Tan et al.

BMC Emergency Medicine (2021) 21:106

https://doi.org/10.1186/s12873-021-00502-7

RESEARCH Open Access

Differences in radiation dose for computed

tomography of the brain among pediatric
patients at the emergency departments: an
observational study
Xi Min Tan1, Mohammad Taufik Bin Mohamed Shah2, Shu-Ling Chong3, Yong-Kwang Gene Ong3, Peck Har Ang4,
Nur Diana Bte Zakaria5, Khai Pin Lee3 and Jen Heng Pek6*

Abstract
Background: Computed tomography (CT) is associated with a risk of cancer development. Strategies to reduce
radiation doses vary between centers. We compared radiation doses of CT brain studies between pediatric and
general emergency departments (EDs), and determine the proportion studies performed within the reference levels
recommended by the International Commission on Radiological Protection (ICRP).
Methods: A retrospective review was carried out in a healthcare network consisting of one pediatric ED and three
general hospital EDs. Pediatric patients less than 16 years old with CT brain studies performed between 1 January
2015 and 31 December 2018 were included. Information on demographic, diagnosis, volume-averaged computed-
tomography dose index and dose length product (DLP) were collected. Effective dose was then calculated from
DLP using conversion factors, termed k-coefficients which were derived using a 16 cm head CT dose phantom.
Results: Four hundred and seventy-nine CT brain studies were performed – 379 (79.1%) at the pediatric ED. Seizure
(149, 31.1%), head injury (147, 30.7%) and altered mental status (44, 9.2%) were the top three ED diagnoses. The
median effective dose estimates were higher in general than pediatric EDs, particularly for those aged > 3 to ≤6
years old [1.57 mSv (IQR 1.42–1.79) versus 1.93 mSv (IQR 1.51–2.28), p = 0.047], > 6 to ≤10 years old [1.43 mSv (IQR
1.27–1.67) versus 1.94 mSv (IQR 1.61–2.59), p = 0.002) and > 10 years old (1.68 mSv (IQR 1.32–1.72) versus 2.03 mSv
(IQR 1.58–2.88), p < 0.001). Overall, 233 (48.6%) and 13 (2.7%) studies were within the reference levels recommended
by ICRP 60 and 103 respectively.
Conclusions: Radiation doses for CT brain studies were significantly higher at general EDs and less than half of the
studies were within the reference levels recommended by ICRP. The development of diagnostic reference levels
(DRLs) as a benchmark and clinical justification for performing CT studies can help reduce the radiation risks in the
pediatric population.
Keywords: Computed tomography, Emergency, Pediatric, Radiation

* Correspondence: [email protected]
6
Department of Emergency Medicine, Sengkang General Hospital, 110
Sengkang E Way, Singapore 544886, Singapore
Full list of author information is available at the end of the article

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Tan et al. BMC Emergency Medicine (2021) 21:106 Page 2 of 9

Background radiation dose level to identify situations where the pa-

Computed tomography (CT) is a valuable diagnostic tool tient dose or administered activity is unusually high, fur-
in the Emergency Department (ED) [1]. However, it in- ther helps with dose optimisation [37]. In healthcare
volves the use of ionizing radiation at much higher doses practices, DRLs help prevent radiation exposures that do
as compared to other diagnostic imaging tests such as x- not provide additional information for patient clinical
rays [2]. Given the increased utilisation of CT in recent management [38]. They also help guide radiology de-
years, concerns have therefore been raised about the po- partments review their practices when patient doses sig-
tential for developing malignancies resulting from expos- nificantly deviate from the DRL, and allow comparisons
ure to ionizing radiation during CT studies [1, 3–5]. The between institutions for quality control purposes. At the
pediatric population is particularly susceptible due to time of writing, there is no established national or local
their radiosensitive organ tissues and long lifespan after DRL guidance for pediatric CT head examinations in
radiation exposure, with an increased incidence of Singapore.
radiation-induced cancers such as leukaemia and brain Therefore, our primary objective was to compare radi-
tumours [1, 6–15]. ation doses used for pediatric CT brain studies between
Previously, radiation doses were similar for pediatric pediatric and general EDs of a healthcare network in
and adult CT techniques – despite the smaller body Singapore, and determine the proportion of CT brain
habitus and increased radiosensitivity of children [16]. studies performed within the reference level recom-
Recommendations for reducing ionizing radiation mended by ICRP [35, 36, 39]. (Supplementary Materials).
dose for pediatric patients started to emerge in the Our secondary objective was to propose a DRL for
early 2000s, led by the “As Low As Reasonably pediatric CT brain studies performed in the EDs. We
Achievable” and “Image Gently” campaigns to raise hypothesize that for pediatric CT brain studies, the me-
awareness about the risks associated with CT studies dian effective radiation dose administered in general EDs
and propose protocols to reduce the radiation dose is higher compared to the pediatric ED, and a greater
for children [13, 16–19]. However, literature on proportion of CT studies is within ICRP 60 and 103 rec-
pediatric multi-slice CT studies reported an effective ommendations at pediatric than general EDs. The find-
dose of about 4 mSv for CT brain examinations, as ings from this work can drive quality improvement
opposed to an effective dose of 1 to 2 mSv in adults, initiatives and ultimately, it is about making CT imaging
suggesting that a gap still exists in clinical practice safe for every pediatric patient in the ED.
[20, 21]. In addition, effective doses in pediatric CT
head studies can vary across healthcare facilities, par-
Methods
ticularly between institutions with dedicated pediatric
Study setting
services and those without [22–28]. Reasons for such
The public healthcare institutions in Singapore are di-
disparities include inappropriate clinical justification;
vided into three healthcare networks, with each serving
patient-related attributes like size, weight, motion,
a specific geographical location. Our healthcare network
and complexity of medical condition; as well as tech-
is the largest and consists of (1) a pediatric tertiary hos-
nical factors like a CT scanner’s acquisition parame-
pital with a pediatric ED and both inpatient and out-
ters, and the level of training or experience of the CT
patient pediatric services; (2) three adult tertiary
technologist and radiologist [23, 29]. As such, there is
hospitals with general EDs and no inpatient or out-
a continual need to push for appropriate justification
patient pediatric service. The pediatric ED is staffed by
of pediatric CT studies with optimisation of radiation
pediatric emergency physicians while the general EDs
dose used [30, 31].
are staffed by emergency physicians who have variable
To this end, a landmark development was when the
experience in pediatric emergency care.
American Association of Physicists in Medicine (AAPM)
established the size-specific dose estimate (SSDE) which
takes into consideration the patient’s size, and allows for Study design
optimisation of radiation dose without sacrificing image A retrospective study was carried out involving pediatric
quality [32–34]. Also, the International Commission on patients, defined by age less than 16 years old, who
Radiological Protection (ICRP) has since updated its age attended the EDs from 1 January 2015 to 31 December
and region-specific effective dose limits from the previ- 2018 and had a CT brain study performed. Data was col-
ous 1990 Publication 60 recommendations to the lected using a standardized form by assessing the elec-
current 2007 Publication 103, based on the latest avail- tronic medical records of the ED visit. Information on
able scientific information of the biology and physics of demographic, diagnosis and radiation dose in terms of
radiation exposure [35, 36]. Finally, the establishment of volume-averaged computed-tomography dose index
a CT dose diagnostic reference level (DRL), defined as a (CTDIvol) and dose length product (DLP) were obtained
Tan et al. BMC Emergency Medicine (2021) 21:106 Page 3 of 9

and analysed. All CT brain studies will be analysed, in- All of the CT brain studies were non-contrasted. There
cluding those repeated in the same ED visit. was no patient with multiple CT brain studies in a single
This study was approved by Institutional Review Board ED visit. The median age of the patients across the four
at SingHealth, with waiver of informed consent. EDs was 7 years (IQR 3 to 12) and there were 290
(60.5%) males. Seizure (149, 31.1%), head injury (147,
CT scanner parameters 30.7%) and altered mental status (44, 9.2%) were the top
Across all EDs, CT brain studies were performed using three ED diagnoses for patients requiring CT brain stud-
one of the following three CT scanners: Toshiba Aqui- ies in the EDs (Table 1).
lion (Toshiba Medical Systems, Tokyo, Japan), Toshiba
Aquilion Prime (Toshiba Medical Systems, Tokyo, CTDIvol, DLP and effective dose for CT brain studies
Japan) or Siemens Somatom Force (Siemens Healthcare, Table 2 shows the parameters of the CT scanners used
Germany). at the pediatric and general EDs.
There were significant differences in both median
Radiation dose parameters CTDIvol and DLP between the pediatric ED and general
Dose indicators of CTDIvol and DLP were obtained. EDs in the > 3 to ≤6 years, > 6 to ≤10 years and > 10 years
CTDIvol reflects the mean absorbed radiation within the age groups. (Supplementary Materials) The median ef-
scan volume based upon standardized CTDI phantoms. fective dose for all CT brain studies was 1.68 mSv (IQR
For CT brain studies, CTDI quantification is based on a 1.43 to 2.10 mSv) which was slightly more than half a
16 cm diameter Plexiglas phantom [21]. DLP, deter- year’s worth of background radiation exposure in the
mined by multiplying the CTDIvol (in mGy) by scan United States (3.1 mSv/year) [40]. Across all age groups,
length (in cm), is a measure of a CT scanner’s radiation there was a trend towards greater median effective doses
output/exposure along a patient’s long axis (in mGy-cm) for CT brain studies performed in the general EDs as
and provides an estimate of the total energy delivered to compared to the pediatric ED. In particular, significant
the CTDI Plexiglas phantom – consequently, the scan differences in the CT brain median effective doses were
length may be estimated by dividing the DLP by the found in the > 3 to ≤6 years (p = 0.047), > 6 to ≤10 years
CTDIvol [21]. (p = 0.002) and > 10 years (p < 0.001) age groups
Effective dose, in mSv, was calculated from DLP by (Table 3).
multiplying DLP with age- and region-specific conver-
sion factors, termed k-coefficients (in mSv/(mGy-cm)), Proportion of CT brain studies with effective doses within
recommended by the ICRP 60 and 103 [35, 36, 39]. the reference levels recommended by ICRP 60 and 103
(Supplementary Materials). Two hundred and thirty-three (48.6%) of all the CT
brain studies done across both pediatric and general EDs
Data analysis fell within the reference levels recommended by ICRP
SPSS version 22 (SPSS, Chicago, IL) was used to perform 60. The proportion is significantly higher in the pediatric
statistical analysis. Frequencies with percentages were ED where 216 (45.1%) were within ICRP 60 definition,
used to present categorical data. Mean ± standard devi- compared to 13 (2.7%) in general EDs (p < 0.001). How-
ation (SD) or median (interquartile range, IQR) was used ever, when the newer ICRP 103 definition was used, only
for continuous data depending on normality. Patients 13 (2.7%) of all CT brain imaging studies were within
were classified into the following five age-group categor- the reference levels, all of which were in the pediatric
ies – ≤6 months, > 6 months to ≤3 years, > 3 years to ≤6 ED (Table 4).
years, > 6 years to ≤10 years, > 10 years – to compare
their effective doses and with the reference levels recom- Proposal of a local diagnostic reference level
mended by ICRP. Chi-square test or Fisher’s exact test Based on the recommendations of National Council on
was used for association between categorical data. Stu- Radiation Protection and Measurements (NCRP) Report
dent’s t-test or Mann-Whitney U test was used for asso- 172 and ICRP 103, the median CTDIvol and DLP values
ciation between continuous data depending on for each age group may be defined as the local DRL.
normality. Statistical significance was taken at p less These proposed DRLs from our study are displayed in
than 0.050. Table 5.

Results Discussion
Demographics CT brain studies remain a sensitive and readily available
A total of 479 pediatric patients had CT brain studies tool for many diagnostic dilemmas in the ED. CT has
performed over the study period – 379 (79.1%) in the the ability to produce images in a quick, non-invasive
pediatric ED and 100 (20.9%) in the three general EDs. and reliable manner, making it the best imaging option
Tan et al. BMC Emergency Medicine (2021) 21:106 Page 4 of 9

Table 1 Patient Demographics

Overall (n = 479) Pediatric ED (n = 379) General EDs (n = 100) p-value
Median Age in Years (Interquartile Range) 7 (3 to 12) 6 (2 to 10) 13 (10 to 15) < 0.001
Gender, n (%) ` 0.426
Male 290 (60.5) 226 (59.6) 64 (64.0)
Diagnosis, n (%) < 0.001
Seizure 149 (31.1) 127 (33.5) 22 (22.0)
Head Injury 147 (30.7) 105 (27.7) 42 (42.0)
Altered Mental Status 44 (9.2) 36 (9.5) 8 (8.0)
Stroke 34 (7.1) 34 (9.0) 0 (0)
Headache, not specified 22 (4.6) 9 (2.4) 13 (13.0)
Meningoencephalitis 21 (4.4) 18 (4.7) 3 (3.0)
Intracranial Neoplasm 11 (2.3) 11 (2.9) 0 (0)
Cardiac Arrest 9 (1.9) 4 (1.1) 5 (5.0)
Syncope 9 (1.9) 5 (1.3) 4 (4.0)
Intracranial Haemorrhage 6 (1.3) 4 (1.1) 2 (2.0)
Ventriculoperitoneal Shunt-related 3 (0.6) 3 (0.8) 0 (0)
Others 24 (5.0) 23 (6.1) 1 (1.0)

Table 2 Parameters of CT Scanners At Pediatric and General EDs

Parameters Pediatric ED General EDs
Tube Potential, kV 100, 120 100,120
Median Tube Current - Exposure Time Product (IQR), mAs
≤ 6 months 148.50 (135.25–184.00) 263.00 (−)
> 6 months to ≤3 years 176.00 (156.00–210.00) 288.00 (257.25–300.00)
> 3 years to ≤6 years 196.00 (181.75–239.00) 294.00 (229.50–336.00)
> 6 years to ≤10 years 244.00 (192.50–260.00) 300.00 (250.00–312.00)
> 10 years 204.00 (187.00–264.00) 320.00 (238.00–360.00)
Median Scan Range (IQR), cm
≤ 6 months 16.32 (15.14–17.36) 12.93 (−)
> 6 months to ≤3 years 18.20 (16.91–19.50) 17.40 (10.89–27.74)
> 3 years to ≤6 years 18.63 (18.00–19.74) 13.41 (11.58–17.24)
> 6 years to ≤10 years 19.17 (18.49–20.32) 17.16 (15.02–18.60)
> 10 years 19.60 (18.78–20.63) 18.49 (16.78–19.39)
Pitch Value 0.55–1.55 0.5–1.55
Rotation Time, seconds 0.28–1.0 0.5–1.0
Collimation, mm
Siemens 128 × 0.6, 192 × 0.6 128 × 0.6, 192 × 0.6
Toshiba 40 × 0.6 40 × 0.6
Reconstruction Technique Iterative Iterative
Section Thickness, mm 3 3
Tan et al. BMC Emergency Medicine (2021) 21:106 Page 5 of 9

Table 3 Comparison of Effective Dose for CT Brain Studies Between Pediatric and General EDs
Age Group Overall (n = 479) Pediatric ED (n = 379) General EDs (n = 100) p-value
Median Effective Dose n (%) Median Effective Dose n (%) Median Effective Dose n (%)
(IQR), mSv (IQR), mSv (IQR), mSv
≤6 months 1.84 (1.60–2.65) 22 (4.6) 1.79 (1.59–2.39) 20 (5.3) 2.95 (−) 2 (2.0) 0.052
> 6 months to ≤3 1.97 (1.67–2.29) 118 1.97 (1.67–2.26) 112 2.57 (1.76–4.01) 6 (6.0) 0.063
years (24.6) (29.6)
> 3 years to ≤6 1.57 (1.42–1.57) 87 1.57 (1.42–1.79) 82 1.93 (1.51–2.28) 5 (5.0) 0.047
years (18.2) (21.6)
> 6 years to ≤10 1.48 (1.30–1.76) 88 1.43 (1.27–1.67) 72 1.94 (1.61–2.59) 16 0.002
years (18.4) (19.0) (16.0)
> 10 years 1.63 (1.38–2.10) 164 1.68 (1.32–1.72) 93 2.03 (1.58–2.88) 71 < 0.001
(34.2) (24.5) (71.0)

at the ED over alternative imaging modalities such as ‘normalized’ effective dose [35]. In neonates and chil-
paediatric cranial ultrasound or magnetic resonance im- dren, an inherently higher sensitivity to the effects of
aging of the brain. Ultrasound is constrained by the fact ionizing radiation can result in doubling of the effective
that it can only be performed prior to fontanelle fusion dose delivered to the irradiated anatomic site (e.g., brain)
in neonates or infants and magnetic resonance imaging compared to an adult [10, 42].
requires patients to be absolutely still for a prolonged The age-stratified effective doses of CT brain studies
duration of which the pediatric population may not be were higher in the younger age groups compared to
able to comply with. CT, however, delivers considerably older age groups; a finding in line with recent publica-
higher radiation doses than these alternatives. Therefore, tions which supports the inverse relationship between
minimizing radiation doses during CT brain scans re- effective dose and age [43, 44]. However, the effective
mains an important quality measure in all hospitals. doses for pediatric CT brain studies performed by gen-
We found that the effective doses of radiation for CT eral EDs were higher, reaching statistical significance in
brain studies were higher in the general EDs than the those aged three and above, adding further evidence to
pediatric ED. By comparing effective doses to the pub- the literature that non-dedicated pediatric centers ex-
lished ICRP 60 and 103 definitions, we found that even posed patients to higher radiation doses during CT stud-
in pediatric institutions, less than 50% met the ICRP 60 ies [45–47]. In addition, it is concerning that there is a
definitions and less than 5% met the newer ICRP 103 wider variation across effective doses in the general EDs
definitions. Therefore, moving forward, we have pro- and a higher proportion of studies exceeding the dose
posed a local DRL based on the median CTDIvol and recommendations of ICRP 60. As ICRP 103 conversion
DLP values for each age group to improve the safety and coefficients are deemed to be more accurate for children
quality of CT brain studies performed in pediatric pa- of different ages, it is therefore alarming that when
tients at our healthcare network. benchmarked against the ICRP 103 effective dose rec-
The term ‘effective dose’, used by health practitioners ommendations, none of the CT brain studies at the gen-
worldwide, is regarded as the most appropriate dose de- eral EDs was within the reference levels [48].
scriptor to quantify and communicate the stochastic For CT studies, effective dose is directly proportional
risks associated with diagnostic procedures involving to the quantity of energy a scanner emits, quantified by
ionizing radiation [41]. It takes into account the relative CTDIvol and DLP. While DLP values help determine es-
sensitivity of a person’s irradiated organs, translating it timations of effective dose using ICRP 103 age-based
into a quantifiable estimate of an individual’s biologic conversion coefficients, CTDIvol, however, is the CT
detriment (e.g., carcinogenesis) – this is referred to as index that ‘best represents the average dose at a
Table 4 CT Brain Studies with Effective Doses within the Reference Levels Recommended by ICRP 60 and 103
Age Group ICRP 60 ICRP 103
Pediatric ED (n = 379) General EDs (n = 100) Pediatric ED (n = 379) General EDs (n = 100)
≤6 months 15 (4.0) 0 (0) 6 (1.6) 0 (0)
> 6 months to ≤3 years 47 (12.4) 2 (2.0) 3 (0.8) 0 (0)
> 3 years to ≤6 years 53 (14.0) 2 (2.0) 1 (0.3) 0 (0)
> 6 years to ≤10 years 62 (16.4) 8 (8.0) 0 (0) 0 (0)
> 10 years 39 (10.3) 5 (5.0) 3 (0.8) 0 (0)
Tan et al. BMC Emergency Medicine (2021) 21:106 Page 6 of 9

Table 5 Proposed Local Diagnostic Reference Level for Pediatric CT dose levels and how it varies across the EDs in our
CT Brain Studies healthcare network. The processes involved in determin-
Age Group Pediatric ED General EDs ing radiation dose estimates, including local DRLs, have
CTDIvol DLP CTDIvol DLP provided us with an evaluation framework and tools for
≤6 months 19 309 27 335 optimizing doses for pediatric CT brain studies per-
> 6 months to ≤3 years 22 405 29 598
formed in our EDs. At the same time, they have shown
us the potential challenges of establishing consensual
> 3 years to ≤6 years 25 448 40 552
DRL for pediatric CT studies. The local DRL values in
> 6 years to ≤10 years 26 494 43 654 this review were well below those reported by our
> 10 years 29 571 50 827 American and European counterparts, which is encour-
aging. However, dose variations found between pediatric
particular point within a scan volume’. [49] The CTDIvol and non-pediatric EDs within our healthcare network
is dependent on several key acquisition parameters such are troubling. Nonetheless, we hope our findings serve
as tube current and scanning rotation time (mAs), tube as a stimulus for a concerted nationwide and unified ap-
potential, pitch setting and detector configuration, as proach to pediatric CT dose optimisation, involving phy-
well as reconstruction technique and slice thickness; all sicians, allied health professionals, and patients.
ultimately contribute to patient’s effective dose [50, 51]. For institutions, we propose having an active approach
Differences in acquisition parameters of the CT scanners to educate and raise awareness among healthcare
at the EDs may account for the lower doses of radiation workers beyond ED and radiology staff as part of our ef-
at the pediatric ED compared to general EDs. Specific- forts to reduce radiation doses in pediatric patients. Im-
ally, general EDs had a higher mAs in all age-groups, plementation of quality control measures to ensure
pediatric ED had a lower gantry rotation time of 0.28 s, competence when dealing with pediatric patients and
and general EDs had a greater proportion of younger monitoring compliance to departmental pediatric proto-
children whose images are acquired at a tube potential cols for scanning should be considered, especially in
of 120 kV voltage setting. centers without dedicated pediatric services. Finally, it is
However, acquisition parameters of the CT scanners our responsibility to ensure that pediatric CT studies are
are not the only reasons for the higher doses used for clinically indicated, and that their acquisition techniques
CT brain studies at the general EDs. While the use of and protocols are optimized. Frequent reviews of
optimal scanning protocols involving pediatric patients pediatric CT protocols to prevent unnecessary radiation
may lead to lower radiation doses during CT brain stud- exposure to our younger population from routine day-
ies, the pediatric protocols are not the default setting at to-day medical practice are highly encouraged.
the general EDs, thereby necessitating a switch by the
radiographer when the study is being performed [52]. Limitations
Furthermore, radiologists at the general EDs may be less This study has several limitations. Firstly, this study was
experienced and familiar with CT studies in pediatric conducted in a single healthcare network consisting of a
patients, therefore making modifications to protocols in pediatric ED and three general EDs in Singapore. All
place by increasing doses of radiation to decrease image four centers are tertiary hospitals and academic centers.
noise for better diagnostic accuracy [26, 28]. All these As EDs in other settings may have different practices, a
deviations can contribute to the higher radiation doses collaboration involving various institutions from mul-
for CT brain studies at the general EDs. tiple countries would be able to provide a better repre-
Optimal radiation doses should be established by regu- sentation of how radiation doses used for CT studies
latory authorities as national DRLs using national survey, differed between pediatric and general EDs. Next, we
or healthcare facilities as local DRLs using current prac- only evaluated non contrasted CT brain studies instead
tice [39]. However, both national and local DRLs are of including all CT studies as the number of CT studies
lacking in Singapore. In our study, we proposed local involving contrast and/or other body regions were per-
DRLs based on the median CTDIvol and DLP at pediatric formed infrequently, leading to inadequate numbers for
and general EDs. In doing so, we hope to call to atten- statistical power and valid comparison of radiation doses
tion the need for better regulation of radiation exposure used between pediatric and general EDs. We also did
from CT studies in pediatric patients. When compared not evaluate the indications for CT and the number of
to European guidelines, the local DRLs were higher, es- CT brain studies with positive or clinically important
pecially those for general EDs. (Supplementary findings.
Materials). In determining the effective dose estimates for
This study is an initial but critical step towards under- pediatric CT brain, we used scanner-derived parameters,
standing where we currently stand in terms of pediatric as well as age- and tube potential-based conversion
Tan et al. BMC Emergency Medicine (2021) 21:106 Page 7 of 9

coefficients recommended by ICRP 103. CTDIvol pro- interpreted data, as well as drafted and revised the manuscript. APH and
vides estimates of radiation output doses based on simi- NDBZ collected data and critically reviewed the manuscript. CSL, OYKG, LKP
analyzed and interpreted data, as well as critically reviewed the manuscript.
lar attenuating objects and do not take into account PJH conceptualized the study, collected data, analyzed and interpreted data,
those substantially different in terms of size or shape, as well as drafted and revised the manuscript. The author(s) read and
particularly in children where significant differences in approved the final manuscript.

size is often encountered. Other methods including Funding

scanner-specific effective dose estimates and size-specific This work was funded by the SingHealth-Duke NUS Emergency Medicine
dose estimates are available. Consequently, patients in Academic Clinical Program Research Grant (EMRG2018003).
this review could have been categorized in other ways
Availability of data and materials
such as size (e.g., effective head diameter). Furthermore, The datasets generated and analyzed during the current study are not
we did not evaluate the quality of images as this would publicly available as per guidelines by Institutional Review Board at
SingHealth, Singapore but may be available from the corresponding author
have improved our understanding of what constitutes
on reasonable request.
image diagnostic adequacy and acceptability across a
spectrum of pediatric radiation dose metrics. Hence, fu- Declarations
ture studies should consider including quantitative and
Ethics approval and consent to participate
qualitative evaluations of diagnostic image quality for This study was approved by Institutional Review Board at SingHealth,
completeness. Lastly, we did not study the long term ef- Singapore (CIRB reference 2019/2360), with waiver of informed consent. All
fects of the higher radiation doses used at the general methods were carried out in accordance with relevant guidelines and
regulations.
EDs on the subsequent development of radiation-
induced cancers. Consent for publication
Not applicable.

Conclusions Competing interests

CT brain remains an important diagnostic imaging tool The authors declare that they have no competing interests.
that is not easily substituted by alternative imaging mo-
Author details
dalities. When performed for appropriate indications 1
Yong Loo Lin School of Medicine, National University of Singapore, 10
with optimized technical parameters, the value of the in- Medical Dr, Singapore 117597, Singapore. 2Department of Radiology,
formation obtained far exceeds the stochastic risks. Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886,
Singapore. 3Department of Emergency Medicine, KK Women’s and Children’s
However, as general EDs have a tendency to administer Hospital, 100 Bukit Timah Rd, Singapore 229899, Singapore. 4Accident and
higher radiation dose during CT brain study compared Emergency Department, Changi General Hospital, 2 Simei Street 3, Singapore
to pediatric ED, there must be strategies in place to jus- 529889, Singapore. 5Department of Emergency Medicine, Singapore General
Hospital, Outram Rd, Singapore 169608, Singapore. 6Department of
tify and optimize the use of CT study by adopting im- Emergency Medicine, Sengkang General Hospital, 110 Sengkang E Way,
aging protocols with reduced radiation doses based on Singapore 544886, Singapore.
national or local standards. This will allow for better
Received: 5 April 2021 Accepted: 13 September 2021
quality management in pediatric CT imaging, so that ra-
diation exposure can be kept “As Low As Reasonably
Achievable” and every pediatric patient can be “Image(d) References
1. Brenner DJ, Hall EJ. Computed tomography - an increasing source of
Gently” in the ED. radiation exposure. N Engl J Med. 2007;357(22):2277–84. https://doi.org/10.1
056/NEJMra072149.
Abbreviations 2. Rehani MM, Berry M. Radiation doses in computed tomography: the
AAPM: American Association of Physicists in Medicine; CTDIvol: Volume- increasing doses of radiation need to be controlled. BMJ. 2000;320(7235):
averaged computed-tomography dose index; DLP: Dose-length product; 593–4. https://doi.org/10.1136/bmj.320.7235.593.
DRL: Diagnostic reference levels; ED: Emergency Department; 3. Einstein AJ, Henzlova MJ, Rajagopalan S. Estimating risk of Cancer
ICRP: International Commission on Radiological Protection; IQR: Interquartile associated with radiation exposure from 64-slice computed tomography
range; SD: Standard deviation; SSDE: Size-specific dose estimate coronary angiography. JAMA. 2007;298(3):317–23. https://doi.org/10.1001/ja
ma.298.3.317.
4. Huda W. Radiation doses and risks in chest computed tomography
Supplementary Information examinations. Proc Am Thorac Soc. 2007;4(4):316–20. https://doi.org/10.1
The online version contains supplementary material available at https://doi.
513/pats.200611-172HT.
org/10.1186/s12873-021-00502-7.
5. Kharbanda AB, Krause E, Lu Y, Blumberg K. Analysis of radiation dose to
pediatric patients during computed tomography examinations. Acad Emerg
Additional file 1. Med. 2015;22(6):670–5. https://doi.org/10.1111/acem.12689.
6. Berrington de Gonzalez A, Salotti JA, McHugh K, Little MP, Harbron RW, Lee
C, et al. Relationship between pediatric CT scans and subsequent risk of
Acknowledgements leukaemia and brain tumours: assessment of the impact of underlying
Not applicable. conditions. Br J Cancer. 2016;114(4):388–94. https://doi.org/10.1038/bjc.201
5.415.
Authors’ contributions 7. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced
TXM performed literature review, collected data, analyzed and interpreted fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176(2):289–96.
data, as well as drafted and revised the manuscript. MTBMS analyzed and https://doi.org/10.2214/ajr.176.2.1760289.
Tan et al. BMC Emergency Medicine (2021) 21:106 Page 8 of 9

8. Chida K, Ohno T, Kakizaki S, Takegawa M, Yuuki H, Nakada M, et al. 27. Nabaweesi R, Ramakrishnaiah RH, Aitken ME, Rettiganti MR, Luo C, Maxson
Radiation dose to the pediatric cardiac catheterization and intervention RT, et al. Injured Children Receive Twice the Radiation Dose at Nonpediatric
patient. AJR Am J Roentgenol. 2010;195(5):1175–9. https://doi.org/10.2214/A Trauma Centers Compared With Pediatric Trauma Centers. J Am Coll Radiol.
JR.10.4466. 2018;15(1 Pt A):58–64.
9. Frush DP, Donnelly LF, Rosen NS. Computed tomography and radiation 28. Strauss KJ, Goske MJ, Towbin AJ, Sengupta D, Callahan MJ, Darge K, et al.
risks: what pediatric health care providers should know. Pediatrics. 2003; Pediatric chest CT diagnostic reference ranges: development and
112(4):951–7. https://doi.org/10.1542/peds.112.4.951. application. Radiology. 2017;284(1):219–27. https://doi.org/10.1148/radiol.201
10. Huang WY, Muo CH, Lin CY, Jen YM, Yang MH, Lin JC, et al. Pediatric head 7161530.
CT scan and subsequent risk of malignancy and benign brain tumour: a 29. Boutis K, Thomas KE. Radiation dose awareness and disclosure practice in
nation-wide population-based cohort study. Br J Cancer. 2014;110(9):2354– pediatric emergency medicine: how far have we come? Br J Radiol. 2016;
60. https://doi.org/10.1038/bjc.2014.103. 89(1061):20160022. https://doi.org/10.1259/bjr.20160022.
11. Journy N, Rehel JL, Le Ducou Pointe H, Lee C, Brisse H, Chateil JF, et al. Are 30. Head Injury: Triage, Assessment, Investigation and Early Management of
the studies on cancer risk from CT scans biased by indication? Elements of Head Injury in Children, Young People and Adults. National Institute for
answer from a large-scale cohort study in France. Br J Cancer. 2015;112(1): Health and Clinical Excellence: Guidance. London. 2014.
185–93. https://doi.org/10.1038/bjc.2014.526. 31. European Commission. Referral Guidelines for Imaging. Available from
12. Krille L, Dreger S, Schindel R, Albrecht T, Asmussen M, Barkhausen J, et al. http://ec.europa.eu/energy/nuclear/radioprotection/publication/doc/118_en.
Risk of cancer incidence before the age of 15 years after exposure to pdf
ionizing radiation from computed tomography: results from a German 32. Larson DB. Optimizing CT radiation dose based on patient size and image
cohort study. Radiat Environ Biophys. 2015;54(1):1–12. https://doi.org/10.1 quality: the size-specific dose estimate method. Pediatr Radiol. 2014;
007/s00411-014-0580-3. 44(Suppl 3):501–5. https://doi.org/10.1007/s00247-014-3077-y.
13. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. 33. Seibert JA, Boone JM, Wootton-Gorges SL, Lamba R. Dose is not always
Cancer risk in 680 000 people exposed to computed tomography scans in what it seems: where very misleading values can result from volume CT
childhood or adolescence: data linkage study of 11 million Australians. BMJ. dose index and dose length product. J Am Coll Radiol. 2014;11(3):233–7.
2013;346(may21 1):f2360–f. https://doi.org/10.1016/j.jacr.2013.10.010.
14. Pearce MSD, Salotti JAP, Little MPP, McHugh KF, Lee CP, Kim KPP, et al. 34. Yu L, Bruesewitz MR, Thomas KB, Fletcher JG, Kofler JM, McCollough CH.
Radiation exposure from CT scans in childhood and subsequent risk of Optimal tube potential for radiation dose reduction in pediatric CT:
leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012; principles, clinical implementations, and pitfalls. Radiographics. 2011;31(3):
380(9840):499–505. https://doi.org/10.1016/S0140-6736(12)60815-0. 835–48. https://doi.org/10.1148/rg.313105079.
15. Valentin J. International commission on radiological P. the 2007 35. ICRP, 1991. 1990 Recommendations of the International Commission on
recommendations of the international commission on radiological Radiological Protection. ICRP Publication 60. Ann ICRP. 1991;21(1–3):4f–201.
protection. Oxford: Published for the International Commission on 36. ICRP, 2007. The 2007 Recommendations of the International Commission
Radiological Protection by Elsevier; 2007. on Radiological Protection. ICRP publication 103. Ann ICRP. 2007;37(2–4):1–
16. Paterson A, Frush DP, Donnelly LF. Helical CT of the body: are settings 332.
adjusted for pediatric patients? Am J Roentgenol. 2001;176(2):297–301. 37. Task Group on Control of Radiation Dose in Computed Tomography. Managing
https://doi.org/10.2214/ajr.176.2.1760297. patient dose in computed tomography. A report of the International
17. Donnelly LF, Emery KH, Brody AS, Laor T, Gylys-Morin VM, Anton CG, et al. Commission on Radiological Protection. Ann ICRP. 2000;30(4):7–45.
Minimizing radiation dose for pediatric body applications of single-detector 38. Clerkin C, Brennan S, Mullaney LM. Establishment of national diagnostic
helical CT: strategies at a large Children's hospital. AJR Am J Roentgenol. reference levels (DRLs) for radiotherapy localisation computer tomography
2001;176(2):303–6. https://doi.org/10.2214/ajr.176.2.1760303. of the head and neck. Rep Pract Oncol Radiother. 2018;23(5):407–12. https://
18. Huda W, Scalzetti EM, Levin G. Technique factors and image quality as doi.org/10.1016/j.rpor.2018.07.012.
functions of patient weight at abdominal CT. Radiology. 2000;217(2):430–5. 39. Brady Z, Ramanauskas F, Cain TM, Johnston PN. Assessment of pediatric CT
https://doi.org/10.1148/radiology.217.2.r00nv35430. dose indicators for the purpose of optimisation. Br J Radiol. 2012;85(1019):
19. Sodhi KS, Krishna S, Saxena AK, Sinha A, Khandelwal N, Lee EY. Clinical 1488–98. https://doi.org/10.1259/bjr/28015185.
application of ‘justification’ and ‘optimization’ principle of ALARA in 40. Metting NF. Ionizing Radiation Dose Ranges (Sievert). 2017. Available at:
pediatric CT imaging: “how many children can be protected from https://imsva91-ctp.trendmicro.com:443/wis/clicktime/v1/query?url=
unnecessary radiation?”. Eur J Radiol. 2015;84(9):1752–7. https://doi.org/10.1 https%3a%2f%2ffanyv88.com%3a443%2fhttps%2fwww.pnnl.gov%2fsites%2fdefault%2ffiles%2fmedia%2ffile%2
016/j.ejrad.2015.05.030. fDose%2520Range%2520Chart%5fSievert%5fJan%25202017%2da.pdf&umid=
20. Brody AS, Frush DP, Huda W, Brent RL. American academy of pediatrics 73FB666D-CA36-D705-A58A-9238160BC2A1&auth=6e3fe59570831a38971684
section on R. radiation risk to children from computed tomography. 9e93b5d483c90c3fe4-b7008eb368e11b2c76590e7e28721ef1bb74df48.
Pediatrics. 2007;120(3):677–82. https://doi.org/10.1542/peds.2007-1910. Accessed 4 Sept 2021.
21. McCollough C, Cody D, Edyvean S, Diagnostic Imaging Council CT 41. McCollough CH, Schueler BA. Calculation of effective dose. Med Phys. 2000;
Committee. American Association of Physicists in Medicine Report No. 96 - 27(5):828–37. https://doi.org/10.1118/1.598948.
The Measurement, Reporting, and Management of Radiation Dose in CT. 42. Brenner DJ, Doll R, Goodhead DT, Hall EJ, Land CE, Little JB, et al. Cancer
2008. risks attributable to low doses of ionizing radiation: assessing what we really
22. King MA, Kanal KM, Relyea-Chew A, Bittles M, Vavilala MS, Hollingworth W. know. Proc Natl Acad Sci U S A. 2003;100(24):13761–6. https://doi.org/10.1
Radiation exposure from pediatric head CT: a bi-institutional study. Pediatr 073/pnas.2235592100.
Radiol. 2009;39(10):1059–65. https://doi.org/10.1007/s00247-009-1327-1. 43. Aw-Zoretic J, Seth D, Katzman G, Sammet S. Estimation of effective dose
23. Sadigh G, Kadom N, Karthik P, Sengupta D, Strauss KJ, Frush D, et al. and lifetime attributable risk from multiple head CT scans in
Noncontrast head CT in children: National Variation in radiation dose ventriculoperitoneal shunted children. Eur J Radiol. 2014;83(10):1920–4.
indices in the United States. AJNR Am J Neuroradiol. 2018;39(8):1400–5. https://doi.org/10.1016/j.ejrad.2014.07.006.
https://doi.org/10.3174/ajnr.A5719. 44. Muhammad NA, Abdul Karim MK, Abu Hassan H, Ahmad Kamarudin M,
24. Strauss KJ, Somasundaram E, Sengupta D, Marin JR, Brady SL. Radiation dose Ding Wong JH, Ng KH. Diagnostic Reference Level of Radiation Dose and
for pediatric CT: comparison of pediatric versus adult imaging facilities. Image Quality among Pediatric CT Examinations in A Tertiary Hospital in
Radiology. 2019;291(1):158–67. https://doi.org/10.1148/radiol.2019181753. Malaysia. Diagnostics (Basel). 2020;10(8):591.
25. Blumfield E, Zember J, Guelfguat M, Blumfield A, Goldman H. Evaluation of 45. Dougeni E, Faulkner K, Panayiotakis G. A review of patient dose and
an initiative to reduce radiation exposure from CT to children in a non- optimisation methods in adult and pediatric CT scanning. Eur J Radiol. 2012;
pediatric-focused facility. Emerg Radiol. 2015;22(6):631–41. https://doi.org/1 81(4):e665–83. https://doi.org/10.1016/j.ejrad.2011.05.025.
0.1007/s10140-015-1335-4. 46. Mohiy HA, Sim J, Seeram E, Annabell N, Geso M, Mandarano G, et al. A dose
26. Goske MJ, Strauss KJ, Coombs LP, Mandel KE, Towbin AJ, Larson DB, et al. comparison survey in CT departments of dedicated pediatric hospitals in
Diagnostic reference ranges for pediatric abdominal CT. Radiology. 2013; Australia and Saudi Arabia. World J Radiol. 2012;4(10):431–8. https://doi.
268(1):208–18. https://doi.org/10.1148/radiol.13120730. org/10.4329/wjr.v4.i10.431.
Tan et al. BMC Emergency Medicine (2021) 21:106 Page 9 of 9

47. Moss M, McLean D. Pediatric and adult computed tomography practice and
patient dose in Australia. Australas Radiol. 2006;50(1):33–40. https://doi.org/1
0.1111/j.1440-1673.2005.01544.x.
48. ICRP, Khong PL, Ringertz H, Donoghue V, Frush D, Rehani M, et al. ICRP
publication 121: radiological protection in pediatric diagnostic and
interventional radiology. Ann ICRP. 2013;42(2):1–63. https://doi.org/10.1016/j.
icrp.2012.10.001.
49. Deak PD, Smal Y, Kalender WA. Multisection CT protocols: sex- and age-
specific conversion factors used to determine effective dose from dose-
length product. Radiology. 2010;257(1):158–66. https://doi.org/10.1148/ra
diol.10100047.
50. Huda W, Vance A. Patient radiation doses from adult and pediatric CT. AJR
Am J Roentgenol. 2007;188(2):540–6. https://doi.org/10.2214/AJR.06.0101.
51. Raman SP, Mahesh M, Blasko RV, Fishman EK. CT scan parameters and
radiation dose: practical advice for radiologists. J Am Coll Radiol. 2013;
10(11):840–6. https://doi.org/10.1016/j.jacr.2013.05.032 State of the Art:
Iterative CT reconstruction techniques. Radiology. 2015;276(2):339–57, DOI:
10.1148/radiol.2015132766.
52. Bone MC, Schlosser MJ, Perlin JB. Re: injured children receive twice the
radiation dose at nonpediatric trauma centers compared with pediatric
trauma centers. J Am Coll Radiol. 2018;15(6):825. https://doi.org/10.1016/j.ja
cr.2017.10.036.

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