American College of Radiology, American College of Emergency Physicians, and American Academy of Pediatrics Offer Guidance on Use of Advanced Imaging in Pediatric Patients

Emergency medicine clinicians often use advanced imaging tools like ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to evaluate injuries and illness in children.  

A new joint policy statement from the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP), and American College of Radiology (ACR) offers guidelines for institutions and medical professionals who care for children to make the best use of advanced imaging in the emergency department by weighing benefits and risks. 

The policy statement, “Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department,” is the result of a multidisciplinary collaboration. The policy statement and an accompanying technical report appear online today in the Journal of the American College of Radiology (JACR), official journal of the ACR, and Pediatrics, published by AAP. The policy statement will be published on July 18 in the Annals of Emergency Medicine (Annals), an official journal of the ACEP. The articles are openly available to read, download, and share. 

Jennifer R. Marin, MD, MSc, FACEP, FAAP, lead author of the policy statement and member of the AAP Committee on Pediatric Emergency Medicine, said, “Technological advances have improved the accuracy, speed, and accessibility of advanced imaging, and in the last several decades there has been a dramatic increase in the use of these studies in the emergency department.”

Dr. Marin added, “But many imaging studies are considered to be of low value, meaning the risks outweigh the benefits. More studies aren’t necessarily better, and it is important that clinicians consider factors, including the radiation exposure from computed tomography and false-positive and incidental findings that increase downstream testing. We know that advanced imaging can also result in longer emergency department stays, and there are risks associated with transport or sedation in an uncooperative child and financial costs to the health system.”

 Aisha Terry, MD, MPH, president of ACEP, said, “These guidelines will remind clinicians to routinely weigh any risk associated with pediatric imaging against the benefits. This will ensure that decisions to image and utilize associated support services are made in a timely and appropriate manner, resulting in optimal benefit to our youngest patients. Further, adopting standardized approaches to evaluate and diagnosis using evidence-based guidelines can improve care coordination as well as shared decision-making between clinicians and families.”  The technical report includes a supplement that provides condition-specific imaging recommendations, including clinical guidelines and pathways from several children’s hospitals that can be useful for providers at the point of care.  Michael R Aquino, MD, DABR, MHSc, section head of Pediatric Imaging at the Cleveland Clinic Imaging Institute and director of Pediatric Overnight Emergency Imaging, stated, “This collaborative effort will help raise the quality of pediatric emergency care. It represents a valuable opportunity to raise awareness of evidence-based imaging guidelines such as the ACR Appropriateness Criteria amongst our patient-facing colleagues.”   Physicians should be familiar with optimal imaging strategies for common pediatric conditions and use publicly available evidence-based guidelines and protocols that are designed to minimize potentially unnecessary imaging and additionally reduce racial and ethnic disparities in imaging delivery.   The AAP, ACEP, and the ACR recommend that emergency departments: 

• Ensure that appropriate computed tomography protocols and parameters are used for pediatric patients 

• Strive to provide ultrasound services as first-line imaging when indicated, such as for appendicitis or nephrolithiasis 

• Develop policies for imaging consultation with a pediatric radiologist, general radiologist with expertise in pediatric imaging or pediatric subspecialist to minimize transfers that may require only imaging review 

 Dr. Marin explained, “One of the easiest ways to optimize advanced imaging in a community emergency department, is to defer imaging in children who are going to be transferred to a pediatric referral center regardless of the imaging result, if the result will not alter management prior to or during transfer. Often, there are delays in accessing outside studies, and many studies need to be repeated if not optimally performed or the images were not transferred successfully.”   The policy statement also contains recommendations for using shared decision-making strategies when more than one reasonable choice regarding imaging exists.  ---  

Notes for Editors 

Published jointly in the Annals of Emergency Medicine and the Journal of the American College of Radiology. 

“Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement,“ by the AMERICAN ACADEMY OF PEDIATRICS Committee on Pediatric Emergency Medicine, Section on Radiology; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS Pediatric Emergency Medicine Committee; AMERICAN COLLEGE OF RADIOLOGY; Jennifer R. Marin, MD, MSc, FAAP, FACEP, Todd W. Lyons, MD, MPH, FAAP, Ilene Claudius, MD, FACEP, Mary E. Fallat, MD, FAAP, FACS, Michael Aquino, MD, Timothy Ruttan, MD, FACEP, FAAP, Reza J. Daugherty, MD, FAAP 

Openly available at: 

JACR: https://doi.org/10.1016/j.jacr.2024.03.015 opens in new tab/window

Annals: https://doi.org/10.1016/j.annemergmed.2024.03.023 (will appear online on July 18) 

Published in the Journal of the American College of Radiology. 

“Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report,” by the AMERICAN ACADEMY OF PEDIATRICS Committee on Pediatric Emergency Medicine, Section on Radiology; AMERICAN COLLEGE OF EMERGENCY PHYSICIANS Pediatric Emergency Medicine Committee; AMERICAN COLLEGE OF RADIOLOGY; Jennifer R. Marin, MD, MSc, FAAP, FACEP, Todd W. Lyons, MD, MPH, FAAP, Ilene Claudius, MD, FACEP, Mary E. Fallat, MD, FAAP, FACS, Michael Aquino, MD, Timothy Ruttan, MD, FACEP, FAAP, Reza J. Daugherty, MD, FAAP 

Openly available at https://doi.org/10.1016/j.jacr.2024.03.016 opens in new tab/window

The full text of the articles is also available to credentialed journalists upon request; contact Eileen Leahy at +1 732 406 1313 or [email protected] opens in new tab/window. Journalists wishing to interview the authors should contact Steve Arnoff, American College of Emergency Physicians, at [email protected] opens in new tab/window or the American College of Radiology Media Team at +1 216 375 6899 or [email protected] opens in new tab/window. 

About Annals of Emergency Medicine (Annals) 

Annals of Emergency Medicine, an official journal of the American College of Emergency Physicians opens in new tab/window, is an international, peer-reviewed journal dedicated to improving the quality of care by publishing the highest quality science for emergency medicine and related medical specialties. In addition to general emergency medicine topics, Annals regularly publishes articles on out-of-hospital emergency medical services, pediatric emergency medicine, injury and disease prevention, health policy and ethics, disaster management, toxicology, and emergency department administration. www.annemergmed.com opens in new tab/window

About the Journal of the American College of Radiology (JACR)  

The official journal of the American College of Radiology opens in new tab/window, JACR opens in new tab/window informs its readers of timely, pertinent, and important topics affecting the practice of diagnostic radiologists, interventional radiologists, medical physicists, and radiation oncologists. The journal’s goals are to improve patient care, support the practice of radiology and imaging, and move the science forward in health services research and policy, clinical practice management, data science, training and education, and leadership. www.jacr.org opens in new tab/window

Annals and JACR are published by Elsevier. 

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