Communicating Radiation Risk in Pediatric Patients

Health care professionals have a shared responsibility for communicating risks and benefits of computed tomography to patients, especially in the case of pediatric patients facing medical imaging procedures.

As part of a special issue of The Journal of the American College of Radiology focused on radiation dose optimization, Joshua Broder, MD, FACEP, associate professor in the division of emergency medicine at Duke University Medical Center, and Donald P. Frush, MD, chief of the division of pediatric radiology at Duke University Medical Center, published an article describing the content and style of conversations that should be used when discussing radiation risk for pediatric patients.

“Communicating risk is essential to the concept of patient autonomy, which is complex in pediatrics because decisions are usually made by caregivers,” Broder said. “A decision-maker can’t make an informed decision without understanding both risk and benefit.” 

In many cases, the clinician ordering the procedure holds the primary responsibility for communicating the risks and benefits, according to the article. The radiologist is then responsible for optimizing the procedure, balancing both the patient’s safety and diagnostic accuracy.

Broder and colleagues admitted in their discussion that it is unrealistic to have a discussion about radiation risk prior to every imaging procedure.

“Differences of opinion exist, but imaging procedures at the higher end of the diagnostic imaging exposure range, such as CT and fluoroscopic procedures, are the most obvious candidates for discussions of risk,” he said. This may include procedures with an exposure of greater than 50 mSv, but that could vary according to the patient’s age and the risk associated with the presenting medical condition.

When having a discussion about radiation risk, Broder said that the language used needs to be comprehensible to the target audience.

“Physicians sometimes struggle with this, using technical terms that aren’t readily understood by patients and families,” he added.

In addition, the message should be communicated with sensitivity, courtesy, compassion, appropriateness and honesty. Importantly, physicians should avoid appearing rushed during these conversations. Caregivers should also be asked if they have any questions about the risks of radiation, and should be offered additional information in the form of online or printed materials.

The most difficult process involved in radiation risk conversations is helping patients and their caregivers balance any long-term risk of radiation with the short-term needs of their presenting medical condition.

“The highest radiation exposures from procedures such as CT in the youngest pediatric patients still represent a small risk relative to baseline cancer risks in the population, and we need to be cautious not to make patients so fearful of radiation that they might refuse an indicated exam,” Broder said.

Broder asks questions like: Is the risk of the medical condition minor? Is the likely speed of progression slow, so that the condition might be recognized in a timely fashion by clinical observation? Is the danger of the condition, if present, limited? Is the patient sufficiently healthy at present that a delayed diagnosis could be tolerated without great harm? 

If the answers to these questions are “yes,” it is often safe to defer imaging, as long as adequate observation or follow-up is available, Broder said. If the answers are “no,” it is likely that the risk of the immediate condition outweighs the risk associated with imaging, so imaging should be performed. 

“Obviously the decision is complex and must be determined on a case by case basis by the physician, patient, and family,” Broder said.