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Physician Blog : Pediatric Perspectives
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This blog for physicians will provide you with practical information you can use in your office while highlighting new techniques and programs available at Helen DeVos Children's Hospital.

 

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photo Dominic Sanfilippo, MD
photo James Fahner, MD
photo William Stratbucker, MD
Archives
 
Thursday, January 14, 2010
Radiation and Children—We Keep a Close Watch
by Pediatric Perspectives at 01:13 PM

Bradford W. Betz, MD, Medical Director, Pediatric Radiology  
Helen DeVos Children's Hospital

Many of you may have heard about or read the two articles on CT scans that were just published in the Archives of Internal Medicine. The articles highlight two major issues with CT scans: One, that the radiation from CT scans may be responsible for 29,000 cancers and 15,000 cancer deaths a year; and two, that there is a wide variation in the amount of radiation used for scans, for even the exact same type of scan.  Bradford W. Betz, MD

 

The amount of attention these articles have been getting in the media surprises me. After all, this news is not new. Just a year ago, another report published in the New England Journal of Medicine suggested that as many as 2 percent of all cancers in the United States might be due to diagnostic scans. And in the pediatric realm, we've had such reports for nearly a decade.

 

While I question some of the assumptions used in these studies, particularly the radiation dosages assumed to trigger cancer (which are extrapolated from atomic bomb blast survivors and radiation industry workers), I think these studies are important. They highlight the need for more evidence-based research into the appropriate indications for CT and the need for more standardization in radiation dosages.

 

Here at Helen DeVos Children's Hospital we have been working for years to provide the lowest possible dose of radiation for all pediatric scans. Two years ago, we created an ALARA committee (ALARA stands for "As Low As Reasonably Achievable"). The committee is charged with monitoring the radiation dose in pediatric radiology to ensure the use of the safest possible amount; developing new ways to reduce the dose even further; and educating healthcare professionals, patients and families about the importance of keeping the dose as low as possible.

 

My greatest concern is that reports like those in the Archives will prevent children from getting the scans they need. While national studies suggest that up to one-third of CT scans in children may be unnecessary, I know that figure is too high for our area. Our community is very conservative about ordering such tests. And, as I'm sure you will agree, CT scans represent one of the greatest advances in medicine in the past few decades. So let the parents of your patients know that if an exam is necessary and there is no other way to get the information we need it shouldn't be withheld for a relatively nebulous risk.

 

Bottom line: There is no question in my mind that CT saves lives.

 

Stay tuned for an article in the next Pediatric Perspectives print edition that highlights the protocols our department uses for pediatric imaging and the steps you can take to ensure that you are ordering the right scan for the right child at the right time.

 

Comments: What are your concerns/questions about CT scans or other diagnostic modalities?

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Wednesday, January 06, 2010
Four Steps To Improve Your Ability to Recognize Child Abuse
by Pediatric Perspectives at 10:29 AM

N. Debra Simms, MD, Director, Center for Child Protection

Helen DeVos Children's Hospital

 

A recent article in Pediatrics found that physicians missed diagnosing abuse in one-fifth of children under age 3 with abuse-related fractures. Factors associated with missed diagnosis included "male gender, extremity versus axially located fracture, and presentation to a primary care setting versus pediatric emergency department or to a general versus pediatric emergency department."N. Debra Simms, MD

 

The results of this excellent study don't surprise me. As a specialist in child abuse and neglect I spend a great deal of time reviewing similar cases on an individual basis. I see these kinds of injuries being missed quite a lot. 

  

I understand that primary care physicians, particularly pediatricians, are under tremendous strain these days, with incredible pressure to see more and more patients in less and less time. Nonetheless, remembering just a few things could improve your ability to diagnose a child who is being abused. Specifically:

 1. Be thorough. If you're examining a child with an injury or suspicious set of symptoms, take a very detailed, complete medical history. Explore the parent or guardian's explanation of the injury. What kind of child is this? A sedentary child or one who likes to leap tall buildings (and thus has a greater risk of self injury)?  Basically, ask yourself if the explanation of the injury makes sense.

 

2. Expand your differential to include child abuse. You think about infection, pathologic fracture, and accidental trauma when you see a child with a fracture or sprain, but do you think about child abuse? If it's not on your list you're not going to consider it. Part of this involves examining your own prejudices. Several studies report that our own prejudices about the "type" of people who abuse children can interfere with our ability to diagnose abuse and neglect.1,2 Recognize that there is no "typical" child abuser. Even a wealthy, white, married woman could be a child abuser. Also keep in mind that a high percentage of fractures in very young children are the result of abuse.3

 

3. Order a radiologic skeletal survey for nonverbal or developmentally delayed children. The American Academy of Pediatrics recommends such tests for all children 2 years and younger, but I base the decision on the individual child. This should be ordered as a skeletal survey, not babygram, so you can identify signs of any other current or old injuries. While the test does expose a child to radiation, the amount is very small and the overall risk is much lower than the risk of sending the child back to an abusive environment.

 

4. Listen to your gut. If something doesn't add up or you hear alarm bells, listen. Call in an abuse/neglect specialist, a pediatric orthopedist, or call the 24-hour Child Protective Services child abuse hotline (800.942.4357). As you know, medical providers are required to report all suspected cases of abuse. I understand your concerns about potentially alienating families, but your first responsibility is to protect the child.

 

 

REFERENCES

1. Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse.JAMA. 2002;288(13):1603-9.

2. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621-6.

3. Leventhal JM, Thomas SA, Rosenfield NS, Markowitz RI. Fractures in young children. Distinguishing child abuse from unintentional injuries. Am J Dis Child. 1993 Jan;147(1):87-92.

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