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Problem Solving in Pediatric Imaging [pdf 1e/first ed] 1st Edition

by Sarah Sarvis Milla MD (Author), Shailee Lala (Author)

• Format: ORIGINAL PDF/PRINT REPLICA 640 pages
• Publisher ‏ : ‎  Elsevier; 1st edition (June 17, 2022)
• Language ‏ : ‎  English
• ISBN-10 ‏ : ‎  1437726127
• ISBN-13 ‏ : ‎  978-1437726121

127.00  USD Original price was: 127.00 USD. 18.00  USD Current price is: 18.00 USD.

• Description

Optimize diagnostic accuracy with Problem Solving in Pediatric Imaging, a new volume in the Problem Solving in Radiology series. This concise title offers quick, authoritative guidance from experienced radiologists who focus on the problematic conditions you’re likely to see―and how to reach an accurate diagnosis in an efficient manner.

• Addresses the practical aspects of pediatric imaging―perfect for practitioners, fellows, and senior level residents who may or may not specialize in pediatric radiology, but need to use and understand it.
• Integrates problem-solving techniques throughout, addressing questions such as, "If I see this, what do I need to consider? What are my next steps?"
• Presents content in a highly useful, real-world manner, with sections on conventional radiography in the ED, NICU, PICU, and CICU; fluoroscopy; body imaging; and neuroradiology.
• Imaging findings are merged with clinical, anatomic, developmental, and molecular information to extract key diagnostic and therapeutic information.
• Contains a section on special topics with chapters on radiation safety and quality assurance.
• Features hundreds of high-quality color images and anatomic drawings that provide a clear picture of what to look for when interpreting studies. Illustrations conveying normal anatomy help you gain an in-depth perspective of each pathology.

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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Nuclear medicine pediatric assessment, protocols, and interpretation.

Mehdi Djekidel ; Krishna Kumar Govindarajan .

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Last Update: February 5, 2024 .

• Continuing Education Activity

Nuclear medicine and other radiological techniques impart some ionizing radiation exposure to patients. Within the pediatric population, the disease distribution of pathology is also different compared to adults. With this in mind, applications differ slightly compared to the adult population. This article outlines the appropriate use of nuclear medicine techniques in the pediatric population.

• Explain the concept of standard of care and problem-solving exams in pediatric nuclear medicine.
• Summarize high yield exams in pediatric nuclear medicine.
• Outline the applications of Nuclear medicine in pediatric oncology.
• Describe the optimal strategy to address radiation exposure in pediatric nuclear medicine.
• Introduction

Pediatric imaging relies heavily on morphological imaging using mostly nonionizing radiation techniques such as ultrasound (US) and magnetic resonance imaging (MRI). Computed tomography (CT) and nuclear medicine (NM) techniques still hold value and are used in high-yield indications. Although nuclear medicine exams have been around for a century, it is only with recent software and hardware improvements that they have gained an impactful clinical role.

Even though the Society for Nuclear Medicine was founded in 1954, the pediatric nuclear medicine organization known nowadays as the Pediatric Council was only created in the 1970s; we can date to 1946 an NRC report in pediatrics looking at radioisotopes in thyroid pathology. The American medical association (AMA) recognized nuclear medicine as an independent specialty in 1971, leading to the creation of the American Board of Nuclear Medicine (ABNM). The various modalities of nuclear medicine in children have led to prompt diagnosis, selection of appropriate procedures, and treatment resulting in improved outcomes.

• Anatomy and Physiology

Children do not act as a scaled-down version of adults. They are unique in terms of anatomy, physiology, and pathology. The biology can be different even within the same disease type. For similar pathology, age can also be a critical prognostic determinant. Radiation exposure is a concern in pediatrics compared to adults. It is felt that children depending on their age, might be slightly more radiosensitive. Additionally, some nuclear medicine procedures evaluate physiological changes in vivo and real-time as they occur through pharmacologic interventions.

In other cases, nonradioactive drugs are used to prepare the patient and optimize radiopharmaceutical uptake for a specific study. There should also be special attention to potential interfering drugs with the uptake mechanism of the radiopharmaceutical. Examples of non-radioactive medications used for the preparation or during the exam include furosemide, acetazolamide, phenobarbital, cholecystokinin analog, angiotensin-converting enzyme inhibitors, adenosine analogs, and dobutamine.

• Indications

Nuclear medicine techniques are highly sensitive. They play a major role in several instances in pediatrics. The major aspect that needs to be considered is that they are used as a standard of care or problem-solving tool, occasionally both, and how they will guide clinical management. The key indications for nuclear medicine techniques are the evaluation of:

• Neuroblastoma
• Pheochromocytoma and paraganglioma
• Miscellaneous tumors
• Thyroid cancer
• Congenital hypothyroidism
• Hyperparathyroidism
• Chronic urinary tract infections and kidney scarring
• Vesicoureteral reflux and scarring
• Obstructive uropathies
• Lymphodysplasias
• Biliary atresia
• Myocardial ischemia
• Meckel's diverticulum
• Medically refractory epilepsy
• Encephalitis
• Brain tumors
• Child abuse
• Lung perfusion pathology
• Gastrointestinal motility disorders
• Chronic microaspirations
• Gastroesophageal reflux
• Fever of unknown origin
• Evaluation of infectious foci/device infections
• Contraindications

Nuclear medicine scans are very safe as the radiopharmaceutical contains a trace amount of the biological compound and therefore has no pharmacological effect. Contraindications would relate to the appropriateness of the test ordered according to the latest guidelines and appropriateness use criteria.

Other contraindications would be related to the use of sedation which is frequently needed in pediatrics. Additionally, when performed, close attention should be paid to any contraindications specific to administering a medication required for the test, including a pharmacological stressor, vasodilator, diuretic, or an angiotensin-converting enzyme inhibitor, or other.

The latest equipment should be obtained. This is especially critical in pediatrics as newer scanners offer much higher temporal and spatial resolutions at lower injected doses, minimizing radiation exposure to the patient. Following strict quality control protocols in the radiopharmacy and the scanner, rooms are critical in delivering the highest quality and safe patient care.

Proper planned maintenance and upkeep of the nuclear medicine equipment is also essential in order to avoid equipment failures and artifacts that may affect the interpretation of studies. The latest total-body PET scanners offer the potential of imaging with a radiation exposure equivalent to a chest X-ray. [1] [2] [3]  This is likely to be valuable and transformative in pediatric oncology patients that may require multiple successive scans to assess response to treatment and monitor disease progression.

Fully trained, board-certified, and licensed nuclear medicine technologists under the supervision of a qualified, licensed, and board-certified nuclear medicine physician oversees the full spectrum of pediatric nuclear medicine. Specific expertise in pediatric nuclear medicine is also important. Certified child life specialists are an integral part of the care team. Qualified pediatric nurses are important for difficult intravenous access and for studies that require the administration of medications.

The anesthesiologist and anesthesiologist technologist play an important role in adult nuclear medicine practice that requires very rarely any sedatives. Proper communication between all these team members and advanced group coordination and planning for challenging cases is necessary.

• Preparation

Preparation for an exam in pediatric nuclear medicine involves several aspects:

• As a rule, proper hydration is essential to optimize the study itself and decrease radiation exposure since hydration enhances rapid clearance of the radiopharmaceutical.
• Specific preparation will depend on the study performed and the radiopharmaceutical administered. For example, fasting for 4 to 6 hours is required for certain studies such as FDG PET (positron emission tomography) scans. However, this fast may be shortened to 2 or 3 hours in babies and for HIDA scans and gastric emptying studies.
• Special attention should be made to withhold any interfering medications.
• Child life involvement is frequently needed before the test to alleviate the child and family's anxiety and assist with the exam.
• A visit to nuclear medicine before the scan day and a tour of the scan room by the child may help prepare the child for the test.
• Making sure toys, snacks, ambiance, mood, relaxing music, and atmosphere are available is essential.
• Distraction devices are helpful in babies and younger children.
• Making sure that safe immobilization devices are available. This includes head holders or straps fitted to the patient's size; otherwise, they will not be effective.  
• Informing the anesthesia team and other team members of the specific requirements of the nuclear medicine test allows for a smooth and safe workflow on the day of the test.
• Technique or Treatment

Over the past decade, nuclear medicine has witnessed significant advances in software, hardware, and novel radiopharmaceutical approvals. This includes SPECT, PET, and hybrid imaging. Many of these advancements have improved the quality of nuclear medicine imaging in children. The field has benefitted from a higher sensitivity and lower radiation exposure in pediatrics.

In children, the acquisition and reconstruction protocols require to be closely monitored. Lower doses may require longer acquisition times. A good balance between dose and imaging time is needed. Motion has to be closely monitored. Strapping, swaddling, and use of varying levels of sedation may be required. Involving the parents and child life experts is essential. Dynamic imaging may be useless if affected by artifacts and cannot be repeated without adding another radiopharmaceutical dose to the patient.

Using the latest software with at least half-time acquisitions and iterative reconstruction techniques is necessary when available. Special expertise is needed to optimize and not hinder quality. Knowledge of all these techniques and how they apply to each patient and what factors may affect them is essential.

• Complications

Radiotracers have a very high safety profile because the active component used to target the specific biological process is present in trace amounts. Complications can be related to the intravenous cannulation process. The radiopharmaceutical injection rarely may cause a rash or swell at the injection site in case of extravasation. Very rarely, headaches and nausea have been reported. Additionally, complications/adverse events related to medication injected as a part of the procedure may be encountered, such as acetazolamide, dobutamine, adenosine, captopril, furosemide, and others.

• Clinical Significance

Nuclear medicine techniques play an important role in the care of pediatric patients. They can diagnose, change management, monitor progression and assess response to therapies. [4] [5] [6]  One should note that children are not small adults, and they frequently require adjustments.

• Time requirements : Nuclear medicine exams require at least 2 to 3 times the time it takes to perform a similar test in adults. Therefore, proper planning and scheduling are required, especially in a medical practice with a mixed adult and pediatrics patient population, to avoid mistakes in scheduling and allow for the proper time to perform the test.
• Early team involvement (child life, nursing, and anesthesia) in difficult cases.
• Proper understanding that there is a spectrum of findings in   normal--negative exams. This ranges from a typical/textbook normal to a normal variant versus atypical normal.
• Proper understanding that there is a spectrum of findings in   abnormal--positive exams. This ranges from a typical/textbook abnormal to an abnormal variant versus atypical abnormal.
• This spectrum knowledge is critical to avoid confusion every time an atypical presentation occurs.
• Proper understanding of the indication of the nuclear medicine exam. Some exams are ordered as a standard of care in all patients with similar pathology. At the same time, others are ordered as problem-solving tools. At other times both apply.
• Appropriate use criteria:  Because nuclear medicine exams involve exposure to ionizing radiation, it is essential to follow the best medical practice, guidelines, and appropriate use criteria as defined by leading medical societies and the literature. [7] [8] [9] [10]
• Optimized scanning time : Because children cannot lay still for the duration of scans, anesthesia may be used at times. Choosing the most appropriate imaging protocol that will provide diagnostic value in the least amount of time is needed. Purchasing the latest technology scanners will allow diagnostic quality imaging with a rapid scanning time with the equivalent of a chest X-ray or lower radiation exposure dose. [1] [2] [3] [11]
• Optimized radiopharmaceutical activity : Purchasing the latest technology scanners will allow diagnostic quality imaging at very low radiopharmaceutical doses, the equivalent of a chest x-ray, or lower radiation exposure dose. [1] [2] [3] [11]  The image gently campaign was developed in late 2007 and since then has been advocating for lower radiation doses in nuclear medicine and diagnostic radiology. This campaign was accompanied by a harmonization in the injected radiopharmaceutical activities in pediatrics aiming for the ALARA principle. [12] [13]  As low as reasonably achievable to get a diagnostic scan. The clinical shift occurred from pretty images to diagnostic images with no artifacts. [14]
• Benefits/risk estimate : Physicians should carefully weigh the benefit-risk ratio before ordering an exam, as with any procedure or test. The benefit of using diagnostic and therapeutic nuclear medicine techniques in pediatrics is huge when best medical practice and guidelines are followed.  
• Indications :
• Lymphoma:  3rd most common malignancy in children. There are mostly two types: Hodgkin's lymphoma and non-Hodgkin's lymphoma. Better outcomes are noted in children compared to adults. However, long-term complications from treatment are center stage. Therefore, de-escalation treatment regimens are being explored that would improve outcomes and decrease immediate and late adverse effects. The role of FDG-PET is established in pediatric lymphomas and has become the standard of care in pediatric Hodgkin lymphoma initial staging, restaging, and response to therapy assessments. [15] [16]  Early PET response in HL is an important prognostic indicator. Newer protocols use dynamic response assessments with FDG PET to modulate therapy or deescalate treatments. This latter is a crucial element to decrease long-term adverse effects from anti-cancer treatment. [17] [18] [19] [20] [21] [22] [23]
• Sarcomas:  Bone sarcomas account for approximately 6 percent of all childhood cancers, and osteosarcomas account for approximately 3 percent of childhood cancers overall. Bone scans can be used to evaluate multifocal disease. However, this is being replaced nowadays with FDG PET-CT scans for staging and restaging assessments. Although whole-body MRI (magnetic resonance imaging) is the mainstay of imaging, it may have some limitations at follow-up with prostheses artifacts and assessing response to treatment. A CT scan with thin slices is required to monitor for any lung metastasis. FDG PET-CT is very good at initial staging, restaging, therapy response assessments, and reports showing sensitivity and specificity in the '90s. One should pay close attention to the PET-CT protocol used and adjust the attenuation correction CT protocol to be able to detect small lung nodule metastasis. This is crucial considering the lung is the site of 80% of metastasis. [24] [25] [26]  Quantitative parameters such as metabolic tumor volume and total lesion glycolysis may be best used to assess response to treatment. [27]  FDG PET at 6 weeks can predict neoadjuvant chemotherapy effect on time to progression and pathologic response. FDG PET was also described to be of prognostic value. [28] [24] [29] [30] [31] [24]  The Children's oncology group recommends FDG PET and or SPECT Bone scanning at initial diagnosis and before any surgery or local control intervention. FDG PET or SPECT bone scanning is also recommended at follow-up surveillance on chemotherapy or post-chemotherapy patients if symptoms arise or if metastatic disease is present on a prior scan.
• Neuroblastoma: Represents 10% of solid tumors in children. It is the most common extracranial solid tumor. [32]  123-I Metaiodobenzylguanadine (MIBG) is used in conjunction with MRI or CT to stage these patients. MIBG is structurally similar to norepinephrine and concentrates in secretory granules of catecholamine-producing neural crest cells. It has high sensitivity and specificity of up to 90%. [33]  Using the latest hybrid imaging SPECT-CT techniques is recommended. [34]  Bone scans are rarely used nowadays but may be helpful if MIBG or PET radiopharmaceuticals are not readily available. Novel PET radiopharmaceuticals such as Iodine 124 MIBG, 18F FDOPA, and 68Ga DOTATATE show higher sensitivities and specificities. [35] [36] [37] [38] [39]  The higher spatial resolution of PET imaging also allows for improved dosimetry when radionuclide therapies are contemplated. [40] [41]  FDG PET is also used in MIBG negative cases and may offer some prognostic value. [42] [43] [44]  Considering the heterogeneity of the disease, combining two radiopharmaceuticals may potentially play an important role. [45]  A novel fluorinated MFBG PET imaging probe is shown to be almost twice more sensitive than Iodine123 MIBG on a lesional analysis basis. [46]
• Pheochromocytoma/p araganglioma: These are rare pediatric tumors. Pheochromocytomas usually arise from the adrenals and paragangliomas from extra-adrenal locations. Pheocromoyctomas frequently will secrete catecholamines, and paragangliomas are quite variable. About two-thirds are sporadic, but several germline mutations have been described, such as  RET ,  SDHD ,  SDHB ,  SDHC ,  SDHAF2 , or  SDHA , VHL ,  TMEM127,  or  MAX  genes. [47] [48] [49]  MIBG scans have traditionally been used to evaluate pheochromocytoma and paragangliomas. The overall limited accuracy has been partially overcome by the use of novel hybrid SPECT-CT techniques. However, newer techniques using PET radiopharmaceuticals are more sensitive and should preferably be used when available. FDG PET scans seem to be superior in patients with SDH mutations, and FDOPA scans are superior in non-SDH mutations. [50]  FDA or FDG PET would be preferable for staging paragangliomas with RET mutations. [51]  Alternatively, Gallium DOTATATE can be used with high accuracy to stage SDH-related paragangliomas located in the head and neck region. Some reports have also suggested the overall superior sensitivity on a lesional basis in paragangliomas in general. [50] [52] [48]  In Pheochromocytomas, FDOPA and FDG are superior. Considering the heterogeneity of disease and lesions and considering the Theranostic paradigm using different radiotracers in the same patient may hold additional value. [53] [54] [52] [55]  MFBG, a newer PET analog to MIBG, demonstrates superior sensitivity and accuracy to the traditional SPECT MIBG scans with about twice the amount of lesions detected. [46] [56] [57]  Further larger studies with pooled data from multiple centers are necessary to further elucidate the preferred radiopharmaceutical in a complex mutational landscape.
• Miscellaneous tumors: FDG PET scans are proven to be highly accurate in staging and restaging gastrointestinal stromal tumors and mixed germ cell tumors. [58] [59] [60] [61] [62] [63]  On the other hand, neuroendocrine tumors and insulinomas are easily characterized and staged with Gallium DOTATATE. [64] [65] [66] [67]  Note should be made that Gallium DOTATATE could be most of the time interchangeable with other similar Gallium DOTANOC, DOTATOC, or copper-based somatostatin receptor-based ligands.
• Thyroid cancer:  Thyroid cancer is uncommon in children compared to adults. Papillary thyroid cancer is the most common type. Although locoregional lymph node and distant metastasis are more frequent than in adults, the prognosis is significantly better, and survival rates are extremely high even with distant metastasis with appropriate treatment. [68]  Iodine scans with or without SPECT-CT and ultrasound are the standard imaging techniques. [69] [70] [71] [72]  The non-iodine avid disease can be imaged successfully with FDG PET. [73] [74] [75]  Medullary thyroid cancer is rare but is best served by using FDOPA PET for staging and restaging when calcitonin levels are higher than 100 pg/ml. [74] [76]
• Congenital hypothyroidism: Pertechnetetate scan is a fairly simple exam to perform. It can pretty accurately distinguish between several etiologies: athyrogenesis (no thyroid uptake), ectopic thyroid/lingual thyroid (uptake is noted outside the expected thyroid bed/lower neck), and thyroid hormone dysgenesis (normal thyroidal uptake). 
• Hyperparathyroidism: Hyperparathyroidism   is rarely encountered in pediatrics and can be evaluated by a sestamibi scan. It can localize parathyroid adenomas. Precise localization in a eutopic or ectopic location can be obtained using hybrid imaging techniques.
• Chronic urinary tract infections and kidney scarring: DMSA scan with planar and SPECT imaging is the most sensitive technique currently available for clinical use to evaluate kidney scarring. [77] [78] [79] [80] [81]  An initial report with PSMA PET has been published, although this is expensive and not widely available. PSMA PET is also not FDA-approved yet.
• Vesicoureteral reflux and scarring: A  DMSA scan is also quite effective in detecting renal scarring in patients with vesicoureteral reflux. [82] [83]  
• Obstructive uropathies:  Ultrasound is the imaging of choice for patients' initial evaluation and follow-up with suspicion of obstructive uropathy. However, diuretic renograms are frequently used to confirm an obstruction and risk-stratify dilated collecting systems. [84] [85]  
• Lymphodysplasias: Lymphoscintigrams   with or without newer hybrid imaging SPECT-CT techniques are simple and accurate studies to evaluate abnormalities of the lymphatic system. It involves the intradermic, more or less subcutaneous injection of a colloid radiopharmaceutical. Indications include congenital lymphodysplasias, lymphedema, lymphatic leaks, lymphangiomas, lymphangiomatosis, Gorham Stout disease, and lymphangiectasia. [86] [87] [88] [89] [90] [91]  It is also helpful in the evaluation of chyluria, chyloperitoneum, and chylothoraces. Protein-losing enteropathies are more effectively evaluated using an HSA scan. [92] [93] [94] [95]
• Biliary atresia (BA): Biliary atresia is deadly without early surgical intervention (Kasai procedure). Optimal outcomes occur when surgery is performed before 45 days of life. Delay in diagnosis can be accompanied by complications such as cirrhosis, portal hypertension, liver failure, a decrease in the success rate of the Kasai procedure, and even death. HIDA scans/hepatobiliary scans evaluate uptake in the liver as well as the hepatobiliary system. Radiopharmaceutical excretion into the bowel excludes BA. Proper preparation with phenobarbital 5-7 days before the scan is essential. [96] [97] [98] [99] [100]  Jancelewicz et al. reported in a cohort of 212 babies (45 with BA) that a normal percutaneous cholangiogram, bowel excretion on a HIDA scan, and blood work variables consisting of a GGT <150U/L and conjugated bilirubin <2.5mg/dL excluded BA with a 100% sensitivity. [100]
• Myocardial perfusion:  Cardiac MRI, echocardiography, and cardiac CT are the mainstays of pediatric imaging. Anatomical information is essential in cardiac congenital anomalies. MRI is nowadays able to provide reproducible stress-induced functional parameters. However, nuclear medicine myocardial perfusion imaging can still be used as a problem-solving tool. It is seldom needed but can be helpful to evaluate for ischemia and risk stratify patients alone or in combination with MR. Common indications are congenital heart disease repair, Kawasaki disease, hypoplastic heart, anomalous origin of the coronaries, coronary bridging, cardiac transplants, and other cardiomyopathies. SPECT or PET can be used with pharmacological stress. Although PET offers the advantage of absolute myocardial blood flow quantification, this should be used with caution, and proper expertise in children should be sought as normal values are quite different and higher compared to adults. [101] [102] [103] [104] [105] [106] [107] [108]
• Meckel diverticulum:  Meckel scan is a simple and highly accurate test to evaluate Meckel diverticulum with a reported sensitivity and specificity in the mid-'90s. [109]  In the few negative cases with high clinical suspicion, a repeat exam may have an additional value in detecting the Meckel's diverticulum. [110]  The addition of novel hybrid imaging techniques with SPECT-CT can be, in some cases, of additional value. [111]
• Medically refractory epilepsy:  Nuclear medicine techniques are valuable in the presurgical workup of medically refractory epilepsy patients. Cerebral blood flow (CBF) SPECT and FDG PET imaging are essential exams to delineate the seizure onset zone (SOZ) required to be resected. Successful SOZ localization is needed for postsurgical seizure freedom. In patients with a clinical semiology amenable to CBF imaging, ictal-interictal subtraction offers accuracy in the '90s. Inter-ictal FDG PET imaging is also very useful in MRI negative cases to detect the SOZ. In MRI-positive cases, FDG PET delineation of the SOZ has also been reported to correlate with outcomes. 
• Encephalitis:  FDG PET is the most sensitive imaging technique to evaluate brain changes in encephalitis. It can also be used to monitor treatment response and metabolic brain changes in cases that later on develop epilepsy. [112] [113] [114]
• Brain tumors: MRI is the gold standard and workhorse of imaging in pediatric brain tumors. However, in some cases, MRI fails to fully characterize a lesion. Aminoacid imaging with C11-methionine, FDOPA, or FET PET can be used as a problem-solving tool in differentiating radiation necrosis changes versus recurrence in radiation treatment planning, defining the surgical extent, and guiding biopsies. [115] [116] [117] [118] [119] [120]  
• Child abuse: Non-accidental injury in babies and children is a challenging clinical conundrum. Diagnosis is crucial, and a high suspicion should always be maintained. Bone scan offers a high sensitivity exam that adds value as an adjunct to the traditional skeletal survey. [121] [122] [123] [124] [125] [126]  Bone scans can also be used in additional pathologies such as sports injuries, scoliosis, trauma, back pain after surgery, osteoid osteoma, and Langerhans histiocytosis. Fluoride PET bone scans offer a high resolution and may replace the traditional bone SPECT scan when available. [127]
• Lung perfusion pathology:  Pulmonary artery anomalies and congenital cardiac malformations can be evaluated with MAA scans. Lung perfusion can be evaluated before and after an intervention. [128] [129] [130] [131]  Ventilation-perfusion scans can be used to assess unilateral hyperlucent lung. [132] [128]  
• Gastrointestinal motility disorders: Delayed gastric emptying is frequently encountered in children. Solid or liquid-based gastric emptying studies can be used to assess gastric emptying. [133] [134] [135] [136]  The solid-based protocol is the most sensitive and preferred when the child can tolerate eating solid foods. Otherwise, the liquid-based protocol is more frequently used as pediatric patients frequently have feeding tubes. The gastric emptying liquid is also used in babies and very young children.
• Chronic microaspirations:  Patients with chronic microaspirations have frequent repeated pulmonary infections. Salivagrams are relatively easy nuclear medicine tests that require little preparation and can detect microaspirations. [137] [138]  One drop of Technetium sulfur colloid or DTPA is administered on the tongue of the child/baby. Visualization of radiotracer accumulation in the lungs is consistent with aspiration. Using a technique administering 3 drops serially has a higher yield and sensitivity in detecting aspirations. Kim et al. showed that salivagrams and videofluoroscopic exams are complementary in detecting aspirations. [139]  On the other hand, it showed that in 290 children, indwelling nasogastric tubes did not affect the positivity rate of salivagrams compared to pediatric patients without nasogastric tubes. [140]
• Gastroesophageal reflux:  In contrast to salivagrams, gastroesophageal reflux studies or milk scans are also used to detect pulmonary aspiration. Jigang et al. compared both techniques in a cohort of 4186 patients and concluded that salivagrams have a much higher detection rate of 20.3% vs. 0.4% for gastroesophageal reflux studies.
• Fever of unknown origin:  A variety of etiologies can be explored using FDG PET scans ranging from systemic inflammatory conditions, rheumatologic diseases/vasculidities, infectious processes, and oncology pathology. [141] [142] [143] [144] [145] [146] [147]  Additionally, FDG PET scans are useful in evaluating conditions with increased inflammatory markers, even in the absence of fever. FDG PET scans can be used to evaluate response to therapies as well.
• Evaluation of device infections:  FDG PET scans are used to evaluate cardiovascular devices and implanted musculoskeletal hardware. [148] [149] [147] [150] [151] [152]  They have demonstrated very high sensitivity and specificity. [153]  It has been shown to be superior to echocardiography and cardiac CT. It has also been shown to be prognostic and correlates well with outcomes. [154] [155]  In contrast, white blood cell scans can also be used in the absence of FDG PET availability and, when used with hybrid imaging, SPECT-CT techniques offer high sensitivity, high specificity, and high reader confidence. [156] [157]
• Enhancing Healthcare Team Outcomes

Pediatric nuclear medicine is a niche field and requires expertise for optimal outcomes. Appropriate use of nuclear medicine exams and their impact on clinical management obviates concerns about radiation exposure. Highly skilled experts such as child life specialists, pediatric anesthesia technologists, pediatric anesthesiologists, pediatric nuclear medicine technologists, pediatric nurses, and pediatric nuclear medicine physicians are needed.

Proper communication and planning are essential. Following best medical practice and society guidelines is paramount. Standardized, harmonized protocols must be followed. An integrated simple and advanced collaborative pathway and constant case discussions between the nuclear medicine team and referring pediatricians and pediatric subspecialists (in oncology, surgery, neurology, neurosurgery, urology, nephrology, rheumatology, gastroenterology, and orthopedics) will deliver optimized outcomes. [Level 3, 4, and 5]

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Encephalitis FDG PET Contributed by Djekidel Mehdi MD

FDOPA Brain Tumor Contributed by Djekidel Mehdi MD

Rasmussen Encephalitis Contributed by Djekidel Mehdi MD

TLE Epilepsy Contributed by Djekidel Mehdi MD

DMSA scan in pediatrics Contributed by Mehdi Djekidel MD

Disclosure: Mehdi Djekidel declares no relevant financial relationships with ineligible companies.

Disclosure: Krishna Kumar Govindarajan declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Djekidel M, Govindarajan KK. Nuclear Medicine Pediatric Assessment, Protocols, and Interpretation. [Updated 2024 Feb 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Evidence-Based Imaging in Suspected Child Abuse: Role of Imaging in Skeletal, Abdominal, and Head Trauma

• Living reference work entry
• First Online: 09 April 2023
• Cite this living reference work entry

• M. Katherine Henry 9 ,
• Arabinda K. Choudhary 10 &
• Sabah Servaes 11  

Part of the book series: Evidence-Based Imaging ((Evidence-Based Imag.))

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Imaging plays a critical role in identifying young victims of physical abuse. While some injuries in abused children will be readily evident on physical examination, others are only revealed through imaging. Here we describe the role of imaging in the evaluation of children when abuse is suspected.

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Gateway CWI. Definitions of child abuse and neglect 2019. Available from: https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/define/ .

U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreamtent 2017. 2019. Available from: https://www.acf.hhs.gov/cb/resource/child-maltreatment-2017 .

U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2018. 2020. Available from: https://www.acf.hhs.gov/cb/resource/child-maltreatment-2018 .

Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL, American Academy of Pediatrics Committee on Child A, Neglect, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014;133(2):e477–89.

Article   PubMed   Google Scholar  

Leventhal JM, Martin KD, Asnes AG. Incidence of fractures attributable to abuse in young hospitalized children: results from analysis of a United States database. Pediatrics. 2008;122(3):599–604.

Valvano TJ, Binns HJ, Flaherty EG, Leonhardt DE. Does bruising help determine which fractures are caused by abuse? Child Maltreat. 2009;14(4):376–81.

Ravichandiran N, Schuh S, Bejuk M, Al-Harthy N, Shouldice M, Au H, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics. 2010;125(1):60–6.

Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K, et al. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009;124(2):509–16.

Lindberg DM, Shapiro RA, Blood EA, Steiner RD, Berger RP, Si E. Utility of hepatic transaminases in children with concern for abuse. Pediatrics. 2013;131(2):268–75.

Lane WG, Dubowitz H, Langenberg P, Dischinger P. Epidemiology of abusive abdominal trauma hospitalizations in United States children. Child Abuse Negl. 2012;36(2):142–8.

Article   PubMed   PubMed Central   Google Scholar  

Pollanen MS, Smith CR, Chiasson DA, Cairns JT, Young J. Fatal child abuse-maltreatment syndrome. A retrospective study in Ontario, Canada, 1990-1995. Forensic Sci Int. 2002;126(2):101–4.

Collins KA, Nichols CA. A decade of pediatric homicide: a retrospective study at the Medical University of South Carolina. Am J Forensic Med Pathol. 1999;20(2):169–72.

Article   CAS   PubMed   Google Scholar  

Trokel M, DiScala C, Terrin NC, Sege RD. Blunt abdominal injury in the young pediatric patient: child abuse and patient outcomes. Child Maltreat. 2004;9(1):111–7.

Barnes PM, Norton CM, Dunstan FD, Kemp AM, Yates DW, Sibert JR. Abdominal injury due to child abuse. Lancet. 2005;366(9481):234–5.

Shanahan ME, Zolotor AJ, Parrish JW, Barr RG, Runyan DK. National, regional, and state abusive head trauma: application of the CDC algorithm. Pediatrics. 2013;132:e1546.

Barlow KM, Minns RA. Annual incidence of shaken impact syndrome in young children. Lancet. 2000;356(9241):1571–2.

Keenan HT, Runyan DK, Marshall SW, Nocera MA, Merten DF, Sinal SH. A population-based study of inflicted traumatic brain injury in young children. JAMA. 2003;290(5):621–6.

Emrick BB, Smith E, Thompson L, Mullett C, Pino E, Snyder K, et al. Epidemiology of abusive head trauma in West Virginia children <24 months: 2000-2010. Child Abuse Negl. 2019;93:215–21.

Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999;281(7):621–6.

Letson MM, Cooper JN, Deans KJ, Scribano PV, Makoroff KL, Feldman KW, et al. Prior opportunities to identify abuse in children with abusive head trauma. Child Abuse Negl. 2016;60:36–45.

Expert Panel on Pediatric I, Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, et al. ACR appropriateness criteria((R)) suspected physical abuse-child. J Am Coll Radiol. 2017;14(5S):S338–S49.

Google Scholar  

Marine MB, Corea D, Steenburg SD, Wanner M, Eckert GJ, Jennings SG, et al. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified? AJR Am J Roentgenol. 2014;202(4):868–71.

Hansen KK, Prince JS, Nixon GW. Oblique chest views as a routine part of skeletal surveys performed for possible physical abuse – is this practice worthwhile? Child Abuse Negl. 2008;32(1):155–9.

Jha P, Stein-Wexler R, Coulter K, Seibert A, Li CS, Wootton-Gorges SL. Optimizing bone surveys performed for suspected non-accidental trauma with attention to maximizing diagnostic yield while minimizing radiation exposure: utility of pelvic and lateral radiographs. Pediatr Radiol. 2013;43(6):668–72.

Karmazyn B, Lewis ME, Jennings SG, Hibbard RA, Hicks RA. The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? AJR Am J Roentgenol. 2011;197(1):W159–63.

Kleinman PK, Morris NB, Makris J, Moles RL, Kleinman PL. Yield of radiographic skeletal surveys for detection of hand, foot, and spine fractures in suspected child abuse. AJR Am J Roentgenol. 2013;200(3):641–4.

Lindberg DM, Harper NS, Laskey AL, Berger RP, Ex SI. Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey: perhaps “uncommon” is more common than suggested. Pediatr Emerg Care. 2013;29(1):26–9.

Section on Radiology, American Academy of Pediatrics. Diagnostic imaging of child abuse. Pediatrics. 2009;123(5):1430–5.

Article   Google Scholar  

Christian CW, Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337–54.

Wood JN, Fakeye O, Feudtner C, Mondestin V, Localio R, Rubin DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014;134(1):45–53.

Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics. 2011;127(1):e47–52.

Wood JN, Henry MK, Berger RP, Lindberg DM, Anderst JD, Song L, et al. Use and utility of skeletal surveys to evaluate for occult fractures in young injured children. Acad Pediatr. 2019;19(4):428–37.

Lindberg DM, Berger RP, Reynolds MS, Alwan RM, Harper NS, Examining Siblings To Recognize Abuse I. Yield of skeletal survey by age in children referred to abuse specialists. J Pediatr. 2014;164(6):1268–73 e1.

Belfer RA, Klein BL, Orr L. Use of the skeletal survey in the evaluation of child maltreatment. Am J Emerg Med. 2001;19(2):122–4.

Barber I, Perez-Rossello JM, Wilson CR, Kleinman PK. The yield of high-detail radiographic skeletal surveys in suspected infant abuse. Pediatr Radiol. 2015;45(1):69–80.

Lindberg DM, Shapiro RA, Laskey AL, Pallin DJ, Blood EA, Berger RP, et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012;130(2):193–201.

Stavas N, Paine C, Song L, Shults J, Wood J. Impact of child abuse clinical pathways on skeletal survey performance in high-risk infants. Acad Pediatr. 2020;20(1):39–45.

Kleinman PL, Kleinman PK, Savageau JA. Suspected infant abuse: radiographic skeletal survey practices in pediatric health care facilities. Radiology. 2004;233(2):477–85.

James SL, Halliday K, Somers J, Broderick N. A survey of non-accidental injury imaging in England, Scotland and Wales. Clin Radiol. 2003;58(9):696–701.

Patel H, Swinson S, Johnson K. Improving national standards of child protection skeletal surveys: the value of college guidance. Clin Radiol. 2017;72(3):202–6.

Swinson S, Tapp M, Brindley R, Chapman S, Offiah A, Johnson K. An audit of skeletal surveys for suspected non-accidental injury following publication of the British Society of Paediatric Radiology guidelines. Clin Radiol. 2008;63(6):651–6.

Offiah AC, Hall CM. Observational study of skeletal surveys in suspected non-accidental injury. Clin Radiol. 2003;58(9):702–5.

van Rijn RR, Kieviet N, Hoekstra R, Nijs HG, Bilo RA. Radiology in suspected non-accidental injury: theory and practice in The Netherlands. Eur J Radiol. 2009;71(1):147–51.

Karmazyn B, Miller EM, Lay SE, Massey JM, Wanner MR, Marine MB, et al. Double-read of skeletal surveys in suspected non-accidental trauma: what we learned. Pediatr Radiol. 2017;47(5):584–9.

Karmazyn B, Wanner MR, Marine MB, Tilmans L, Jennings SG, Hibbard RA. The added value of a second read by pediatric radiologists for outside skeletal surveys. Pediatr Radiol. 2019;49(2):203–9.

Barber I, Bixby SD, Morris NB, Kleinman PL, Perez-Rossello JM, Chang PT, et al. An electronic tool for systematic reporting of fractures on skeletal surveys in suspected child abuse: prototype development and physician feedback. Pediatr Radiol. 2014;44(12):1564–72.

Slovis TL, Strouse PJ, Strauss KJ. Radiation exposure in imaging of suspected child abuse: benefits versus risks. J Pediatr. 2015;167(5):963–8.

Berger RP, Panigrahy A, Gottschalk S, Sheetz M. Effective radiation dose in a skeletal survey performed for suspected child abuse. J Pediatr. 2016;171:310–2.

Bulloch B, Schubert CJ, Brophy PD, Johnson N, Reed MH, Shapiro RA. Cause and clinical characteristics of rib fractures in infants. Pediatrics. 2000;105(4):E48.

Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of abuse among young children with rib fractures: a systematic review. Pediatr Emerg Care. 2019;35(2):96–103.

Barsness KA, Cha ES, Bensard DD, Calkins CM, Partrick DA, Karrer FM, et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J Trauma. 2003;54(6):1107–10.

Ruest S, Kanaan G, Moore JL, Goldberg AP. The prevalence of rib fractures incidentally identified by chest radiograph among infants and toddlers. J Pediatr. 2019;204:208–13.

Brennan B, Henry MK, Altaffer A, Wood JN. Prevalence of abuse and additional injury in young children with rib fractures as their presenting injury. Pediatr Emerg Care. 2021;37(12):e1451–6.

Kleinman PK, Perez-Rossello JM, Newton AW, Feldman HA, Kleinman PL. Prevalence of the classic metaphyseal lesion in infants at low versus high risk for abuse. AJR Am J Roentgenol. 2011;197(4):1005–8.

Thackeray JD, Wannemacher J, Adler BH, Lindberg DM. The classic metaphyseal lesion and traumatic injury. Pediatr Radiol. 2016;46(8):1128–33.

Lee GS, Methratta ST, Frasier LD. Classic metaphyseal lesion of distal tibia following footling breech delivery. Pediatr Radiol. 2019;49(13):1840–2.

Grayev AM, Boal DK, Wallach DM, Segal LS. Metaphyseal fractures mimicking abuse during treatment for clubfoot. Pediatr Radiol. 2001;31(8):559–63.

Quigley AJ, Stafrace S. Skeletal survey normal variants, artefacts and commonly misinterpreted findings not to be confused with non-accidental injury. Pediatr Radiol. 2014;44(1):82–93; quiz 79–81.

Kleinman PK, Belanger PL, Karellas A, Spevak MR. Normal metaphyseal radiologic variants not to be confused with findings of infant abuse. AJR Am J Roentgenol. 1991;156(4):781–3.

Eide P, Djuve A, Myklebust R, Forseth KF, Nottveit A, Brudvik C, et al. Prevalence of metaphyseal injury and its mimickers in otherwise healthy children under two years of age. Pediatr Radiol. 2019;49(8):1051–5.

Tsai A, Connolly SA, Ecklund K, Johnston PR, Kleinman PK. Subperiosteal new bone formation with the distal tibial classic metaphyseal lesion: prevalence on radiographic skeletal surveys. Pediatr Radiol. 2019;49(4):551–8.

Mandelstam SA, Cook D, Fitzgerald M, Ditchfield MR. Complementary use of radiological skeletal survey and bone scintigraphy in detection of bony injuries in suspected child abuse. Arch Dis Child. 2003;88(5):387–90; discussion -90.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Bainbridge JK, Huey BM, Harrison SK. Should bone scintigraphy be used as a routine adjunct to skeletal survey in the imaging of non-accidental injury? A 10 year review of reports in a single centre. Clin Radiol. 2015;70(8):e83–9.

Drubach LA, Johnston PR, Newton AW, Perez-Rossello JM, Grant FD, Kleinman PK. Skeletal trauma in child abuse: detection with 18F-NaF PET. Radiology. 2010;255(1):173–81.

Marine MB, Hibbard RA, Jennings S, Karmazyn. Ultrasound findings in classic metaphyseal lesions: emphasis on the metaphyseal bone collar and zone of provisional calcification. Pediatr Radiol. 2019; 49(7):913–21.

Tsai A, McDonald AG, Rosenberg AE, Gupta R, Kleinman PK. High-resolution CT with histopathological correlates of the classic metaphyseal lesion of infant abuse. Pediatr Radiol. 2014;44(2):124–40.

Baier W, Mangham C, Warnett JM, Payne M, Painter M, Williams MA. Using histology to evaluate micro-CT findings of trauma in three post-mortem samples - first steps towards method validation. Forensic Sci Int. 2019;297:27–34.

Berdon WE, Feldman KW. A modest proposal: thoracic CT for rib fracture diagnosis in child abuse. Child Abuse Negl. 2012;36(2):200–1.

Hong TS, Reyes JA, Moineddin R, Chiasson DA, Berdon WE, Babyn PS. Value of postmortem thoracic CT over radiography in imaging of pediatric rib fractures. Pediatr Radiol. 2011;41(6):736–48.

Shelmerdine SC, Langan D, Hutchinson JC, Hickson M, Pawley K, Suich J, et al. Chest radiographs versus CT for the detection of rib fractures in children (DRIFT): a diagnostic accuracy observational study. Lancet Child Adolesc Health. 2018;2(11):802–11.

Wootton-Gorges SL, Stein-Wexler R, Walton JW, Rosas AJ, Coulter KP, Rogers KK. Comparison of computed tomography and chest radiography in the detection of rib fractures in abused infants. Child Abuse Negl. 2008;32(6):659–63.

Sanchez TR, Grasparil AD, Chaudhari R, Coulter KP, Wootton-Gorges SL. Characteristics of rib fractures in child abuse-the role of low-dose chest computed tomography. Pediatr Emerg Care. 2018;34(2):81–3.

Sanchez TR, Lee JS, Coulter KP, Seibert JA, Stein-Wexler R. CT of the chest in suspected child abuse using submillisievert radiation dose. Pediatr Radiol. 2015;45(7):1072–6.

Perez-Rossello JM, Connolly SA, Newton AW, Zou KH, Kleinman PK. Whole-body MRI in suspected infant abuse. AJR Am J Roentgenol. 2010;195(3):744–50.

Sonik A, Stein-Wexler R, Rogers KK, Coulter KP, Wootton-Gorges SL. Follow-up skeletal surveys for suspected non-accidental trauma: can a more limited survey be performed without compromising diagnostic information? Child Abuse Negl. 2010;34(10):804–6.

Harlan SR, Nixon GW, Campbell KA, Hansen K, Prince JS. Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed? Pediatr Radiol. 2009;39(9):962–8.

Hansen KK, Keeshin BR, Flaherty E, Newton A, Passmore S, Prince J, et al. Sensitivity of the limited view follow-up skeletal survey. Pediatrics. 2014;134(2):242–8.

Zimmerman S, Makoroff K, Care M, Thomas A, Shapiro R. Utility of follow-up skeletal surveys in suspected child physical abuse evaluations. Child Abuse Negl. 2005;29(10):1075–83.

Bennett BL, Chua MS, Care M, Kachelmeyer A, Mahabee-Gittens M. Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal. BMC Res Notes. 2011;4:354.

Harper NS, Eddleman S, Lindberg DM, Ex SI. The utility of follow-up skeletal surveys in child abuse. Pediatrics. 2013;131(3):e672–8.

Harper NS, Lewis T, Eddleman S, Lindberg DM, Ex SI. Follow-up skeletal survey use by child abuse pediatricians. Child Abuse Negl. 2016;51:336–42.

Powell-Doherty RD, Raynor NE, Goodenow DA, Jacobs DG, Stallion A. Examining the role of follow-up skeletal surveys in non-accidental trauma. Am J Surg. 2017;213(4):606–10.

Goddard L, Bowkett B, Kenwright D. Elasticity of abdominal wall vessels in children: clinical implications in child abuse. ANZ J Surg. 2014;84(10):755–7.

Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics. 2009;124(6):1595–602.

Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD. Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use? Pediatr Radiol. 2011;41(1):92–8.

Christian CW, Neglect CoCAa, Pediatrics AAo. The evaluation of suspected child physical abuse. Pediatrics. 2015;135(5):e1337–54.

Fortin K, Wood JN. Utility of screening urinalysis to detect abdominal injuries in suspected victims of child physical abuse. Child Abuse Negl. 2020;109:104714.

Miglioretti DL, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700–7.

Menichini G, Sessa B, Trinci M, Galluzzo M, Miele V. Accuracy of contrast-enhanced ultrasound (CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT. Radiol Med. 2015;120(11):989–1001.

Armstrong LB, Mooney DP, Paltiel H, Barnewolt C, Dionigi B, Arbuthnot M, et al. Contrast enhanced ultrasound for the evaluation of blunt pediatric abdominal trauma. J Pediatr Surg. 2018;53(3):548–52.

Valentino M, Serra C, Pavlica P, Labate AM, Lima M, Baroncini S, et al. Blunt abdominal trauma: diagnostic performance of contrast-enhanced US in children – initial experience. Radiology. 2008;246(3):903–9.

Sessa B, Trinci M, Ianniello S, Menichini G, Galluzzo M, Miele V. Blunt abdominal trauma: role of contrast-enhanced ultrasound (CEUS) in the detection and staging of abdominal traumatic lesions compared to US and CE-MDCT. Radiol Med. 2015;120(2):180–9.

Catalano O, Aiani L, Barozzi L, Bokor D, De Marchi A, Faletti C, et al. CEUS in abdominal trauma: multi-center study. Abdom Imaging. 2009;34(2):225–34.

Wang MY, Kim KA, Griffith PM, Summers S, McComb JG, Levy ML, et al. Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528–34.

Hilmes MA, Hernanz-Schulman M, Greeley CS, Piercey LM, Yu C, Kan JH. CT identification of abdominal injuries in abused pre-school-age children. Pediatr Radiol. 2011;41(5):643–51.

Larimer EL, Fallon SC, Westfall J, Frost M, Wesson DE, Naik-Mathuria BJ. The importance of surgeon involvement in the evaluation of non-accidental trauma patients. J Pediatr Surg. 2013;48(6):1357–62.

Carter KW, Moulton SL. Pediatric abdominal injury patterns caused by “falls”: a comparison between nonaccidental and accidental trauma. J Pediatr Surg. 2016;51(2):326–8.

Wood J, Rubin DM, Nance ML, Christian CW. Distinguishing inflicted versus accidental abdominal injuries in young children. J Trauma. 2005;59(5):1203–8.

Trokel M, Discala C, Terrin NC, Sege RD. Patient and injury characteristics in abusive abdominal injuries. Pediatr Emerg Care. 2006;22(10):700–4.

Roaten JB, Partrick DA, Nydam TL, Bensard DD, Hendrickson RJ, Sirotnak AP, et al. Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center. J Pediatr Surg. 2006;41(12):2013–5.

Roaten JB, Partrick DA, Bensard DD, Hendrickson RJ, Vertrees T, Sirotnak AP, et al. Visceral injuries in nonaccidental trauma: spectrum of injury and outcomes. Am J Surg. 2005;190(6):827–9.

Yu YR, DeMello AS, Greeley CS, Cox CS, Naik-Mathuria BJ, Wesson DE. Injury patterns of child abuse: experience of two level 1 pediatric trauma centers. J Pediatr Surg. 2018;53(5):1028–32.

Lane WG, Lotwin I, Dubowitz H, Langenberg P, Dischinger P. Outcomes for children hospitalized with abusive versus noninflicted abdominal trauma. Pediatrics. 2011;127(6):e1400–5.

Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, et al. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol. 2018;48(8):1048–65.

Rubin DM, Christian CW, Bilaniuk LT, Zazyczny KA, Durbin DR. Occult head injury in high-risk abused children. Pediatrics. 2003;111(6 Pt 1):1382–6.

Glenn K, Nickerson E, Bennett CV, Naughton A, Cowley LE, Morris E, Murtagh U, Kontos K, Kemp AM. Head computed tomography in suspected physical abuse: time to rethink? Arch Dis Child. 2020:archdischild-2020-320192. https://doi.org/10.1136/archdischild-2020-320192 .

Daley H, Smith H, McEvedy S, King R, Andrews E, Hawkins F, Guppy N, Kiryazova T, Macleod R, Blake E, Harrison R. Intracranial injuries on computed tomography head scans in infants investigated for suspected physical abuse: a retrospective review. Arch Dis Child. 2020:archdischild-2020-319762. https://doi.org/10.1136/archdischild-2020-319762 .

Henry MK, Feudtner C, Fortin K, Lindberg DM, Anderst JD, Berger RP, et al. Occult head injuries in infants evaluated for physical abuse. Child Abuse Negl. 2020;103:104431.

Wilson PM, Chua M, Care M, Greiner MV, Keeshin B, Bennett B. Utility of head computed tomography in children with a single extremity fracture. J Pediatr. 2014;164(6):1274–9.

Shaikh H, Wrotniak BH, Mazur PM. Occult head injury in children less than 2 years with suspected child abuse in the emergency department. Pediatr Emerg Care. 2019;35(9):596–9.

Fingarson A, Fortin K. Yield of neuroimaging in infant physical abuse evaluations: do infant age and injury type matter? J Emerg Med. 2019;57(2):195–202.

Henry MK, Lindberg DM, Wood JN. More data, more questions: no simple answer about which children should undergo screening neuroimaging for clinically occult abusive head trauma. Child Abuse Negl. 2020;107:104561.

Culotta PA, Crowe JE, Tran QA, Jones JY, Mehollin-Ray AR, Tran HB, et al. Performance of computed tomography of the head to evaluate for skull fractures in infants with suspected non-accidental trauma. Pediatr Radiol. 2017;47(1):74–81.

Martin A, Paddock M, Johns CS, Smith J, Raghavan A, Connolly DJA, et al. Avoiding skull radiographs in infants with suspected inflicted injury who also undergo head CT: “a no-brainer?”. Eur Radiol. 2020;30(3):1480–7.

Prabhu SP, Newton AW, Perez-Rossello JM, Kleinman PK. Three-dimensional skull models as a problem-solving tool in suspected child abuse. Pediatr Radiol. 2013;43(5):575–81.

Parisi MT, Wiester RT, Done SL, Sugar NF, Feldman KW. Three-dimensional computed tomography skull reconstructions as an aid to child abuse evaluations. Pediatr Emerg Care. 2015;31(11):779–86.

Choudhary AK, Jha B, Boal DK, Dias M. Occipital sutures and its variations: the value of 3D-CT and how to differentiate it from fractures using 3D-CT? Surg Radiol Anat. 2010;32(9):807–16.

Buttram SD, Garcia-Filion P, Miller J, Youssfi M, Brown SD, Dalton HJ, et al. Computed tomography vs magnetic resonance imaging for identifying acute lesions in pediatric traumatic brain injury. Hosp Pediatr. 2015;5(2):79–84.

Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. J Neurosurg Pediatr. 2019;24(5):481–8.

Kralik SF, Supakul N, Wu IC, Delso G, Radhakrishnan R, Ho CY, et al. Black bone MRI with 3D reconstruction for the detection of skull fractures in children with suspected abusive head trauma. Neuroradiology. 2019;61(1):81–7.

Lindberg DM, Stence NV, Grubenhoff JA, Lewis T, Mirsky DM, Miller AL, et al. Feasibility and accuracy of fast MRI versus CT for traumatic brain injury in young children. Pediatrics. 2019;144(4).

Flom L, Fromkin J, Panigrahy A, Tyler-Kabara E, Berger RP. Development of a screening MRI for infants at risk for abusive head trauma. Pediatr Radiol. 2016;46(4):519–26.

Ryan ME. Rapid magnetic resonance imaging screening for abusive head trauma. Pediatr Radiol. 2020;50(1):13–4.

Burstein B, Saint-Martin C. The feasibility of fast MRI to reduce CT radiation exposure with acute traumatic head injuries. Pediatrics. 2019;144(4).

Narang SK, Fingarson A, Lukefahr J, Council on Child A, Neglect. Abusive head trauma in infants and children. Pediatrics. 2020;145(4).

Rabbitt AL, Kelly TG, Yan K, Zhang J, Bretl DA, Quijano CV. Characteristics associated with spine injury on magnetic resonance imaging in children evaluated for abusive head trauma. Pediatr Radiol. 2020;50(1):83–97.

Kadom N, Khademian Z, Vezina G, Shalaby-Rana E, Rice A, Hinds T. Usefulness of MRI detection of cervical spine and brain injuries in the evaluation of abusive head trauma. Pediatr Radiol. 2014;44(7):839–48.

Baerg J, Thirumoorthi A, Vannix R, Taha A, Young A, Zouros A. Cervical spine imaging for young children with inflicted trauma: expanding the injury pattern. J Pediatr Surg. 2017;52(5):816–21.

Choudhary AK, Ishak R, Zacharia TT, Dias MS. Imaging of spinal injury in abusive head trauma: a retrospective study. Pediatr Radiol. 2014;44(9):1130–40.

Governale LS, Brink FW, Pluto CP, Schunemann VA, Weber R, Rusin J, et al. A retrospective study of cervical spine MRI findings in children with abusive head trauma. Pediatr Neurosurg. 2018;53(1):36–42.

Henry MK, French B, Feudtner C, Zonfrillo MR, Lindberg DM, Anderst JD, et al. Cervical spine imaging and injuries in young children with non-motor vehicle crash-associated traumatic brain injury. Pediatr Emerg Care. 2021;37(1):e1–6.

Henry MK, Wood JN. Advanced cervical spine imaging in abusive head trauma: an update on recent literature and future directions. Acad Pediatr. 2018;18(7):733–5.

Choudhary AK. Understanding the importance of spinal injury in abusive head trauma (AHT). Pediatr Radiol. 2020;50(1):15–6.

Choudhary AK, Bradford RK, Dias MS, Moore GJ, Boal DK. Spinal subdural hemorrhage in abusive head trauma: a retrospective study. Radiology. 2012;262(1):216–23.

Nikam RM, Kandula VV, Yue X, Krishnan V, Kumbhar SS, Averill LW, et al. Birth-related subdural hemorrhage: prevalence and imaging morphology. Pediatr Radiol. 2021;51(6):939–46.

Kemp AM, Jaspan T, Griffiths J, Stoodley N, Mann MK, Tempest V, et al. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Arch Dis Child. 2011;96(12):1103–12.

Thamburaj K, Soni A, Frasier LD, Tun KN, Weber SR, Dias MS. Susceptibility-weighted imaging of retinal hemorrhages in abusive head trauma. Pediatr Radiol. 2019;49(2):210–6.

Gencturk M, Cam I, Koksel Y, McKinney AM. Role of susceptibility-weighted imaging in detecting retinal hemorrhages in children with head trauma. Clin Neuroradiol. 2021;31(3):611–7.

Zuccoli G, Panigrahy A, Haldipur A, Willaman D, Squires J, Wolford J, et al. Susceptibility weighted imaging depicts retinal hemorrhages in abusive head trauma. Neuroradiology. 2013;55(7):889–93.

Choudhary AK, Bradford R, Dias MS, Thamburaj K, Boal DK. Venous injury in abusive head trauma. Pediatr Radiol. 2015;45(12):1803–13.

Hymel KP, Wang M, Chinchilli VM, Karst WA, Willson DF, Dias MS, et al. Estimating the probability of abusive head trauma after abuse evaluation. Child Abuse Negl. 2019;88:266–74.

Maguire SA, Kemp AM, Lumb RC, Farewell DM. Estimating the probability of abusive head trauma: a pooled analysis. Pediatrics. 2011;128(3):e550–64.

Pfeiffer H, Cowley LE, Kemp AM, Dalziel SR, Smith A, Cheek JA, et al. Validation of the PredAHT-2 prediction tool for abusive head trauma. Emerg Med J. 2020;37(3):119–26.

Miller Ferguson N, Sarnaik A, Miles D, Shafi N, Peters MJ, Truemper E, et al. Abusive head trauma and mortality-an analysis from an international comparative effectiveness study of children with severe traumatic brain injury. Crit Care Med. 2017;45(8):1398–407.

Barlow KM, Thomson E, Johnson D, Minns RA. Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. Pediatrics. 2005;116(2):e174–85.

Bonnier C, Nassogne MC, Saint-Martin C, Mesples B, Kadhim H, Sebire G. Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome. Pediatrics. 2003;112(4):808–14.

Wright JN, Feyma TJ, Ishak GE, Abeshaus S, Metz JB, Brown ECB, et al. Subdural hemorrhage rebleeding in abused children: frequency, associations and clinical presentation. Pediatr Radiol. 2019;49(13):1762–72.

Campbell KA, Berger RP, Ettaro L, Roberts MS. Cost-effectiveness of head computed tomography in infants with possible inflicted traumatic brain injury. Pediatrics. 2007;120(2):295–304.

Noorbakhsh KA, Berger RP, Smith KJ. Identification of abusive head trauma in high-risk infants: a cost-effectiveness analysis. J Pediatr. 2020;227:176–83 e3.

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Department of Radiology and Safe Place: Center for Child Protection and Health, Children’s Hospital of Philadelphia, Philadelphia, PA, USA

M. Katherine Henry

Radiology, UAMS, Little Rock, AR, USA

Arabinda K. Choudhary

Department of Radiology, West Virginia University, Morgantown, WV, USA

Sabah Servaes

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Correspondence to M. Katherine Henry .

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Department of Radiology, 3NW, Children's Hospital of Philadelphia, Philadelphia, PA, USA

Hansel J. Otero

Summer L. Kaplan

Dept Of Radiology, MCH Radiology, Miami Children's Hospital, Miami, FL, USA

L Santiago Medina

Dept of Radiology, Virginal Mason Medical Center, Seattle, WA, USA

C. Craig Blackmore

Zionsville, IN, USA

Kimberly E Applegate

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Henry, M.K., Choudhary, A.K., Servaes, S. (2022). Evidence-Based Imaging in Suspected Child Abuse: Role of Imaging in Skeletal, Abdominal, and Head Trauma. In: Otero, H.J., Kaplan, S.L., Medina, L.S., Blackmore, C.C., Applegate, K.E. (eds) Evidence-Based Imaging in Pediatrics. Evidence-Based Imaging. Springer, Cham. https://doi.org/10.1007/978-3-030-38095-3_65-1

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DOI : https://doi.org/10.1007/978-3-030-38095-3_65-1

Received : 31 January 2022

Accepted : 04 February 2022

Published : 09 April 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-38095-3

Online ISBN : 978-3-030-38095-3

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