The Alliance for Radiation Safety in Pediatric Imaging was founded in 2007 to promote radiation protection for children worldwide through awareness, education, and advocacy. The mission of the Alliance is to use the science of social marketing to provide open-source educational materials and eliminate barriers to implementation of “best practice” at the local level. This article reviews 5 years of progress and identifies future goals to enhance radiation protection for children.
In 2007, the Alliance for Radiation Safety in Pediatric Imaging was created to promote radiation protection for children worldwide. The Alliance was conceptualized by the Society for Pediatric Radiology (SPR) to expand its message of pediatric radiation protection, initiated through its ALARA (as low as reasonably achievable) conferences . Cofounded by the SPR, the American College of Radiology (ACR), the American Society of Radiologic Technologists (ASRT), and the American Association of Physicists in Medicine (AAPM), the Alliance has grown to 72 medical professional societies and agencies, representing more than 800,000 medical imaging professionals. The Alliance developed social marketing campaigns (e.g., Image Gently) that deliver straightforward educational messages focused on medical imaging safety for children  via print and electronic advertising, traditional media relations and public affairs efforts, and social media (Facebook, Twitter, and so on).
To date, the Alliance has sponsored campaigns in CT, diagnostic fluoroscopy and interventional radiology, and nuclear medicine and has a new campaign, Back to Basics, that is focused on digital radiography (Fig. 1). The mission of the Alliance is “to change practice” locally, nationally, and internationally by raising awareness and “providing opportunities to lower radiation dose when imaging children.” Although the increased growth and name recognition of the Alliance is important, the mission of the group (i.e., implementing positive change) must be accomplished for such expansion to be meaningful. This article highlights some of the accomplishments of the campaign and provides important goals yet to be achieved to significantly improve delivery of safe, high-quality imaging care to children.
Goal 1: Provide Parents With Information Before Performance of Imaging Procedures
Parents want to be informed about their child’s imaging procedures. Simple brochures increase parents’ understanding about the benefits and potential risks of medical imaging that uses ionizing radiation. Image Gently developed six pamphlets for parents, many of which were translated into 16 languages, and developed a robust Website (www.imagegently.org) to house these materials for download by parents, medical professionals, government agencies, and health care organizations worldwide.
The brochures empower parents with basic information about their child’s examination and afford them the opportunity to ask questions before the imaging test. This process of informed decision making provides the underpinning for a partnership between caregivers and family, which is encouraged by the Institute of Medicine  as a fundamental aspect of medical professionalism.
Goal 2: Tailor Equipment to the Pediatric Patient
The Alliance has held two Image Gently vendor summits that included scientists and educators from industry in CT and digital radiography, represented through the Medical Imaging & Technology Alliance (MITA), and that were attended by representatives of the U.S. Food and Drug Administration (FDA), radiologists, radiologic technologists, and medical physicists. The relationships forged at these meetings provided a basis for tangible results including eight online CT modules created by ASRT and four sponsored by CT manufacturers. Other accomplishments include successful advocacy for a common exposure terminology for digital radiography with acceptance of the International Electrochemical Commission Exposure Index standard by MITA . Recently, the FDA held a public meeting requesting feedback about its guidance document for premarket approval of imaging equipment using ionizing radiation on children. Participating Alliance representatives emphasized the unmet needs related to equipment and education for medical professionals performing pediatric imaging . Implementation of these refinements should improve safe use of medical imaging equipment.
Goal 3: Enhance Education and User Support for Imaging Equipment for the Pediatric Population
The Alliance developed Microsoft PowerPoint presentations and other educational resources available on its Website for medical professionals who perform pediatric imaging associated with each campaign. The Alliance worked closely with the International Atomic Energy Agency to edit their comprehensive curriculum for medical physicists. Because of rapid advancements in technology, end users of equipment need training on how to leverage the equipment’s design features to optimize radiation dose in children. The Image Wisely campaign, a sister organization targeting adults undergoing medical imaging, has a feature on its Website (www.imagewisely.org) called “My Equipment” that was developed as part of the campaign’s initial initiative on CT. These microsites were developed and are maintained by CT manufacturers regarding both adult and pediatric imaging. As the Image Wisely site addresses other modalities, Image Wisely will invite manufacturers to expand their microsites. Eventually, this expansion will include information about safe equipment use for children for all imaging modalities. Vendors’ Website addresses should be displayed on their equipment to facilitate access to educational information, and information on pediatric radiation protection should be included in instruction manuals for each piece of equipment.
Goal 4: Automatically Calculate and Record Size-Specific Radiation Dose Estimates
The AAPM responded to a request from the pediatric imaging community at the CT vendor summit for a better size-based dose estimate for children. It created a new, simple method to estimate pediatric radiation doses for the chest, abdomen, or pelvis from a CT scan. This method , which converts volume CT dose index (CTDIvol) values to a size-specific dose estimate (SSDE), is a substantial advancement in knowledge and medical practice. The SSDE metric allows more accurate dose estimates that can be used in patient records as well as in scientific research and quality improvement. The calculation and display of SSDE on CT scanners before scanning and the recording of this metric in the DICOM-structured report (both currently under consideration) will be major advances for children.
Goal 5: Record and Track Individual Patient Examinations and Eventually Radiation Dose
The Image Gently Medical Imaging record card embraces the importance of recording medical examinations by offering parents a means to list the imaging tests their child has received, including dates and location of the examinations. It is currently not possible to record individual patient dose information; the metrics used and the variability of radiation doses from a chest radiograph, a radionuclide cystogram, and a CT scan of the head are currently not additive for an individual patient with respect to risk. The medical community needs to pursue methods to estimate individual patient organ dose. As national registries develop, further clarification of radiation risk will evolve.
Goal 6: Develop Diagnostic Reference Levels for Pediatric Imaging
The Alliance with the FDA developed a safety checklist and Practice Quality Improvement (PQI) project for pediatric digital radiography. The diagnostic and interventional radiology Web pages have open-source safety checklists that may be downloaded and used with every pediatric patient. A PQI project in pediatric CT is on the Image Gently Website. The pediatric nuclear medicine community developed national guidelines on radiopharmaceutical doses that are promoted by the Alliance and the Society of Nuclear Medicine and Molecular Imaging as part of the Go With the Guidelines campaign. The ACR through its Dose Index Registry (DIR) has strongly supported the pediatric CT community with the development of a research registry, which is developing diagnostic reference levels. Diagnostic reference levels provide an upper target, such as the 75th percentile, for radiation dose for a specific imaging examination above which a facility or practice should assess its performance and take action as needed. The ACR plans to incorporate digital radiography into the DIR within the next year. These registries are significant advances. However, current diagnostic reference levels are still far from comprehensive for pediatric CT and have yet to be developed for pediatric digital radiography, diagnostic fluoroscopy, and interventional fluoroscopy in the United States . The development of pediatric diagnostic reference levels for medical imaging using ionizing radiation is fundamental to quality improvement and care of children.
The Alliance for Radiation Safety in Pediatric Imaging, through its Image Gently campaign, provides a voice for children in radiation protection and serves as a resource for safe and effective imaging through its founding member societies. Its advocacy mission spotlights children, a population particularly vulnerable to radiation exposure. There is need for continued emphasis on optimization through improved radiation dose estimates based on size and monitoring these dose estimates. The Alliance looks forward to its next 5 years of collaboration with parents, the manufacturing community, government agencies, other regulatory and advisory organizations, and allied health groups to achieve the goals critical to better care for children.
We gratefully acknowledge the administrative and creative work of Jennifer Boylan, Society for Pediatric Radiology, and Coreen Bell, Alliance for Radiation Safety in Pediatric Imaging.
Slovis TL. ALARA Conference Proceedings: the ALARA concept in pediatric CT—intelligent dose reduction. Pediatr Radiol 2002; 32:217–317
U.S. Food and Drug Administration Website. Public workshop: device improvements for pediatric x-ray imaging. www.fda.gov/MedicalDevices/News-Events/WorkshopsConferences/ucm301989.htm. Published July 16, 2012. Accessed July 22, 2012
American Association of Physicists in Medicine Website. Boone JM, Strauss KJ, Cody DD, McCollough CH, McNitt-Gray MF, Toth TL. Size-specific dose estimate (SSDE) in pediatric and adult body CT examinations: AAPM Report No. 204 www.aapm.org/pubs/reports/rpt_204.pdf. Published in 2011. Accessed July 18, 2012
American College of Radiology Website. ACR practice guideline for diagnostic reference levels in medical X-ray imaging. www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Reference_Levels.pdf. Revised 2008. Accessed July 22, 2012