Medical imaging plays a central role in diagnosing disease in children. Imaging modalities such as computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, and standard radiography each offer unique benefits and risks. For pediatric patients, concerns about ionizing radiation exposure are especially important because children’s tissues are more sensitive to radiation compared to adults and they have a longer lifetime for potential effects to manifest. Recent research published in the Journal of the American College of Radiology highlights meaningful differences in how imaging is used for pediatric patients in children’s hospitals versus non‑children’s hospitals. This article explores those findings in depth, discusses the implications for pediatric imaging safety and quality, and suggests areas for future research and practice improvements.
Imaging has transformed modern medicine. Standard radiography or X‑rays are quick and widely available. A standard chest X‑ray gives valuable diagnostic information with relatively low radiation exposure. CT scans provide detailed three-dimensional images and can detect subtle abnormalities in bones and soft tissues. However, CT uses ionizing radiation at a significantly higher dose compared to plain radiography. MRI and ultrasound do not use ionizing radiation at all. MRI uses magnetic fields and radiofrequency pulses to create detailed internal images. Ultrasound uses high-frequency sound waves to visualize structures in real time. Because MRI and ultrasound do not use radiation, these are often preferable when feasible for children.
Ionizing radiation exposure is associated with a very small increased risk of cancer over a lifetime. Children are more radiosensitive than adults. Their cells are dividing more rapidly, which increases vulnerability to DNA damage caused by radiation. Children also have a longer remaining lifespan during which radiation-induced malignancies could develop. These factors make understanding and optimizing imaging utilization in pediatrics essential for minimizing unnecessary harm.
The study published in the Journal of the American College of Radiology by Casey E. Pelzl and colleagues analyzed more than 5.4 million pediatric outpatient hospital claims submitted to Medicaid in 2018 and 2019. The analysis compared how children’s hospitals and non‑children’s hospitals used imaging modalities for pediatric patients. The research included outpatient hospital facility encounters and emergency department visits for children aged zero to seventeen years.
The researchers found that more than half of the outpatient visits examined were to children’s hospitals, and radiography and ultrasound were the two most commonly used imaging modalities overall. Notably, use of CT scans and X‑rays was significantly more frequent at non‑children’s hospitals, while children’s hospitals used ultrasound and MRI at higher rates. Specifically, radiography was used in about 11.8 percent of visits at non‑children’s hospitals compared to 7.5 percent at children’s hospitals. CT scans were performed in roughly 1.0 percent of visits at non‑children’s hospitals compared to 0.5 percent of visits at children’s hospitals. Conversely, ultrasound was used in 2.5 percent of children’s hospital visits compared to 1.7 percent at non‑children’s hospitals, while MRI usage was 0.9 percent at children’s hospitals compared to 0.5 percent at non‑children’s hospitals.
These differences persisted even after controlling for age groups, patient comorbidity scores, and whether the visit occurred at an outpatient facility outside of an emergency department or in an emergency department. Children aged zero to five and those with higher complexity scores were more likely to be seen at children’s hospitals.
The study’s primary implication relates to radiation exposure and pediatric safety. Because CT and X‑rays expose children to ionizing radiation, their higher use at non‑children’s hospitals suggests that children treated in these settings may receive more radiation on average than those treated at children’s hospitals. Given children’s heightened sensitivity to radiation, these differences raise important questions about practice patterns and safety protocols in general hospitals that treat pediatric patients.
Ultrasound and MRI offer alternatives that avoid radiation exposure. MRI is particularly useful for soft tissue evaluation while ultrasound is effective for many abdominal, musculoskeletal, and vascular assessments. If general hospitals adopt protocols that favor ultrasound and MRI when appropriate, similar to patterns seen at children’s hospitals, this could reduce overall radiation exposure in pediatric care.
Imaging decisions are influenced by a range of factors including clinician training, access to technology, practice culture, and facility protocols. Children’s hospitals often have dedicated pediatric radiologists and protocols designed specifically for children. These may include pediatric-specific positioning, sedation techniques, and radiation dose reduction strategies. By comparison, non‑children’s hospitals may have less pediatric expertise and fewer pediatric protocols in place. This could contribute to a greater reliance on radiography and CT, especially in urgent or complex cases.
The study underscores the need for broader adoption of pediatric imaging protocols across all hospital types. Efforts like the Image Gently and Image Wisely campaigns aim to promote radiation safety and appropriate use of imaging in children. Greater implementation of these guidelines in non‑children’s hospitals could help reduce unnecessary radiation exposure while maintaining diagnostic quality.
The findings align with broader research that highlights variability in pediatric imaging use across settings. Previous studies have found that imaging rates and radiation exposure can vary widely among hospitals and across conditions. For example, research on inpatient imaging found high use of X‑rays and ultrasounds, with a significant proportion of radiation exposure occurring in emergency and general hospital settings. These trends suggest a need for continued efforts to optimize imaging practice and to reduce unwarranted variation in care.
Efforts to reduce radiation exposure should also consider specific clinical contexts. Some studies have documented significant variability in head CT use for infants in neonatal intensive care units across pediatric hospitals, despite overall declines in head CT utilization over time. These data suggest that even within pediatric focused facilities, variation exists and that dose stewardship strategies may help promote consistent best practice.
Non‑children’s hospitals often care for pediatric patients, especially in rural and community settings where children’s hospitals may not be readily accessible. Investing in training for clinicians and radiology staff in pediatric imaging protocols can help ensure that imaging decisions are tailored to children’s needs. Education should emphasize radiation safety principles and alternatives to ionizing radiation when clinically appropriate.
Implementing quality improvement initiatives that focus on imaging utilization can help reduce unnecessary imaging and radiation exposure. Such initiatives might include auditing imaging orders, using clinical decision support tools, and establishing imaging review committees that regularly assess current practice against pediatric imaging guidelines.
National and international guideline development organizations can play a role by promoting standardized criteria for imaging use in children. These guidelines should incorporate the latest evidence on diagnostic accuracy, safety, and radiation risks. Greater dissemination and implementation of these criteria could reduce unwarranted variation between hospitals.
This study also highlights areas for future research. Researchers could explore the downstream clinical outcomes associated with different imaging patterns, examine whether variations affect diagnostic accuracy or patient outcomes, and identify barriers to the adoption of pediatric protocols in general hospital settings. Longitudinal research could assess whether efforts to reduce radiation exposure lead to measurable changes in imaging practice and long-term health outcomes.
The Journal of the American College of Radiology study offers important insights into how imaging modalities are used in children’s hospitals compared to non‑children’s hospitals. The data show a consistent pattern where imaging that exposes children to ionizing radiation is used more frequently in non‑children’s hospitals, while modalities that do not involve ionizing radiation are used more frequently in children’s hospitals. These findings have implications for radiation safety, clinical decision making, and health policy. Efforts to standardize pediatric imaging protocols, enhance clinician education, and promote best practices can help optimize the use of medical imaging in children and ensure safer, high quality care across all hospital settings.
Pelzl CE and colleagues. Imaging Utilization Among Pediatric Beneficiaries at Children’s Hospital Versus Non‑Children’s Hospital Outpatient Facilities Using Medicaid Claims. Journal of the American College of Radiology. January 20, 2026.
This blog post is for informational purposes only. The information presented is based on published research and medical sources. It does not constitute medical advice. Individual clinical decisions should be made in consultation with qualified healthcare professionals. Patient care may vary based on personal health history and individual circumstances. Always seek personalized medical advice before making decisions about diagnosis and treatment.\
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