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Commentary From the Section on Radiology

October 13, 2023

Commentary From the Section on Radiology

The American Academy of Pediatrics (AAP) Section on Radiology (SORa) was established in 1979 for the purpose of improving the care of infants, children, adolescents, and young adults through education, research, and teaching of pediatric radiology. The SORa furthers the mission by developing educational programs, policy statements, and clinical guidance for practicing pediatricians and the medical community at large. Additionally, the SORa supports advocacy efforts to improve the imaging care for the children we serve.

For these commentaries, we performed a literature search for all imaging-related publications, quickly identifying original important papers that, to this day, inform how pediatric radiology is practiced for the benefit of children in the US and around the world. Although a myriad of topics were found, we decided to focus on 2 topics that, in spite of the many technological advances of the last 75 years, remain philosophically similar and common practice to all radiologists caring for children: (1) the noninvasive evaluation of the brain parenchyma with transcranial ultrasound and (2) the use of imaging in cases of suspected or confirmed child abuse.

75 Years of Pediatrics: Celebrating Over 50 Years Reporting Brain Ultrasound Advances

Hansel J. Otero, MD, FAAP1, Mariangeles Medina-Perez, MD, FAAP2

Affiliations: 1Pediatric Radiologist, Children’s Hospital of Philadelphia, Philadelphia, PA; 2Pediatric Radiologist, Children’s of Alabama, Birmingham, AL

Highlighted Articles From Pediatrics

Most readers of Pediatrics understand that cranial ultrasound examination in very preterm infants and in older infants with neurological signs or at high risk for central nervous system pathology has become a standard of diagnostic imaging. The 2020 American Academy of Pediatrics clinical report “Routine Neuroimaging of the Preterm Brain1 and the December 2022 Committee on Fetus and Newborn technical report “Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes2 support the utility of this diagnostic modality. However, few readers will appreciate that the first report on the use of ultrasound for the evaluation of ventricular dilation dates back to 1968. Over 50 years ago, Lombroso et al3 reported the use of 2-dimensional ultrasound to study ventricular size in 600 children. The difficult to understand images from the novel technology were acquired with an articulated-arm b-mode machine that had little resemblance to modern scanners and a much lower spacial and temporal resolution. At that time, ultrasound images were compared to the gold standard, pneumoencephalography, an invasive technique in which a small amount of air was injected into the cerebrospinal fluid spaces via a lumbar puncture and then the child repositioned, and the head tilted to make the air reach the ventricles (Figure 1). Lombroso’s publication marked the beginning of a 50-year technologic evolution.

Renowned radiology pioneers Drs. Herman Grossman, John Kirkpatrick, and Leonard Swischuk were among the authors of a 1974 publication “Ultrasonography in Children from the Committee on Radiology.4 This article noted that although ultrasound could assess shift of midline structures in the brain, detect hydrocephalus, and reassess ventricular size after surgical decompression, ultrasound remained an experimental modality whose findings required confirmation with pneumoencephalography or arteriography.

In 1978, Papile et al5 first described the incidence and evolution of subependymal and intraventricular hemorrhage in low weight newborns using computed tomography (CT) and first described the grading system that is still widely employed today. However, it was the Pediatrics article by Silverboard et al in 1980 that compared the use of ultrasound in the evaluation of intracranial hemorrhage and posthemorrhagic hydrocephalus to CT.6 This seminal report documented a high sensitivity of ultrasound to detect high-grade hemorrhages and hydrocephalus but a lower ability to discern small hemorrhages. Although modern ultrasound images can be of superb quality, ultrasound still exhibits a lower sensitivity to detect small hemorrhages compared to modern CT or MRI; the slightly lower sensitivity is tolerated in clinical practice because small germinal matrix hemorrhages and hemorrhage confined to the choroid plexus do not affect long-term neurologic outcomes to the same extent that higher-grade hemorrhages do. Moreover, this paper brilliantly describes the benefits of cranial ultrasound as a safe, less expensive, bedside study that can be performed serially to document the evolution of ventricular size. In fact, this 1980 publication even resembles current practice in its recommendation as a screening test for high-risk patients and the frequency for repeat scans in patients with documented intraventricular hemorrhage “at least biweekly initially, and then weekly, until ventricular size has stabilized.” To a remarkable degree, current AAP recommendations mirror those from 1980.

We celebrate this seminal paper that has remained valid for over 40 years while acknowledging the giant leaps that cranial ultrasound technology has experienced and the continued enhancements that are in process. Many new ultrasound-based technologies remain in early stages of development and/or adoption, including 3D acquisitions, elastography, contrast enhanced studies, and microvascular flow imaging (Figure 2).7 These new ultrasound technologies have the potential to further our understanding of central nervous system pathology and to improve the care for preterm and term infants. We look forward to reading about these advances in Pediatrics for years to come.


  1. Hand IL, Shellhaas RA, Milla SS, Committee on Fetus and Newborn, Section on Neurology, Section on Radiology. Routine neuroimaging of the preterm brain. Pediatrics. 2020;146(5):e2020029082
  2. Stewart DL, Elsayed Y, Fraga MV, et al. Use of point-of-care ultrasonography in the NICU for diagnostic and procedural purposes. Pediatrics. 2022;150(6):e2022060053
  3. Lombroso CT, Erba G, Yogo T, Logowitz N. Two-dimensional ultrasonography: a method to study normal and abnormal ventricles. Pediatrics. 1968;42(1):157-174
  4. Grossman H, Felman A, Kirkpatrick JA, et al. Ultrasonography in children. Pediatrics. 1974;54(4):480-481
  5. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J Pediatr. 1978;92(4):529-534
  6. Silverboard G, Horder MH, Ahmann PA, Lazzara A, Schwartz JF. Reliability of ultrasound in diagnosis of intracerebral hemorrhage and posthemorrhagic hydrocephalus: comparison with computed tomography. Pediatrics. 1980;66(4):507-514
  7. Hwang M, Piskunowicz M, Darge K. Advanced ultrasound techniques for pediatric imaging. Pediatrics. 2019;143(3):e20182609

Figure 1. From: Lombroso CT, Erba G, Yogo T, Logowitz N. Two-dimensional ultrasonography: a method to study normal and abnormal ventricles. Pediatrics. 1968;42(1):157-174

Figure 2. From: Hwang M, Piskunowicz M, Darge K. Advanced ultrasound techniques for pediatric imaging. Pediatrics. 2019;143(3):e20182609

The Diagnosis of Child Abuse and the Important Role of Imaging Over Time

Luka A. Bugarski, MD1, Sabah Servaes, MD, FAAP2

Affiliations: 1Department of Radiology, West Virginia University School of Medicine, Department of Radiology, 2Department of Radiology, West Virginia University School of Medicine

Highlighted Articles From Pediatrics

Radiology has played an enormous role in the practice of pediatrics since the first radiographs of children were obtained at the end of the 19th century. Imaging is instrumental to the diagnosis and ultimate management of numerous clinical problems encountered in any setting where children receive care. One such problem is the scourge of non-accidental trauma in children.

The role of radiology in the evaluation of suspected non-accidental trauma was first brought to light by Caffey in 1946.1 However, understanding of this medical diagnosis and appropriate response was not widely known or published until years later. The fundamental routine use of diagnostic imaging and medicolegal and social safeguards that protect children from recurrent abuse and ultimately devastating injuries and death were lacking prior to the 1960s. A commentary written by Katherine Bain, MD, and published in Pediatrics in 19632 illustrates this notable contrast: nationwide mandatory reporting, which we now view as indispensable, was all but an early initiative dubbed the “Model State Law” of The Children’s Bureau in 1961. The language found in the draft bill outlined in this work has been codified into law with little modification by every state house in the nation. At the time, the diagnosis of child abuse was frustrated by a lack of scientific understanding, the lack of a clear framework for addressing clinical concerns for child abuse, contemporary attitudes toward what are now termed social determinants of health, and the perceived role of the physician. The proposed legal framework aimed to change medical culture and practice and to catalyze further efforts to identify, assess, and manage suspected child abuse in a more consistent way. The current AAP guidance affirms the modern expectation that the physician play a key role in the thorough evaluation and reporting of suspected cases of child abuse, remain a resource to the child and family, and assist in legal processes in the best interest of the child.3

A case series by Robert J. Touloukian, MD, published in Pediatrics in 1968, furthered the scientific understanding and awareness of blunt injury to the abdomen that occurs in many cases of non-accidental trauma.4 In this work, Dr. Touloukian describes 5 unfortunate children who died from blunt injury to the abdomen secondary to child abuse. Prior to this work, much of the discussion and understanding regarding what was then known as “maltreatment syndrome” or “battered child syndrome” revolved around the then well-known association of traumatic findings on examination, long bone injuries, and subdural hematoma in children who were likely victims of abuse. Dr. Touloukian elucidated the significant potential for, and lethality of, complicated blunt injuries to the abdomen in cases of child abuse. We now have a scientific understanding of why abdominal injury is associated with a high risk of mortality and delayed diagnosis, which is in direct agreement with the situation and cases presented in 1968. Of note, skeletal radiography was not performed in any of the cases presented in this work and was recommended by the author. When this case series occurred, the tremendous utility of cross-sectional imaging in identifying abdominal pathology rapidly and accurately was more than a decade from realization. There have since been recommendations based on sentinel injuries and abnormal lab values that would lead to further evaluation, such as cross-sectional imaging.5 Skeletal radiography, which was available at the time, but not yet widely implemented in such cases, is now regarded as essential to the diagnosis of non-accidental trauma and often uncovers suspicious injuries, prompting further evaluation.

Much of the medical evidence that underlies a suspicion of non-accidental trauma, and ultimately reporting and removal of children from dangerous households, is derived from radiological examination. The integration of the patient’s history, physical examination, laboratory findings and radiological findings in diagnosing abusive injuries and ultimately reporting them was clearly articulated by Vincent J. Fontana, MD, in his work “The Diagnosis of Maltreatment Syndrome in Children,” published in Pediatrics in 1971.6 The “Physician’s Index of Suspicion” Dr. Fontana outlined in this work remains pertinent. He articulated the principle that certain findings are better appreciated on delayed imaging and can be most readily appreciated with the modern practice of obtaining a repeat skeletal survey 2 weeks after injury. Further work, largely advancing through a close interplay of the clinical and radiological realms, aimed to improve the accuracy of identifying the abused patient while avoiding missed contributory diagnoses such as metabolic bone disease or truly accidental injuries. Imaging takes a primary role in drawing these distinctions.

Twenty years later, a landmark retrospective study by Susan Thomas, MD, and colleagues advanced the framework set forth by Dr. Fontana.7 The purpose of this work at the time it was written was to provide guidance to physicians on which long bone injuries in young children are likely accidental, and which are not, to enable accurate reporting and accurate testimony. Radiographic findings provided the needed characterization of injuries to enable these aims. The criteria for distinguishing abusive and accidental injuries set forth in this work have permeated medical education, pediatrics, emergency medicine, and radiology. Findings from this study are also supported by recent investigations inclusive of an expectation of a known significant trauma in accidental fractures of the femur in young children.

This set of works shows the progression of medical practice and professional associations in addressing child abuse and the science of describing and detecting non-accidental trauma in children. Much progress has been made toward the goal of preventing recurrent trauma through more accurate recognition of suspicious injuries, social changes in the form of mandatory reporting and more vigorous legal processes, efforts to reduce bias in patient care and the ultimate reporting of suspicions of child abuse, and advances in imaging technology that now can detect previously unseen and potentially lethal deep soft tissue injuries. The accurate and timely diagnosis of child abuse has a robust scientific basis which now spans 8 decades. Present and future scientific contributions will lead to further improvements in the diagnostic accuracy and management of suspected child abuse cases.


  1. Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematoma. Am J Roentgenol Radium Ther. 1946;56(2):163-173
  2. Bain K. The physically abused child. Pediatrics. 1963;31(6):895-898
  3. Christian CW, Committee on Child Abuse and Neglect. The evaluation of suspected child physical abuse. 2015;135(5):e1337-1354
  4. Touloukian RJ. Abdominal visceral injuries in battered children. Pediatrics. 1968;42(4):642-646
  5. Henry MK, Bennett CE, Wood JN, Servaes S. Evaluation of the abdomen in the setting of suspected child abuse. Pediatr Radiol. 2021;51(6):1044-1050
  6. Fontana VJ. The diagnosis of the maltreatment syndrome in children. Pediatrics. 1973;51(4):780-782
  7. Thomas SA, Rosenfield NS, Leventhal JM, Markowitz RI. Long-bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics. 1991;88(3):471-476
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