Radiation protection and imaging stewardship

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Target exams

Red flags

• A child referred for repeat CT surveillance without a documented justification or a consideration of a non-ionising substitute — cumulative effective dose accumulates silently across years in the shunted, oncology and complex chronic patient, and each repeat request is a stewardship decision
• An adult CT protocol applied to an infant or small child — the same milliampere-seconds and kilovoltage peak over-delivers dose to a body that scatters it poorly and is several times more radiosensitive; a size-specific paediatric protocol is mandatory
• A justified, urgent CT delayed or refused because the radiation risk has been exaggerated to the family — the lifetime attributable risk of a single paediatric CT is small, and a necessary scan is never withheld on radiation grounds alone
• Multiphase CT requested when a single phase answers the question — non-contrast, arterial, venous and delayed phases multiply the dose by the number of phases, and each added phase must be justified by a change in management
• Routine gonadal shielding continued on modern equipment in the belief that it protects the child — current ACR-AAPM and national guidance recommends discontinuing it because the benefit is negligible and it can increase dose or degrade the image
• An ionising imaging study performed in a pregnant adolescent without a documented pregnancy check, a justification, and a record of the counselling — the fetus and the young woman are both protected by a deliberate decision, not by reflex

Life stages

Care settings

Clinical exam formats

Board mappings

• Investigations and procedures: principles of radiation protection and imaging stewardship
• Apply the ALARA principle and justify every ionising-radiation request in a child
• Recognise the cumulative radiation burden of repeated imaging in chronic disease
• Current 2026 PREP curriculum — Learning goal 11: Investigations and procedures
• Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Investigations and procedures
• Justified, optimised and benchmarked imaging in children using diagnostic reference levels
• Written Examination
• Clinical Applications
• Patient-safety and stewardship scenarios in imaging
• Short Cases
• Communication scenarios — counselling a parent about radiation risk and consent for imaging
• Patient-safety scenarios — the over-imaged child and Choosing Wisely
• 11. Investigating and managing paediatric presentations
• Level 2: Requests ionising imaging with appropriate justification and radiation awareness
• Patient safety: applies the three pillars of radiological protection and diagnostic reference levels
• Applied Knowledge in Practice (AKP)
• Foundations of Practice (FOP)
• Principles of radiation protection, justification and dose optimisation in children
• Clinical
• Communication scenarios — imaging, consent and radiation risk
• Safe and cost-conscious requesting of investigations
• General Pediatrics Content Outline — Imaging and radiation safety in paediatric practice
• General Pediatrics Content Outline — Patient safety and quality improvement
• General Pediatrics EPA: Request ionising imaging with justification and radiation awareness
• Patient Care 3: Procedural skills and investigation selection
• Systems-Based Practice: safe, cost-conscious and radiation-aware imaging stewardship
• Practice-Based Learning: audit and reduce unnecessary imaging
• Medical Expert
• Health Advocate
• Pediatrics: request ionising imaging with appropriate justification, optimisation and radiation awareness