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The main purpose of any patient that comes to the hospital is to get healed or health condition improved. On the other hand, it is the obligation of the Radiographer to ensure that image of diagnostic value is obtained. Radiographic examination of the padediatric comes with its peculiar challenges, which the radiographer must overcome in the quest to get image of diagnostic quality. The research method used is a non-experimental survey method. The population of study is 52 Radiographers in the tertiary institutions in Enugu metropolis, comprising of UNTH, NOHE and ESUTH. 49 was the sample size. These challenges include uncooperativeness of the child (37.5%), incorrect positioning and immobilization of the child (31.26%), control of involuntary movement (25%), radiation protection and so on. 63.3% of the respondents endorsed parental or caregiver assistance as the method of immobilization most efficient for them. Overcoming these challenges boils down to the radiographer’s ingenuity in approaching the child, technical preparation in the diagnostic room, availability of all the necessary facilities to keep the child successfully immobilized and presence of child-friendly environment.


Title page    –        –        –        –        –        –        –        –        –        –        -i

Approval page     –        –        –        –        –        –        –        –        –        ii

Dedication  –        –        –        –        –        –        –        –        –        –        -iii

Acknowledgement         –        –        –        –        –        –        –        –        –        iv

Abstract      –        –        –        –        –        –        –        –        –        –        -v

Table of content   –        –        –        –        –        –        –        –        –        -vi

List of tables        –        –        –        –        –        –        –        –        –        vii

CHAPTER ONE                                                                                      

1.0 INTRODUCTION                                                                              

1.1 Background of the study   –        –        –        –        –        –        –        -1

1.2 Statement of problems-     –        –        –        –        –        –        –        -3

1.3 Objectives of study  –        –        –        –        –        –        –        –        -3

1.4 Significance of study         –        –        –        –        –        –        –        –        -4

1.5 Scope of the study   –        –        –        –        –        –        –        –        -4

1.6  Literature review     –        –        –        –        –        –        –        –        -5

CHAPTER TWO                                                                                               

2.0 THEORETICAL BACKGROUND                                                  

2.1.1 Psychological stages of development of children  –        –        –        -11

2.1.2 Child development and psychology  –        –        –        –        –        -12

2.1.3 Psychological consideration in paediatric examinations           –        -14

2.1.4 Radiographer’s attitude to the paediatric patient –        –        –        -15

2.2 Ethical responsibility of the radiographer to the paediatric patient                -16

2.2.1 High quality examinations       –        –        –        –        –        –        -16

2.2.2 Communication    –        –        –        –        –        –        –        –        16

2.2.3 Compassion and respect –        –        –        –        –        –        –        -17

2.2.4 Physical safety      –        –        –        –        –        –        –        –        -17

2.3 Dedicated environment for the paediatrics     –        –                  –        -18

2.3.1 The reception        –        –        –        –        –        –        –        –        -18

2.3.2 The diagnostic room       –        –        –        –        –        –        –        -18

2.4 Patient care and preparation     –        –        –        –        –        –        -19

2.4.1 Mode of appointment    –        –        –        –        –        –        –        -20

2.4.2 Pre-investigation introduction and child/parent evaluation                –        -20

2.4.3 Pre-investigation preparation and care for common routine

procedures  –        –        –        –                  –        –        –        –        -20

2.4.4 Preparation and care for special (contrast) procedure    –        –        -23

2.4.5 Immobilization      –        –        –        –        –        –        –        –        -24

2.4.6 Radiation protection      –        –        –        –        –        –        –        -25

2.5.0 Practical radiographic techniques      –        –        –        –        –        -26

2.5.1 Equipment and accessories      –        –        –        –        –        –        -26

2.5.2 The Skull     –        –        –        –        –        –        –        –        –        -28

2.5.3 The Chest    –        –        –        –        –        –        –        –        –        -29

2.5.4 The Abdomen       –        –        –        –        –        –        –        –        -30

2.6.0 Alternative medical imaging modalities       –        –        –        –        -31

2.6.1 Computed Tomography(CT)   –        –        –        –        –        –        -32

2.6.2 Ultrasound  –        –        –        –        –        –        –        –        –        -32

2.6.3 Magnetic Resonance Imaging(MRI)   –        –        –        –        –        -32

2.6.4 Nuclear medicine  –        –        –        –        –        –        –        –        -33





3.0 Resaerch design       –        –        –        –        –        –        –        –        -34

3.1 Population of study –        –        –        –        –        –        –        –        34

3.2 Pample size    –        –        –        –        –        –                  –        –        -34

3.3 Instrument of data collection      –        –        –        –        –        –        -34

3.4 Method of data collection  –        –        –        –        –        —       –        -35

3.5 Analytical procedure         –        –        –        –        –        –        –        –        -35

CHAPTER FOUR                                                                                    

4.1 Data presentation and analysis   –        –        –        –        –        –        -36

4.2 Discussion      –        –        –        –        –        –        –        –        –        -47


5.1 Summary of findings         –        –        –        –        –        –        –        –        -52

5.2 Recommendations   –        –        –        –        –        –        —       –        -54

5.3 Area of further study         –        –        –        –        –        –        –        –        -54

5.4 Conclusion     –        –        –        –        –        –        –        –        –        -55

5.5 Limitations     –        –        –        –        –        –        –        –        –        -55




Table 1: Frequency of Paediatric Patients Encounter

Table 2: Uncooperativeness prior to Radiographic Examination.

Table 3: Method(s) used to gain the child’s Cooperation

Table 4: Immobilization Devices available in the Radiology Department

Table 5: Most efficient of the Immobilization methods

Table 6: Frequency of Repeat Cases in restive paediatrics

Table 8: Quality of image obtained from effective communication between the Radiographer and other members of the Medical Team.


Fig 1 :Most difficult age group

Fig 2: Most frequent cause of poor quality images

Fig 3:Educational level for incorporating special training programme on Paediatrics




Paediatrics is the branch of medicine concerned with the development, care and diseases of babies and children1. The paediatric patient includes neonates, infants and children up to the age of 12. On the other hand, Paediatric Radiography refers to the radiographic investigation which involves the imaging of babies and children. Special dedicated equipment and accessories are used to acquire high-quality images. The images produced are of a valuable adjunct for effective diagnosis and treatment of clinical conditions. Thus, Paediatricians and Surgeons are able to ascertain the necessity of surgery and evade the complications therein.

Dr. Caffey J.P while working at Babies Hospital in New York as the hospital’s first in-house radiologist realized that the field of radiology was wide open for a physician of scholarly bent and paediatric background. He rapidly taught himself the range of normal appearances and the plain film manifestations of children’s diseases. However, some of the radiographs he viewed were of poor quality, resulting in wrong diagnosis. His meticulous, disciplined approach led, in 1945, to the first edition of Paediatric X-ray Diagnosis, a major step towards establishing paediatric radiography as a discipline in radiology2. However, few dedicated paediatric radiographers exist outside specialist children’s units of most hospitals in United States. It is inappropriate for inexperienced radiographers to undertake unsupervised paediatric radiography, for example on call or out of routine department hours. Thus,all Radiographers providing Children’s imaging should have specialist training to provide the expertise and judgment required in this demanding specialist area of radiography3.

Imaging children comes with distinct challenges. Unlike adults, children cannot always understand or comprehend a change of environment. When children are ill, they follow their instincts, which is usually to cry and stay close to their parents. This presents a huge challenge for the radiographer, who must try to gain the child’s trust and co-operation.  Once this has been achieved there is another big challenge of keeping the child still or immobilized for the radiographic examination to be carried out. This can be very difficult for children in a lot of pain.

The need to prevent avoidable exposure to ionizing radiation is another facet of the challenges relevant in radiographic examination of paediatrics.

However, paediatric radiography, despite being acknowledged as an imaging specialism, does not have a strong presence in either undergraduate or postgraduate radiography education programmes, and the availability of current published literature aimed at general radiographers is extremely limited. Thus, paediatric radiography is not recognised as an extended role for state registered radiographers and has no recognition within Agenda for Change3 in the United States of America. Paediatric radiography has no formal career structure and thus there is little incentive for radiographers to specialise in this area.

The research intends evaluating these challenges as encountered by radiographers, in the stride to obtain a good image of diagnostic value, in these tertiary institutions, as well as their possible solutions.












  1. Radiographic images of diagnostic quality are often difficult to produce in the paediatrics because of apprehension and uncooperativeness of children prior to the investigation.
  2. Radiographs of paediatrics are often of poor diagnostic quality because of incorrect positioning and unsuccessful immobilization of the patient.
  3. Control of involuntary movement and respiration in children is a challenge to the Radiographer.



  1. To find out the challenges or problems encountered by Radiographers in paediatric cases in the tertiary institutions in Enugu metropolis.
  2. To find out strategies adopted by Radiographers in overcoming these challenges.
  3. To find out the level of professionalism display by the Radiographer to apply various radiographic techniques to overcome the challenges in paediatric radiography in these tertiary institutions.
  4. To ascertain the ingenuity of the Radiographer in developing skills to overcome these challenges.



  1. The study will reveal the challenges and solutions in the quest to obtain a radiograph of diagnostic quality in paediatric patients.
  2. The study will also reveal the measures adopted by the Radiographer in obtaining a quality radiograph amidst the restiveness of paediatric patients.
  3. The study will stimulate in the radiographer the quest to acquire specialist training in the management and care of paediatric patient.



The study is restricted to Radiographers practising in tertiary institutions in Enugu metropolis, which includes University of Nigeria Teaching Hospital (UNTH), National Orthopaedic Hospital Enugu (NOHE) and Enugu State University Teaching Hospital (ESUTH), Parklane. These tertiary institutions were chosen because of their sizes and patient throughput in the radiology department. Thus, they have relatively larger number of Radiographers. The study is a prospective research and involves the use of a well-structured questionnaire for data collection.



The responsibility of every health care practitioner is to ensure that the standard of care delivered to paediatric patient is of high quality and is appropriate to the age and level of understanding displayed by him or her amidst the challenges therein. Sequel to this Hardy and Boynes stated that successful radiographic studies are dependent on two things:

  1. the radiographer’s attitude and approach to a childand
  2. the technical preparation in the room.4

Stewart Whitley A. et al went further, in Clark’s Positioning in Radiography, to state that dedicated paediatric areas, rooms, equipment and staff all lead to a far higher likelihood of a high-quality examination, at an achievable low dose, without protracted investigation times and without causing undue stress to the child, parent or staff.5 Thus, understanding of a child’s needs, development, psychology and the range of pathology5 is an act of ingenuity required of the radiographer.

The significance of justification, optimization and protection cannot be overemphasized. Helen M. Warren-Forward stated that optimization of radiographic image is said to have been obtained if the patient has achieved an acceptable level of dose and the image is of diagnostic value.6 He postulated that in the near future, it will probably be recommended that radiographers measure patient doses and compare them to reference level.6 This is as a result of the fact that ionizing radiation has the potential to induce cancer. This is in line with the International Commission on Radiological Protection(ICRP) postulate that the dose response relationship for cancer induction is linear down to zero i.e. without threshold.7Thus the need to consider radiation protection of staff, paediatric patients, caregivers and the general public is paramount. For these groups the same general principles apply, and these are the justification, optimization and individual limitation of dose.

The justification of a practice states, “No practice involving exposure to radiation should be adopted unless it produces sufficient benefit to the exposed individuals or to society to offset the radiation detriment it causes, in other words the benefit must exceed the harm”.7 The Royal College of Radiologists’ (RCR) handbook, Making the BestUse of a Department of Clinical Radiology addresses the need for advice on justification and where at all possible recommendations are evidence based.8 The guidelines also give advice regarding appropriate imaging pathways in paediatrics. To elucidate further, Cook et al in Referral criteria for 17 common paediatric investigation emphasized on the need to know not only when investigation should be carried out but also when not to do so as well as when more superior clinical referral is required. For example, an abdominal radiograph in non-specific abdominal pain is unlikely to demonstrate pathology in the absence of loin pain, haematuria, diarrhoea, a palpable mass, abdominal distension or suspected inflammatory bowel disease; a follow-up chest X-ray (CXR) is not required routinely for follow-up of simple pneumonia in a clinically well child; and some radiographs should not be performed routinely before there has been development of certain normal structures, e.g. sinuses, nasal bones, scaphoids.9

In general, pediatric radiography should always use as short exposure times andas high mA as possible to minimize image blurring that may result from patient motion. J.V. Cook et al posited that children can be uncooperative and obstructive when undergoing radiography and often challenge the very technique and ability of the imaging staff within whose custody they have been temporarily placed.10 However, even with short exposure times, preventing motion during exposures is a constant challenge in pediatric radiography, and effective methods of immobilization are essential. Thus the significance of the radiographer understanding childhood cannot be underplayed.

In the context of diagnostic imaging, Stewart Whitley A. et al divided childhood into six main age groups, each of which has different needs and capabilities:

  • Birth to six months;
  • Infancy (six months to three years);
  • Early childhood (three to six years);
  • Middle childhood (six to 12 years)5;

These categories of paediatric patients pose degrees of challenges during radiographic investigation based on their level of maturity. Thus Sinclair D. and Dangerfield P. posited that growth is the progressive development of a living being, or any part of it, from its earliest stage of maturity11. However, in health care the term “growth” is usually restricted to mean physiological and anatomical changes that occur.4 On the other hand, Schickedza J.A et al had it that the term development is commonly used to describe the psychological and cognitive advances of a child and the acquisition of motor and sensory skills.12He posited that, however, although children of the same age can be at different developmental stages , the order in which growth and development occurs is generally consistent for all children.12  For example, ossification of the carpus occur in the same order for all children, but the exact age at which carpal bones ossify can vary remarkably. Thus, Maryann Hardy and Stephen Boynes stressed that radiographers should combine psychological and cognitive approach with a general understanding of the child development process in overcoming the challenges of paediatric radiography.4

The term “Restraint” is generally reserved for use within the mental health while the more general terminology used within health care is “Immobilisation”.4 Stedmans Medical Dictionary put it that to immobilize a person is to render him/her fixed or incapable of moving13,whereas restraint is forcible confinement14, limitation or restriction15. From these definitions, it is clear that the difference between the two terms is the degree of force necessary to accomplish the restriction. Kohn M.M. et al stated that paediatric restraint could be occasionally undertaken in order to achieve diagnostic radiographic images. In their studies they identified that the most frequent causes of inadequate and poor quality imaging of children were incorrect radiographic positioning and unsuccessful immobilization of the patients.16 This poses the greatest challenge to the radiographer; as the European Guidelines on Quality Criteria for Diagnostic Radiographic Images in Paediatrics states that patient positioning prior to exposure to radiation must be exact whether or not the patient cooperates.16 Thus, the use of physical restraints in the immobilization of young children becomes of utmost importance.


However, experience within UK imaging departments has shown that immobilization devices that rely on the child being strapped into position are rarely efficient in achieving adequate immobilization in children over 3months of age17 without the cooperation of the child and the guardian.18 Regardless of how empathic the staff are, children feel at their most comfortable with their parents and in surroundings that they might consider familiar19

The restraint and immobilization of children raises many ethical and professional considerations. Harrison C. and Kenny N.P. et al emphasized that restraint compromises the dignity and liberty of the child and therefore to restrain a child solely to facilitate an examination, rather than the concern that the child may cause serious bodily harm to himself/herself or another, may not be ethical.20 This could be prompted by Robinson and Collier’s research, in 1996, in which the educational and ethical issues perceived by nurses with regard to “holding patients still” were assessed. They found out that nurses did have concerns in this regard, particularly as the majority felt it was the restraint and not pain that caused the most distress to the child.21

Immobilization must only be applied if the treatment is beyond doubt in the best interest of the child22. Thus, Maryann Hardy and Stephen Boynes concluded that it is essential to involve paediatrics and their families (caregivers) in the decision-making process to ensure that a high-quality radiographic service is being delivered. This begins by working with families to ensure effective patient understanding and cooperation and is achieved through effective communication and consideration of the child’s need for comfort and support throughout the imaging examination.4


There are increasing numbers of radiographic examinations and many of these examinations result in patient overexposure. Steven Don in his research stated that the younger the age of exposure, the greater the risk because of the latency period needed to induce the malignancy and the greater the effective dose.23This is in support of Pierce and Preston’s findings in their study of the atomic bomb survivors, which had it that the youngest children were ten times more sensitive than middle aged adults24.

On the other hand, Jack Oliver Haller et al noted that CT(computed tomography) accounts for perhaps 70% of the effective radiation dose.25 N.O. Egbe et al in their research in three Eastern Nigerian hospitals noted that the entrance skin doses(ESDs) measurements on children undergoing radiological examinations show doses very much higher than recommended values.26  Thus, strict adherence to ALARA (as low as reasonably achievable) principle as currently the best guide to balancing the risk versus benefit of a radiological examination should be checkmated. In this regard, Stewart Whitley A. emphasized that careful coning is an important tool in dose reduction and improved image quality5; stressing the need for the use of lead shield devices in protecting sensitive organs of the body.


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