Radiation Protection in Paediatric Radiology

1. Radiation Protection in Paediatric Radiology Standards and Guidelines in Radiological Procedures in Children L08

2. 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

3. 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.

4. 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

5. Why do we need Standards and guidelines ? • 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

6. 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

7. UNSCEAR • UNSCEAR: United Nations Scientific Committee on the Effects of Atomic Radiation: • Assess and report levels and effects of exposure to ionizing radiation http://www.unscear.org/

8. ICRP • ICRP: International Commission on Radiological Protection • Provides recommendations and guidance on all aspects of protection against ionizing radiation http://www.icrp.org/

9. IAEA • 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 http://www.iaea.org/

10. International framework for radiation protection

11. IAEA Safety Practices Safety Fundamentals and Standards TECDOCs Technical Reports Safety Guides

12. 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”

13. Medical Exposure 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)

14. Responsibilities • Principal responsibility for radiation protection • Legal person subject of authorization (licensee) and employer • Subsidiary responsibilities Supervisor Medical Practitioner Worker Radiologists

15. BSS Responsibilities Advice of a qualified expert, medicalphysicist Radiologist Patient Protection Training criteria Justification Optimization Equipment design and suppliers Quality assurance

16. 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

17. 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)

18. 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

19. 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

20. 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;

21. Optimization • Once justified, examinations must be optimised: • Generic: for examination type and equipment and procedures involved • Specific: for the individual patients

22. 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

23. 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)

24. 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)

25. Unintended exposure • Unintended exposures of patients arise from failures in justification, failures in optimisation or errors

26. Accidental Medical Exposures • … any diagnostic exposure substantiallygreater 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

27. 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

29. BSS Responsibilities Personal protective devices Individual exposure monitoring Occupational Protection Workplace monitoring Pregnant workers Health surveillance

30. Dose limits for occupationally exposed workers and members of the public ICRP 103

31. 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

32. http://europa.eu.int/comm/environment/radprot http://rpop.iaea.org/RPOP/RPoP/Content/AdditionalResources/Training/1_TrainingMaterial/index.htm

33. Applying standards in practice European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatrics, July 1996. EUR 16261 EN Free PDF version available at: http://www.cordis.lu/fp5-euratom/src/lib_docs.htm

34. EUR 16261 EN

35. Quality Criteria List

37. Example: MCU

38. 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

39. 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)

40. http://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/1_Radiology/Standards.htmhttp://rpop.iaea.org/RPOP/RPoP/Content/InformationFor/HealthProfessionals/1_Radiology/Standards.htm

41. 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

42. 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.

43. 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.

44. 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).