PEDIATRIC RADIOGRAPHY

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INTRODUCTION:
Radiological examinations are fundamentally the same
whether the patient is child or adult. Protection from unnecessary radiation is very important , most of the radiological examinations are not painful. Yet small

children often vigorously resist such examination. It becomes necessary for technologists to take the child in confidence, which may take some time .

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APPROACH TO THE CHILD:
One who wishes to have successful relationship with children must

like children & not only happy with well children but also with the
sick children who often tired, cranky & frightened . One must understand the fears, needs & desires of children.

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Medical personnel who deals with children should develop a sensitivity against child reaction. technologists & nurses prepare the child. .CONT…….. Our hospital has posters & toys to prepare the children. By the help of parents.

Technologists need to learn to observe & quickly evaluate the children.Cont……. their level of maturity & ability to communicate. .

speak softly & smoothly & offer a bottle of milk.YOUNG INFANTS (ABOUT 6 MONTH . Reacting to pain stimulates total body movements & loud crying may cease upon distraction. Ask to bring his/her favorite Toy. 7 . Ask the parent to hold the child.2YEARS): They often are playful or sleepy.

8 . Preschooler are eager to please & a game like atmosphere can facilitate our work.PRESCHOOLERS (3 – 5 YEARS): Preschooler can understand instructions & explanations if they are offered with an understanding of child likely precaution . Praise must be given when the child tries to cooperate.

But some can examine only after sedation. Some examined with the help of their Parents.MENTALLY RETARDED CHILDREN: Some mentally retarded children can be examined without problem . 9 . Teachers or Hospital attendants.

Most parents can give their child important support. lead apron to protect from scattered radiation. so should be encouraged to accompany the child. Parents should be given lead gloves.PARENTS IN RADIOGRAPHIC ROOM: Pediatric radiologists & technologists believed that parents who wish to accompany their child should be permitted to do so. 10 .

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12 .COMPUTERISED RADIOGRAPHY (CR): With the help of imaging plate we can reduce the dose to the infants that is our main target. DIGITAL RADIOGRAPHY: With the help of flat panel detector we can have direct acquisition of the radiograph.

ADVANTAGES OF CR & DR:  Less radiation dose to the patients.  With CR & DR we can use ALARA principle more efficiently.  From technologists point of view examination is quicker in flat panel digital radiography because there is no use of cassette. 13 .  Here we have advantages of post processing & PACS.

PORTABLE RADIOGRAPHY: It is beneficial because of no need to bring the child to the radiographic room if the condition of child is critical. We should use gowns. Use proper collimation. 14 . masks. Usually infants are under treatment in ICU so we have to take some precautions : We should take care of different equipments attached to child. Set accurate exposure factors to avoid more radiation dose. gloves & sterile sheets to the cassettes to avoid any infection.

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16 . No rotation No blurring of lungs. diaphragm & abdominal structure.CHEST AND ABDOMEN RADIOGRAPH EVALUATION CRITERIA: The following should be clearly demonstrated: Anatomy from apices to pubic symphysis in thoracic & abdominal region.

Variation of distance b/w tube & patient means more variability in exposure. Line voltage variation in room will affect the output. Care must be taken so that the primary beam is perpendicular to film.SPECIAL RADIATION PROTECTION PROBLEMS WITH PORTABLE EQUIPMENT: There is greater potential to unnecessarily expose personnel & other patients. especially when grid is used. 17 .

RADIOGRAPHIC TECHNIQUE: It is important that the technologists have a different plan for procedure with children. A suggested sequences of procedure are as follows: 18 . films & the energy of the operator as well as minimizing the amount of radiation to the patients. The advantages include saving time.

Read requisition form carefully. 2. Explain the procedure if the patient is old enough to understand.Cont…… 1. Speak courteously & take him in higher confidence . Call the patients in the radiographic room. 19 . 3. 4.

9 Start the rotar and check till last moment 10 Make exposure. 7 Position the patient. 6 Set machine for exposure. 8 Shield the gonadal area if necessary. .5 Assemble necessary equipments .

this board is radiolucent & allow uniform contact of all bones. AP -Projection 21 . A piece of splint board. balsawood or Lucite are placed on the back of the hand & held on either side. limb can be held in position with plastic panel held by sand bags.UPPER LIMB RADIOGRAPHY:  When the child is too young to cooperate. Indications : Colle’s # Green stick #   1. 2. The hands of uncooperative patient are more easily held in position.

Knees and lower extremities are easier to radiograph in prone position. because the knees can flex & contact remain uniform. Examination for possible fracture require special care. FA.Cont……… A direct lateral view of wrist. CR: Pass through centre of cassette. rough handling can increase the displacement of bone fragments. elbow & humerus with infants and uncooperative children are taken in supine position .Projection Lateral .Projection 22 . causing further damage to blood vessels & other soft tissues. PA .

EVALUATING THE IMAGE:
Most striking difference between adult and pediatric patient is radiographic appearance of limb. As the bones of child are cartilaginous, their bones are growing, epiphyseal plates at the end of bones sometimes appear as fracture. So it should be correctly visualize either it is a fracture or any stage of ossification in bones.

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CHEST RADIOGRAPHY:
 It is the most common radiographic procedure performed. PREPARATION : Remove all lockets & chains. Have the patients be undressed completely from waist up. Apply a sheet on the cassette to prevent from hypothermia . Infants & children younger than 4 year are best examined in supine position.

 1. 2.
3.

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AP (SUPINE POSITION):
 The children are placed in supine position on the cassette, a compression band is placed over the pelvis & adhesive tapes are used to immobilize the legs. The head & arms are cradled b/w two sand bags. The head must not be turned, this will oblique the chest INDICATION : Pneumonia Cough & sneezing Empyema CHD (congenital heart disease) TB
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 1. 2. 3. 4. 5.

L AP VIEW 26 .

To see free air or fluid in the pleural space.LATERAL POSITION:  Supine child which are fixed in sponge immobilization device or with compression band as can be radiograph by horizontal expsure. 27 . the baby is rotated in lateral decubitus position. 2. affected side up for air & down for fluid. EXPOSURE: Make Exposure When child take deep breath (crying) Watching The Abdomen: Abdomen of child will extend on inspiration  1.

LATERAL PROJECTION 28 .

Cont……. 4.  CR : T4 – T5 29 .Patient is made to stand/sit in front of vertical cassette holder in PA position..  Upright radiograph done on the 3-10 year old. 3. their arms held over their head or drape their arms on side of x-ray cassette holder. Watching Chest Wall: Ribs will be outlined on inspiration . Watching the rise & fall of sternum. This is done in:  PA-POSITION : .

L 30 .

EXPOSURE: films are taken at expiration when the children are relaxed. An upright film should be included when condition such as obstruction. sub diaphragmatic hernia or abscesses. 31 .ABDOMEN RADIOGRAPHY: The standard AP (supine) position are recommended in all infants & children.

B. supine position A. D. b. AP SUPINE OPTIONAL LATERAL AP SUPINE AP OR PA with horizontal beam. b. Abdominal mass a. b. Abdominal distension Suspected bowel obstruction C. Suspected perforation a.PATHOLOGY AND RECOMMENDED VIEWS: Information required by clinician Recommended views a. AP SUPINE OPTIONAL LATERAL 32 . a. b. lateral decubitus position AP SUPINE LATERAL with horizontal beam.

3.  1. 2. INDICATION : Pathology Diseases Congenital dislocation Trauma PREPARATION : All images of abdomen & pelvic girdle should be performed with dipar completely removed.HIP RADIOGRAPHY:   1. The hip & pelvis are commonly examined radiograph in both pediatric & adult. 33 . 4.

Because wet dipar produce significant artifacts on radiographs. often rendering them under diagnostic.  POSITIONING:  The child lies supine on x-ray table on top of the cassette or a specially designed cassette holder. which is placed at the end of table with the median saggital plane of the trunk at right angles to the midline of cassette . 34 . 3.Cont…… 2. Before beginning arrange all necessary sponges. Velcro strips & Velcro restraining band on table . gonadal shielding.

the fingers of holder under the calves of baby & the thumbs of holder on the knees. 35 .  The legs of baby are held straight with the hands of holder positioned firmly around each leg. the knees should be held together and flexed. a sand bag is placed on either side of trunk of baby with the arm of child left unrestrained . To maintain this position.Cont……. If using cassette holder at the end of table.

Immobilization devices should be such that they did not stick to children. we can use clamp immobilization. 1. would not move but for preschooler.SKULL RADIOGRAPHY:  It is very challenging job for technologists. 2. But problems associated with cranial radiography in children can be improved by: IMMOBILIZATION: because small child once positioned. 36 . Avoidance of use of grid in children under the age of 1 year is an important dose saving measure.

. 3.Cont……. A short exposure time required to avoid movement unsharpness. 4.  INDICATION: 1. Neuroblastoma 3. Pituitary gland disorder 4. Trauma 2. Children of 7 years of age need almost as much exposure as an adult because their skull are almost fully grown. Hydrocephalus 37 .

38 .Cont……. views are done. • AP View: • Central ray pass through nasion. Generally AP & LAT.

Generally done in supine position .Passes midway b/w glabella & external occipital protuberance . CR: .• LATERAL: . 39 .

To show whole body bone density . 40 .INFANTOGRAM: .

41 .(2) BONE AGE: Bone is the maturation of the child. VIEW: . which can be check by comparing appearance and maturation of certain primary and secondary bone centers. In child 312 bones are present as compare to adult who has 206 bones .PA Projection of bilateral wrist.

 VIEW. 42 .  AP projection of the lower extremities.GROWTH STUDY (SCANOGRAM):  Growth study is measurement of Iength of lower extremities by direct measurement of radiographic bone length.

VITAMIN DEFICIENCY STUDY: It is a survey of those portion of body in which there is chronic deficiency of Vitamin “C” and “D”. Rickets). 43 .  VIEWS.  A) AP projection of wrist and knees (e.g.

APPROACH TO SPECIAL PROCEDURE: IVP MCU BARIUM STUDY 44 .

IVP • It is a radiological examination of KUB by injecting the CM intravenously .

. 5) Hydronephrosis. 2) UTI.. 46 . Indications: 1) Pain in abdomen. 4) Renal Calculus. 3) Hematuria.Cont……. 6) Poor Kidney function.

5 years. • I Dulcolax Tablet previous one night. • I Dulcolax tablet previous 2 nights.PATIENT PREPARATION: No preparation below 4 years but ask for empty stomach by 4 hours and allowed very light dinner on previous night. • For child> 8 years. 47 . • For child >= 4.

• • • • • • • • Film sequence Plain film After giving CM 7 min. Iopamidol . NON IONIC: Iohexol.E film 48 . film 15 min. film 30 min. film Full bladder P. Conray.CONTRAST: IONIC: Urografin. Trazograf .

Abdominal compression is not used in children. 49 .Cont…….

(2) MCU: It is retrograde examination of bladder & urethra by filling it with CM through a catheter under sterile method  INDICATIONS: 1) Reflux urinary tract infection. 50 . 2) Neurogenic bladder. 3) Vesico-uretric reflux.

EQUIPMENT: Fluoroscopy with spot film device and tilting table. PROCEDURE: I) First of all preliminary film of bladder are taken. 51 . Any residual urine is drained & CM is slowly dripped into bladder up to full capacity & filling is observed by fluoroscopy. 2) urethra is anaesthetized by xylocaine gel before introducing urethral catheter. 3) catheter is introduced.

5) Supine full bladder film is taken to see capacity & outline of bladder & also to see any filing defect or diverticulum. 6) Micturating views i.Cont…… 4) Catheter is removed if patient is ready to micturate. B/l oblique 7) Take PE film. 52 . NOTE: antibiotic is given for days after examination to prevent any infection.e.

METHODS: I) Barium swallow: .BARIUM STUDY: It is to demonstrate GI tract by BaSO4 CM. INDICATION: I) Regurgitation 2) Esophageal varices. 53 .It is investigation of esophagus up to GE junction by introducing barium orally. 4) Esophageal stricture. 3) Esophageal diverticulum.

AP & Lat.VIEWS OR FILMING: 1) Upper esophagus . 2) Lower esophagus-RAO & Lat. 3) GE Junction -LPO & Lat 54 .

For small children aqueous media is preferred because of aspiration. INDICATION: I) Peptic ulcer 2) GI hemorrhage. & duodenum by giving CM orally. 55 . stomach. 4) Intestinal disorder.(2) BARIUM MEAL: It is a radiological investigation of esophagus. 3) Failure of rotation of stomach.

VIEWS OR FILMING: 1) 1ST film. 3) 3rd film-R Lat position of filled stomach. 4) 4th film-4 spot of duodenal loop RAO and Rt. Lat. 56 . 2) 2nd film-RAO-mucosal film of stomach.of lower esophagus including GE junction.

4) Abdominal mass. INDICATION: 1) Diarrhoea.BMFT: It is radiological investigation of bowel duodenum to IC junction. 5) Malrotation from 57 . 2) Partial obstruction. 3) Inflammation.

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2) Hirsch sprung disease. INDICATION: 1) Constipation. 59 .BARIUM ENEMA: Investigation of colon by retrograde introduction of cm.

5) Sexual abuse. 4) Slap marks. TYPE of ABUSE: 1) Bone injuries. hit). 60 . 2) Abdominal injury ( kicked. 3) Inflicted burn.CHILD ABUSE: Technologist should approach to an abused child in same way as that of other injured or ill child.

IMMOBILIZATION Immobilization is required in pediatric because they do not understand the need to hold still in a fixed position .

Children • Get down to child size • Kindness • Patience .

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Pediatric Immobilization • • • • • • Communication Sheets Tape Velcro straps Octastop board Pigg-O-Stat .

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SLEEPING IS BEST IMMOBILIZATION .

• An infant or child must never be immobilized so tightly that small movements are impossible.such repetation may indeed test one’ patience .PRECAUTIONS • An immobilized child must never be left alone in room except for the moment the exposure is made. • Frequently the child will ask for the description of the procedure a number of times .

3) Use of high speed intensifying screen. 73 .RADIATION PROTECTION: 1) Keeping the number of radiograph examination to a minimum consistent with health and welfare. I P plates & reduced exposure time. 2) Avoid repeat. hip. 4) Proper shielding of gonad. pelvis & abdomen according to examination. 5) Proper collimation.

8) Pregnant woman is not allowed to accompany the child.Shielding 7) Use of lead gloves & apron by technologist & attendant if present. 74 . 9) During radiography of upper limbs protect the upper torso of all children.Distance .Time .Cont…… 6) Follow ALARA Principle( as low as reasonably achievable) .

CONCLUSION: Above points shows that children require special attention when they are to be radio graphed. 75 . immobilization plays important role in pediatric radiography and radiation protection is must in pediatric radiography.

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