Chest radiograph (paediatric)

The chest radiograph is one of the most commonly requested radiographic examinations in the assessment of the paediatric patient. Depending on the patients' age, the difficulty of the examination will vary, often requiring a specialist trained radiographer familiar with a variety of distraction and immobilisation techniques. 

Indications

Performing chest radiography on paediatric patients can be for a number of indications ¹:

• respiratory disease (e.g. respiratory distress syndrome)
• cardiac disease
• bronchiolitis
• pneumonia
• pulmonary tuberculosis
• pneumothorax
• trauma
• foreign bodies
• septic screen
• confirming the location of line placement (e.g. PICC, ETT, NGT etc.) 

Projections

Standard projections

As paediatrics vary in their level of co-operation, various projections can be utilised to suit the patient's needs and age:

• PA erect 
  • performed on older patients (teenage years), not advisable for younger patients due to their attention span (looking away from the 'camera' and everyone else can make for a very agitated child)
• AP erect
  • ideal for cooperative younger children (i.e. between 3-7 years old) due to the ease of positioning and immobilisation
• AP supine
  • performed when imaging unconscious or uncooperative children
• AP supine (neonatal) 
  • performed mobile in the neonate unit 

Additional projections

• lateral view
  • not often performed in paediatrics
  • can be used to highlight pathology in the mediastinum, costophrenic recess and localise lesions ²
• cross-table lateral view
  • utilised in patients under the age of 6 months
  • not often performed in paediatrics
  • can be used to highlight pathology in the mediastinum, costophrenic recess and localise lesions ²

Patient preparation

Patients should remove any clothing and jewellery from waist up; particularly clothing with metal or shiny decorative material. Plaited hair should be untied ².

Tips for paediatric chest radiography

Often difficulties in imaging the paediatric chest include:

• motion artifact
• insufficient inspiration

To overcome these, a variety of techniques can be used:

• distract the patient with toys, games and/or conversation
• perform immobilisation with blankets and velcro straps
• use child-appropriate language (e.g. 'stand still like a soldier' and 'breathe in, you are about to go diving underwater!')

Immobilisation techniques 

Immobilisation techniques will vary from department to department. A radiographer or parent being in the room with the patient holding them still has been cited as a commonly used technique ³ in the Australian context. Other departments will make use of restraint devices, there is debate around the use of 'restraint' and if it fits the category of 'immobilisation' ⁴.

Lead shielding

Contact lead shielding is no longer recommended for any paediatric examination, multiple radiological societies have released statements supporting the cessation of this practice ^5-8 the most comprehensive guidance statement on this matter (86 pages) is a joint report found at this citation ⁹.
Please see your local department protocols for further clarification as they may differ from these recommendations.