August 2008, VOLUME 191
NUMBER 2

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August 2008, Volume 191, Number 2

Pediatric Imaging

Original Research

Pediatric Body MDCT: A 5-Year Follow-Up Survey of Scanning Parameters Used by Pediatric Radiologists

+ Affiliation:
1Both authors: Department of Radiology, Division of Pediatric Radiology, Duke University Medical Center, 1905 McGovern-Davison Children's Health Center, Box 3808 DUMC, Durham, NC 27710.

Citation: American Journal of Roentgenology. 2008;191: 611-617. 10.2214/AJR.07.2989

ABSTRACT
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OBJECTIVE. The purpose of this study was to evaluate how pediatric body MDCT scanning parameters (i.e., the principal determinants of radiation dose) have changed since a prior survey conducted in 2001.

MATERIALS AND METHODS. The survey used in this study consisted of 27 questions addressing practice setting; equipment; and scanning parameters including kilovoltage, tube current, and pitch. Members of the Society for Pediatric Radiology (SPR) received an email with a link to the Web-based survey. Respondents were asked to complete only one survey to represent their practice and indicate the number of pediatric radiologists their response represented.

RESULTS. Sixty-one responses representing 337 pediatric radiologists were received. Eighty-four percent of respondents practice in a university or children's hospital. No respondents reported using a peak kilovoltage setting of higher than 120 kVp for routine chest or abdomen scans. Those using 110 kVp or less increased from 4% to 48% for chest CT and from 1% to 32% for abdominal CT (p < 0.001). Weight-based adjustments in tube current are used by 98% of respondents. Tube current tends to increase with a patient's age or weight, with most pediatric body imaging examinations being performed with a tube current of less than 150 mA. The mean tube current used across all age groups decreased between 31 and 61 mA (p < 0.001), with the largest percentage decreases in patients in the 0–4 years age group.

CONCLUSION. Since 2001, the peak kilovoltage and tube current settings, two principal parameters determining radiation dose, used by SPR members have decreased significantly for pediatric body MDCT. It is a reasonable assumption that these changes are due to efforts to increase awareness about the risks of radiation.

Keywords: ALARA principle, MDCT, pediatric imaging, radiation safety, scanning parameters

Introduction
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Before 2002, an estimated 7.1 million annual pediatric CT examinations were performed in the United States [1]. Since 2002, CT examinations have increasingly been performed in the pediatric population. For example, chest and abdominal examinations of children have increased out of proportion to the frequency of visits to the emergency department in a recent 5-year period [2]. The justification for this increasing use has been questioned in light of the potential risks of radiation exposure to children [3]. Increasing use becomes more problematic if the ALARA (as low as reasonably achievable) principle is not followed and techniques are not appropriately adjusted, especially to the size of the child [46]. In community practice, this lack of adjustment was reported by Paterson et al. [7]. As a follow-up to those data, Hollingsworth et al. [8] surveyed members of the Society for Pediatric Radiology (SPR) and found a greater use of age-adjusted body CT examinations. Although assessing the impact of dose reduction strategies to minimize the risks of radiation has been emphasized [9, 10] and CT radiation awareness continues to be an important topic [3, 11], to our knowledge, no comparable survey assessing routine pediatric MDCT examination parameters has been performed since 2001. Our purpose was to assess current pediatric body MDCT practice, emphasizing parameters that determine radiation dose, and compare this with practice as surveyed in 2001 [8].

Materials and Methods
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The Web-based survey consisted of questions related to pediatric body MDCT. Institutional review board exemption was obtained because the survey results remained anonymous. This Web-based survey was performed through a survey engine used by the SPR (www.SurveyMonkey.com) and was accessed using a link sent via email to SPR members. Members were contacted two times 1 week apart with a total time of 2 weeks from the initial mailing to closing of the survey. The anonymous responses were automatically collected and tabulated by the survey engine.

Respondents were instructed to complete one survey per group or institution and indicate the number of SPR members or pediatric (> 50% of practice is pediatric patients) radiologists that the responses represented. Responses were intended to reflect the institution or practice routine protocols for chest and abdominal CT in the pediatric population rather than more specialized protocols such as high-resolution CT or CT angiography. The survey contained 27 questions. For comparison purposes, questions were modeled after the 2001 survey (published in 2003) [8], and divided into those addressing practice demographics; scanner type; and scanning parameters, including peak kilovoltage (kVp), tube current (mA), and pitch. Because the technology of MDCT has changed during the interval between surveys, the selections could not be identical. For example, the 4-MDCT LightSpeed scanner (GE Healthcare) has effective collimation width options of 4 × 5, 4 × 2.5, 4 × 1.25, and 4 × 0.0625 mm, whereas the 64-MDCT LightSpeed scanner offers widths of 40 mm (64 × 0.625) or 20 mm (32 × 0.625). Whenever possible, the same question from the 2001 survey was retained, such as tube current or peak kilovoltage range. In particular, we used the same arbitrary age divisions (i.e., 0–4, 5–8, 9–12, and 13–16 years) as a surrogate for child size (weight or height) for questions about tube current. If groups used more than one scanner, respondents were instructed to answer questions based on the scanner that is used for most of their pediatric work. If respondents use a nonhelical scanner, they were asked to not complete the survey. Essentially, we are considering this survey to be a 5-year follow-up to the 2001 survey.

The counts of the ordered categories of current and voltage were compared between the 2001 and 2006 surveys by means of a Mantel-Haenszel chisquare test.

Results
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A total of 61 responses representing 337 pediatric radiologists were received. This is 25% of the SPR membership (1,355 members) at the time of the survey. In the instructions, a single respondent was asked to complete the survey for each institution to eliminate identical, redundant responses from a practice such as a children's hospital where there may be 15–30 pediatric radiologists. This strategy simplifies the survey process, as well as avoids potential weighting issues if multiple radiologists completed the survey from one institution and only one from another similarly staffed practice. We also thought that our results would better represent CT practice than if we asked for single responses. The 2001 survey received 94 responses; in that survey, respondents were not asked about group size. Not all respondents to our follow-up survey answered all the questions. Percentages were rounded to the nearest whole number.

Demographics and Scanner Information

Most respondents practice at a university (49%, 30/61) or a children's (34%, 21/61) hospital. The remaining members practice at a community hospital (10%, 6/61) or in a community-based nonhospital group (7%, 4/61). The responses for average number of pediatric body CT examinations per day per institution were fairly distributed over the five choices ranging from zero to 2 up to more than 11. These numbers are increased slightly compared with the prior survey in 2001 (Fig. 1). Seventy-four percent (45/61) of respondents use equipment from a single manufacturer. Half (49%, 30/61) use more than one type of scanner from the same manufacturer. The number of channels per scanner is illustrated in Table 1.

TABLE 1: Maximum Number of Channels of the Primary CT Scanner Used by Members of the Society for Pediatric Radiology

2006 Scanning Parameters

The survey addressed routine scanning parameters regarding pediatric chest or abdominal MDCT. Detailed results for the scanning parameters are provided in Tables 2, 3, 4, 5. Note that the percentages in this section disregard the response of “unknown” to allow more accurate comparison with the results of the prior study (the percentages in the tables are raw data). The following are selected salient results.

TABLE 2: Routine Kilovoltage Used for Pediatric Chest MDCT

TABLE 3: Routine Kilovoltage Used for Pediatric Abdominal MDCT

TABLE 4: Routine Tube Current Used for Pediatric Chest MDCT

TABLE 5: Routine Tube Current Used for Pediatric Abdominal MDCT

Peak kilovoltage—For routine pediatric chest and abdominal CT, 100% of those who responded indicated that they use a peak kilovoltage of 120 kVp or less (Tables 2 and 3). Of those who responded, 110 kVp or less is used by 48% (21/44) for chest and 32% (14/44) for abdominal CT.

Tube current—Nearly all respondents (98%) use either a weight-based (78%, 36/46) or an age-based (20%, 9/46) protocol for pediatric patients (Tables 4 and 5). One respondent (2%) uses the same tube current for all pediatric patients. The trend is to use a higher tube current setting with increasing age and a slightly higher tube current setting for abdominal CT than for chest CT.

In children 0–4 years old, a tube current of less than 100 mA is used by 97% (32/33) for chest CT and 88% (28/32) for abdominal CT. Of those indicating a response, 48% (16/33) for chest CT and 28% (9/32) for abdominal CT use less than 50 mA. No respondents use 150 mA or more.

For chest CT in children 5–8 years old, 82% (27/33) of respondents use a tube current of less than 100 mA and 15% (5/33) use a tube current of less than 50 mA. For abdominal CT, 63% (20/32) of those indicating a response use a tube current of less than 100 mA and 97% (31/32) use less than 150 mA.

When performing chest CT in children 9–12 years old, 94% (31/33) of respondents use a tube current of less than 150 mA and 55% (18/33) use a tube current of less than 100 mA. For abdominal CT, 88% (28/32) use less than 150 mA and 31% (10/32) use less than 100 mA.

figure
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Fig. 1 Estimated number of pediatric patients (< 18 years) undergoing body CT (chest or abdomen [includes pelvis]) examinations per day. CT of chest and abdomen (or abdomen and pelvis) was considered two studies. Results of 2001 [8] and 2006 surveys are compared.

In children 13–16 years old, 84% (27/32) of respondents for chest CT and 66% (21/32) of respondents for abdominal CT use a tube current of less than 150 mA. A tube current of 150 mA or higher is used by 16% (5/32) for chest CT and 34% (11/32) for abdominal CT.

The average tube current for each age group was calculated using the midpoint of each range (e.g., 75 mA for 50–99 mA) for each response in that range. For routine pediatric chest CT, the average tube currents are as follows: 52.3 mA for children 0–4 years, 79.5 mA for children 5–8 years, 102.3 mA for children 9–12 years, and 123.4 mA for children 13–16 years. The average tube currents for routine pediatric abdominal CT are as follows: 70.3 mA for children 0–4 years, 92.2 mA for children 5–8 years, 115.6 mA for children 9–12 years, and 143.8 mA for children 13–16 years.

Gantry rotation time—Most respondents (78%, 21/27) do not vary the gantry cycle time for routine pediatric CT of the chest and abdomen, but 22% (6/27) do vary cycle time by patient weight. The rotation time most frequently used is 0.5 second (57%, 17/30), with 83% (25/30) using a gantry rotation time of 0.4–0.6 second. We elected to assess tube current separate from the tube current–time (mAs) product for comparison with the previous study [8].

Detector collimation—Seventeen percent (5/29) of respondents for chest CT and 13% (4/30) of respondents for abdominal CT report using the thinnest possible collimation. The widest possible collimation is used by 10% (3/29) for chest CT and 17% (5/30) for abdominal CT.

Pitch—A total of 96% of respondents use a pitch of 1.5 or less. For routine pediatric CT, most (79%, 23/29 for chest CT; 83%, 24/29 for abdominal CT) of those indicating a selection use a pitch of 1.00–1.49. A pitch of 0.50–0.99 is used by 17% (5/29) for chest CT and 10% (3/29) for abdominal CT.

Comparison of Current Data with 2001 Survey Results

The prior survey represents data that were collected in 2001 [8]. Again, the percentages in the text are rounded to the nearest whole number with unknown responses not used for calculation purposes. Results in the figures represent raw data and therefore percentages are slightly different because the response “unknown” is included.

Peak kilovoltage—The percentage of respondents using a peak kilovoltage of 120 kVp or less for routine pediatric scans increased from 86% (62/72) in 2001 to 100% in 2006 for chest CT (Fig. 2) and from 82% (56/68) to 100% for abdominal CT (Fig. 3). Those using 110 kVp or less increased from 4% (3/72) to 48% for chest CT (p < 0.001) and from 1% (1/68) to 32% (p < 0.001) for abdominal CT.

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Fig. 2 Peak kilovoltage routinely used for pediatric chest MDCT. Amount used has decreased from 2001 [8] to 2006, with 100% of those indicating a value in 2006 survey selecting 120 kVp or less (p < 0.001).

Tube current—In children 0–4 years old, the percentage of respondents using a tube current of less than 100 mA increased from 42% (29/69) in 2001 to 97% in 2006 for routine chest CT (Fig. 4) and from 28% (19/67) to 88% for routine abdominal CT (Fig. 5). Respondents using less than 50 mA increased from 4% (3/69) in 2001 to 48% in 2006 for chest CT and from 0% (0/67) to 28% for abdominal CT. No respondents to the current survey reported using 150 mA or more compared with 14% (10/69) for chest CT and 24% (16/67) for abdominal CT of respondents to the 2001 survey.

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Fig. 3 Peak kilovoltage routinely used for pediatric abdominal MDCT. Amount used has decreased from 2001 [8] to 2006, with 100% of those indicating a value in 2006 survey selecting 120 kVp or less (p < 0.001).

For chest CT in children 5–8 years old, the percentage of respondents selecting a tube current of less than 100 mA increased from 19% (13/68) in 2001 to 82% in 2006 and the percentage using less than 50 mA increased from 0% (0/68) to 15%. Of the respondents indicating a tube current for abdominal CT, those using less than 100 mA increased from 6% (4/66) in 2001 to 63% in 2006 and those using less than 150 mA increased from 65% (43/66) to 97%.

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Fig. 4 Tube current routinely used for pediatric chest MDCT. Compared with 2001, there has been a trend to use less tube current in children ranging in age from 0 to 4 years. No respondents from current survey selected tube current value of 150 mA or more. Mean tube current between 2001 [8] and 2006 was significantly lower (p < 0.0001), as they were for abdominal MDCT in children 5–8 and 9–12 years old.

When scanning the chest in children 9–12 years old, the percentage using a tube current of less than 150 mA increased from 64% (43/67) in 2001 to 94% in 2006. The percentage using a tube current of less than 100 mA increased from 10% (7/67) to 55%. For abdominal CT of children 9–12 years old, the percentage of respondents selecting a tube current of less than 150 mA increased from 42% (28/67) in 2001 to 88% in 2006 and the percentage selecting a tube current of less than 100 mA increased from 4% (3/67) to 31%.

In children 13–16 years old, the percentage using a tube current of less than 150 mA increased from 53% (35/66) in 2001 to 84% in 2006 for routine chest CT (Fig. 6) and from 27% (18/66) to 66% for routine abdominal CT (Fig. 7).

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Fig. 5 Tube current routinely used for pediatric abdominal MDCT in children ranging in age from 0 to 4 years. Since prior survey [8], amount of tube current used has decreased. For example, 24% of respondents use less than 50 mA compared with 0% in 2001. Mean tube current between 2001 [8] and 2006 was significantly lower (p < 0.0001), as they were for abdominal MDCT in children 5–8 and 9–12 years old.

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Fig. 6 Tube current routinely used for pediatric chest MDCT. Even in older children, trend was to use less tube current since 2001 [8]. For example, 71% of respondents selected tube current value less than 150 mA compared with 40% in 2001.

Comparisons of the average tube current used in 2001 and 2006 for routine pediatric chest and abdominal CT are illustrated in Figures 8 and 9. The average tube current decreased between 31 and 61 mA for all age ranges. The percentage decreases were largest in the younger age groups. For routine pediatric chest CT, the average tube current decreased by 54% in children 0–4 years old, by 40% in children 5–8 years old, by 29% in children 9–12 years old, and by 20% in children 13–16 years old. The average tube current for routine pediatric abdominal CT decreased by 44% in 0–4 year olds, by 37% in 5–8 year olds, by 28% in 9–12 year olds, and by 18% in 13–16 year olds. Again, the largest changes were in the youngest age groups.

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Fig. 7 Tube current routinely used for pediatric abdominal CT. Even in older children, trend was to use less tube current. For example, 57% of respondents selected tube current value less than 150 mA compared with 21% in 2001 [8].

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Fig. 8 Mean tube current used by members of Society for Pediatric Radiology for pediatric chest MDCT over several age ranges compared with 2001 [8]. Mean tube current used decreased between 32 and 61 mA for each age range.

Gantry rotation time—Gantry rotation time options have changed since 2001 when the options were 0.8 and 1.0 second. Gantry cycle time was not surveyed in 2001. In the present survey, 83% of respondents who answered the question used rotation times from 0.4 to 0.6 second. Although we are not able to directly compare mAs, the data suggest that the mAs would be even lower currently than in 2001 based on the lower rotation times.

The counts of the ordered categories of current and voltage were compared between the 2001 and 2006 responses. The comparisons were done independently for chest and abdomen values, and the “unknown” levels were not used in the comparisons. In all cases, the p value from the comparison was less than or equal to 0.001. In all cases, except the tube currents used for abdomen and chest CT of children 13–16 years old, the p value was less than 0.0001.

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Fig. 9 Mean tube current used by members of Society for Pediatric Radiology for pediatric abdominal MDCT over several age ranges compared with 2001 [8]. Mean tube current decreased between 31 and 55 for each age range.

Discussion
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The primary purpose of our study was to provide data about current pediatric body MDCT practice and to compare our results with those of a prior survey [8] to assess for changes that indicate that the techniques being used are potentially providing a lower radiation exposure to children undergoing body CT. In the past 5 years, there has been much focus on the risks of radiation including multiple journal articles, the SPR ALARA conference [5], practice guidelines through the American College of Radiology (ACR) as well as CT accreditation programs, and protocols through manufacturers. To the best of our knowledge, there has been no study to examine the potential impact of this material on practice patterns among pediatric radiologists. Given that MDCT use is estimated to have increased more than 60% over a 5-year period [1], the importance of minimizing dose is even more compelling.

Our results indicate that parameters for pediatric body MDCT have changed significantly over the 5-year interval between surveys, with the overwhelming indication that the changes in technical adjustments would provide a lower radiation dose in the ensuing 5 years. The results from those respondents familiar with their institutions' protocols are encouraging and show that two of the principal parameters (mA and kVp) that control radiation dose to pediatric patients undergoing routine MDCT of the chest or abdomen have decreased significantly since 2001. This finding is particularly true in the younger pediatric patients who are relatively more susceptible to the risks of radiation exposure.

Tube current is a major factor in controlling patient radiation dose. Prior investigational work [12] and review of clinical investigations [13] have shown that relatively reduced tube current can be used while still obtaining diagnostic images. Our study found that age- or weight-based scanning is practiced by most pediatric radiologists. The tube current used decreased across all age groups between 31 and 61 mA. Decreases in the mean tube current were most marked in the 0- to 4-year-old age group, as illustrated by a 54% decrease for chest MDCT and a 44% decrease for abdominal MDCT. In children 0–4 years old, the percentage of respondents using less than 100 mA for chest and abdominal CT were 97% and 88%, respectively, compared with 42% for chest and 28% for abdominal MDCT in 2001. Importantly, no respondents on the current survey reported using 150 mA or more for body CT in the 0- to 4-year-old group compared with 2001 results of 14% of respondents for chest CT and 24% for abdominal CT. In addition, the mAs product would show even greater decreases given the current use of faster gantry rotation times (0.8–1.0 second in 2001 vs 83% using 0.4–0.6 second in 2006) and significantly lower mean tube current for body MDCT across all age groups.

Data from other studies indicate that reducing kilovoltage is an important option in controlling radiation dose [14, 15]. The kilovoltage used for routine pediatric chest and abdominal CT has significantly decreased since the prior survey. For example, 100% of respondents now use a peak kilovoltage of 120 kVp or less for routine pediatric chest and abdominal CT. Notably, those selecting 110 kV or less increased from 4% to 48% for chest CT and from 1% to 32% for abdominal CT.

Nearly all (98%) of those selecting a protocol reported using an age- or weight-based protocol for pediatric patients. However, 22% (13/59) of respondents marked unknown or skipped the question (two respondents stopped the survey before questions about scanning parameters). Up to 49% of respondents (29/59) either marked unknown or did not complete the questions regarding peak kilovoltage and tube current. It should be noted that a lower percentage of respondents selected unknown than on the prior survey for all questions about protocols, including peak kilovoltage and tube current, suggesting a greater awareness of individual parameters in 2006 than 5 years earlier.

Other factors that may play a role in reducing radiation exposure from CT examinations are total beam collimation and pitch. Effective beam collimation or width (generally the number of rows × the individual collimator thickness) was not assessed in this survey because the prior survey dealt only with single-detector helical CT. In addition, individual collimator thickness options have changed since single-detector CT where the collimator thickness was fixed. We elected to inquire about collimation thicknesses to assess whether practices use techniques where thin sections could be reconstructed versus thicker collimation where options for relatively thin-section (e.g., submillimeter) reconstructions may be more limited. However, comparing technology at the time of the present survey with that of 5 years earlier is problematic. For example, 64-slice technology was not widely available in 2001 and there were different options for the minimal slice thickness for reconstruction. For example, on a 4-MDCT scanner made by GE Healthcare, the minimum slice thickness depended on how the original scan was designed. One could not reconstruct a slice thinner than 1.25 mm if the configuration was 1.25 × 4 (rows). On the current 64-detector row (slice) scanner made by GE Healthcare, one always has the option of 0.625-mm-thick slices. Also, the radiation dose difference between using thick slices (e.g., 1.25 mm) or thin slices (e.g., 0.625 mm) is less clear than with tube current and peak kilovoltage, so we elected not to compare these data. However, we did find that the thinnest possible collimation is used routinely by 17% for chest CT and 13% for abdominal CT. Among possibilities, this could mean that individuals do not routinely perform multiplanar and 3D reconstructions for pediatric body MDCT.

Large pitches provide a lower dose than small pitches, all other parameters being equal. Although previous work with helical CT showed that pitches of 1.5 are adequate for pediatric CT [16, 17], similar work has not followed for the newest MDCT technology. A pitch of 0.50–0.99 is used by 17% for chest CT and 10% for abdominal CT. These numbers suggest that an additional reduction in radiation exposure would be achieved by those using pitches between 1.0 and 1.5.

Our survey was conducted by email to SPR members with a link to a Web-based survey engine. Advantages of this method include no cost for paper or mailings, rapid response time, ease of use, anonymity, and automated tabulation of results by the survey engine. Although we received only 61 responses, this represented nearly one fourth of the North American SPR membership and is in-line with prior electronic surveys conducted by the SPR [8].

There are several limitations with our study. One limitation is the number of respondents who did not complete the entire survey. Our survey was email-based, which may limit responses from radiologists who prefer to communicate through other means, such as traditional post. We polled only members of the SPR who subspecialize in imaging children. The practice of members outside the SPR is not known and may vary. We are currently developing a survey method that will target individuals who do some pediatric MDCT as part of their practice but who are not SPR members. Also, most respondents were from university or pediatric hospitals. Thus, these survey data may not adequately reflect pediatric radiology performed in community settings or where there is no SPR member.

Importantly, our survey also does not address the issue of image quality and diagnostic yield. It has not been proven that the lower doses being used are of equivalent diagnostic quality and allow acceptable accuracy in answering all clinical questions. However, it is reasonable to assume that the parameters in the current survey represent routine practice and thus acceptable image quality. Moreover, this information reflects only general or standard practice, not more specialized protocols such as high-resolution chest CT or renal stone protocols. In addition, we arbitrarily assigned patients to age and weight ranges for tube current instead of exact values. This was done to keep the survey short and allow comparison with the 2001 survey.

With the increased prevalence of MDCT, another limitation is that parameters from 2001 may not necessarily translate into the same radiation exposure as identical parameters currently. For example, 100 mA 5 years ago may represent a lower dose than 100 mA currently depending on the model of scanner and manufacturer; the same tube current and peak kilovoltage settings for different scanners may not translate into similar doses. We also did not assess the use of tube current modulation, and respondents were asked to report what was the closest target single tube current for the region (chest MDCT or abdominal and pelvic MDCT) and age. In addition, the parameters discussed are contributors to dose, and we did not determine to what extent dose was decreased. Our survey also addressed only routine pediatric body MDCT. Although we believe that lower parameters, especially tube current and peak kilovoltage, indicate the potential for lower dose, we did not fully assess whether CT is being used more indiscriminately over the first 5 years after the 2001 survey, which could negate dose savings by these technical adjustments.

Finally, although the decreased percentage of unknown responses seen on the 2006 survey compared with the 2001 survey is encouraging, it remains unclear why any survey was not completed. Speculations include not having significant time, not understanding questions, loss of interest, or information that was not fully available (e.g., mA or kVp). A reasonable assumption may be that Web-based surveys are more apt to lead to incomplete surveys than standard paper surveys because letters are more likely to be discarded if incomplete rather than returned incomplete.

In conclusion, our survey shows that MDCT parameters that control radiation dose changed significantly in the 5-year interval between surveys, suggesting that doses delivered to children are lower than previously. Assuming a potential risk of low-level radiation, these lower doses would translate into lower stochastic risks—namely, cancer development. These data also could serve as a source for development of further guidelines for MDCT practice in children, such as through the ACR [11]. Further work should include periodic surveys, perhaps increasing the population surveyed to include those practicing pediatric MDCT who are not SPR members.

Address correspondence to M. E. Arch ().

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