M.
Paediatrics
Minimise x-irradiation in
children, especially those with long term problems
(For head injury in children see Trauma Section K)
CLINICAL PROBLEM |
INVESTIGATION |
RECOMMENDATION |
COMMENT |
||
| CNS | |||||
| Congenital disorders | M1 | MRI | Indicated | [C] | Definitive exam for all malformations and avoids x-irradiation. Sedation usually required for young children. Consider US in neonates. 3D CT may be needed for bone anomalies. |
| Large head circumference ?hydrocephalus |
M2 | US | Indicated | [B] | US indicated where anterior fontanelle is open. MRI indicated for older children. (CT may be appropriate if MRI not available.) |
| Epilepsy | M3 | SXR | Not indicated | [B] | Poor yield. |
| MRI or NM | Specialised investigation | [B] | MRI usually more appropriate than CT, SPECT also used in some centres. | ||
| Deafness in children | M4 | MRI, CT | Specialised investigation | [C] | Both MRI and CT may be necessary in children with congenital and post-infective deafness. |
| Hydrocephalus ?shunt malfunction (see A10) |
M5 | XR US or MRI |
Indicated Indicated |
[B] [B] |
XR should include whole valve system. US if practical, MRI in older children (or CT if MRI unavailable). NM used in some centres. |
| Developmental delay ?cerebral palsy | M6 | MRI | Specialised investigation | [B] | See also M15 for skeletal investigation of growth failure. |
| Headaches | M7 | SXR | Not indicated routinely | [B] | If persistent or associated with clinical signs refer for specialised investigations. |
| MRI | Specialised investigation | [B] | In children MRI is preferable if available because of absence of x-irradiation. | ||
| ?Sinusitis | M8 | Sinus XR | Not indicated routinely | [B] | Not indicated before 5 yrs as the sinuses are poorly developed; mucosal thickening can be a normal finding in children. A single undertilted OM view may be more appropriate than the standard OM view depending on the child's age. |
| Neck and Spine | |||||
| Torticollis without trauma | M9 | XR | Not indicated | [B] | Deformity is usually due to spasm with no significant bone changes. If persistent, further imaging may be indicated following consultation. |
| Back or neck pain | M10 | XR | Indicated | [B] | Back pain is uncommon in children without a cause. Follow-up is needed if infection is suspected. |
| NM | Specialised investigation | [B] | When pain continues and XRs are normal. Useful in painful scoliosis. | ||
| MRI | Specialised investigation | [B] | See also The Spine Section C. MRI defines spinal malformations and excludes associated thecal abnormality. | ||
| ?Spina bifida occulta | M11 | XR | Not indicated | [B] | A common variation and not in itself significant (even in enuresis). However, neurological signs would require investigation. |
| Hairy patch, sacral dimple | M12 | XR | Not indicated | [B] | |
| US | Indicated | [B] | US may be useful in the neonatal period to screen for underlying tethered cord, etc. | ||
| MRI | Specialised investigation | [B] | MRI particularly if neurological signs are present. | ||
| Musculoskeletal | |||||
| ?Non accidental injury ?child abuse (For head injury see Section K) |
M13 | XR of affected parts | Indicated | [B] | Local policies will apply; close clinical/radiological liaison essential. Skeletal survey for those under 2 yrs after clinical consultation. May occasionally be required in the older child. Consider MRI of brain, even in the absence of cranial apparent injury. |
| NM | Specialised investigation | [B] | Sensitive for occult spine/rib fracture in the younger child where history unavailable. | ||
| Limb injury: opposite side for comparison | M14 | XR | Not indicated routinely | [B] | Seek radiological advice. |
| Short stature, growth failure | M15 | XR for bone age | Indicated at appropriate intervals | [B] | 2-18 yrs: left (or non-dominant) hand/wrist only. Premature infants and neonates: knee (specialised investigation). May need to be supplemented with a skeletal survey and MRI for hypothalamus and pituitary fossa (specialised investigations). |
| Irritable hip | M16 | US | Indicated | [B] | US will delineate effusions which can be aspirated for diagnostic and therapeutic purposes. XRs can be delayed, but should be considered when the symptoms are persistent. Consider NM or MRI when Perthes' disease is suspected and plain XRs are normal. |
| Limp | M17 | XR pelvis | Indicated | [C] | Gonad protection is used routinely unless shields will obscure area of clinical suspicion. If slipped epiphyses is likely, lateral XRs of both hips are needed. |
| US or NM or MRI | Specialised investigation | [B] | According to local policy, expertise and availability. | ||
| Focal bone pain | M18 | XR and US | Indicated | [B] | XR may be normal initially. US can be helpful particularly in osteomyelitis. |
| NM or MRI | Specialised investigation | [B] | Increasing use of MRI here. | ||
| Clicking hip ?dislocation |
M19 | US | Indicated | [B] | XR may be used to supplement US examination. XR indicated in the older infant. |
| ?Osgood-Schlatter's disease | M20 | XR | Not indicated | [C] | Although bony radiological changes are visible in Osgood-Schlatter's disease these overlap with normal appearances. Associated soft tissue swelling should be assessed clinically rather than radiographically. |
| Cardiothoracic | |||||
| Acute chest infection | M21 | CXR | Not indicated routinely | [B] | Initial and follow-up films are indicated in the presence of persisting clinical signs or symptoms or in the severely ill child. Consider the need for CXR in PUO. Children may have pneumonia without clinical signs. |
| Recurrent productive cough | M22 | CXR | Not indicated routinely | [C] | Children with recurrent chest infection tend to have normal CXRs (apart from bronchial wall thickening). Routine follow-up CXR not indicated unless collapse present on initial CXR. Suspected cystic fibrosis requires specialist referral. |
| Inhaled FB (suspected) (see Section K) |
M23 | CXR | Indicated | [B] | History of inhalation often not clear. Bronchoscopy is indicated, even in the presence of a normal CXR. Expiratory films usually sufficient to confirm the presence of air trapping. Chest screening in young children not routinely indicated in view of the high radiation dose. |
| Wheeze | M24 | CXR | Not indicated routinely | [B] | Children with asthma usually have normal CXR apart from bronchial wall thickening. Sudden unexplained wheeze CXR indicated, may be due to inhaled FB (above). |
| Acute stridor | M25 | XR | Not indicated | [B] | Epiglottitis is a clinical diagnosis, but consider FB (above). |
| Heart murmur | M26 | CXR | Not indicated routinely | [C] | Specialist referral needed; cardiac US may be indicated. |
| Gastointestinal | |||||
| Intussusception | M27 | AXR Furthing imaging |
Indicated Specialised investigation | [C] [B] |
Local policies require close paediatric, radiological and surgical liaison. Where expertise is available, both US and contrast enema (air or barium) can confirm diagnosis and guide reduction. |
| Swallowed FBs (see Section K) |
M28 | AXR | Not indicated routinely | [C] | Except for sharp or potentially poisonous
FBs, e.g. batteries. See Section K. |
| CXR (including neck) | Indicated | [C] | If there is doubt whether the FB has passed, an AXR after 6 days may be indicated. | ||
| Minor trauma to abdomen | M29 | AXR | Not indicated | [C] | US may be used as initial investigation but CT is more specific, particularly in visceral trauma. XRs may show bone injury in severe trauma. The principles for the investigation of major trauma in children similar to those in adults (see Major Trauma, K40-K42). |
| Projectile vomiting | M30 | US | Indicated | [A] | US can confirm the presence of hypertrophic pyloric stenosis, especially where clinical findings are equivocal. |
| Recurrent vomiting | M31 | Upper GI contrast study | Not indicated routinely | [C] | This symptom covers a wide range from obstruction in the neonatal period to reflux, posseters and children with migraine. US may be helpful to confirm malrotation. However, upper GI contrast studies may be indicated to exclude malrotation even with normal abdominal XR. Contrast studies in neonates should be undertaken as a specialised investigation. |
| Persistent neonatal jaundice | M32 | US NM |
Specialised investigations | [B] | Early and prompt investigation is essential. The absence of dilation in the intrahepatic bile duct does not exclude an obstructive cholangiopathy. |
| Rectal bleeding | M33 | NM | Specialised investigation | [B] | If Meckel's diverticulum is a possibility do NM first. Small bowel contrast studies may also be necessary. NM also useful in investigation of inflammatory bowel disease. Endoscopy is preferable to Ba enema for assessment of polyps and inflammatory bowel disease. US can be used to diagnose duplication cysts. |
| Constipation | M34 | AXR | Not indicated routinely | [C] | Many normal children show extensive faecal material; impossible to assess significance of radiological signs. But AXR can help specialists in refractory cases. |
| Contrast enema | Not indicated routinely | [B] | If Hirschsprung's disease is suspected, specialist referral plus biopsy is preferred to radiological studies. | ||
| Palpable abdominal/ pelvic mass | M35 | US | Indicated | [B] | If malignancy is suspected, further imaging should be performed in a specialised centre. |
| Uroradiology | |||||
| Enuresis | M36 | Imaging | Not indicated routinely | [B] | US and urodynamic studies may be needed in cases of persistent enuresis. |
| Continuous wetting | M37 | US IVU |
Indicated Indicated | [B] | Both examinations may be needed to evaluate duplex system with ectopic ureter. |
| Impalpable testis | M38 | US | Indicated | [B] | To locate inguinal testis. |
| MRI | Specialised investigation | [B] | MRI may be helpful to locate an intra-abdominal testis, but increasingly laparoscopy is the investigation of choice. | ||
| Antenatal diagnosis of urinary tract dilatation | M39 | US | Indicated | [B] | Local protocols should be established. Mild dilatation can normally be monitored by US. Low threshold for specialist referral. |
| Proven urinary tract infection | M40 | Imaging US/ NM / cystography | Specialised investigations | [C] | There is wide variation in local policy.
Much depends on local technology and expertise. Most patients should remain on
prophylactic antibiotics pending the results of investigations. The age of the patient
also influences decisions. There is much current emphasis on minimising radiation dose;
hence AXR is not indicated routinely (calculi rare). Expert US is the key investigation in all imaging strategies at this age. Thereafter NM provides data about renal structure (DMSA) and has virtually replaced the IVU here. NM will establish function, exclude obstruction and can also be used for cystography (direct or indirect). Formal direct XR cystography is still needed in the young (e.g. < 2 yrs) male patient where delineation of the anatomy (e.g. urethral valves) is critical. |