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| M. Paediatrics | |||||||
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CLINICAL/DIAGNOSTIC PROBLEM |
INVESTIGATION |
RECOMMENDATION (GRADE) |
COMMENT |
DOSE |
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| Central
nervous system
(For head injury in children see section K) |
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| Congenital
disorders:
head |
MRI | Indicated (B) | Definitive exam for all malformations, avoiding x-irradiation. CT may be needed to define bone and skull base anomalies. Sedation or GA may be required for infants and young children, and in some cases therefore CT may be preferred. | 0 | |||
| Congenital
disorders:
spine |
MRI | Indicated (B) | Definitive exam for all malformations, avoiding x-irradiation. CT may be needed to delineate bone detail. Sedation or GA may be required for infants and young children. | 0 | |||
| Abnormal
head appearance:
hydrocephalus |
US | Indicated (B) | US indicated where anterior fontanelle is open. Where sutures are closed/closing, MRI is indicated (older children). CT may be appropriate if MRI is not available | 0 | |||
| SXR | Specialised investigation (C) | SXR and low-dose CT with 3-D reconstructions are indicated in craniostenosis. | I | ||||
| Epilepsy | MRI | Specialised investigation (C) | Specialist clinical assessment and EEG investigation should usually be undertaken before MRI, unless there are signs of raised intracranial pressure or an acute neurological deficit. There is no routine indication for CT | 0 | |||
| PET/NM/SPECT/rCBF | Specialised investigation (C) | Useful in pre-surgical evaluation | II-IV | ||||
| SXR | Not indicated (B) | Poor yield | I | ||||
| Deafness in children | MRI and/or CT | Specialised investigation (C) | Both MRI and CT may be necessary in children with congenital and post-infective deafness | 0/II | |||
| Hydrocephalus ?shunt malfunction | XR | Indicated (B) | XR should include whole valve system | I | |||
| US/MRI | Indicated (B) | US if practicable; MRI in older children (or CT if MRI unavailable). Neurosurgeons may still want cross-sectional imaging even if US is performed. New programmable valves cause problems in MRI. US of abdomen is indicated if CSF (cerebrospinal fluid) collection is likely. | 0/0 | ||||
| Developmental delay ?cerebral palsy | MRI | Specialised investigation (C) | Remains a controversial are with regard to whom to screen and why. Further studies are needed to improve the accuracy of predicting patient outcome, particularly using newer MRI techniques of diffusion, spectroscopy, and functional imaging. | 0 | |||
| Headache | SXR | Not indicated (C) | If headache is persistent or associated with clinical signs, refer patient for specialised investigations | I | |||
| MRI/CT | Specialised investigation (B) | In children MRI is preferable if available because of absence of x-irradiation. | 0/II | ||||
| Sinusitis | XR sinuses | Indicated only in specific circumstances (B) | Not indicated at < 5 years old as the sinuses are poorly developed; mucosal thickening can be a normal finding in children. | I | |||
| Neck and spine | |||||||
| Torticollis without trauma | XR | Indicated only in specific circumstances (B) | Muscular causes are most common, but when history and examination are atypical, XRs are advised. | I | |||
| CT | Indicated only in specific circumstances (B) | Persistent torticollis for one week justifies further imaging following consultation. | II | ||||
| US | Indicated (B) | In congenital torticollis, US of neck muscles is a useful diagnostic tool in confirming sternocleidomastoid tumour in infants. If US is negative, XR and cross-sectional imaging are indicated. | 0 | ||||
| Back pain | MRI/CT | Indicated (B) | Persistent back pain in children may have an underlying cause and justifies investigation. Choice of imaging follows consultation. Back pain with scoliosis or neurological signs merits MRI/CT. | 0/II | |||
| Spina bifida occulta | US/MRI | Not indicated (C) | A common variation and not in itself significant. Investigation is only indicated if neurological signs are present. | 0/0 | |||
| Hairy patch, sacral dimple | US/MRI | Indicated only in specific circumstances (B) | Isolated sacral dimples and pits may be safely ignored (<5 mm from midline; <25 mm from anus). US of the neonatal lumbar spine and canal is the initial investigation of choice if there are are other stigmata of spinal dysraphism or associated congenital abnormalities, e.g. cloacal exstrophy anorectal malformation spectrum (CEARMS). MRI is indicated if neurological signs are present or there is a discharging lesion. | 0/0 | |||
| Neonatal hypothyroidism | NM | Specialised investigation (B) | TC-99m or I-123 thyroid scintigraphy is the most accurate diagnostic test to detect thyroid dysgenesis or one of the inborn errors of T4 synthesis in patients with congenital hypothyroidism. | II | |||
| Musculoskeletal | |||||||
| Non-accidental
injury/child abuse
(For head injury see section K) |
Skeletal survey | Indicated (age 0-2 years) (A) | Age
0-2 years, CT of the head is mandatory.
Age 3-5 years, XR clinically suspicious area. Age > 3 years skeletal survey is not generally indicated, as children > 3 can usually describe where pain is located. Examination should be performed by radiographers trained in paediatric radiological techniques. |
II | |||
| NM | Indicated (B) | Bone scintigraphy is indicated in children > 2 years if the skeletal survey is equivocal. Abnormal bone findings must always be correlated with clinical history, physical examination and pertinent XRs. | II | ||||
| Limb
injury:
Opposite side for comparison |
Comparison XRs of the joint on the contralateral side | Not indicated (B) | Seek radiological advice. | I | |||
| Short stature, growth failure | XR for bone age | Indicated (A) | Child
aged 1 year and over: Left (or non-dominant) hand/wrist only.
XR may need supplementing with further specialised investigations. Skeletal scintigraphy if dysplasia is suspected. MRI of hypothalamus-pituitary fossa if central hormone failure is a possibility. |
I | |||
| Irritable hip | US | Indicated (B) | US will confirm presence of an effusion but will not discriminate sepsis from transient synovitis. | 0 | |||
| XR | Not indicated initially (C) | XR, which may include a frog lateral view, is required if slipped upper femoral epiphysis or Perthes' disease is suspected or if symptoms persist. If symptoms persist, then follow-up should be as for the limping child. | I | ||||
| Limping | US | Indicated (B) | US will confirm presence of an effusion but will not discriminate sepsis from transient synovitis. | 0 | |||
| XR | Not indicated initially (B) | Children with a limp need proper clinical assessment. If pain persists, or localising signs are present, XR is indicated. | I | ||||
| MRI | Specialised investigation (C) | Should be used after discussion with radiologist. | 0 | ||||
| NM | Not indicated initially (B) | XR and US should be performed before NM. NM is useful for localisation when XR and US are normal. The age of the child is an important factor in limiting the diagnostic possibilities. | II | ||||
| Focal bone pain | XR | Indicated (B) | XR should be the first-line investigation, though MRI and NM are more sensitive than XR in detecting occult infection or fracture. | I | |||
| NM | Specialised investigation (B) | XR should be obtained initially. Skeletal scintigraphy is useful if pain is not well localised. A negative multiphasic study does not exclude active arthritis. | II | ||||
| MRI | Specialised investigation (C) | Particularly useful if the child can localise the site of the pain | 0 | ||||
| US | Specialised investigation (C) | US can detect occult infection | 0 | ||||
| Clicking hip: dislocation | US | Indicated (A) | US is indicated where there is clinical doubt about developmental dysplasia of the hip but not for routine screening. XR may be necessary in the old child. | 0 | |||
| Osgood-Schlatter disease | XR | Indicated only in specific circumstances (C) | Although bony radiological changes are visible in Osgood-Schlatter disease, these overlap with normal appearances. Associated soft tissue swelling should be assessed clinically rather than radiologically. | I | |||
| Cardiothoracic | |||||||
| Acute chest infection | CXR | Indicated only in specific circumstances (A) | CXR indicated if symptoms persist despite treatment or in severely ill children. If CXR is performed and demonstrates simple pneumonia, routine follow-up CXR is not required | I | |||
| Recurrent productive cough | CXR | Indicated only in specific circumstances (C) | In general, children with recurrent productive cough have CXRs which are normal or show peribronchial thickening. Routine follow-up CXR is not indicated unless atelectasis is seen on initial CXR. Suspected cystic fibrosis or immune deficiency require specialist referral. | I | |||
| Cystic fibrosis | NM | Indicated only in specific circumstances (B) | Perfusion lung scintigraphy is useful in selected cases, especially if surgery is contemplated. | II | |||
| Inhaled foreign body (suspected) | CXR | Indicated | CXR is indicated, though often normal. If there is clinical suspicion of an inhaled foreign body, bronchoscopy is mandatory. While air trapping is the most common sign seen in patients with inhaled foreign bodies, it is seen infrequently and the routine use of expiratory XRs is not warranted. Fluoroscopy is often a better and easier alternative to expiratory XR. | I | |||
| Wheeze | CXR | Indicated only in specific circumstances (B) |
In most children with wheeze, the CXR is either normal or shows features of uncomplicated asthma or bronchiolitis, such as hyperinflation or peribronchial cuffing. In selected cases, such as those with fever or localised crackles, the CXR may be useful in guiding patient management. |
I | |||
| Acute stridor | Lateral XR soft tissue neck | Indicated only in specific circumstances (B) | Epiglottitis and croup are clinical diagnoses. Lateral neck XRs may be of value in children with stable airway in whom an obstructing foreign body or retropharyngeal abscess is possible. | I | |||
| Heart murmur | CXR/US | Indicated only in specific circumstances (C) | Specialist referral is needed; cardiac US may be indicated. | I/0 | |||
| Gastrointestinal | |||||||
| Intussusception | US-guided or fluoroscopy-guided hydrostatic/pneumatic reduction | Indicated (A) | US
has a high sensitivity in diagnosing intussusception but is
operator-dependant. It is useful in assessing blood flow and identifying
lead points and small bowel intussusceptions.
Pneumatic reduction has a higher success rate than traditional hydrostatic reduction. However, there is a slightly higher risk of perforation (approximately 1%). Absolute contraindications are perforation, shock and peritonitis. |
0/II | |||
| Swallowed foreign body | AXR | Indicated only in specific circumstances (C) | Only for sharp or potentially poisonous foreign body, e.g. battery. | I | |||
| CXR including neck | Indicated (B) | If there is doubt whether the foreign body has passed, an AXR after six days may be indicated | I | ||||
| Blunt abdominal trauma | AXR | Indicated only in specific circumstances (B) | Clinical assessment of the patient should be used to determine which patients require furthur evaluation by imaging. AXR is of limited use after minor trauma unless there are positive physical signs suggestive of intra-abdominal pathology or injury to the spine or bony pelvis. | I | |||
| US | Indicated only in specific circumstances (B) | US may be used to search for the presence of free fluid following blunt abdominal trauma, but a negative examination does not exclude the presence of intra-abdominal injury. | 0 | ||||
| CT | Specialised investigation (B) | CT with IV contrast remains the primary imaging investigation of choice to detect the presence and extent of intra-abdominal injuries following blunt abdominal trauma, and will guide the level or intensity of hospital and post-discharge management of the patient. US may be useful in the follow-up of known organ injuries, to reduce the total radiation burden to the patient. | III | ||||
| Projectile vomiting in infants | US | Indicated (A) | US can confirm the presence of hypertrophic pyloric stenosis, especially where clinical findings are equivocal. | 0 | |||
| Recurrent vomiting | Contrast meal +/- follow-through | Indicated only in specific circumstances (C) | Recurrent vomiting in children can be caused by a wide variety of conditions, many of which cannot be diagnosed radiologically. An upper GI contrast study is not indicated for diagnosis of simple gastro-oesophageal reflux. Where significant gastro-oesophageal reflux has been shown on pH studies, an upper GI contrast study may be indicated to exclude a significant structural abnormality such as hiatus hernia or malrotation. If there are other associated clinical symptoms/signs, e.g. bile-stained vomit, the case for contrast studies is much stronger. | II | |||
| NM | Specialised investigation (C) | Gastric emptying may be measured with Tc-99m-labelled solid or fluid meal. This may be combined with scintigraphic evaluation of gastro-oesophageal reflux. | II | ||||
| Persistent neonatal jaundice | US | Specialised investigation (B) | Early (<10 weeks) and prompt investigation is essential. The absence of dilatation in the intrahepatic bile ducts does not exclude obstructive cholangiopathy. | 0 | |||
| NM | Specialised investigation (B) | Hepatobiliary scintigraphy with TC-99m - labelled IDA derivatives. This cannot confirm biliary atresia if there is no bowel activity | II | ||||
| GI bleeding (per rectum) | AXR | Indicated only in specific circumstances (C) | Imaging strategy depends on the age of the patient and severity of bleeding, diagnostic possibilities and clinical presentation. AXR is required if necrotising enterocolitis is suspected. | I | |||
| US | Specialised investigation (C) | US for diagnosis of intussusception and demonstration of duplication cysts. Upper or lower GI endoscopy is often the most useful next investigation. Consider a small bowel enema if the suspected pathology is inaccessible to endoscopy | 0 | ||||
| NM | Specialised investigation (C) | NM is used for detecting active bleeding sites including Meckel's diverticulum. Angiography is used for investigation of rapid haemorrhage or chronic haemorrhage not found by other means. | II | ||||
| Acute abdominal pain | US | Specialised investigation (C) | Acute abdominal pain can be due to a diverse range of causes. US can be helpful in further assessment but needs to be guided by clinical findings. | 0 | |||
| AXR | Indicated only in specific circumstances (C) | Rarely of value and best performed under specialist guidance. Generally AXR is not undertaken prior to US. | II | ||||
| Constipation | AXR | Indicated only in specific circumstances (C) | There is a wide variation in the amount of faecal residue shown on the AXR and good correlation with constipation has not been proven. Additionally there is inter-observer variation in interpretation. AXR can help specialists in the management of intractable constipation. | II | |||
| Contrast enema | Indicated only in specific circumstances (C) | Non-radiological investigations, i.e. rectal manometry and biopsy are preferred. Contrast enema may have a role if these are not available and referral is difficult. | II | ||||
| Palpable abdominal/pelvic mass | US | Indicated (C) | Indicated in the evaluation of all suspected abdominal masses. If the presence of a mass is confirmed, the patient should be referred to a specialist centre. | 0 | |||
| Genitourinary | |||||||
| Continuous wetting | US | Indicated (B) | In toilet-trained girls with a history of continuous dribbling/wetting, an ectopic infrasphincteric ureter must be excluded. US of the whole renal tract including the bladder and pelvis is recommended in addition to video-urodynamics. Imaging of the urinary tract in children with solely night-time enuresis is of limited value. | 0 | |||
| XR lumbosacral spine | Indicated (B) | Indicated in children with abnormal neurology or skeletal examination, in addition to those with bladder wall thickening/trabeculation demonstrated on US or neuropathic vesicourethral dysfunction on video-urodynamics. | II | ||||
| NM | Indicated only in specific circumstances (B) | DMSA imaging is useful in the detection and localisation of the dysplastic kidney and upper moiety of a duplex system | II | ||||
| IVU | Indicated only in specific circumstances (B) | To confirm the ectopic infrasphincteric ureters in girls with known duplex system on US and/or DMSA imaging. | II | ||||
| CT/MRI | Specialised investigation (B) | CT/MRI may be of value to locate the dysplastic kidney or dysplastic occult moiety when US and DMSA imaging have failed. MRI urography, if available, is an alternative to IVU | III/0 | ||||
| Impalpable testis | US | Indicated (B) | To locate testis within the inguinal canal | 0 | |||
| MRI/laparoscopy | Specialised investigation (C) | MRI may be of value after US to locate intra-abdominal testis, but laparoscopy is generally preferred. | 0 | ||||
| Fetal renal pelvic dilatation | US | Indicated (B) | Ideally US should be performed post-partum at 72 hours and again at 4 to 6 weeks. Other imaging investigations including MCUG (micturating cystouretography) and diuretic renography should be performed as per local protocol | 0 | |||
| NM | Specialised investigation (B) | In cases of persistent postnatal pelvic dilatation, MAG-3 diuretic renography is essential to estimate renal uptake function (differential function) as well as drainage. | II | ||||
| Proven urinary tract infection | US | Specialised investigation (C) | There is a wide variation in local policy. Much depends on local technology and expertise. Most patients should remain on prophylactic antibiotics pending the results of investigations. The age of the patient also influences decisions. There is much current emphasis on minimising radiation dose; hence AXR is not indicated routinely (calculi are rare). Expert US is the key investigation in all imaging strategies at this age. | 0 | |||
| NM | Specialised investigation (A) | There is an increasing trend to examine the acutely ill child secondary to urinary tract infection with a DMSA study in the acute setting. In the out-patient setting, to exclude a scar a DMSA study should be done 3 to 6 months after a proven urinary tract infection. NM will establish function and exclude obstruction. | II | ||||
| XR cystography | Specialised investigation (A) | Direct XR cystography is still needed in the young (e.g. <2 years old) male patient where the delineation of the anatomy (e.g. urethral valves) is critical. | II | ||||
| NM | Specialised investigation (B) | NM can also be used for direct or indirect cystography. | II | ||||
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