My last post raised questions about the overuse of CT imaging in children, which researchers projected could prove hazardous to kids in the form of excess solid tumors at some point in the kid’s lifetime. It’s one study, but as the study shows, a growing peer-reviewed data base points towards hazards that could be avoid.
Key issues that the researchers and editorialists raised include:
- Around the country, pediatric radiation doses are not standardized and they could be reduced substantially to improve patient safety;
- CT hits kids with 100 to 500 times as much radiation as standard x-rays.
- In what cases, is sending your kid for another test distracting from real care and helping them get well?
- What questions should parents ask to determine the tradeoffs in having their kid imaged or going through any test, or not?
Of all medical imaging tests, so far, CT stands out for the most compelling projection of harm –spelled out in terms of projected excess solid tumors that could have been avoided in a child’s lifetime if careful referral and dosing protocols were in place.
“It’s very well shown that CT scans for minor head injuries are usually of no benefit,” Ricardo Quinonez, MD, Director of Research and Quality, Pediatric Hospital Medicine, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, and Executive Chair, American Academy of Pediatrics, Section Chair of Hospital Medicine, said in an interview. “For simple abdominal pain, simply watching it is best.
Excess CT Scans Not Only Concern
Quinonez also addressed use of magnetic resonance (MR) imaging in children under age 7. “Most kids need sedation and safety is not a completely settled question, with anesthesia having negative consequences on brain function.” Quinonez questioned whether MR is being overused more and more. Even though no negative consequences from the magnets have been observed directly, there are downstream risks, potentially unnecessary surgeries.”
Another concern is the use of chest x-rays for asthma and bronchulitis. Quinonez stressed that diagnosing these problems can be done clinically, meaning hands-on physical exam of the patient. Chest x-rays subject kids to radiation. Depending on where it is done, the dose may be adjusted to the child’s weight, which should be standard, but you may not be assured of that outside of a children’s hospital. Quinonez also pointed out that if you give a chest x-ray to three radiologists to read, you may get three different interpretations. Armed with results from a chest x-ray, kids may end up with unnecessary antibiotics. When this happens often enough, antibiotic resistance may develop.
Repeat imaging is also widespread. How many times have you gone to one doctor, mentioned that you or your child had a specific study done, and you have been stonewalled, told: “We like to do our own.” Again, you have to wonder whether the second or third repeat study in a short interval was really necessary.
Resources You Can Use
Projects aimed at dialing back unnecessary imaging are getting around. However, from the response to my first post, the news is not getting around enough. For example, the American Board of Internal Medicine/Society of Pediatric Hospital Medicine Choosing Wisely campaign has prepared a tip sheet listing 5 Things Physicians and Patients Should Question. An American Academy of Pediatrics tip sheet provides additional information.
The Image Gently campaign, organized by pediatric radiologists concerned with safety, has a slew of materials that you may find helpful when deciding whether or not to have an imaging study. Included on their page is a link for a sheet you can use to track all of your child’s medical imaging studies.
The National Cancer Institute has a sheet for health care providers on appropriate use of CT in children. It includes issues that pediatricians and parents should discuss.
On repeat imaging. Have you ever had an x-ray report that said something to discourage you from doing a follow up test. I’d love to see a radiologist say something like given the extremely low likelihood that this incidentaloma is anything of concern no follow up is felt to be the safest option unless you have reason to believe otherwise. No instead you get, this finding appears most likely benign, but repeat testing in X months is recommended to assure stability. (and when that is done another follow up later is likely to follow). It’s good business, looks good to the lawyers, and is almost always done. Screw the patient, my tech and I wear lead gowns.