1. Radiation Protection in Paediatric Radiology
Part No...., Module No....Lesson No
Module title
Radiation Protection in Paediatric Radiology
Standards and Guidelines in Radiological Procedures in Children
L08
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology 1

2. Educational Objectives
Part No...., Module No....Lesson No
Module title
Educational Objectives
At the end of the programme, the participants
should become familiar with:
International standards & guidelines
Responsibilities of medical practitioners
How these standards are applied in paediatric radiology
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

3. Part No...., Module No....Lesson No
Module title
Answer True or False
ICRP provides recommendations for use in diagnostic radiology for the protection of the patients and staff.
Dose limits apply to medical exposures of patients.
Radiologists need special training for paediatric radiology.
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

4. Part No...., Module No....Lesson No
Module title
Contents
Why we do need standards and guidelines?
International framework of radiation protection for medical exposures
Application of basic principles of radiation protection in paediatric radiology
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

5. Why do we need Standards and guidelines ?
Part No...., Module No....Lesson No
Why do we need Standards and guidelines ?
Module title
International Standards are a set of mandatory requirements agreed on by worldwide consensus
Application of standards and guidelines ensures implementation of principles:
To minimize the occurrence of stochastic effects
To avoid tissue reactions
Children are recognized as a special case
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

6. International framework for radiation protection
Part No...., Module No....Lesson No
Module title
International framework for radiation protection
Requirement that there be a clear delineation of responsibility extending from the level of the highest official body of the hospital or clinic involved, to the operational level
Relies on three principles adopted in most regulatory systems throughout the world:
Justification of the activity or practice involved
Optimization of the activity in terms of risks, costs, benefits etc.
Limitation of the doses received by various groups including workers and the general public
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

7. Part No...., Module No....Lesson No
UNSCEAR
Part No...., Module No....Lesson No
Module title
UNSCEAR: United Nations Scientific Committee on the Effects of Atomic Radiation:
Assess and report levels and effects of exposure to ionizing radiation
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

8. Part No...., Module No....Lesson No
ICRP
Part No...., Module No....Lesson No
Module title
ICRP: International Commission on Radiological Protection
Provides recommendations and guidance on all aspects of protection against ionizing radiation
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

9. Part No...., Module No....Lesson No
IAEA
Part No...., Module No....Lesson No
Module title
IAEA: International Atomic Energy Agency
Establish standards of safety for the protection of health and minimization of danger to life, in collaboration with the appropriate organs of the UN and the specialized agencies concerned, and provide for the application of these standards
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

10. International framework for radiation protection
Part No...., Module No....Lesson No
International framework for radiation protection
Module title
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

11. Part No...., Module No....Lesson No
Module title
IAEA
Safety
Practices
Safety
Fundamentals and Standards
TECDOCs
Technical
Reports
Safety
Guides
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology 11

12. Part No...., Module No....Lesson No
Module title
International Basic Safety Standard (BSS)
“…marks the culmination of efforts that have continued over the past several decades towards the harmonization of radiation protection and safety standards internationally”
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

13. Part No...., Module No....Lesson No
Medical Exposure
Module title
Radiation doses incurred:
By patients as part of their own medical or dental diagnosis or treatment
By individuals (other than those occupationally exposed) knowingly exposed while voluntarily helping patients
By volunteers exposed for biomedical research purposes (must be under approved protocol; usually children may not participate, only exceptionally and for their own diagnosis or treatment)
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

14. Part No...., Module No....Lesson No
Module title
Responsibilities
Principal responsibility for radiation protection
Legal person subject of authorization (licensee) and employer
Subsidiary responsibilities
Supervisor
Medical Practitioner
Worker
Radiologists
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

15. Part No...., Module No....Lesson No
Module title
BSS
Responsibilities
Advice of a qualified expert, medical physicist
Radiologist
Patient Protection
Training criteria
Justification
Optimization
Equipment design and suppliers
Quality assurance
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

16. Responsibilities for Medical Exposure
Part No...., Module No....Lesson No
Module title
Responsibilities for Medical Exposure
Medical exposure has to be prescribed by a medical practitioner (justification)
Medical practitioners are assigned the primary task and obligation of ensuring overall patient protection and safety in the prescription of, and during the delivery of, medical exposure
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

17. Responsibility for Medical Exposure
Part No...., Module No....Lesson No
Module title
Responsibility for Medical Exposure
… training criteria are to be specified or be subject to approval, as appropriate, by the Regulatory Authority in consultation with relevant professional bodies (i.e., cardiology, radiology, interventional cardiology)
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

18. Part No...., Module No....Lesson No
Module title
Justification
Education and training of both referring physicians and radiologists plays a crucial role in ensuring that justification works well in practice
The knowledge required for Justification includes:
Clinical history, including examinations already performed,
Potential benefits of the action,
Awareness of short term and long term consequences, including the risks,
Up-to-date knowledge of any available alternative actions,
Knowledge of the consequences of not taking any action, and
Knowledge of referral guidelines and/or appropriateness criteria where they are available
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

19. Justification of medical exposures and dose limits
Part No...., Module No....Lesson No
Module title
Justification of medical exposures and dose limits
ICRP has recommended that dose limits not be applied to medical exposures
Even with the higher radiation sensitivity of children, this recommendation is also applied to paediatrics
It is based on the fact that the exposed individual will derive benefit from the procedure, provided it has been properly justified
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

20. Responsibility for Medical Exposure
Part No...., Module No....Lesson No
Module title
Responsibility for Medical Exposure
… the imaging and quality assurance requirements of the Standards should be fulfilled with the advice of a qualified expert in … medical physics
Optimization requirement on equipment design: ensure that whether imported into or manufactured in the country where it is used, the equipment conforms to applicable standards of the:
International Electrotechnical Commission (IEC)
International Organisation for Standardization (ISO) or to equivalent national standards;
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

21. Part No...., Module No....Lesson No
Module title
Optimization
Once justified, examinations must be optimised:
Generic: for examination type and equipment and procedures involved
Specific: for the individual patients
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

22. Part No...., Module No....Lesson No
Module title
Optimization
Ensure that the appropriate equipment be used
The medical practitioner, the technologist or other imaging staff select the relevant combination of parameters, that results in:
minimum patient exposure consistent with acceptable image quality and the clinical purpose of the examination,
paying particular attention to this selection for paediatric radiology and interventional radiology
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

23. Diagnostic reference levels (DRL)
Part No...., Module No....Lesson No
Module title
Diagnostic reference levels (DRL)
Guidance for radiologists and other practitioners to help to achieve good examinations at reasonable dose levels
In paediatric radiology, adoption and use of paediatric protocols
If DRLs are exceeded regularly, the practice involved should be investigated.
DRL for an examination is derived from a regional, national, or sometimes international, survey of the doses for that examination ( usually taken as the third quartile value for the dose distribution obtained in the survey)
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

24. Part No...., Module No....Lesson No
Module title
Dose constraints
Dose constraints are used as an upper bound on the doses that individuals might expect to receive in comforting, caring for or assisting with immobilization of a patient
Should not be applied as a dose limit
Exposure of comforters and carers is considered as medical exposure (dose constraint is applied)
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

25. Part No...., Module No....Lesson No
Module title
Unintended exposure
Unintended exposures of patients arise from failures in justification, failures in optimisation or errors
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

26. Accidental Medical Exposures
Part No...., Module No....Lesson No
Module title
Accidental Medical Exposures
… any diagnostic exposure substantially greater than intended …
Investigation required
Calculate or estimate doses received
Indicate corrective measures
Submit a report
Inform the patient and his/her doctor about the incident
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

27. Part No...., Module No....Lesson No
Module title
Pregnancy issues
Special care should be observed with respect to:
irradiation of pregnant or potentially pregnant
occupationally exposed workers
comforters and carers
members of the public
Pregnancy can occur in adolescent girls, thus precautions for this group should be followed for exposures which may involve a foetus
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

28. Part No...., Module No....Lesson No
Module title
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

29. Part No...., Module No....Lesson No
Module title
BSS
Responsibilities
Personal protective devices
Individual exposure monitoring
Occupational Protection
Pregnant workers
Workplace monitoring
Health surveillance
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

30. Part No...., Module No....Lesson No
Module title
Dose limits for occupationally exposed workers and members of the public
Type of limit
Occupational
Public
Effective dose
20 mSv/year
1 mSv/year
Annual equivalent dose
Lens of the eye
150 mSv
15 mSv
Skin
500 mSv
50 mSv
Hand and feet
ICRP 103
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

31. Education and training
Part No...., Module No....Lesson No
Module title
Education and training
Special education and training related to radiation protection in paediatric radiology, techniques and equipment used:
medical practitioners providing radiological services
other professions including medical physicists and technologists
Further, continuous professional development allows professionals to continue to cope with new developments
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

32. Part No...., Module No....Lesson No
Module title
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

33. Applying standards in practice
Part No...., Module No....Lesson No
Module title
Applying standards in practice
European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatrics, July 1996.
EUR EN
Free PDF version available at:
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

34. Part No...., Module No....Lesson No
Module title
EUR EN
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

35. Part No...., Module No....Lesson No
Module title
Quality Criteria List
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

36. Part No...., Module No....Lesson No
Module title
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

37. Part No...., Module No....Lesson No
Module title
Example:
MCU
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

38. Criteria related to images
Part No...., Module No....Lesson No
Module title
Criteria related to images
The Image Criteria for paediatric patients presented for a particular type of radiograph are those deemed necessary to produce an image of standard quality
No attempt has been made to define acceptability for particular clinical indications
The image criteria allow an immediate evaluation of the image quality, with respect to:
the smaller body size, the age-dependent body composition, lack of co-operation and other functional differences
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

39. Criteria related to images
Part No...., Module No....Lesson No
Module title
Criteria related to images
A lower level of image quality may be acceptable for certain clinical indications
An inferior image quality, however, cannot be justified unless it is set for clinical indication to reduce radiation dose
The fact that the X-Ray was taken from a non-cooperative paediatric patient (anxious, crying, heavily resisting) is not an excuse for producing an inferior quality image which is often associated with an unnecessary dose (due to the need for a repeat exam)
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

40. Part No...., Module No....Lesson No
Module title
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

41. Part No...., Module No....Lesson No
Module title
Summary
Radiation protection system has an international framework
Radiology of children is different from adult radiology
The special requirements that arise apply to all aspects of the radiation protection system, including:
justification
optimization, including the use of DRL
All persons directing and conducting medical radiation exposure of children, including radiologists and technologists, should have received recognised education and training in their discipline
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

42. Part No...., Module No....Lesson No
Module title
Answer True or False
ICRP provides recommendations for use in diagnostic radiology for the protection of the patients and staff.
Dose limits apply to medical exposures of patients.
Radiologists need special training for paediatric radiology.
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

43. Part No...., Module No....Lesson No
Module title
Answer True or False
True – ICRP’s principles of justification, optimization and dose limitation and specific recommendations in different conditions are available for the protection of the patients and staff.
False – There are no regulatory dose limits that apply to medical exposures of patients. However, DRLs are available.
True – In view of peculiar situations in paediatric radiology, specific training is required.
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology

44. Part No...., Module No....Lesson No
Module title
References
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Radiological Protection in Medicine, Publication 105, Elsevier, Oxford (2008).
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Recommendations of the ICRP, Publication 60, Pergamon Press, Oxford (1991).
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, Recommendations of the ICRP, Publication 103, Elsevier, Oxford (2008).
FOOD AND AGRICULTURE ORGANIZATION OF THE UNITED NATIONS, INTERNATIONAL ATOMIC ENERGY AGENCY, INTERNATIONAL LABOUR ORGANIZATION, OECD NUCLEAR ENERGY AGENCY, PAN AMERICAN HEALTH ORGANIZATION, WORLD HEALTH ORGANIZATION, International Basic Safety Standards for Protection Against Ionizing Radiation and for the Safety of Radiation Sources, Safety Series No. 115, IAEA, Vienna (1996).
EUROPEAN COMMISION, Council Directive 1997/43/Euratom on health protection of individuals against ionizing radiation in relation to medical exposure, Off. J. Eur. Commun. L. 180, 22–27 (1997).
EUROPEAN COMMISSION, Referral Guidelines for Imaging, Luxembourg, Radiation Protection 118, Office for Official Publications of the European Communities, Luxembourg (2001) and Update Mars 2008
EUROPEAN COMMISSION, Guidelines on Education and Training in Radiation Protection for Medical Exposures. Radiation Protection 116, Office for Official Publications of the European Communities, Luxembourg, (2000).
EUROPEAN COMMISSION, European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatrics, Rep. EUR 16261, Office for Official Publications of the European Communities, Luxembourg Communities, Luxembourg, (1996).
IAEA Post Graduate Educational Course in Radiation Protection in Pediatric Radiology