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Technician and a patient entering magnetic resonance imaging (MRI)

AAP reports outline how to optimize advanced imaging in ED

June 27, 2024

Advanced imaging, specifically ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI), is a mainstay in the evaluation and management of the ill or injured child in the emergency department (ED). Advances in technology, including rapid MRI protocols, have improved the accuracy, speed and accessibility of imaging.

Although the use of imaging has increased dramatically over time, studies show there have not been commensurate improvements in patient outcomes. In fact, many of the advanced imaging tests performed in the ED are considered to be low value, with the risks outweighing the net patient benefit.

A new AAP policy statement and technical report aim to assist clinicians in the use of advanced imaging in the care of the ill or injured child in the ED. Titled Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department, the statements are a multidisciplinary collaboration among the AAP, the American College of Emergency Physicians and the American College of Radiology.

The technical report includes a supplement that provides condition-specific imaging recommendations, including clinical guidelines and pathways from several children’s hospitals that can be useful for providers at the point of care.

The policy statement is available at, and the technical report is at Both will be published in the July issue of Pediatrics.

Risks of imaging

Risks associated with advanced imaging studies in children include radiation exposure from CT and the associated small but increased risk of future malignancy; testing that may result from false-positive and incidental findings; longer ED stays; transport from the ED, which is particularly relevant for critically ill or injured patients; risks associated with sedation in an uncooperative child; and financial costs to patients and the health system.

Imaging and pediatric readiness

Studies have shown that while the vast majority of children seek care at non-pediatric EDs, pediatric patients are responsible for only 20% of volumes in general EDs.  

EDs across the country strive to provide high-quality emergency care to children (pediatric readiness) through pediatric-specific competencies and policies and ensuring pediatric equipment and other resources are available. Ensuring high-quality, appropriate advanced imaging is an important aspect of pediatric readiness. Both ED-based and primary care providers have a responsibility to optimize advanced imaging to minimize risks and maximize benefits.


Following are some of the recommendations in the policy statement. 

It is important for EDs to:

  • ensure that appropriate CT protocols and parameters that adhere to the ALARA (as low as reasonably achievable) principle are used for pediatric patients;
  • strive to provide ultrasound services as first-line imaging when indicated (e.g., appendicitis, nephrolithiasis); and
  • have policies for imaging consultation with a pediatric radiologist, general radiologist with expertise in pediatric imaging or pediatric subspecialist to minimize transfers that may require only imaging review.

Primary care physicians, physician assistants and nurse practitioners who refer patients for ED evaluation should:

  • be familiar with optimal imaging strategies for common pediatric conditions and
  • become knowledgeable about imaging resources at local EDs to guide decisions on where to refer patients, when appropriate.

Emergency physicians, physician assistants and nurse practitioners should:

  • have an understanding of evidence-based guidelines, such as the American College of Radiology Appropriateness Criteria and clinical decision rules that assist with risk stratification to assist with imaging decisions;
  • use shared decision-making strategies when more than one reasonable choice regarding imaging exists, e.g., immediate CT imaging, transfer to a pediatric center for ultrasound or discharge with return precautions for a patient with abdominal pain who is at low risk for appendicitis; and
  • defer imaging to the receiving facility when a child is being transferred, if the results will not affect management before or during the transfer. Such imaging delays definitive treatment, may increase the number of imaging studies performed and can result in higher radiation exposure and costs.

Dr. Marin is a lead author of the policy statement and technical report and is a former member of the AAP Committee on Pediatric Emergency Medicine.

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