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EXPOSURE OF PEDIATRIC EMERGENCY PATIENTS TO IMAGING EXAMS, NOWADAYS AND IN TIMES OF COVID-19: AN INTEGRATIVE REVIEW

ABSTRACT

Objective:

To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19.

Data sources:

Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded.

Data synthesis:

61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review.

Conclusions:

It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children’s exposure to ionizing agents.

Keywords:
Pediatrics; Emergencies; Diagnostic imaging; Medical overuse; Coronavirus infections; COVID-19

RESUMO

Objetivo:

Analisar dados da literatura sobre exposição desnecessária de pacientes da emergência pediátrica a agentes ionizantes dos exames de imagem, na atualidade e em tempos de COVID-19.

Fontes de dados:

Entre abril e julho de 2020 ocorreu a seleção dos artigos, utilizando-se as bases de dados: Biblioteca Virtual em Saúde, PubMed e Scientific Electronic Library Online. Utilizaram-se os descritores: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] e [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Incluíram-se artigos disponíveis na íntegra, em português ou inglês, publicados no período de 2016 a 2020 ou de 2019 a 2020, e artigos que contemplassem o tema. Excluiu-se artigos sem aderência com a temática e textos duplicados.

Síntese dos dados:

Identificaram-se 61 publicações, sendo 17 utilizadas para a elaboração desta revisão. Alguns exames de imagem utilizados nos Setores de Urgência e Emergência (SUEs) pediátricos, por emitirem radiação ionizante, aumentam a possibilidade de desenvolver malignidades futuras nas crianças. Destarte, há instrumentos de decisão clínica que possibilitam diminuir requisições de exames desnecessários, evitando a sobremedicalização e os gastos hospitalares. Ademais, com a pandemia da COVID-19, cresceu a preocupação com o uso excessivo de exames de imagem na população pediátrica, o que reafirma a problematização deste estudo.

Conclusões:

Veem-se como necessárias a capacitação da equipe hospitalar, a utilização de instrumentos de decisão clínica e a confecção de protocolos que possam avaliar a singularidade da criança. Isso permitirá reduzir o número de exames requeridos, possibilitando economia de custos hospitalares e redução da exposição de crianças a agentes ionizantes.

Palavras-chave:
Pediatria; Emergências; Diagnóstico por imagem; Sobremedicalização; Infecções por coronavírus; COVID-19

INTRODUCTION

Computed tomography (CT), magnetic resonance imaging (MRI), X-ray and ultrasound (US) are widely used imaging examinations in Urgency and Emergency Services (UEs) for pediatric diagnosis and follow-up. However, these resources should be used carefully, together with the clinical judgment from health professionals, so that there is no overuse.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...

Nowadays, due to technological advances, there has been an increase in the use of examinations, especially CTs. This is the physicians’ preferred choice in the UEs, because of the fast digitalization of images, which reduces the time of sedation in children.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
Therefore, there was an increase in the number of studies about the potential risks of exposure to ionizing radiation caused by imaging examinations, due to the tendency to develop genetic changes and future malignancies.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...

On March 11, 2020, the World Health Organization (WHO) declared a pandemic caused by COVID-19.33. World Health Organization [homepage on the Internet]. WHO director-general’s opening remarks at the media briefing on COVID-19 - 11 March 2020 [cited 2020 Jul 15]. Available from: Available from: https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
https://www.who.int/dg/speeches/detail/w...
By July 9 of the same year, more than 11.8 million cases and 544 thousand deaths had been reported around the world.44. World Health Organization [homepage on the Internet]. WHO director-general opening remarks at the member state briefing on the COVID-19 pandemic evaluation - 9 July 2020 [cited 2020 Jul 15]. Available from: Available from: https://www.who.int/dg/speeches/detail/who-director-general-opening-remarks-at-the-member-state-briefing-on-the-covid-19-pandemic-evaluation---9-july-2020
https://www.who.int/dg/speeches/detail/w...
Even though infected children manifest less severe symptoms in comparison to adults,55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
they can be hospitalized and exposed to ionizing radiation exams. Therefore, there is a growing concern about the potential overuse of imaging examinations in this population.

This review aimed to analyze literature data about the unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and in times of COVID-19.

METHOD

This is an integrative literature review (ILR) whose purpose is to synthetize and analyze studies that are available, from several methodological approaches, about the theme in question.66. Souza MT, Silva MD, Carvalho R. Integrative review: what is it? How to do it? Einstein (São Paulo). 2010;8:102-6. http://dx.doi.org/10.1590/s1679-45082010rw1134
https://doi.org/http://dx.doi.org/10.159...
Therefore, the identification of a large sample allows the evaluation, the critical discussion of the results and the development of a conclusion based on scientific evidence.66. Souza MT, Silva MD, Carvalho R. Integrative review: what is it? How to do it? Einstein (São Paulo). 2010;8:102-6. http://dx.doi.org/10.1590/s1679-45082010rw1134
https://doi.org/http://dx.doi.org/10.159...

To elaborate the research question, we used the PICO strategy - population, intervention, comparison and outcomes (Table 1). This review aims at answering: “What does the literature show about the unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and in times of COVID-19?”. Then, we continued with the following stages of ILR: determination of databases, application of descriptors, and inclusion and exclusion criteria (Identification); analysis of titles and content of the abstracts of the identified articles (Screening); evaluation and critical inspection of studies in full (Eligibility); and definition of the analyzed articles for the confection of the IRL (Inclusion).66. Souza MT, Silva MD, Carvalho R. Integrative review: what is it? How to do it? Einstein (São Paulo). 2010;8:102-6. http://dx.doi.org/10.1590/s1679-45082010rw1134
https://doi.org/http://dx.doi.org/10.159...

Table 1
PICO Strategy: population, intervention, comparison and outcomes (results).

We selected the articles between April and July, 2020, using the following databases: Virtual Health Library, PubMed and Scientific Electronic Library Online (SciELO). The search descriptors were used in two stages, and were selected from the Health Science Descriptors (DeCS), combined in pairs based on the Boolean logic: AND or OR. In the first search, we used: (pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse). In the second search, the following were used: (Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging).

The search in the databases respected the following inclusion criteria: articles available in full, in Portuguese or in English, published from 2016 to 2020 (1st search) or from 2019 to 2020 (2nd search), and articles that contemplated the exacerbated use of imaging exams in pediatric emergency rooms. The exclusion criteria were: articles without adherence to the theme and duplicated texts in the databases.

Sixty-one publications were identified, being three in the Virtual Health Library (5%), 58 in PubMed (95%), and none in SciELO (0%). In the identification stage, we excluded four texts due to duplicity, and 16 for not being available in full. Therefore, in the screening stage we analyzed 41 articles. Of these, after reading the title and abstract, 13 were excluded for not being related to the theme, and eight for not answering the research question. Thus, 20 articles were included in the eligibility stage; three were excluded after the texts were read in full, for not answering the research question. So, the final sample of this ILR comprised 17 articles (Figure 1).

Figure 1
Flow of the selection process of articles for integrative review.

For data extraction and analysis, we used a Microsoft Excel® spreadsheet that included: authors, country of origin/year of publication, journal, study method and type of analyzed imaging examination.

The copyrights were respected by preserving the content exposed by the authors and by referencing the information extracted from the articles available in public domain.

RESULTS AND DISCUSSION

Of the 17 analyzed articles, four were performed in the United States of America (USA); four, in China; two, in Italy; two, in Israel; two in the Republic of Korea; one, in Canada; one, in the Netherlands; and one, in Turkey. All articles were published in English. Regarding the year of publication, there was higher incidence in 2020 (seven articles), followed by 2018 (four articles), 2019 (two articles), 2017 (two articles) and 2016 (two articles). All of the analyzed articles contemplated the overuse of imaging examinations in pediatric emergency patients nowadays (Table 2) and in times of COVID-19 (Table 3). The analysis of the selected studies allowed the definition of seven categories.

Table 2
General characteristics of the included studies about the overuse of imaging examinations in pediatric emergency, nowadays.
Table 3
General characteristics of the included studies about the overuse of imaging examinations in pediatric emergency, in times of COVID-19.

1st category - the relation between computed tomography and magnetic resonance imaging and the use of X-ray in pediatric emergency

In the retrospective study carried out in the USA,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
it was observed that the main imaging examinations used in the clinical investigation of pediatric patients are CT and MRI, both with its pros and cons, thus defining their utility. In comparison to MRI, CT tends to be cheaper, faster and more sensitive to bone fractures,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
besides presenting high diagnostic accuracy.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
However, a major disadvantage is the exposure of patients to ionizing radiation.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
On the other hand, MRI demonstrates to be less accessible, have higher costs and be less tolerable among younger children when compared to CT.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
However, It is a more favorable alternative regarding the reduction of radiation.77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
That justifies the high number of studies performed in the past few years about MRI, in order to reduce the exposure of pediatric patients to ionizing agents.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...

A cohort study performed in Israel88. Reiter J, Breuer A, Breuer O, Hashavya S, Rekhtman D, Kerem E, et al. A quality improvement intervention to reduce emergency department radiography for bronchiolitis. Respir Med. 2018;137:1-5. https://doi.org/10.1016/j.rmed.2018.02.014
https://doi.org/https://doi.org/10.1016/...
points out that the thoracic X-ray is used for different respiratory emergencies, especially bronchiolitis, even if there is no recommendation for its use, according to the American Academy of Pediatrics (AAP).88. Reiter J, Breuer A, Breuer O, Hashavya S, Rekhtman D, Kerem E, et al. A quality improvement intervention to reduce emergency department radiography for bronchiolitis. Respir Med. 2018;137:1-5. https://doi.org/10.1016/j.rmed.2018.02.014
https://doi.org/https://doi.org/10.1016/...
A similar orientation was identified in the North-American analysis,99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
which does not advise the use of thoracic X-ray to treat acute exacerbation of asthma.99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
The analysis conducted in the Republic of Korea1010. Kwon H, Jung JY. Effectiveness of a radiation reduction campaign targeting children with gastrointestinal symptoms in a pediatric emergency department. Medicine (Baltimore). 2017;96:e5907. https://doi.org/10.1097/md.0000000000005907
https://doi.org/https://doi.org/10.1097/...
stated there are many physicians using the X-ray in the screening of non-specific abdominal symptoms due to difficulties in diagnosis. Therefore, there is a flaw in relation to the recommendations defined in protocols and the reality of medical practice, which corroborates the exaggerated use of imaging tests in the pediatric population.

2nd category - the relation between ionization and possible malignancies associated with imaging examinations

An analysis conducted in the USA11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
showed that CT is related to future risks of developing malignanies,11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,1111. Rawlins KW, Allen DZ, Onwuka AJ, Elmaraghy CA. Computed tomography use patterns for pediatric patients with peritonsillar abscess. Int J Pediatr Otorhinolaryngol. 2019;123:22-5. https://doi.org/10.1016/j.ijporl.2019.04.027
https://doi.org/https://doi.org/10.1016/...
especially in younger patients,11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
for being an examination that uses ionizing radiation.

Another study99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
showed that, in childhood, the cells grow fast and become more prone to developing cancer when exposed to ionizing radiation. Besides, the small body area contributes with higher dose of accumulated radiation.1010. Kwon H, Jung JY. Effectiveness of a radiation reduction campaign targeting children with gastrointestinal symptoms in a pediatric emergency department. Medicine (Baltimore). 2017;96:e5907. https://doi.org/10.1097/md.0000000000005907
https://doi.org/https://doi.org/10.1097/...
It was estimated that 1.5-2% of malignant neoplasms in the USA may have been caused by radiation from CTs.1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...
Besides, it is assumed that CTs in the pediatric population may be related to 5,000 future annual cases of cancer.1111. Rawlins KW, Allen DZ, Onwuka AJ, Elmaraghy CA. Computed tomography use patterns for pediatric patients with peritonsillar abscess. Int J Pediatr Otorhinolaryngol. 2019;123:22-5. https://doi.org/10.1016/j.ijporl.2019.04.027
https://doi.org/https://doi.org/10.1016/...

A study carried out in the Netherlands1313. Broers MC, Niermeijer JF, Kotsopoulos IA, Lingsma HF, Bruinenberg JF, Catsman-Berrevoets CE. Evaluation of management and guideline adherence in children with mild traumatic brain injury. Brain Inj. 2018;32:1028-39. https://doi.org/10.1080/02699052.2018.1469047
https://doi.org/https://doi.org/10.1080/...
showed that the performance of a head CT increases the risk of developing a future brain tumor. This risk increases with the performance of additional CTs, and becomes even higher when the exposure involves children aged less than 5 years.1313. Broers MC, Niermeijer JF, Kotsopoulos IA, Lingsma HF, Bruinenberg JF, Catsman-Berrevoets CE. Evaluation of management and guideline adherence in children with mild traumatic brain injury. Brain Inj. 2018;32:1028-39. https://doi.org/10.1080/02699052.2018.1469047
https://doi.org/https://doi.org/10.1080/...
For patients in this same age group, the assumption is that one case of leukemia will appear for every 5,250 head CTs.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...

3rd category - the financial impact of the excessive use of imaging examinations in the hospital environment

In an administrative database analysis,1414. Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, et al. Low-value diagnostic imaging use in the pediatric emergency department in the United States and Canada. JAMA Pediatr. 2019;173:e191439. https://doi.org/10.1001/jamapediatrics.2019.1439
https://doi.org/https://doi.org/10.1001/...
there was a retrospective study including visits to pediatric UEs from 2006 to 2016, in four hospitals in Canada (1,783,753 visits) and 26 hospitals in the USA (21,807,332 visits). The observation was that the North-American and Canadian populations have different financial and care structural organizations.1414. Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, et al. Low-value diagnostic imaging use in the pediatric emergency department in the United States and Canada. JAMA Pediatr. 2019;173:e191439. https://doi.org/10.1001/jamapediatrics.2019.1439
https://doi.org/https://doi.org/10.1001/...
In both countries, professionals are paid for the number of provided medical services; however, Canadian doctors have a global view of hospital management and governmental budget restrictions. Therefore, there is a reduction in the total number of requested and provided services per year.1414. Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, et al. Low-value diagnostic imaging use in the pediatric emergency department in the United States and Canada. JAMA Pediatr. 2019;173:e191439. https://doi.org/10.1001/jamapediatrics.2019.1439
https://doi.org/https://doi.org/10.1001/...
Besides, in the USA there is a higher tendency of performing imaging examinations, even when there is no indication for it, in order to avoid the lack of documents in a possible lawsuit; unlike in Canada, which has 25% of lawsuits due to medical negligence, in comparison to the cases in the USA.1414. Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, et al. Low-value diagnostic imaging use in the pediatric emergency department in the United States and Canada. JAMA Pediatr. 2019;173:e191439. https://doi.org/10.1001/jamapediatrics.2019.1439
https://doi.org/https://doi.org/10.1001/...

Thus, the conclusion is that North-American physicians, in comparison to Canadian physicians, perform excessive procedures, which results in major increase in hospital expenses.1414. Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, et al. Low-value diagnostic imaging use in the pediatric emergency department in the United States and Canada. JAMA Pediatr. 2019;173:e191439. https://doi.org/10.1001/jamapediatrics.2019.1439
https://doi.org/https://doi.org/10.1001/...
A similar fact was identified in a retrospective study carried out in Turkey,1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...
which stated that the improper use of imaging examinations causes major economic losses for hospital UEs. Imaging examinations, when performed without necessity, generate an approximate cost of US$ 20 billion; the non-performance of improper imaging examinations, regardless of the type, could generate an annual saving of US$ 81 billion.1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...

4th category - the difference between hospitals in the use of imaging examinations in the pediatric Urgency and Emergency services

There is a tendency for UEs in general hospitals to request more imaging examinations than in exclusively pediatric hospitals,99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
especially when it comes to CTs.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
Another variation occurs between teaching and non-teaching hospitals, as observed in a study carried out in the Netherlands.1313. Broers MC, Niermeijer JF, Kotsopoulos IA, Lingsma HF, Bruinenberg JF, Catsman-Berrevoets CE. Evaluation of management and guideline adherence in children with mild traumatic brain injury. Brain Inj. 2018;32:1028-39. https://doi.org/10.1080/02699052.2018.1469047
https://doi.org/https://doi.org/10.1080/...
This difference was analyzed by the chi-square test, identifying fewer head CTs in two regional, non-teaching general hospitals (23.3 and 25.9%) in comparison to the teaching hospital (44.1%).1313. Broers MC, Niermeijer JF, Kotsopoulos IA, Lingsma HF, Bruinenberg JF, Catsman-Berrevoets CE. Evaluation of management and guideline adherence in children with mild traumatic brain injury. Brain Inj. 2018;32:1028-39. https://doi.org/10.1080/02699052.2018.1469047
https://doi.org/https://doi.org/10.1080/...

A similar fact was observed in a Canadian study1414. Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, et al. Low-value diagnostic imaging use in the pediatric emergency department in the United States and Canada. JAMA Pediatr. 2019;173:e191439. https://doi.org/10.1001/jamapediatrics.2019.1439
https://doi.org/https://doi.org/10.1001/...
that compared the purposes of imaging examinations between pediatric emergency units in Canada and in the USA. The use of thoracic X-ray to handle bronchiolitis (absolute difference of 6.8%) and asthma (absolute difference of 0.7%) was lower in Canada, as well as the use of abdominal X-ray for constipation (absolute difference of 23.7%) and abdominal pain (absolute difference of 20.6%).1414. Cohen E, Rodean J, Diong C, Hall M, Freedman SB, Aronson PL, et al. Low-value diagnostic imaging use in the pediatric emergency department in the United States and Canada. JAMA Pediatr. 2019;173:e191439. https://doi.org/10.1001/jamapediatrics.2019.1439
https://doi.org/https://doi.org/10.1001/...

5th category - instruments used to reduce the exposure to ionizing agents in pediatric emergency patients

Several instruments are used to guide health professionals as to the use of imaging examinations, in order to reduce the unnecessary exposure to ionizing agents in pediatric UE patients.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
,88. Reiter J, Breuer A, Breuer O, Hashavya S, Rekhtman D, Kerem E, et al. A quality improvement intervention to reduce emergency department radiography for bronchiolitis. Respir Med. 2018;137:1-5. https://doi.org/10.1016/j.rmed.2018.02.014
https://doi.org/https://doi.org/10.1016/...
,99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
,1010. Kwon H, Jung JY. Effectiveness of a radiation reduction campaign targeting children with gastrointestinal symptoms in a pediatric emergency department. Medicine (Baltimore). 2017;96:e5907. https://doi.org/10.1097/md.0000000000005907
https://doi.org/https://doi.org/10.1097/...
,1111. Rawlins KW, Allen DZ, Onwuka AJ, Elmaraghy CA. Computed tomography use patterns for pediatric patients with peritonsillar abscess. Int J Pediatr Otorhinolaryngol. 2019;123:22-5. https://doi.org/10.1016/j.ijporl.2019.04.027
https://doi.org/https://doi.org/10.1016/...
,1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...
The Alvarado Score is used for abdominal CT.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
For head CT, the following instruments were reported: Pediatric Emergency Care Applied Research Network (PECARN),11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
,1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...
National Emergency X-Radiography Utilization Study (NEXUS),11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE)11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
and Canadian Assessment of Tomography for Childhood Head Injury (CATCH).11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
The last two, however, were considered little reliable for clinical use due to their low sensitivity.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...

The Alvarado Score22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
is an instrument used for acute appendicitis and abdominal pain, in order to reduce and limit the use of CT, thus favoring the use of US and MRI. However, the adherence to this instrument was not effective in reference hospitals, unlike pediatric hospitals.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...

The PECARN11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
,1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...
is a clinical decision instrument widely used in hospitals for the orientation of head CT in cases of traumatic brain injury (TBI).22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
The focus of this tool is to identify patients with low risk of developing major clinical complications, without the need to being submitted to a CT.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
The PECARN not only has high sensitivity and low specificity,11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
but it also has negative predictive value of approximately 100% for TBIs with high clinical relevance.22. Ohana O, Soffer S, Zimlichman E, Klang E. Overuse of CT and MRI in paediatric emergency departments. Br J Radiol. 2018;91:20170434. https://doi.org/10.1259/bjr.20170434
https://doi.org/https://doi.org/10.1259/...
Besides these characteristics, the PECARN can also be used to detect and classify the severity of pathologies, with 74.8% of sensitivity and 91.7% of specificity.1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...
The instrument allows to estimate the duration of hospitalization and, therefore, leads to the reduction of hospital resources and contact of the patient with radiation.1212. Gökharman FD, Aydın S, Fatihoğlu E, Koşar PN. Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness. Turk J Med Sci. 2017;47:1770-7. https://doi.org/10.3906/sag-1703-206
https://doi.org/https://doi.org/10.3906/...
This instrument presents excellent screening and is similar to medical judgment, so it is recommended by the AAP.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...

NEXUS is a clinical decision instrument used for pediatric patients with TBI11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
,77. Rao S, Rao S, Rincon S, Caruso P, Ptak T, Raja AS, et al. Assessment of pediatric neurotrauma imaging appropriateness at a level I pediatric trauma center. J Am Coll Radiol. 2016;13:788-93. https://doi.org/10.1016/j.jacr.2016.02.022
https://doi.org/https://doi.org/10.1016/...
which aims at assisting physicians in the identification of low-risk patients, who do not need a CT request, and high-risk patients, who will require intervention.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
The great differential of this tool is the use of clinical judgment to conduct this risk stratification.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
This instrument properly classified all high-risk patients who should be submitted to neurosurgery, presenting a 100% sensitivity level.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
However, a study11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
pointed out that the real sensitivity of the instrument is of 87.2%. Through the use of NEXUS, together with clinical judgment, the head CT requests decreased in up to 34% of low-risk pediatric patients.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...

By comparing the PECARN and the NEXUS instruments, the conclusion was that sensitivity, in both cases, is similar, even though the analyzed samples are different.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
There is a difference in the way children can be classified regarding CT requests, considering that PECARN was developed for all patients with TBI, whereas NEXUS assesses only children previously determined by clinical judgment.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
This additional criterion of NEXUS directly implies on the reduction of unnecessary imaging examinations in approximately 10%.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...

6th category - proposals of intervention

The need for using clinical judgment together with the guiding instruments of imaging examination requests was emphasized in order to optimize the diagnosis in pediatric UEs.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...
These tools not only contribute with the knowledge of the medical professional, but also allow low-risk patients to be safely excluded from imaging examination requests, preventing overuse.11. Gupta M, Mower WR, Rodriguez RM, Hendey GW. Validation of the pediatric NEXUS II head computed tomography decision instrument for selective imaging of pediatric patients with blunt head trauma. Acad Emerg Med. 2018;25:729-37. https://doi.org/10.1111/acem.13431
https://doi.org/https://doi.org/10.1111/...

The reimbursement policy for the quality of the provided service, and not for the number of procedures, can be an alternative to reduce imaging examinations and prescription of medication.99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
It was suggested to audit and do collaborative benchmarking with the hospital staff in order to reduce examination overuse.99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
Besides, UEs of general and pediatric hospitals can cooperate providing an integrated service for patients, by sharing pediatric guidelines.99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...
The training emergency programs of general hospitals should highlight the specificities of children in comparison to adults.99. Chamberlain JM, Teach SJ, Hayes KL, Badolato G, Goyal MK. Practice pattern variation in the care of children with acute asthma. Acad Emerg Med. 2016;23:166-70. https://doi.org/10.1111/acem.12857
https://doi.org/https://doi.org/10.1111/...

Among the analyzed articles, some implemented effective proposals to reduce the use of imaging examinations. In the cohort study,88. Reiter J, Breuer A, Breuer O, Hashavya S, Rekhtman D, Kerem E, et al. A quality improvement intervention to reduce emergency department radiography for bronchiolitis. Respir Med. 2018;137:1-5. https://doi.org/10.1016/j.rmed.2018.02.014
https://doi.org/https://doi.org/10.1016/...
an intervention that aims at limiting the use of thoracic X-ray to diagnose bronchiolitis and assess if pediatric UEs follow the current guidelines was implemented. Before intervention, the level of radiography was 44%, and then decreased to 36.6%. A similar reduction occurred in the hospitalization rates, which decreased from 76.8 to 69.8%. The conclusion was that the proposed approach was successful to reduce financial costs, pharmacological treatments and exposure to ionizing agents, as indicated in AAP guidelines. The authors suggested that similar interventions should be implemented in other pediatric UEs.88. Reiter J, Breuer A, Breuer O, Hashavya S, Rekhtman D, Kerem E, et al. A quality improvement intervention to reduce emergency department radiography for bronchiolitis. Respir Med. 2018;137:1-5. https://doi.org/10.1016/j.rmed.2018.02.014
https://doi.org/https://doi.org/10.1016/...

A study1111. Rawlins KW, Allen DZ, Onwuka AJ, Elmaraghy CA. Computed tomography use patterns for pediatric patients with peritonsillar abscess. Int J Pediatr Otorhinolaryngol. 2019;123:22-5. https://doi.org/10.1016/j.ijporl.2019.04.027
https://doi.org/https://doi.org/10.1016/...
analyzed the implementation of a policy whose purpose was to reduce the use of CT in patients with suspicion of peritonsillar abscess, recommending that professionals in the UEs request the evaluation of otolaryngologists before requiring imaging examinations in pediatric patients with unspecific physical examination. The efficacy of this policy was proven by observing a 13% reduction in the use of CT in the analyzed populations. This demonstrated that the evaluation by an expert, with clinical experience, reduces the number of unnecessary complementary examinations and leads to more accurate requests.1111. Rawlins KW, Allen DZ, Onwuka AJ, Elmaraghy CA. Computed tomography use patterns for pediatric patients with peritonsillar abscess. Int J Pediatr Otorhinolaryngol. 2019;123:22-5. https://doi.org/10.1016/j.ijporl.2019.04.027
https://doi.org/https://doi.org/10.1016/...

7th category - use of imaging examinations in pediatric patients in times of COVID-19

The infection by SARS-CoV-2 in pediatric patients has shown milder, non-typical symptoms, with lower mortality rates, in comparison to adult patients.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
,1515. Zheng F, Liao C, Fan QH, Chen HB, Zhao XG, Xie ZG, et al. Clinical characteristics of children with coronavirus disease 2019 in Hubei, China. Curr Med Sci. 2020;40:275-80. https://doi.org/10.1007/s11596-020-2172-6
https://doi.org/https://doi.org/10.1007/...
,1616. Shen Q, Guo W, Guo T, Li J, He W, Ni S, et al. Novel coronavirus infection in children outside of Wuhan, China. Pediatr Pulmonol. 2020;55:1424-9. https://doi.org/10.1002/ppul.24762
https://doi.org/https://doi.org/10.1002/...
,1717. Xu G, Yang Y, Du Y, Peng F, Hu P, Wang R, et al. Clinical pathway for early diagnosis of COVID-19: updates from experience to evidence-based practice. Clin Rev Allergy Immunol. 2020;59:89-100. https://doi.org/10.1007/s12016-020-08792-8
https://doi.org/https://doi.org/10.1007/...
One of the analyzed explanations is the fact that the immune system of children is still immature, which leads to reduced inflammatory effect - and lower cytokine release - and, consequently, lower clinical expression.1616. Shen Q, Guo W, Guo T, Li J, He W, Ni S, et al. Novel coronavirus infection in children outside of Wuhan, China. Pediatr Pulmonol. 2020;55:1424-9. https://doi.org/10.1002/ppul.24762
https://doi.org/https://doi.org/10.1002/...

Imaging examinations are essential for diagnosis and for the early detection and monitoring of COVID-19.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
,1717. Xu G, Yang Y, Du Y, Peng F, Hu P, Wang R, et al. Clinical pathway for early diagnosis of COVID-19: updates from experience to evidence-based practice. Clin Rev Allergy Immunol. 2020;59:89-100. https://doi.org/10.1007/s12016-020-08792-8
https://doi.org/https://doi.org/10.1007/...
CT is a widely used instrument in the investigation of the infection,55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
,1717. Xu G, Yang Y, Du Y, Peng F, Hu P, Wang R, et al. Clinical pathway for early diagnosis of COVID-19: updates from experience to evidence-based practice. Clin Rev Allergy Immunol. 2020;59:89-100. https://doi.org/10.1007/s12016-020-08792-8
https://doi.org/https://doi.org/10.1007/...
,1818. Huang EP, Sung CW, Chen CH, Fan CY, Lai PC, Huang YT. Can computed tomography be a primary tool for COVID-19 detection? Evidence appraisal through meta-analysis. Crit Care. 2020;24:193. https://doi.org/10.1186/s13054-020-02908-4
https://doi.org/https://doi.org/10.1186/...
,1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
even though it does not distinguish it from other viral pneumonias.1717. Xu G, Yang Y, Du Y, Peng F, Hu P, Wang R, et al. Clinical pathway for early diagnosis of COVID-19: updates from experience to evidence-based practice. Clin Rev Allergy Immunol. 2020;59:89-100. https://doi.org/10.1007/s12016-020-08792-8
https://doi.org/https://doi.org/10.1007/...
However, CT exposes patients to unnecessary radiation, and health professionals, to higher risk of cross contamination in the hospital.1818. Huang EP, Sung CW, Chen CH, Fan CY, Lai PC, Huang YT. Can computed tomography be a primary tool for COVID-19 detection? Evidence appraisal through meta-analysis. Crit Care. 2020;24:193. https://doi.org/10.1186/s13054-020-02908-4
https://doi.org/https://doi.org/10.1186/...
,1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
Thus, the American College of Radiology, in March 2020, advised against the use of this examination as a primary diagnostic method.1818. Huang EP, Sung CW, Chen CH, Fan CY, Lai PC, Huang YT. Can computed tomography be a primary tool for COVID-19 detection? Evidence appraisal through meta-analysis. Crit Care. 2020;24:193. https://doi.org/10.1186/s13054-020-02908-4
https://doi.org/https://doi.org/10.1186/...
However, CT should be chosen in some clinical situations, together with the reverse transcription-polymerase chain reaction (RT-PCR).1818. Huang EP, Sung CW, Chen CH, Fan CY, Lai PC, Huang YT. Can computed tomography be a primary tool for COVID-19 detection? Evidence appraisal through meta-analysis. Crit Care. 2020;24:193. https://doi.org/10.1186/s13054-020-02908-4
https://doi.org/https://doi.org/10.1186/...

Thoracic X-ray presents low sensitivity and specificity in the detection of pneumonia caused by COVID-19.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
On the other hand, CT is better for detecting changes in the early stage of the disease.1717. Xu G, Yang Y, Du Y, Peng F, Hu P, Wang R, et al. Clinical pathway for early diagnosis of COVID-19: updates from experience to evidence-based practice. Clin Rev Allergy Immunol. 2020;59:89-100. https://doi.org/10.1007/s12016-020-08792-8
https://doi.org/https://doi.org/10.1007/...
For these reasons, it is the alternative of choice in relation to thoracic X-ray, suggested by some radiology societies.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
However, a retrospective study from a Chinese center,1616. Shen Q, Guo W, Guo T, Li J, He W, Ni S, et al. Novel coronavirus infection in children outside of Wuhan, China. Pediatr Pulmonol. 2020;55:1424-9. https://doi.org/10.1002/ppul.24762
https://doi.org/https://doi.org/10.1002/...
which analyzed nine pediatric patients with COVID-19, demonstrated that most CTs did not show changes; only two children had minor unilateral ground-glass opacities. In a Chinese retrospective study1515. Zheng F, Liao C, Fan QH, Chen HB, Zhao XG, Xie ZG, et al. Clinical characteristics of children with coronavirus disease 2019 in Hubei, China. Curr Med Sci. 2020;40:275-80. https://doi.org/10.1007/s11596-020-2172-6
https://doi.org/https://doi.org/10.1007/...
that analyzed 25 infected children, 24 were submitted to CT; of these, eight (33.3%) did not present radiological changes. These disparate data suggest that further studies are necessary to verify the reliability of the use of CT in the infected pediatric population.

Studies55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
,1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
,2020. Smargiassi A, Soldati G, Borghetti A, Scoppettuolo G, Tamburrini E, Testa AC. et al. Lung ultrasonography for early management of patients with respiratory symptoms during COVID-19 pandemic. J Ultrasound. 2020;1-8. https://doi.org/10.1007/s40477-020-00501-7
https://doi.org/https://doi.org/10.1007/...
showed that lung ultrasound (LUS) is a reliable alternative for the diagnosis of the new coronavirus. One advantage of LUS is that it is more sensitive than thoracic X-ray1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
and it does not expose children to the ionizing radiation present in other imaging examinations.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
,1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
LUS is possible to be performed by the medical team in the bed side, reducing the risks of cross contamination.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
,1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
It also provides reliable data for evaluation, diagnosis and clinical follow-up of acute respiratory failure.1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
When the pediatric patient is admitted to the UEs, with symptoms suggestive of the new coronavirus and visible lung impairment at LUS, there is a high chance that the child has viral pneumonia.2020. Smargiassi A, Soldati G, Borghetti A, Scoppettuolo G, Tamburrini E, Testa AC. et al. Lung ultrasonography for early management of patients with respiratory symptoms during COVID-19 pandemic. J Ultrasound. 2020;1-8. https://doi.org/10.1007/s40477-020-00501-7
https://doi.org/https://doi.org/10.1007/...
So, the examination can be used as a standardized tool to perform differential diagnoses2020. Smargiassi A, Soldati G, Borghetti A, Scoppettuolo G, Tamburrini E, Testa AC. et al. Lung ultrasonography for early management of patients with respiratory symptoms during COVID-19 pandemic. J Ultrasound. 2020;1-8. https://doi.org/10.1007/s40477-020-00501-7
https://doi.org/https://doi.org/10.1007/...
and the early evaluation of patients with suspicion of COVID-19.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...

Therefore, it is necessary to establish guidelines for pediatric cases of infection by the new coronavirus, in order to prevent the overuse of examinations in this population.1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
Besides, it is important to train doctors from different specialties to recognize the pathological findings of LUS and to store the results in a database, in order to create, in the future, an automatic algorithm to identify these echographic patterns.2020. Smargiassi A, Soldati G, Borghetti A, Scoppettuolo G, Tamburrini E, Testa AC. et al. Lung ultrasonography for early management of patients with respiratory symptoms during COVID-19 pandemic. J Ultrasound. 2020;1-8. https://doi.org/10.1007/s40477-020-00501-7
https://doi.org/https://doi.org/10.1007/...
However, the use of other imaging examinations should not be ruled out,55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...
,1919. Cho YJ, Song KH, Lee Y, Yoon JH, Park JY, Jung J, et al. Lung ultrasound for early diagnosis and severity assessment of pneumonia in patients with coronavirus disease 2019. Korean J Intern Med. 2020;35:771-81. https://doi.org/10.3904/kjim.2020.180
https://doi.org/https://doi.org/10.3904/...
such as CT and thoracic X-ray, considering the fast evolution of the SARS-CoV-2 infection1717. Xu G, Yang Y, Du Y, Peng F, Hu P, Wang R, et al. Clinical pathway for early diagnosis of COVID-19: updates from experience to evidence-based practice. Clin Rev Allergy Immunol. 2020;59:89-100. https://doi.org/10.1007/s12016-020-08792-8
https://doi.org/https://doi.org/10.1007/...
and the different clinical staging of the disease.55. Musolino AM, Supino MC, Buonsenso D, Ferro V, Valentini P, Magistrelli A, et al. Lung ultrasound in children with COVID-19: preliminary findings. Ultrasound Med Biol. 2020;46:2094-8. https://doi.org/10.1016/j.ultrasmedbio.2020.04.026
https://doi.org/https://doi.org/10.1016/...

This review allowed to identify that, nowadays, there is a tendency for the exacerbated use of imaging examinations in pediatric patients in UEs. Therefore, it is necessary to train the hospital clinical staff, the use of clinical decision instruments and the confection of efficient protocols that can assess the singularity of the child. This will allow short and long-term benefits: reduction in the number of examination requests, enabling to save in hospital costs, reduce the exposure of pediatric patients to ionizing agents, considering that these can cause future malignancies.

Because of the infection by the new coronavirus, strategies are necessary so that there is no overmedicalization in the pediatric population. One of them is the creation of guidelines that limit the use of examinations with ionizing radiation and favor the use of LUS. Therefore, it is possible to gather, afterwards, a database of characteristic ultrasound and radiological findings to facilitate the diagnosis of infection by SARS-CoV-2.

The analyzed studies allowed to recognize the importance of this theme and its global diffusion, especially in North-American, European and Asian continents. However, there were no Brazilian studies about the theme, and its conduction is recommended to follow up the tendencies of international research and validation of the aforementioned instruments.

REFERENCES

Funding

  • The study did not receive any funding.

Publication Dates

  • Publication in this collection
    18 Dec 2020
  • Date of issue
    2022

History

  • Received
    05 Aug 2020
  • Accepted
    12 Sept 2020
  • Published
    15 Dec 2020
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