type. The hypothesis of this study was that academic pediatric CT facilities have optimized
CT protocols that may result in a lower and less variable radiation dose in children.

Materials and Methods: A retrospective study of doses (mean patient age, 12 years; age range, 0–21 years) was performed by using
data from the National Radiology Data Registry (year range, 2016–2017) (n = 239 622). Three examination types were evalu-
ated: brain without contrast enhancement, chest without contrast enhancement, and abdomen-pelvis with intravenous contrast
enhancement. Three dose indexes—volume CT dose index (CTDIvol), size-specific dose estimate (SSDE), and dose-length product
(DLP)—were analyzed by using six different size groups. The unequal variance t test and the F test were used to compare mean dose
and variances, respectively, at academic pediatric facilities with those at other facility types for each size category. The Bonferroni-
Holm correction factor was applied to account for the multiple comparisons.

Results: Pediatric radiation dose in academic pediatric facilities was significantly lower, with smaller variance for all brain, 42 of 54
(78%) chest, and 48 of 54 (89%) abdomen-pelvis examinations across all six size groups, three dose descriptors, and when com-
pared with that at the other three facilities. For example, abdomen-pelvis SSDE for the 14.5–18-cm size group was 3.6, 5.4, 5.5,
and 8.3 mGy, respectively, for academic pediatric, nonacademic pediatric, academic adult, and nonacademic adult facilities (SSDE
mean and variance P , .001). Mean SSDE for the smallest patients in nonacademic adult facilities was 51% (6.1 vs 11.9 mGy) of
the facility’s adult dose.

Conclusion: Academic pediatric facilities use lower CT radiation dose with less variation than do nonacademic pediatric or adult
facilities for all brain examinations and for the majority of chest and abdomen-pelvis examinations.
© RSNA, 2019

Patric and adult patients was rarely made, leading to

rior to the early 2000s, a distinction between pedi-
poor management of radiation dose and image quality
during CT scanning (1–3). During this time, acquisi-
tion techniques were rarely adjusted based on body size
(3). Initial recommendations for radiation dose reduc-
tion appeared (2,4,5) and were followed by amplifica-
tion by the Image Gently Alliance in the United States
(6,7) and throughout the world (8). In 2010, the Image
Wisely campaign addressed similar concerns as they per-
tain to adult imaging (9).
Advances in radiation awareness have occurred through
education, hardware and software development, and avail-
able radiation dose indexes. These advances have stemmed
from a collective desire among facilities, national and in-
ternational associations, and CT manufacturers to improve
health care for all patients, especially pediatric patients
undergoing CT. In 2011, the size-specific dose estimate
(SSDE) (10) was developed to enable patient dose estima-
tion with improved accuracy and precision in patients of
every size (11). The American College of Radiology initi-
ated its dose index registry (DIR) (12,13), which contained
dose indexes for more than 45 000 000 CT examinations as
This copy is for personal use only. To order printed copies, contact reprints@rsna.org
of July 2017 (14). These data enable the development of
size-based diagnostic reference levels that imaging sites can
use to develop targeted pediatric CT doses.
Reports of improved pediatric and adult CT technique
changes based on patient size appeared beginning in 2008
with the Image Gently Alliance (15–16) and were followed
by publications from the American Association of Physi-
cists in Medicine in 2016 and 2017 (17). Despite these
available recommendations, opportunities for improve-
ment in the management of pediatric CT doses remain.
Published reports of study periods prior to 2014 compar-
ing pediatric CT dose indexes at adult community facilities
support the need for this improvement (18–23). However,
these studies focused on one type of CT study in specific
populations. A national survey was needed. The DIR, a
dose registry that collects deidentified CT examination
data from participating facilities throughout the United
States, is a good tool to use to assess the national differ-
ences between types of practices, patient characteristics,
and examination types. We hypothesized that mean dose
index levels and variances, respectively, were lower and less
varied in academic pediatric facilities than in other facility
types for each dose category. The purpose of this study was
 Strauss et al

Abbreviations Table 1: Patient Size Grouping Based on Effective

Diameter
CTDIvol = volume CT dose index, DIR = dose index registry, DLP =
dose-length product, SSDE = size-specific dose estimate Effective Lateral Average Average
Diameter (cm)* Thickness (cm) Weight (kg) Age (y)
Summary
Academic pediatric facilities use lower radiation dose than do nonaca- Brain
demic pediatric or adult facilities for all brain CT examinations and for 0–14 0–12.5 0–8 0–0.5
the majority of chest and abdomen-pelvis CT examinations. .14–15.5 .12.5–14 .8–15 .0.5–3
.15.5–17 .14–15 .15–25 .3–7
Key Points
.17–18 .15–16 .25–60 .7–17
nn For abdomen-pelvis CT (patient size range, 14.5–18 cm), size-
specific dose estimates (SSDEs) were 3.6, 5.4, 5.5, and 8.3 mGy .18 .16 .60 .17
for academic pediatric, nonacademic pediatric, academic adult, Abdomen-Pelvis
and nonacademic adult facilities, respectively (P , .001 for com- 0–14.5 0–16.5 0–12 ,2
parison). .14.5–18 .16.5–21.5 .12–23 .2–7
nn Academic pediatric facilities had protocols that resulted in lower .18–22 .21.5–27 .23–45 .7–13
radiation dose at chest CT than did 78% of other facilities (non-
academic pediatric, academic adult, and nonacademic adult facili- .22–25 .27–31 .45–60 .13–17
ties). .25–28.5 .31–35 .60–70 .17–21
nn Academic pediatric facilities had protocols that resulted in lower .28.5 .35 .70 .21
radiation dose for abdomen-pelvis CT than did 89% of other fa- Chest
cilities (nonacademic pediatric, academic adult, and nonacademic 0–14.5 0–16.5 0–8 ,0.5
adult facilities).
.14.5–18 .16.5–21.5 .8–20 .0.5–6
.18–22 .21.5–27 .20–40 .6–12
to compare DIR pediatric CT dose indexes as a function of pa- .22–25 .27–31 .40–55 .12–16
tient size and to analyze differences between academic pediatric, .25–28.5 .31–35 .55–65 .16–20
nonacademic pediatric, academic adult, and nonacademic adult .28.5 .35 .65 .20
facilities during pediatric CT imaging. Note.—Data are ranges. Range of average ages versus lateral
dimensions for head, chest, and abdomen-pelvis are based on
Materials and Methods published data (25). Range of average weights versus lateral
dimensions for head, chest, and abdomen-pelvis are based on
published data (26).
Dose Index Registry * Effective diameter (10) = (anterior/posterior dimension · lateral
The DIR is compliant with the Health Insurance Portabil- dimension)0.5.
ity and Accountability Act. The DIR has institutional review
board assurance of status of exemption from patient written
informed consent. No industry support was provided. The au- demic. Pediatric facilities were defined according to The Chil-
thors had total control of the data and information submitted dren’s Hospital Association list of approximately 250 pediatric
for publication. This study included data from January 2016 facilities in the United States, and 107 (43%) of these 251
through December 2017 for three types of single-scan pediat- facilities were academic. Dose indexes at academic pediatric
ric CT examinations: brain CT without intravenous contrast facilities were used as benchmarks; dose indexes in the other
material, chest CT without intravenous contrast material, and three facility groups were compared with the benchmark by
abdomen-pelvis CT with intravenous contrast material in pa- using appropriate statistical tests.
tients 21 years of age or younger. Examinations without effec-
tive diameter calculations (10,24) necessary to estimate SSDE, Patient Size Grouping
examinations performed at facilities that contributed data from Dose records for the three CT examinations were analyzed
fewer than 30 total examinations, and examinations in which based on patient effective diameter (10) of the anatomy in
multiple scans were performed were excluded. The dose in- the direct radiation beam calculated from localizer scan im-
dexes used in this study consisted of volume CT dose index ages of the examination (24). The six size groups for chest and
(CTDIvol), dose-length product (DLP), and SSDE. The DIR abdomen-pelvis examinations and the five size groups for the
provided all three indexes for the chest and abdomen-pelvis brain examinations are listed in Table 1. While target doses
examinations. An SSDE method for brain CT examinations are best compared with the thickness (path length of pri-
does not currently exist (10). mary x-rays) through the patient’s irradiated anatomy (effec-
tive diameter), some facilities use a patient’s age or weight out
Facility Classification of convenience. However, the largest 3-year-old patient may
The 519 facilities participating in this study were grouped into have the same abdominal thickness as the smallest 18-year-
four categories: (a) academic pediatric, (b) nonacademic pedi- old patient (25). Likewise, endo- and ectomorphic patients
atric, (c) academic adult, and (d) nonacademic adult institutions. of the same weight have different thicknesses. Despite these
A teaching facility linked to a medical school was considered facts, average age (25) and weight (26) associated with each
an academic institution; the remaining facilities were nonaca- size group are provided in Table 1 as a tool. The lateral thick-

Radiology: Volume 291: Number 1—April 2019 n radiology.rsna.org 159

Radiation Dose for Pediatric CT

Table 2: Overall Relative Difference in SSDE and DLP between Facility Types as Compared with Academic Pediatric
Facilities

SSDE (mGy) DLP (mGy·cm)

Effective Nonacademic Nonacademic Nonacademic

Diameter (cm) Pediatric Academic Adult Adult Pediatric Academic Adult Nonacademic Adult

Chest
0–14.5 4.9/2.3 (2.1) 4.2/2.3 (1.8) 2.5/2.3 (1.1) 40/17 (2.4) 39/17 (2.3) 21/17 (1.2)
18–22 5/2.6 (1.9) 4.7/2.6 (1.8) 5.2/2.6 (2.0) 73/37 (2.0) 69/37 (1.9) 79/37 (2.1)
.28.5 5.6/4.5 (1.2) 8.3/4.5 (1.8) 8.3/4.5 (1.8) 185/155 (1.2) 273/155 (1.2) 283/155 (1.8)
Abdomen-Pelvis
0–14.5 4.2/4.2 (1.0) 7.0/4.2 (1.7) 6.1/4.2 (1.5) 59/45 (1.3) 118/45 (2.6) 71/45 (1.6)
18–22 5.5/4.3 (1.3) 5.6/4.3 (1.3) 6.7/4.3 (1.6) 130/90 (1.4) 129/90 (1.4) 155/90 (1.7)
.28.5 9.4/5.8 (1.6) 12/5.8 (2.1) 12/5.8 (2.1) 459/290 (1.6) 599/290 (2.1) 604/290 (2.1)
Brain
0–14 21/20 (1.1) 23/20 (1.2) 29/20 (1.5) 353/306 (1.2) 358/306 (1.2) 452/306 (1.5)
15.5–17 39/24 (1.6) 42/24 (1.8) 44/24 (1.8) 697/454 (1.5) 716/454 (1.1) 744/454 (1.6)
.18 36/23 (1.6) 44/23 (1.9) 44/23 (1.9) 644/435 (1.5) 768/435 (1.8) 789/435 (1.8)
Note.—Data are for facility type/academic pediatric facility, respectively. Data in parentheses are relative difference. DLP = dose-length
product, SSDE = size-specific dose estimate.

Table 3: Type of Facility Numbers of CT Examinations and Demographic Distribution of Study Population

No. of Examinations Mean Age (y)*

Facility Type No. of Facilities Total Male Patients Female Patients Overall Male Patients Female Patients
Academic pediatric 10 (1.9) 23 958 (10.0) 13 419 (56.0) 10 503 (43.8) 9 (0–21) 9 (0–21) 9 (0–21)
Nonacademic pediatric 19 (3.7) 34 524 (14.4) 18 779 (54.4) 15 643 (45.3) 10 (0–21) 9 (0–21) 10 (0–21)
Academic adult 51 (9.8) 264 42 (11.0) 13 840 (52.3) 12 470 (47.2) 15 (0–21) 14 (0–21) 15 (0–21)
Nonacademic adult 439 (84.6) 155 377 (64.7) 72 765 (46.8) 82 203 (52.9) 15 (0–21) 15 (0–21) 16 (0–21)
Total 519 240 301 118 803 120 819 … … …
Note.—Unless otherwise indicated, data are number of facilities or patients, and data in parentheses are percentages. There were 679 cases
in which patient sex was unknown.
* Data in parentheses are the range.

nesses associated with the effective diameters are also provided
for technologists who measure patient thickness mechanically
with calipers or electronically on the localizer image to verify
the acquisition technique selected on the scanner prior to the
actual examination.
Size-specific Mean Dose Analysis
The mean dose level in academic pediatric facilities ( µ APD)
was compared with that in the other three facility groups—the
nonacademic pediatric ( µ NPD), academic adult ( µ AAD), and
nonacademic adult ( µ NAD ) facility groups—by performing an
unequal variance two-sample t test (Welch test) (27) individu-
ally for all three dose indexes (CTDIvol, DLP, and SSDE) for
each examination type. The unequal variance t test was chosen
since the radiation dose data did not satisfy the assumption of
the standard Student t test, which required equal variance be-
tween the facility groups. The assumptions of the unequal vari-
ance t test were (a) normality and (b) independence. The radia-
tion dose records were considered independent of each other
by assuming that no patient underwent multiple examinations
on the same day. Two years of data were analyzed to satisfy the
normality assumption by using the central limit theorem. For
each examination type and size group, a one-sided t test was
performed to evaluate the hypothesis that mean dose levels in
the academic pediatric facilities were lower than mean radia-
tion doses in the other facility types ( µ APD < µ OTHER ), where
the null hypothesis would indicate no significant mean dose
difference between the four facility types. By using the aca-
demic pediatric facility as the baseline, the relative percentage
difference between µ APD and µ OTHER was calculated for the
defined category for dose indexes and patient sizes.
Size-specific Dose Variance Analysis
A one-sided F test was used to test the hypothesis that variance
in the academic pediatric facilities ( S APD ) was smaller than that
in the other facility types ( S APD < SOTHER ) for all the dose in-
dicators applicable to the examination where the null hypoth-
esis would indicate no significant difference in dose variance
between the four facility types. The same assumptions as the
unequal variance t test also hold for the F test.

160 radiology.rsna.org n Radiology: Volume 291: Number 1—April 2019


Correction for Multiple Comparisons
The significance level of the tests was corrected to suppress the
familywise error rate (mean and variance) that could lead to
false-positive findings. The Holm-Bonferroni correction was
used to modify the level of the tests by providing protection
against type I error rate while resulting in a slightly higher type
II error rate (28). The corrected level of the test, α k , was based
on the following equation:
α
αk = (1),
( N − k + 1)
Radiology: Volume 291: Number 1—April 2019 n radiology.rsna.org
Strauss et al
Figure 1: Box plots show (a) volume CT dose index (CTDIvol), (b)
dose-length product (DLP), and (c) size-specific dose estimate (SSDE)
for chest examinations for four facility types as a function of effective
diameter. The top and bottom boundaries of each box are the third
and first quartiles of the data, respectively; the horizontal line is the
median value. Whiskers extend to 1.5 times the standard deviation of
the data. In general, lowest to highest SSDE and DLP for the four facil-
ity types, in order, are academic pediatric, nonacademic pediatric,
academic adult, and nonacademic adult.
where N is the number of comparisons (or individual hypoth-
esis) made, α (equal to 0.05) is the overall level of the test, and
the formula is applied after sorting the P values of all the tests
in ascending order and testing the null hypothesis for every kth
test, sequentially. The total number of tests (N) was the product
of the three facility types compared to academic pediatric fa-
cilities and the number of different dose indexes. A failure of
the t tests indicated no evidence for a difference in the mean
dose level between academic pediatric facilities and the com-
pared facility type. Similarly, a failure of the F tests indicated
no evidence of a smaller variance in mean dose level between
academic pediatric facilities and the compared facility type. All
percentage relative differences in Table 2 were calculated with
the following formula:
/ (2),
where µ OTHER represents the mean for one of the three facility
types compared with academic pediatric facility mean ( µ APD).
Results
Table 3 lists the number of each facility type, the number of
examinations from each facility type, and the demographic
161
Radiation Dose for Pediatric CT
distribution of the study population. While the number of
total pediatric facilities participating in the study was less
than 10% of the study’s total, pediatric facilities contributed
more than 24% of the total number of examinations. A total
of 239 622 submitted examinations were analyzed, includ-
ing 151 386 brain, 4258 chest, and 84 657 abdomen-pelvis
examinations. There were 120 819 (50.4%) and 118 803
(49.6%) studies in female and male subjects, respectively.
While the age range for male and female patients at each
facility type was 0–21 years, the mean age ranged from 9
to 10 years at pediatric facilities and was 15 years at adult
facilities.
162
Figure 2: Box plots show (a) volume CT dose index (CTDIvol), (b)
dose-length product (DLP), and (c) size-specific dose estimate (SSDE)
for abdomen-pelvis examinations for four facility types as a function
of effective diameter. The top and bottom boundaries of each box are
the third and first quartiles of the data, respectively; the horizontal line
is the median value. Whiskers extend to 1.5 times the standard devia-
tion of the data. In general, lowest to highest SSDE and DLP, in order,
for the four facility types are academic pediatric, nonacademic pediat-
ric, academic adult, and nonacademic adult.
Figures 1–3 show the CT dose indexes as a function of patient
size, facility type, and examination type. The overall values of
SSDE for abdomen-pelvis examinations are approximately 50%
greater than the respective values for chest examinations. The
overall DLP values for abdomen-pelvis CT are approximately
double those for chest CT. Tables 4–6 lists size-specific mean
values and standard deviations for the SSDE (where applicable),
CTDIvol, and DLP. The P values of the mean (t test) and variance
(F test) of the comparisons of academic pediatric facilities to the
other three types of facilities are listed in Tables 4–6. The sample
size for chest examinations was less than 50 studies for seven of
24 size groups primarily in adult facilities for smaller patients.
The sample sizes of all abdomen-pelvis and brain size groups
were larger than 50 examinations. Figure 4 shows examples of
acquired images of the three types of CT studies analyzed.
For chest and abdomen-pelvis examinations, respectively,
across all six size groups, three dose descriptors, and three fa-
cilities compared with the academic pediatric facility, 42 (78%)
and 48 (89%) of 54 of the unequal variance t tests with Holm-
Bonferroni correction applied indicated the academic pediatric
facilities had lower mean doses (P , .01). For the same exami-
nations, 96% (52 of 54) and 94% (51 of 54), respectively, of
F tests indicated that academic pediatric facilities had smaller
variance in dose levels (P , .01). For all t and F tests for brain
examinations, the null hypothesis was rejected. Overall, these
radiology.rsna.org n Radiology: Volume 291: Number 1—April 2019
 Strauss et al

Figure 3: Box plots show (a) volume CT dose index (CTDIvol) and (b) dose-length product (DLP) for brain examinations for four facility types as
a function of effective diameter. The top and bottom boundaries of each box are the third and first quartiles of the data, respectively; the horizontal
line is the median value. Whiskers extend to 1.5 times the standard deviation of the data. In general, lowest to highest SSDE and DLP for the four
facility types, in order, are academic pediatric, nonacademic pediatric, academic adult, and nonacademic adult.

results suggest that mean dose is lower and less variable in aca-
demic pediatric facilities than in the other three facility types.
The majority of cases in which we failed to reject the null hy-
pothesis occurred in comparisons with a sample size of fewer
than 50 examinations, which occurred in patients who gener-
ally had effective diameters of 0–18 cm (Tables 4–6). Because
we used the Holm-Bonferroni correction, there were instances
in which P was less than 0.05 but greater than α k and hence
was not statistically significant.
Table 2 shows the means of the selected dose indexes for three
group sizes (average ages were ,2 years, approximately 10 years,
and .21 years) for the other three facility classifications as com-
pared with those in the academic pediatric facility. SSDE and
DLP are included for the abdomen-pelvis and chest examina-
tions. CTDIvol is listed for the brain examinations. In general, the
mean values of the dose indexes increase in the following order:
academic pediatric, nonacademic pediatric, academic adult, and
nonacademic adult, which results in the relative differences in
Table 2. For example, for the smallest size group, mean CTDIvol of
the brain retrospectively has values of 20, 21, 23, and 29 mGy, re-
spectively. For the medium size group of the abdomen-pelvis, the
mean SSDE has values of 4.3, 5.5, 5.6, and 6.7 mGy, respectively.
Discussion
The analysis of dose descriptors from a national survey of
three types of pediatric CT examinations showed that aca-
demic pediatric facilities deliver a significantly lower radia-
tion dose with a significantly smaller variance to pediatric pa-
tients when compared with nonacademic pediatric, academic
adult, and nonacademic adult facilities. This result held for
all brain examinations and for 42 of 54 (78%) chest and 48
of 54 (89%) abdomen-pelvis examinations across all six size
groups, three dose descriptors, and three facilities when com-
pared with radiation dose at the academic pediatric facility.
Also, variance for the academic pediatric facilities was signifi-
cantly less for all brain examinations and the vast majority of
chest and abdomen-pelvis examination size groupings among
the different facilities (52 of 54 [96%] and 51 of 54 [94%],
respectively). Reduction of both mean dose index and vari-
ance through careful practice improvement better serves the
patient population than does a program that only reduces the
mean dose index.
The previously reported calculated SSDE values in academic
pediatric facilities (15,16) and those in this study were dependent
on the year of the study for all sizes of patients. The mathematical
fits in Figures 4 (15) and 1c (16) enable calculation and compari-
son of results from 2009 (abdomen CT) and 2013 (chest CT),
respectively, with the results of this study (Tables 4, 5) in 2016
and 2017. For the abdomen, the SSDE in this study was 4.2 of
8.4 (50%), 4.3 of 11.5 (37%), and 5.8 of 15.6 (37%) of the study
results in 2009 for the smaller than 14.5 cm, 18–22 cm, and larger
than 28.5 cm size groups, respectively. For the same size groups,
the SSDE of the chest in this study was 2.3 of 2.6 (88%), 2.6 of
3.8 (68%), and 4.5 of 6.3 (71%) of the study results in 2013.
In our study, the majority of examinations used iterative recon-
struction, while this dose reduction technique was not available
in the five academic pediatric facilities in 2009, but was available
in some academic pediatric facilities in 2013. In addition, when
patient doses were compared between two different time periods
since 2000, the more recent dose reports were lower than the prior

Radiology: Volume 291: Number 1—April 2019 n radiology.rsna.org 163

Radiation Dose for Pediatric CT

Table 4: Mean, Standard Deviation, and P Value for Three Dose Indexes for Abdomen-Pelvis Examinations Grouped
by Patient Size and Facility Type

SSDE (mGy) CTDIvol (mGy) DLP (mGy·cm)

Sample P Value P Value P Value P Value P Value P Value

Size and Facility Type Size Mean 6 SD (t test) (F test) Mean 6 SD (t test) (F test) Mean 6 SD (t test) (F Test)
0–14.5 cm
Academic pediatric 93 4.2 6 4 … … 1.8 6 1 … … 45 6 30 … …
Nonacademic 126 4.2 6 4 .534* .387* 1.8 6 2 .468* .003 58.8 6 96 .066* ,.001
  pediatric
Academic adult 84 768 .002 ,.001 363 .001 ,.001 118.3 6 182 ,.001 ,.001
Nonacademic adult 86 6.1 6 13 .111* ,.001 2.7 6 6 .087* ,.001 71.3 6 115 .021* ,.001
14.5–18 cm
Academic pediatric 211 3.6 6 2 … … 1.8 6 1 … … 59.7 6 33 … …
Nonacademic 312 5.4 6 3 ,.001 ,.001 2.7 6 1 ,.001 ,.001 98.4 6 70 ,.001 ,.001
  pediatric
Academic adult 200 5.5 6 4 ,.001 ,.001 2.7 6 2 ,.001 ,.001 102.5 6 98 ,.001 ,.001
Nonacademic adult 619 8.3 6 18 ,.001 ,.001 4.1 6 9 ,.001 ,.001 134.1 6 162 ,.001 ,.001
18–22 cm
Academic pediatric 626 4.3 6 2 … … 2.5 6 1 … … 90.1 6 56 … …
Nonacademic 1102 5.5 6 3 ,.001 ,.001 3.1 6 2 ,.001 ,.001 129.9 6 98 ,.001 ,.001
  pediatric
Academic adult 598 5.6 6 4 ,.001 ,.001 3.2 6 2 ,.001 ,.001 128.5 6 96 ,.001 ,.001
Nonacademic adult 3284 6.7 6 5 ,.001 ,.001 3.8 6 3 ,.001 ,.001 154.9 6 117 ,.001 ,.001
22–25 cm
Academic pediatric 800 563 … … 3.2 6 2 … … 117.9 6 90 … …
Nonacademic 1448 6.3 6 3 ,.001 .994* 462 ,.001 .982* 182.3 6 105 ,.001 ,.001
  pediatric
Academic adult 1373 7.2 6 5 ,.001 ,.001 4.6 6 3 ,.001 ,.001 221 6 111 ,.001 ,.001
Nonacademic adult 9322 8.1 6 4 ,.001 ,.001 5.3 6 3 ,.001 ,.001 238.7 6 138 ,.001 ,.001
25–28.5 cm
Academic pediatric 817 5.1 6 3 … … 3.7 6 2 … … 148.9 6 112 … …
Nonacademic 1826 7.7 6 3 ,.001 ,.001 5.6 6 2 ,.001 ,.001 262.9 6 146 ,.001 ,.001
  pediatric
Academic adult 2364 8.5 6 4 ,.001 ,.001 6.1 6 3 ,.001 ,.001 302.6 6 145 ,.001 ,.001
Nonacademic adult 16 566 9.6 6 4 ,.001 ,.001 6.9 6 3 ,.001 ,.001 318.2 6 178 ,.001 ,.001
. 28.5 cm
Academic pediatric 2800 5.8 6 3 … … 5.8 6 4 … … 289.6 6 213 … …
Nonacademic 3442 9.4 6 7 ,.001 ,.001 9.3 6 7 ,.001 ,.001 459.1 6 405 ,.001 ,.001
  pediatric
Academic adult 3193 12.1 6 6 ,.001 ,.001 11.5 6 7 ,.001 ,.001 599.2 6 404 ,.001 ,.001
Nonacademic adult 33 357 11.9 6 6 ,.001 ,.001 11.8 6 7 ,.001 ,.001 603.6 6 417 ,.001 ,.001
Note.—CTDIvol = volume CT dose index, DLP = dose-length product, SD = standard deviation, SSDE = size-specific dose estimate.
* Case was not significant after applying the Bonferroni-Holm correction.

dose reports (1–3,29,30). These reductions are most likely due to
technologic improvements in the CT scanners as opposed to any
practice differences in different types of facilities.
In a previous study, five academic pediatric hospitals reported
that pediatric radiologists with 9—23 years of experience were
comfortable interpreting images of 1-year-old patients with half
the radiation dose used for a standard-size adult in the same fa-
cility (15,16). However, radiologists with less experience inter-
preting pediatric images may require increased doses to decrease
image noise to provide equivalent care for pediatric patients. The
relative differences in SSDE (trunk) or CTDIvol (head) in Table 2
indicate that adult or nonacademic pediatric facilities use one to
two times the radiation dose used in academic pediatric depart-
ments at the time of this study.
A limited number of studies have compared dose indexes
between academic pediatric and other facilities. A study from
2008 of 40 adult community hospitals (18) found high CTDIvol
and DLP values with a wide variance of 2–42 mGy and 58–
2030 mGy·cm, respectively, compared with mean values of
3 mGy 6 2 and 130 mGy·cm 6 96 for an academic pedi-
atric hospital. A 2014 study compared 233 CT examinations
performed at community hospitals with 287 examinations per-
formed at a pediatric facility and found that CTDIvol in the
community hospitals was 75% greater (8.6 vs 4.9 mGy) than

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 Strauss et al

Table 5: Mean, Standard Deviation, and P Value for Three Dose Indexes for Chest Examinations Grouped by Patient
Size and Facility Type

SSDE (mGy) CTDIvol (mGy) DLP (mGy·cm)

Sample P Value P Value P Value P Value P Value P Value

Size and Facility Type Size Mean 6 SD (t test) (F test) Mean 6 SD (t test) (F test) Mean 6 SD (t test) (F test)
0–14.5 cm
Academic pediatric 57 2.3 6 1 … … 1 6 0.4 … … 17.3 6 8 … …
Nonacademic 48 4.9 6 3 ,.001 ,.001 2.1 6 1 ,.001 ,.001 39.8 6 24 ,.001 ,.001
  pediatric
Academic adult 17 4.2 6 4 .050* ,.001 1.8 6 2 .046* ,.001 38.6 6 63 .091* ,.001
Nonacademic adult 15 2.5 6 2 .333* .006 1.1 6 1 .377* .004 21 6 17 .209* .002
14.5–18 cm
Academic pediatric 77 2.6 6 1 … … 1.3 6 1 … … 27.8 6 17 … …
Nonacademic 74 562 ,.001 ,.001 2.5 6 1 ,.001 ,.001 57.3 6 43 ,.001 ,.001
  pediatric
Academic adult 19 463 .016* ,.001 261 .015* ,.001 47.2 6 39 .022* ,.001
Nonacademic adult 12 2.4 6 2 .666* .039 1.2 6 1 .664* .037* 29.5 6 34 .430* .007
18–22 cm
Academic pediatric 259 2.6 6 2 … … 1.5 6 1 … … 37.1 6 44 … …
Nonacademic 175 564 ,.001 ,.001 2.8 6 2 ,.001 ,.001 72.6 6 51 ,.001 .023
  pediatric
Academic adult 47 4.7 6 5 .003 ,.001 2.6 6 3 .003 ,.001 68.8 6 88 .009 ,.001
Nonacademic adult 28 5.2 6 3 ,.001 .003 2.9 6 1 ,.001 .005 79.1 6 52 ,.001 .149*
22–25 cm
Academic pediatric 282 2.8 6 1 … … 1.8 6 1 … … 53.3 6 38 … …
Nonacademic 201 4.7 6 2 ,.001 ,.001 361 ,.001 ,.001 90.8 6 49 ,.001 ,.001
  pediatric
Academic adult 86 4.7 6 3 ,.001 ,.001 362 ,.001 ,.001 102.8 6 78 ,.001 ,.001
Nonacademic adult 53 5.6 6 3 ,.001 ,.001 3.6 6 2 ,.001 ,.001 109.9 6 75 ,.001 ,.001
25–28.5 cm
Academic pediatric 431 3.9 6 2 … … 2.8 6 1 … … 96.6 6 53 … …
Nonacademic 334 4.5 6 2 ,.001 ,.001 3.2 6 2 ,.001 ,.001 107.1 6 63 .007 ,.001
  pediatric
Academic adult 198 5.7 6 4 ,.001 ,.001 4.1 6 3 ,.001 ,.001 143.3 6 102 ,.001 ,.001
Nonacademic adult 124 765 ,.001 ,.001 5.1 6 4 ,.001 ,.001 199.7 6 267 ,.001 ,.001
.28.5 cm
Academic pediatric 729 4.5 6 2 4.5 6 2 155.1 6 94
Nonacademic 430 5.6 6 4 ,.001 ,.001 5.4 6 5 ,.001 ,.001 184.7 6 190 .001 ,.001
  pediatric
Academic adult 273 8.3 6 5 ,.001 ,.001 7.9 6 6 ,.001 ,.001 272.9 6 212 ,.001 ,.001
Nonacademic adult 288 8.3 6 4 ,.001 ,.001 8.2 6 5 ,.001 ,.001 283.1 6 240 ,.001 ,.001
Note.—CTDIvol = volume CT dose index, DLP = dose-length product, SD = standard deviation, SSDE = size-specific dose estimate
* Case was not significant after applying the Bonferroni-Holm correction.

in the pediatric hospital (20). A 2012–2013 brain CT survey
including 250 hospitals suggested that dose indexes did not
vary significantly by region of the country, trauma level, teach-
ing status, CT accreditation, number of CT scanners, or use of
dedicated pediatric CT protocols. However, the reported CT-
DIvol at dedicated children’s hospitals was 19% (22.3 vs 27.6
mGy) lower than that at the general hospitals (22).
Our study had some limitations that may have led to biased
results: data in Table 3 indicate only 10 and 19 of 519 total fa-
cilities were academic or nonacademic pediatric facilities, respec-
tively; thus, fewer than 59 000 of the total 240 000 examinations
in our study came from pediatric facilities; only the three most
common types of pediatric CT examinations—brain, chest, and
abdomen-pelvis—are included in our study. Because of the vol-
untary nature of data submission to DIR and the inability to
randomly sample data due to a limited number of patients and
facilities in each size category, this study may not have completely
mitigated participation bias; finally, for chest and abdomen-pel-
vis examinations, only sites that chose to submit localizer scan
images, which were needed to calculate effective diameter used
to calculate SSDE, were included in our study. In addition, de-
spite the inclusion of 2 full years of national data, the sample size
of six of 68 (9%) of our defined size ranges of effective diameter
failed to exceed a sample size of 50, which weakened the power

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Radiation Dose for Pediatric CT

Table 6: Mean, Standard Deviation, and P Value for Three Dose Indexes for Brain Examinations Grouped by Patient
Size and Facility Type

CTDIvol (mGy) DLP (mGy·cm)

Facility Type Sample Size Mean 6 SD P Value (t test) P Value (F test) Mean 6 SD P Value (t test) P Value (F test)
0–14 cm
Academic pediatric 7110 19.7 6 8 … … 306.3 6 147 … …
Nonacademic pediatric 11 170 21.1 6 11 ,.001 ,.001 353 6 200 ,.001 ,.001
Academic adult 3274 22.5 6 14 ,.001 ,.001 357.5 6 238 ,.001 ,.001
Nonacademic adult 16 454 28.5 6 17 ,.001 ,.001 451.6 6 280 ,.001 ,.001
14.0–15.5 cm
Academic pediatric 4602 23.3 6 11 … … 434.6 6 159 … …
Nonacademic pediatric 6281 33.6 6 14 ,.001 ,.001 588.2 6 242 ,.001 ,.001
Academic adult 4820 37 6 18 ,.001 ,.001 620 6 265 ,.001 ,.001
Nonacademic adult 30 780 39.1 6 18 ,.001 ,.001 643.5 6 276 ,.001 ,.001
15.5–17 cm
Academic pediatric 2650 24.1 6 9 … … 453.8 6 136 … …
Nonacademic pediatric 3600 38.7 6 13 ,.001 ,.001 696.7 6 248 ,.001 ,.001
Academic adult 4599 42.1 6 16 ,.001 ,.001 716.1 6 241 ,.001 ,.001
Nonacademic adult 23 835 44.4 6 17 ,.001 ,.001 743.8 6 282 ,.001 ,.001
17–18 cm
Academic pediatric 978 24.2 6 7 … … 457.4 6 136 … …
Nonacademic pediatric 1119 39.4 6 12 ,.001 ,.001 725 6 245 ,.001 ,.001
Academic adult 1598 45.4 6 14 ,.001 ,.001 777.9 6 229 ,.001 ,.001
Nonacademic adult 7376 48.4 6 16 ,.001 ,.001 833.9 6 293 ,.001 ,.001
.18 cm
Academic pediatric 1433 23.1 6 8 … … 434.8 6 155 … …
Nonacademic pediatric 2836 36 6 14 ,.001 ,.001 644 6 280 ,.001 ,.001
Academic adult 3699 43.9 6 15 ,.001 ,.001 767.6 6 254 ,.001 ,.001
Nonacademic adult 13 171 44.2 6 18 ,.001 ,.001 789.1 6 338 ,.001 ,.001

Figure 4: Representative image quality at the reported mean volume CT dose index (CTDIvol) level for an academic pediatric facility. (a) Repre-
sentative unenhanced brain CT image in a 5-year-old patient who measured 14.2 cm (lateral) had a CTDIvol of 23.7 mGy and a dose-length prod-
uct (DLP) of 408.2 mGy·cm. (b) Representative unenhanced chest CT image in a 7-year-old 23-kg patient who measured 19.7 cm (lateral) had
a CTDIvol of 1.3 mGy and a DLP of 29.8 mGy·cm. (c) Representative contrast-enhanced abdomen-pelvis CT image in an 8-year-old 29-kg patient
who measured 20.9 cm (lateral) had a CTDIvol of 2.2 mGy and a DLP of 85.1 mGy·cm.

of the statistical analysis. The calculated means in our study can
only be used as an estimate of the median value (achievable
dose) for each size group, patient examination, and facility type;
the medians for this type of dose study typically are less than
their corresponding mean. Finally, analysis of different patient
populations, indications, image quality, and practices of differ-
ent types of facilities—all of which affect differences in patient
doses—was beyond the scope of our study.
Substantial progress has been made in pediatric CT dose re-
duction. Abdominal CT dose in the smallest pediatric patients

166 radiology.rsna.org n Radiology: Volume 291: Number 1—April 2019


in nonacademic adult facilities in our study was 51% (6.1 vs
11.9 mGy) of the adult dose (Table 4). In 2001, staff were not
trained to size adjust their CT radiographic techniques for small
children (3), which would have delivered at least double the dose
to the smallest patients when compared with the largest. Despite
this progress, careful management of pediatric patient dose is not
complete. Our study found patient doses in adult facilities to be
up to double the dose (Table 2) of the academic pediatric facility
for the same size patient. Our study found reduced variance of
pediatric patient CT dose in academic pediatric facilities when
compared with nonacademic, academic adult, and nonacademic
adult facilities for all patient sizes. It is recommended that each
facility charge a team of their radiologists, technologists, and
medical physicists to compare patient CT dose indexes with the
values in this national survey. A serious dose analysis and pro-
tocol review should be conducted to identify possible ways to
better manage CT doses.
Acknowledgments: The authors thank Joanne Lovelace for her expertise in
managing the references for this article and J.R. Wells, Y. Zhang, and E. Samei of
the Duke University Clinical Imaging Physics Group for allowing use of their code
to automatically estimate the effective diameter (patient size) from localizer images
within the ACR’s DIR.
Author contributions: Guarantors of integrity of entire study, K.J.S., E.S., D.S.,
S.L.B.; study concepts/study design or data acquisition or data analysis/interpreta-
tion, all authors; manuscript drafting or manuscript revision for important intellec-
tual content, all authors; approval of final version of submitted manuscript, all au-
thors; agrees to ensure any questions related to the work are appropriately resolved, all
authors; literature research, K.J.S., E.S., J.R.M., S.L.B.; clinical studies, E.S., S.L.B.;
statistical analysis, E.S., D.S., S.L.B.; and manuscript editing, all authors
Disclosures of Conflicts of Interest: K.J.S. disclosed no relevant relationships.
E.S. disclosed no relevant relationships. D.S. disclosed no relevant relationships. J.R.M.
disclosed no relevant relationships. S.L.B. disclosed no relevant relationships.
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