Back to Basics in Pediatric Imaging

New Image Gently® initiative educates the imaging community and the public on opportunities to optimize radiation dose in digital radiography.back to basics

Many things in life require balance: work and play, study and application, or even too much or too little of just about anything.

To help the entire imaging team appropriately weigh image quality and radiation dose during pediatric imaging, Image Gently® launched Back to Basics, a campaign designed to educate individuals about X-ray imaging, specifically digital radiography.

Optimal Images and Dose

"Digital radiology brought many improvements [to imaging], including the capability to transmit images system-wide for instantaneous viewing by caregivers," explains Susan D. John, MD, FACR, campaign committee co-chair. "However, technical processes used for digital acquisition of images are different from those used in screen-film radiology, and knowledge about these differences and how they impact patient dose ... may have lagged behind implementation of the technology," she says.

For example, "with screen-film radiography, underexposed or overexposed images were readily identified; an overexposed film was dark and uninterpretable. The radiologic technologist knew to decrease technique to achieve the desired result. With digital radiology, this direct feedback has been lost," explains Marilyn J. Goske, MD, in Pediatric Radiology.1 This makes it important for the imaging team to understand the exposure index and deviation index.

In an effort to make digital images more easily read, John notes, the balance sometimes leans toward overexposure, which increases the radiation dose administered to pediatric patients. "Although exposure indicators are available on acquisition devices, these indicators are not standardized between manufacturers," she adds.

To help establish and maintain optimally exposed images, the Back to Basics campaign is designed to educate everyone involved in image gentlyproviding digital radiography to young patients, including radiologists, radiologic technologists, medical physicists, and vendors, as well as patients and their families. According to John, the campaign's goals are to improve "digital radiograph quality in children and [ensure] lowest possible radiation exposures through multiple practice quality improvement projects and online educational materials," which were developed by the campaign.

These educational resources include five free PowerPoint presentations: Introduction to Digital Radiography, Using Exposure Indicators to Improve Digital Radiography, Digital Image Acquisition Systems, Immobilization Tips in Pediatric CR/DR, and Ten Steps to Help Manage Radiation Dose in Pediatric Digital Radiography, which are available on the Image Gently website ( In addition, the campaign committee members have developed instructional tools such as a CR/DR safety checklist, sponsored by the FDA, which reminds radiographers about critical safety steps to be used in routine radiography. The safety checklist includes an instructional manual and a practice quality improvement project.

"In the past, technologists would use calipers to measure body thickness to help them set the technique," explains Steven Don, MD, who also serves as campaign co-chair. "We are urging a recommitment to the use of calipers and technique charts, especially when using manual technique to standardize the approach to digital radiography in children. In addition, grids are not necessary on body parts smaller than 10-12 centimeters in anteroposterior dimension. The approach should be a departmental quality improvement effort. As routine radiography is the most commonly performed imaging study in children, it is important that we get it right every time."

Group Effort

Although radiologists do not acquire the images, Don notes that "the radiologist needs to understand what the technologist does and how the new technology impacts the image quality and patient dose." This kind of understanding can only be gained from a team effort. Keith J. Strauss, MSc, FACR, medical imaging physicist and campaign committee member, elaborates: "You're going to get the best result if you have a technologist, a radiologist, and a medical physicist all working cooperatively to create the best protocol. The technologist has the technical expertise of working with pediatric patients on a day-to-day basis, the radiologist has the medical expertise, and the medical physicist has the physics expertise."

Greg Morrison, RT, chief operating officer of the American Society of Radiologic Technologists, agrees: "It really does take some teamwork to make things happen and to produce an actual image." He also notes, "It's the technologist who has the last opportunity to ensure that ... the dose is as low as possible for the clinical task."

Children and families can learn about the role of the technologist — and all individuals involved in the imaging process — through educational resources such as patient brochures. This information is available now on the Image Gently website (

1. Goske M, Charkot E, Herrmann T, et al. “Image Gently: Challenges for Radiologic Technologists When Performing Digital Radiography in Children.” Pediatric Radiology 2011;41:611–19.

By Brett Hansen

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