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Helical CT of the Body: A Survey of Techniques Used for Pediatric Patients

¹ Department of Radiology, Box 3808, Division of Pediatric Radiology, Rm. 1905A, McGovern-Davison Children's Health Center, Duke University Medical Center, Erwin Rd., Durham, NC 27710.
² Office of Information Technology, Duke University Medical Center, Durham, NC 27710.
³ Department de Radiologia, Hospital Materno-Infantil, Ciudad Sanitaria Valle de Hebron, Barcelona 08035, Spain.

Received June 28, 2002; accepted after revision August 6, 2002.

 
Address correspondence to C. Hollingsworth.

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. Our purpose was to assess the current practice of helical CT of the body in pediatric patients through a survey of members of the Society for Pediatric Radiology.

MATERIALS AND METHODS. The survey consisted of 53 questions addressing demographics; oral and IV contrast media administration; and age-based (age groups, 0-4, 5-8, 9-12, and 13-16 years) scanning parameters, including tube current, kilovoltage, slice thickness, and pitch. Respondents accessed the Web-based survey via a uniform resource locator link included in an e-mail to the members of the Society for Pediatric Radiology automatically sent every week for three weeks. Survey results were automatically tabulated.

RESULTS. Most (83%) respondents were based in children's or university hospitals at the time of the survey. Virtually all (99%) used nonionic IV contrast material. For body scanning, 21-32% used less than 2.0 mL/kg of body weight; we found the percentage of respondents who used power injection to be approximately equal to the percentage of those who used manual injection (47%). Age-based adjustments are made; however, 11-26% of CT examinations of children younger than 9 years are performed using more than 150 mA. A notable finding was that 20-25% of respondents did not know specific parameters used for their examinations.

CONCLUSION. Although pediatric radiologists do practice age-adjusted helical CT, variable scanning techniques are used, potentially delivering high doses of radiation. Information on current practices in helical CT of the body in children can serve as a foundation for future recommendations and investigations into helical CT in pediatric patients.

Introduction

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CT is an important imaging modality for examining children, and its use is increasing [1,2,3]. Despite this trend, only general guidelines are available for the use of body CT in pediatric patients [4,5,6]. In particular, the need for size-based helical CT has only recently been emphasized [6]. These preliminary guidelines were derived in part from survey data gathered in an investigation of techniques used to obtain pediatric CT scans received for interpretation from regional institutions and imaging practices. The survey findings indicated that many scanning parameters are not adjusted to suit the size of the child undergoing CT [7]. Given the recent attention to radiation risks and CT in children and the need for adjustments in parameters in this population [3, 8,9,10,11], a broader understanding of the actual practice of body CT in pediatric patients would be helpful.

Although several recent surveys of members of various societies concerning CT techniques used in adult patients have appeared in the literature [12, 13], we have found that no such data establishing CT practices for scanning the body in pediatric patients are available. Information on CT techniques used for children is important for several reasons. First, it could be used by radiologists to modify their existing practice and could serve as a basis for investigations into the usefulness of common CT techniques for purposes such as lesion detection. This information could also become the foundation for regulatory agency recommendations or guidelines (e.g., from the United States Food and Drug Administration) or for establishment of appropriateness criteria or CT accreditation (e.g., from the American College of Radiology). Data may also provide a reference for institutional review committees evaluating proposals on CT techniques for scanning children. For these reasons, we sought to assess the practice of CT of the body in pediatric patients through a survey of the membership of the Society for Pediatric Radiology using Web-based technology.

Materials and Methods

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The Web-based survey was accessed by a uniform resource locator link sent via e-mail to 765 e-mail addresses of members of the Society for Pediatric Radiology. The survey was prepared, mailed, and collected (between November 2000 and January 2001) in collaboration with the Office of Information Technology at Duke University Medical Center. We constructed the questionnaire using an electronic survey creation tool (Decision Source; Decisive Technology, Nashville, TN). A total of three weekly mailings were automatically launched. After the initial mailing, surveys were sent only to those who had not yet responded. The server that was used to mail the survey automatically collected the responses and tabulated the data, which gave us continuous and immediate access to an analysis of the completed forms. Although respondents were encouraged to fill out the survey electronically, the survey could be printed out and sent via standard mail.

Among the instructions given to the respondents was the request that only one member of a group fill out the survey. Responses were intended to reflect the general practice of body CT in pediatric patients rather than specific protocols such as high-resolution chest CT or CT angiography. Respondents first were asked to indicate whether conventional slice-by-slice CT was the primary technique used in their practices. We wanted only those respondents who used helical CT to complete the entire survey. The instructions also indicated that addresses were not linked to any of the collected data, thus allowing anonymous reporting.

The survey contained 53 questions addressing helical CT techniques used for examinations of the body in children. Questions were divided into demographic, contrast media, and scanning parameter categories. For the contrast media and CT parameters categories, respondents were given choices of "always," "usually," "sometimes," "rarely," and "never" to answer questions. For the purposes of data analysis, we arbitrarily defined routine practice to be reflected by responses of "always" or "usually." Scanning parameters were assessed using arbitrary age divisions (0-4, 5-8, 9-12, and 13-16 years) that were based on previous methodology [7].

Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
We received responses from 94 (12.3%) of the 765 members of the Society for Pediatric Radiology. Although this response rate appears to be low, each response can represent the CT protocols used by an entire practice or institution. For example, in a children's hospital, one response represented as many as 20-25 members. Because not all respondents answered all questions, the denominator for the results was not always 94. Six respondents chose to submit data via standard mail, and these responses were entered manually into the data pool. Percentages were rounded to the nearest unit integer, so the sum of percentages within each analysis did not always equal 100.

Demographics
Among our respondents, 45% (42/94) practiced at a children's hospital and 38% (36/94), at a university-based hospital. The remaining 17% (16/94) were affiliated with either a community-based hospital or community-based private practice group. The use of helical CT was widespread, with 98% of respondents reporting use of helical CT. Most respondents who used helical CT (73%; 67/92) performed between zero and eight body CT examinations per day. Results for frequency of examinations are presented in Table 1. Finally, 75% (66/88) of respondents interpreted examinations on film (hard copy) before dictating radiology reports, and 10% routinely performed soft-copy monitoring.

Oral and IV Contrast Materials
Table 2 summarizes the practice of oral contrast administration. More than 90% of respondents routinely used oral contrast material for pediatric abdominal helical CT. Of note is the finding that 66% (61/92) of Society for Pediatric Radiology radiologists reported that they did not routinely use oral contrast material in the setting of trauma.

Tables 3,4,5,6 summarize data for IV contrast administration. Nearly all respondents (99%; 90/91) who answered this question indicated routine use of low-osmolar IV contrast material. The routine dose of IV contrast material reported by 58% (52/90) of radiologists for chest CT scans and by 70% (62/89) for abdominal CT scans was 2.0 mL/kg of body weight. Thirty-two percent (29/90) of radiologists administered less than 2.0 mL/kg of body weight for chest examinations, and 21% (19/89) administered less than 2.0 mL/kg of body weight for abdominal examinations. Only 2% (2/90) of the respondents administered more than 2.0 mL/kg of body weight for both chest and abdominal CT. Eight percent (7/90) of respondents indicated that they did not know the amount of IV contrast material that was routinely administered.

In regard to the technique for the administration of IV contrast material, manually administered bolus injection and power injection methods were used equally; each method was reported to be routinely used by 47% of the respondents. Use of power injection with central venous catheters was a relatively uncommon method (16%; 14/88). Bolus-tracking technology was also infrequently used, reported by 7% (4/57) of the respondents for chest CT and by 12% (7/57) for abdominal CT.

The timing of the onset of scanning with respect to contrast material is indicated in Tables 5 and 6. For chest CT, 44% (38/87) of respondents indicated that the delay between the completion of administration of contrast material and the onset of scanning was 0-10 sec. Twenty-five percent (22/87) used a delay of 11-20 sec. Seventeen percent (15/87) began scanning the chest during the injection of IV contrast material. For abdominal scanning, reported delays were generally between 0-30 sec (70%; 62/88). As with the chest CT, a small percentage of respondents initiated abdominal scanning during the injection of IV contrast material (10%; 9/88). Three percent of respondents were unaware of the delay between the IV contrast material administration and the onset of scanning.

Scanning Parameters
Survey results pertaining to specific scanning parameters, including kilovoltage, tube current, and slice thickness, are included in Tables 7,8,9,10,11,12,13.

Kilovoltage.—We found little variation in the kilovoltage used. Among our respondents, 4% reported using less than 120 kVp for chest and abdominal CT in children, and 66% (59/90) indicated that they routinely used 120 kVp for scanning in the pediatric population.

Tube current.—Adjustments in tube current were made more frequently for younger children. For examining the youngest children (0-4 years), 33% (29/89) of the respondents used less than 100 mA for chest CT, and 22% (19/88) used less than 100 mA for abdominal CT. However, some children in this same age group were still being exposed to relatively high doses of radiation. Among our respondents, 11% (10/89) reported using a tube current of 150 mA or greater for chest CT in children 4 years old or younger, and 18% (16/88) reported using the same dose for abdominal CT in children in that age group.

For CT of children who were 5 through 8 years old, only 15% (13/88) of the respondents performed chest CT with a tube current less than 100 mA; only 5% (4/87) performed abdominal CT with a tube current less than 100 mA. For chest CT in this age group, 18% (16/88) of the respondents reported using a tube current that exceeded 150 mA, and 26% (23/87) reported using this level of tube current for performing abdominal CT.

In scanning children who were 9 through 12 years old, 28% (24/87) of respondents reported using a tube current greater than 150 mA for chest CT, and 44% (39/88) reported using that level of tube current for abdominal CT. Notably, 11% (10/87) of respondents reported performing chest CT at more than 200 mA in children of this age group, and 16% (14/88) reported performing abdominal CT with a tube current at that level.

In scanning the oldest group of children (13-16 years), 17% (15/88) of the respondents reported performing chest CT, and 24% (21/87) reported performing abdominal CT at more than 200 mA. Between 20% and 25% of our respondents for the different age groups reported they had no knowledge of whether age-based scanning adjustments for chest and abdominal CT were used.

Slice thickness.—In general, thinner CT slice thickness is appropriate in examining infants and small children, although the optimal collimation depends on the indication for the examination. For chest CT in children 4 years old or younger, 33% (30/90) of the respondents used a slice thickness of 2.0-3.9 mm and 50% (45/90) used a slice thickness of 4.0-5.9 mm.

The trend was to increase slice thickness as the age of the children increased. Fifty percent (45/90) of respondents used a slice thickness of 4.0-5.9 mm for children 5-8 years old, and another 27% (24/90) used 6.0-7.9 mm for chest CT in children in this age group. The trend of increased collimation continued for chest CT in children 9-12 years old. Thirty percent (27/89) of respondents used a slice thickness of 4.0-5.9 mm; 57% (51/89) used a slice thickness greater than 6.0 mm. The slice thicknesses commonly used in abdominal CT in children showed a similar increase as the ages of the children increased. In examinations of children 4 years or younger, 82% (73/89) of respondents reported using a slice thickness of 2.0-5.9 mm; only 25% (22/89) of the respondents scanned older children (9-12 years old) with a similar slice thickness.

Pitch.—The pitch selected for chest and abdominal CT varied little with single- and dual-detector array scanners. Most respondents indicated routinely using a pitch of either 1.0 or 1.5 with single-detector array scanners and either a 2.0 or 3.0 pitch with dual-detector array scanners. Specifically, concerning single-detector scanners, 35% (27/77) of the respondents routinely used a pitch of 1.0, and 40% (31/77) routinely used a pitch of 1.5 for chest CT. For abdominal CT, 24% (19/78) routinely used a pitch of 1.0, and 37% (47/78) routinely used a pitch of 1.5. Fourteen percent (11/77) indicated they were unaware of the specific pitch used for chest and abdominal CT with single-detector scanners. With dual-detector array scanners, 21% (6/29) routinely used a pitch of 2.0, and 21% (6/29) routinely used a pitch of 3.0 for both chest and abdominal CT. Forty-five percent (13/29) were unaware of the specific pitch used for chest and abdominal CT performed with dual-detector array scanners.

Discussion

Top Abstract Introduction Materials and Methods Results Discussion References

 
Our survey was performed to provide previously unavailable data about the current practice of helical CT of the body in pediatric patients. Our results indicate the variability in this practice and, more important, show that some of the parts of current practice are unknown. Our findings reflect the practices of a subspecialty group composed of radiologists in the Society of Pediatric Radiology. Members of the society are hospital- and university-based radiologists and community-based practitioners. Most (83%) of our respondents worked in university or children's hospital practices at the time of the survey.

The use of oral contrast material for routine abdominal CT is ubiquitous. However, approximately one third (31/92) of respondents routinely used oral contrast material in patients who had sustained trauma. The routine use of oral contrast medium in children remains controversial; we suspect that the controversy is due to a lack of diagnostic information and a potential (albeit a small) risk of aspiration.

The findings of our survey indicate that pediatric radiologists now pay more attention to size-based adjustments than was found in a previous report [7] in which no perceptible adjustments were made. However, several of our findings are items of concern. First, it is interesting that 15-40% of respondents were not aware of the techniques used at their institutions, particularly those parameters determining radiation exposure. A reasonable assumption is that this lack of knowledge implies a lack of size-based scanning. Thus, it is conceivable that more children are exposed to higher doses of radiation than our survey indicates.

With respect to tube current, we found that size-based scanning is practiced by pediatric radiologists. For example, 33% of the respondents indicated that they performed helical CT of the chest in children 4 years old and younger with a tube current of less than 100 mA. In children 5-8 years old, chest CT was performed with less than 100 mA by 15% of respondents. We did not inquire about specific tube current settings. Instead, respondents were asked to select from categories consisting of a range of values: 0-49, 50-99, 100-149, 150-199, and 200 mA or greater. We estimated mean tube current by assigning all responses to a single mean midrange tube current value. For example, for the 50- to 99-mA group, we assigned all responses to the mean of that category, 75 mA. Results of this estimated mean tube current are provided in Table 10.

We found a trend of increased tube current with increased age and overall lower tube current used for chest CT than for abdominal CT in each age group. This practice is recommended for single-detector helical CT of the body in pediatric patients [14] and was notably absent from a prior survey of techniques by Paterson et al. [7]. Although 22% of the respondents reported performing abdominal CT with a tube current of less than 100 mA in children 4 years old and younger and 5% of the respondents reported using 100 mA in children 5-8 years old, we found that some children are still being exposed to relatively high amounts of radiation. For example, 14% of the respondents performed chest CT, and 16% performed abdominal CT with tube currents equal to or greater than 200 mA.

For pediatric single-detector CT, pitches of 1.5 or greater have been recommended for general body scanning [6, 15, 16]. Our survey, however, indicates that this technique is not widely practiced. In regard to single-detector array CT scanners, 42% of the respondents reported performing chest examinations, and 33% of the respondents reported performing abdominal examinations with a pitch of less than 1.5 Similarly, for dual-detector array CT scanners, 31% of respondents reported performing chest examinations, and 33% reported performing abdominal examinations with a pitch of less than 3.0.

With respect to kilovoltage, 3% of respondents performed chest CT, and 1% performed abdominal CT in children using less than 120 kVp. Recent data suggest that kilovoltage may be an important parameter for controlling radiation dose [14]. Because 66% of respondents used a single kilovoltage—120 kVp—for all examinations, we believe that an investigation of the effect of modifying kilovoltage on scanning quality, radiation dose, and lesion detection is justified. Kilovoltage of 120 may not be the optimal level for examining infants.

Our survey was conducted electronically via Web-based technology and e-mail. To the best of our knowledge, this survey is the first completed through the Society for Pediatric Radiology using such technology. This type of survey can be conducted at a relatively low cost; we incurred no mailing costs to send the survey or to ensure its return. Additional mailings were also performed without cost. Although fees for mailing lists may vary, we were able to obtain the addresses for our survey without charge. By using an electronic survey, we accrued no costs for paper. The survey response rate is in-line with those reported by other electronic surveys conducted through the Society for Pediatric Radiology (Bisset G, personal communication).

Another advantage of an electronic survey is rapid receipt of responses, perhaps because a survey in this format is easy to fill out. With the electronic survey software, the survey mailing, responses, and interval between mailing and response receipt are automatically tracked, and the survey data are automatically compiled; data collection can be configured for anonymity. The software also automatically re-mailed surveys at weekly intervals (the interval is adjustable) to those who had not responded as a reminder to complete and return the survey. Web-based technology will be increasingly used as a means of gathering and dispensing information. Our investigation supports the benefits of this technology.

Our study has several limitations. In regard to size-based CT scanning, we used age as a rough equivalent to size. We acknowledge that classifying groups of children in this fashion may be less accurate, but we assumed that such a classification would make it easier to respond to the inquiries. In regard to radiation dose, we asked about tube current, not milliampere-seconds, because we assumed that gantry rotation cycle time would be a less familiar parameter. In addition, at the time the survey was performed, most CT scanners had a limited rotation time of 0.8 or 1.0 sec.

Another limitation is that our survey was accessible only through a computer. However, the survey could also be printed and reviewed at the respondent's convenience. Ninety-five responses from a mailing of 765 may appear to be a low percentage of response. However, many responses represented multiple members of the Society for Pediatric Radiology. Even without this qualification, our response percentage is in-line with other surveys conducted through the Society for Pediatric Radiology (Bisset G, personal communication). Furthermore, by sending e-mail surveys only to members of the Society for Pediatric Radiology, we inquired about the current body CT practice in pediatric patients from members of a subspecialty group. We could have surveyed other groups but elected to assess the practice of body CT among pediatric radiologists. A survey of the European Society for Pediatric Radiology membership was initially considered, but an e-mail address list for this group was not available.

Finally, the practice of helical CT of the body in pediatric patients varies by necessity. We sought to assess the general or routine CT practice. Some guidelines pertaining to helical CT in pediatric patients have been published only recently [6] (Table 14). We found variations in both tube current and slice thickness parameters.

Body CT in pediatric patients is rapidly evolving, with multidetector CT being increasingly used. However, given the fact that multidetector CT is even more complex than helical CT [2], it is reasonable that CT practices may vary even more than single-detector (or dual-detector) helical CT. Development of a multidetector CT survey is currently underway.

In conclusion, our investigation provides data about CT of the body in pediatric patients. This information can be useful in establishing or modifying an individual practice and in establishing broader guidelines and recommendations (i.e., for governmental or medical organizations). These data also provide justification for research on scanning parameters, such as kilovoltage, that affect radiation dose. Although the need for age-specific scanning is receiving more attention than it did previously, a substantial number of CT examinations in children are performed with relatively few adjustments. These data indicate the need for continued size-based scanning and education about the issues of radiation dose and pediatric CT techniques.

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