Eur Radiol

DOI 10.1007/s00330-012-2639-3

COMPUTED TOMOGRAPHY

IAEA survey of paediatric computed tomography practice in 40

countries in Asia, Europe, Latin America and Africa:
procedures and protocols
Jenia Vassileva & Madan M. Rehani &
Kimberly Applegate & Nada A. Ahmed &
Humoud Al-Dhuhli & Huda M. Al-Naemi

Received: 13 May 2012 / Accepted: 25 July 2012

# European Society of Radiology 2012

Abstract survey of CT technology, exposure parameters, CT proto-

Objective To survey procedures and protocols in paedi- cols and doses.
atric computed tomography (CT) in 40 less resourced Results Modern MDCT systems are available in 77 % of the
countries. facilities surveyed with dedicated paediatric CT protocols
Methods Under a project of the International Atomic Ener- available in 94 %. However, protocols for some age groups
gy Agency, 146 CT facilities in 40 countries of Africa, Asia, were unavailable in around 50 % of the facilities surveyed.
Europe and Latin America responded to an electronic Indication-based protocols were used in 57 % of facilities.
Estimates of radiation dose using CTDI or DLP from stan-
Please see end of the article for complete list of authors. dard CT protocols demonstrated wide variation up to a
Electronic supplementary material The online version of this article factor of 100. CTDIvol values for the head and chest were
(doi:10.1007/s00330-012-2639-3) contains supplementary material, between two and five times those for an adult at some sites.
which is available to authorized users. Sedation and use of shielding were frequently reported;
J. Vassileva immobilisation was not. Records of exposure factors were
National Centre of Radiobiology and Radiation Protection, kept at 49 % of sites.
Sofia, Bulgaria Conclusion There is significant potential for improve-
ment in CT practice and protocol use for children in
M. M. Rehani (*)
International Atomic Energy Agency, less resourced countries. Dose estimates for young chil-
Wagramer Strasse 5, P.O. Box 100, 1400 Vienna, Austria dren varied widely. This survey provides critical base-
e-mail: M.Rehani@iaea.org line data for ongoing quality improvement efforts by the
IAEA.
M. M. Rehani
e-mail: madan.rehani@gmail.com Key Points
• Paediatric computed tomography (CT) practice was
K. Applegate audited in 40 less resourced countries.
Emory Radiology,
• This audit revealed widespread (up to 100 times) variation
Atlanta, GA, USA
in radiation dose.
N. A. Ahmed • Specific CT protocols for certain age groups were fre-
Sudan Atomic Energy Commission, quently (ca. 50 %) unavailable.
Khartoum, Sudan
• This survey demonstrates significant potential for im-
H. Al-Dhuhli provement in paediatric CT practice.
Sultan Qaboos University, • Multinational networking is an effective mechanism for
Al Khod, Oman quality improvement.
H. M. Al-Naemi
Hamad Medical Corp. Hamad General Hospital, Keywords Computed tomography . Paediatric CT . Patient
Doha, Qatar doses . Radiation protection, CT protocols

Introduction
Computed tomography (CT) is a widely used and valuable
imaging investigation that provides medical benefit in clin-
ically justified situations [1, 2]. However, the radiation risk
should be minimised through use of specific protocols ad-
justed for the child’s body size and practices that promote
radiation protection such as proper immobilisation and
shielding when appropriate [3–12].
Most of the publications on radiation protection of
patients in CT originate from North America or Western
Europe, and very limited published information is available
from less resourced countries. The International Atomic
Energy Agency (IAEA) has initiated projects in many less
resourced countries on the radiation protection of patients
[13]. Results from the IAEA initial paediatric CT project
indicated large variations in the weighted CT dose index
(CTDIw1) by a factor of 55 [14]. These findings revealed the
need for a deeper survey of practice in paediatric CT to
understand both CT utilisation in children and the degree of
optimisation of clinical protocols. The IAEA work to date
has assessed the frequency of paediatric CT in a large
number of the less resourced countries of the world as well
as the level of appropriate use of common CT examinations
in children [15]. There are a number of issues that require
further evaluation, including doses to paediatric patients and
technical aspects of performing CT in children. This article
covers the survey of these aspects in 40 less resourced
countries with the aim of identifying potential interventions
to optimise CT procedures and reduce doses in children.
Materials and methods
This being a continuation of a previous study, the informa-
tion on Materials and methods covered in the previous paper
[15] is not being repeated here. The details about participat-
ing countries, CT facilities and counterparts, how these were
chosen, professional background of the counterparts, the
way forms were developed by the IAEA and provided to
the counterparts, instructions provided to counterparts on
which part of forms should be filled out by counterparts,
by radiologists and by radiographers, duration of data col-
lection, mechanism for providing feedback by study coor-
dinators to counterparts on results obtained and feedback on
corrective action have all been described in an earlier paper
[15]. Counterparts acted independently in giving responses
to the survey questionnaire with scientific intent.
1 installed after 2005; 40 (27 %) between 1997 and 2004; 5
The current nomenclature according to Dosimetry in Diagnostic
Radiology: An International Code of Practices, Technical Reports
Series 457, IAEA, 2007 is CW for CTDIw and CVOL for CTDIvol
Eur Radiol
Electronic appendix 1: Participating countries by geo-
graphic region.
The data presented in this article include a survey of the
technology of CT equipment, dose indices and typical expo-
sure parameters for routine CT examinations of the head, chest
and abdomen for five different age groups: <1 year, >1–
5 years, >5–10 years, >10–15 years and adults. Age groups
were chosen to allow comparison of the results with those of
other large-scale studies [16–20].
The survey also included the availability of dedicated
imaging protocols for paediatric examinations or indication
-based protocols; the projection routinely used for scout
imaging in children; typical body coverage of the scout
images for CTs of the abdomen and pelvis; the routine
imaging mode (sequential or helical) for paediatric head
CT for trauma and typical angle of the gantry for head CT;
and the use of automatic exposure control (AEC). Further,
the availability of bismuth breast and eye shields, availabil-
ity of immobilisation devices, frequency of use of sedation
for small children (<5 years old), need for caregivers in the
CT room and use of protective aprons for parents were
surveyed.
Data analysis
Wherever relevant, the typical exposure parameters for rou-
tine CT of the head, chest and abdomen and the
corresponding CTDI values were compared between CT
facilities with the same CT equipment by applying
Student’s t-test to the mean values. A p value of <0.05
was considered significant.
Results
CT technology in participating facilities
Data from 146 CT facilities in 126 hospitals from the 40
countries that responded are included in this article: 73 CTs
in Asia, 51 in Europe, 12 in Latin America and 10 in Africa.
Electronic appendix 2: CT distribution by manufacturer,
model, country and year of installation.
Only 33 systems (23 %) were single-detector CT
(SDCT), and 113 (77 %) were MDCT. SDCTs were reported
from Armenia, Bulgaria, Czech Republic, Iran, Lebanon,
Lithuania, FYR of Macedonia, Peru, Poland, Slovakia,
Syria, Sudan and Tanzania. Among MDCTs, 23 (20 %)
had 2–6 detector rows, 45 (40 %) had 16–40 detector rows,
and 45 (40 %) had 64 or more detector rows. As expected,
there was a huge variation in equipment age: 97 (66 %) were
(3 %) before 1996. For four of the systems (3 %), the year of
installation was unknown.
Eur Radiol
Whether the equipment was new or second hand at the
time of installation was not surveyed. Approximately 15 %
of the systems installed after 2005 were old SDCT models,
which indicates that they would most likely be classified as
second-hand equipment. AEC was reported to be available
in 123 of the facilities (84 %). Availability of dose display in
CTDIw or CTDIvol and DLP was declared in 116 of facilities
(79 %) with none declaring “I do not know”. Dose display
data were verified by measurements with a standard dosim-
etry phantom in only 28 (20 %) facilities.
CT protocols
Results are presented for CT of the head, chest and abdomen
in five age groups: <1 year, >1–5 years, >5–10 years, >10–
15 years and adults (Tables 1, 2 and 3).
Imaging mode
Information on the use of the sequential or helical mode for
different CT examinations is provided in Table 1. For head
examinations, the sequential mode was used in 57–60 % of
protocols for children of different age groups and 66 % for
adults. For the chest and abdomen, the helical mode was
used in 91–95 % in different age groups, with a slightly
higher use in children than in adults.
Tube voltage
Table 2 summarises a wide range of tube voltages,
between 80 and 150 kV, in use for both children and
adults. The most frequently used tube voltage for both
was 120 kV. For example, for the age group <1 year it
was used in 58 % of protocols for head, 49 % for chest
and 49 % for abdomen examinations. This is a higher
kV than necessary. There was an increasing frequency
of use of 120 kV with patient age for the head up to
66 % for the age group 10–15 years and 68 % for
adults; for the chest and abdomen up to around 64 %
for the age group 10–15 years and 75 % for adults.
In ten facilities (7 %), tube voltages exceeding 120 kV
were used for children. In two systems, 140 kV was used for
chest examination in all age groups except <1 year, and in
Table 1 Frequency (percent) of the use of different imaging modes (sequential/helical)
Imaging mode Head Chest
< 1 year 1– 5 5–10 10–15 Adult < 1 year 1–5 5–10
years years years
Sequential (%) 57 58 58 60 66 8 7
Helical (%) 43 42 42 40 34 92
two systems even 150 kV was reported for the chest and
abdomen examination of children aged 1–15 years and
adults. In abdominal CT, less than 120 kV was used in
30 % of children aged <1 year, 28 % aged 1–5 years,
16 % aged 5–10 years, 12 % aged 10–15 years but in only
5 % of adults. The lowest kilovoltage, 80 kV, was used most
frequently for chest examination—in 14 % of the age group
<1 year, 10 % of the age group 1–5 years, 2 % of the age
group 5–10 years, 1 % of the age group 10–15 years and
1 % of adults.
Tube current to time product
The mean values of mAs ranged from 160 to 298 for the
head, from 67 to 143 for the chest and from 85 to 180 for the
abdomen (Fig. 1). A strong trend towards an increase in
current to time product with age was found.
Tube current utilised in different systems ranged from
50 mA to 700 mA, depending on the body part undergoing
imaging and the size of the patient. For younger children
10 years old and less, the tube current ranged from 50 to as
high as 380 mA for head examination, from 42 to as high as
350 mA for a chest examination and from 40 to as high as
700 mA for the abdomen.
Rotation time
For head examination, the most frequently utilised time for
children of all age groups was 0.5–0.8 s (overall 40–45 % of
protocols depending on the age) followed by 1 s (35–42 %
of protocols). For the chest, 0.5–0.6 s rotation time was used
in 45–50 % of protocols, 0.7–0.8 s in around 20 % and 1 s in
11–12 %. For the abdomen, rotation time below 0.8 s was
used in 83–90 % of protocols and 1 s in around 10 %.
Pitch
Values between 0.3 and 2 were reported for different exami-
nations and age groups. For head examination, pitch value 1
or less was used in 91 % of facilities, with no difference
among age groups. For chest examination, pitch values be-
tween 1 and 2 were used in 67 % of adult protocols and 71 %
of paediatric protocols. Similarly for the abdomen, the pitch
Abdomen
10–15 Adult < 1 year 1–5 5–10 10–15 Adult
years years years years years years
6 8 9 7 6 5 8 9
93 94 92 91 93 94 95 92 91
 Eur Radiol

Table 2 Use of different tube voltages (kV) as percentage of protocols with indicated kV

Tube voltage Head Chest Abdomen

< 1 year 1–5 5–10 10–15 Adult < 1 year 1–5 5–10 10–15 Adult < 1 year 1–5 5–10 10–15 Adult
years years years years years years years years years

80 kV 8 4 2 2 0 14 10 2 1 1 10 5 1 1 1
90 kV 1 1 1 0 0 1 1 0 0 0 1 1 0 0 0
100 kV 12 8 5 5 1 10 10 9 5 0 14 16 10 7 1
110 kV 6 6 5 3 0 4 5 5 4 1 5 5 5 4 3
120 kV 57 63 64 66 68 49 53 56 64 74 49 49 58 64 75
130–150 kV 3 4 6 6 20 4 6 5 6 11 3 4 4 5 9
NAa 13 14 17 17 11 18 16 22 18 12 18 18 21 18 12
no answer 5 5 5 5 11 5 5 7 6 12 5 5 7 6 12
a
NA means that the protocol for this age group is not available

varied between 1 and 2 in 60 % of adult protocols and 66–
71 % of paediatric protocols, depending on the age group.
Radiation dose estimates: CTDI values
Seventy-nine percent of survey respondents (116/146)
reported that dose display was available. However, dose
information was collected by 102 (70 %). For 19 facilities
dose display was provided in CTDIw and for 83 in CTDIvol.
Table 3 presents minimum, maximum, median and 75th
percentile values of CTDIvol from the routine protocols of
83 CT systems. For comparison of the results, published
diagnostic reference level (DRL) values from the UK [17],
Germany [18], Switzerland [19] and France [20] are also
included in Table 3. Median CTDIvol values increase with
age. The ratio of max/min CTDIvol values varied between
different examinations and age groups—from 15 for abdo-
men CT in the 5–10-year age group up to 100 for chest CT
in the <1-year age group. Variation between maximum and
minimum up to a factor of 49 were found between protocols
from the 19 facilities with CTDIw display.
Analysis of the protocols showed that in 12 of the CT
systems (8 %), CTDI values for paediatric patients were
higher than for adults in at least one age group and for
one type of examination. For example, in the case using
64-detector-row CT, the CTDI vol for the head was
between 31.3 and 59.4 mGy for children of different ages
compared to the very low value of 12.3 mGy for adults.
In this facility, 120 kV was used for all ages and a tube
current between 140 and 380 mA for children of different
age groups versus 170 mA for adults. Similarly, in another
4-detector-row CT system CTDIvol for the chest examina-
tion of infants was 28.4 mGy versus 11.7 mGy for adults.
The comparison of protocols for this system indicated that
fixed parameters of 120 kV and 129 mA with 0.875 pitch
were used for all ages.
In one of the SDCT systems, adult protocols were used
for children: with CTDIw display, the values for children
were double those of adults for head examination (64 mGy
versus 34 mGy), for chest examination (16.4 mGy versus
7.8 mGy), and 50 % higher for abdomen examination
(11.7 mGy versus 7.8 mGy). Similarly, in the case of an-
other SDCT the same tube voltage, tube current and pitch
were used for chest and abdomen examinations of all ages,
but a lower rotation speed was used in children than in
adults, resulting in double the CTDIw for children under
10 years of age.
The variation in protocol settings is demonstrated in
Table 4, where protocols from eight CT facilities using the
same model showed a 4-fold variation in CTDI dose values
for head examination, 14-fold for chest and 6-fold for ab-
domen examination.
Responses from CT operators
Responses regarding protocol optimisation and radiation
protection methods were received from 141 CT operators
from all 40 participating countries.
Electronic appendix 3: Detailed summary by geographi-
cal region.
CT protocols
Dedicated imaging protocols for paediatric examinations
were widely available (94 % of respondents). Indication-
based protocols were available in only 58 % of facilities.
Scout image
Seventy-three percent of respondents reported that the ante-
roposterior (AP) projection was usually used, posteroante-
rior (PA) in 9 %, lateral in 4 %, both AP and lateral in 5 %
Eur Radiol

61.0
13.4
18.2

*DRL values given by Shrimpton et al. [17] are in CTDIvol,16 for all examinations of children aged <1–10 years; DRL values given by Galanski et al. [18] and Brisse and Aubert [20] are in
350

2.0

14
head abdomen

Tube current to time product, mAs

–
–
–
chest

Adult
300

45.0

14.3
2.0

9.6

16
10
–

–
15 years 250

CTDIvol,16 for head and in CTDIvol,32 for chest and abdomen examinations for all ages; DRL values given by Verdun et al. [19] are in CTDIvol as displayed by the CT system
29.8

12.0
30*
10–

2.0

7.6

6.5
13

7
200
10 years

75.0

13.0 150
20*
0.8

6.3

4.5
5–

9
4
5 years

100
40.1

10.7
20*
0.8

5.0

2.5
1–

CTDIvol,16 is measured in a PMMA phantom with a diameter of 16 cm and CTDIvol,32 is measured in a PMMA phantom with a diameter of 32 cm
Abdomen

50
< 1 year

99.0
10.9
15.5
4.7

12

< 1y

1-5y

5-10y

10-15y

Adult
Adult

42.0

13.2
0.5

7.5

6.8
12
–

Fig. 1 Mean values of the tube current to time product utilised for
15 years

head, chest and abdomen examinations as a function of patient age

27.4

10.0
20*
10–

0.5

5.5

4.3
5.5
10

(based on the manufacturer’s requirements for tube–current

10 years

modulation) and AP/PA in the remaining 8 %.

Table 3 Statistical parameters of the distribution of CTDIvol and diagnostic reference levels from the literature

40.1

13*
0.5

4.9
8.2

2.7
3.5
5–

Head CT mode for trauma and gantry angulation

5 year

40.1

12*
0.4

3.4
7.0

1.7
1–

Fifty-two percent of the CT operators indicated that paedi-

< 1 year

atric head CT for trauma was more often performed in

Chest

280.0
59.1
75.2

sequential mode, while 45 % used helical mode. While

4.5

65

65 % of the operators in the European regions chose se-

Adult

250.0

quential mode, the preference for helical mode was 64 % in

14.5

41.0
58.1

60
60

Latin America, 54 % in Asia and 57 % in Africa.

–

Eleven of the operators (8 %) stated no gantry tilt, mostly

15 years

159.4

because this option was not available. The remaining 92 %

36.0
46.1
10–

5.0

50
40
50
50

were tilting the gantry at angles between 7 and 22°, depend-

ing on the patient position, in order to avoid eye lens
10 years

exposure.
115.0
29.7
37.7
2.7
5–

45
30
40
40

Tube current modulation

5 years

2.3
96.5
22.5
29.0
30
20
33
30
1–

Automatic exposure control for tube current modulation was

available in 84 % of CT systems in the survey. A high
Switzerland, 2008 [19]
Germany, 2007 [18]

percentage of operators always used the AEC option for

France, 2009 [20]

all body parts (74 %), with the highest frequency in Asian
UK, 2005 [17]

countries (79 %) and lowest in Latin America (45 %, sample

< 1 year

size010 responses).
median
75%ile
Head

max
min

Bismuth shields
DRL in CTDIvol
CTDIvol (mGy)

Bismuth shields were not available in most of the countries.

Parameter

Breast shields were available in only 11 % and eye shields in

(mGy)

only 8 % of CT facilities. In our sample, bismuth shields

were known and available in 19 % of Asian and 7 % of
 Eur Radiol

Table 4 Protocols for head,

chest and abdomen examination Device Mode Tube voltage, kV Tube current, mA Tube rotation, s Pitch value CTDIvol, mGy
of infants (<1 year) in eight CT number
facilities with the same 64-
detector-row model (Light Head examination
Speed VCT, GE) 39 Helical 100 100 0.5 0.53 10.4
40 Sequential 120 125 1 NA 22.2
102 Sequential 120 240 0.5 NA 21.3
29 Sequential 120/100 200/130 1 NA 24/16
8 Sequential 80 200 0.8 NA 6
124 Sequential 120 240 0.5 0.5 21.3
119 Helical 120 80 0.6 0.9 10
Range 80–120 80–240 0.5–1 0.5–0.9 6–24
Chest examination
39 Helical 80 129 0.5 1.3 1.9
40 Helical 120 120 0.5 0.98 10.2
102 Helical 80 240 0.5 0.98 2.6
29 Helical 100 180 0.4 0.98 3.2
8 Helical 120 80 0.4 1.37 4.5
124 Helical 80 25 0.5 0.9 0.7
119 Helical 120 80 0.6 0.9 10
Range 80–120 25–240 0.4–0.6 0.9–1.37 0.7–10.2
Abdomen examination
39 Helical 80 100 0.5 1.3 2
40 Helical 120 125 0.4 0.98 8.5
102 Helical 100 240 0.4 0.98 10.3
29 Helical 100 180 0.4 0.98 3.2
8 Helical 120 125 0.4 1.37 9
124 Helical 100 300 0.9 0.9 12.7
119 Helical 100 80 0.6 0.9 2
Range 80–120 80–300 0.4–0.9 0.9–1.37 2–12.7

European facilities and were unknown in Latin American Caregiver support

and African facilities.
Immobilisation devices
There was wide availability of immobilisation devices: 85 %
of facilities had different immobilisation means available—
most often straps (79 %), but also swaddling clothes, plastic
holders for the head or body, foam pads, sponges, sand bags,
pillows and other objects.
Use of sedation
When imaging small children (<5 years old), 46 % of operators
used sedation in more than half of the cases, and 14 % sedated
all of these young children. Only 7 % of the operators stated
that they “hardly ever” used sedation. In 10 % of facilities
when sedation was used more often, immobilisation devices
were also not available, but in 48 % of facilities with available
immobilisation means sedation was used in more than half of
the paediatric patients. No geographic variation was found.
The need for a person to support a small child in the CT
room was stated to be: always (17 %), >50 % of the time
(31 %), <50 % (34 %) and hardly ever (18 %). When the
answer “hardly ever” was chosen, participants explained
that they use sedation instead (69 %), immobilisation devi-
ces (23 %) or both (8 %). When support of paediatric
patients was needed, this was done 89 % of the time by
parents and 11 % by medical staff, with no significant
difference in answers between regions. When parents were
in the room, 94 % of respondents indicated that they wear
protective lead aprons. In 79 % of facilities if medical staff
worked in the room they had personal dosimeters.
Dose records
Patient dose records were kept at 49 % of facilities, with the
highest frequency in Europe (55 % of participating facili-
ties), and in 49 % of Asian, 36 % of Latin American and
14 % of African facilities. Seven percent of respondents
Eur Radiol
were not aware whether such records were available. When
records were kept, in 82 % they were in the patient elec-
tronic file and in 18 % they were recorded manually in a
physical file. In 51 % of facilities patient dose records were
not kept.
Availability of medical physicists
Fifty percent stated medical physicists were available. This
was 34/60 (57 %) in Europe, 32/63 (51 %) in Asia, 3/11
(27 %) in Latin America and 2/7 (29 %) in Africa. The
figures for the degree of availability were: in ten of the
facilities that had access to medical physicists (14 %), the
medical physicist was available full time in radiology
departments, in 9 facilities (13 %) there was a part-time
medical physicist (up to 50 % in radiology), and in 52
(73 %) he/she was available on request in less than 20 %
of situations. In most cases, the medical physicist was in-
volved in quality control, patient dose calculation and radi-
ation protection advice, and in only 28 % was he/she
involved in optimisation of imaging protocols.
Discussion
This IAEA multinational study of practices in CT examina-
tions of children demonstrated that modern MDCT with
dose display and dose-saving techniques was available in
less resourced countries. It also showed that in most facili-
ties, paediatric-specific protocols were being used but these
CT protocols were not well optimised.
Dose values and imaging protocols
Significant observations include: In 8 % of the devices
CTDI values for paediatric patients were higher than for
adults in at least one age group and one examination, in
40 % of facilities the imaging protocols were not adapted to
the body size, and in 13 % of them the same protocol was
used for all age groups. Large variations were found in
CTDI values for the same CT examination and the same
age group (Table 3). The variation of CTDIvol (in 83 facil-
ities) was highest for chest examination—by a factor of 100
in the age group <1 year. For devices with CTDIw display
(19 facilities), variations were by a factor of 49, the highest
being for chest examinations of children aged <5 years.
These were important findings that necessitated feedback
and correction. These variations were not unexpected, based
on some wide-scale national surveys in Western European
countries [16–20]. Dose variations in this survey were
higher than in other surveys, which may be due to the
multinational span.A possible explanation for these results
could be differing survey dates and methods and the
difference in protocol adaptation to body size. Another
reason may be uncertainty about CTDI values displayed
by the equipment; therefore, verification of dose displays
should be performed by phantom measurements [17].
Dose reduction by lowering the tube current, tube voltage
and rotation time or increasing the pitch value should take
into account the level of image noise that can be tolerated
for a particular clinical indication, which means that proto-
cols should be adapted not only to body size, but also to the
particular indication [4–8, 10–12, 21]. Only 30 % of facil-
ities for newborns and 12 % of facilities for older children
used less than 120 kV, demonstrating opportunities for
optimisation interventions [23–27].
A positive observation was the strong trend towards an
increase in the mean tube current and mAs with age, dem-
onstrating that tube current is largely adapted to body size in
most CT facilities, despite high individual variations within
the same age group [28].
However, in more than 50 % of facilities, manufacturers’
pre-programmed protocols were used without any change,
or, if protocols were locally created or modified, this was
usually done only once after installation of a new machine,
mostly by the manufacturer’s representative. The need for
more training on optimisation approaches through the crea-
tion of regional networks of specialists under the IAEA
umbrella was recognised as a very important and helpful
tool.
Validation of displayed CTDI data by measurements was
carried out in less than 20 % of facilities and in all proba-
bility most CT systems display CTDI for body regions in a
32-cm phantom regardless of patient size or age. This would
underestimate CTDI for paediatric chest and abdomen
examinations by a factor of almost 2 because for all paedi-
atric body examinations CTDI should ideally be measured
using a 16-cm phantom [16, 17, 22]. Thus, an error depend-
ing on the pitch factor is likely.
Dose records and awareness
This survey demonstrated that patient dose records were
kept in less than half of the facilities. The highest frequency
of dose recording was found in European countries, likely
because European legislation requires dose recording devi-
ces and performance of patient dose assessment for CT
examinations [29].
The need for patient dose recording and tracking of
cumulative doses of individual patients is becoming a hot
topic nowadays since the IAEA initiated the Smart Card/
SmartRadTRack project [30, 31]. Publication of a paper in
2009 on recurrent CTs resulting in effective doses higher
than 100 mSv for individual patients as well as reports from
the USA regarding non-optimised CT procedures causing
deterministic effects [32] added momentum to support

patient dose tracking [30, 31]. In 21 % of the devices, dose
display was not available, and in 51 % of the facilities, dose
records were not kept at all, which made it difficult to verify
the process.
Limitations of the work reported
This article covers only situational assessment, and impact
assessment will be covered in the next paper.
A number of limitations of such multinational surveys
should be taken into account: the language barrier, with
more than 30 non-English languages in this group, created
situations of different interpretation by many participants
concerning the contents of the forms and thus the correct-
ness of the data provided, as well as variation in the back-
ground and competence of the people who provided data.
The lack of medical physicists in more than 50 % of facil-
ities of course adds to the difficulty, in particular when the
process of verification of displayed values and optimisation
of protocols were needed. For the remaining 50 % of sit-
uations where the availability of a medical physicist was
declared, in many situations he/she was not hospital-based
and not involved in the optimisation process before this
project, creating the challenge of training.
The number of questionnaire respondents in different
countries ranged from 1 to 12 per country. An estimate of
national practice can be made only when more participants
from a country participate. In this survey, 27 out of 40
countries had participation of less than 10 % of the CT
facilities in the country. In order to reduce uncertainty in
the survey, mentoring and feedback were actively used and
several clarifications were required during the data analysis.
In conclusion, this article, reporting the largest multina-
tional study of CT practice in 40 less resourced countries
initiated by the IAEA, has identified areas of strength and
weakness in the justification and optimisation of CT practice
for children. With the wide variation in dose estimates for
young children, there is great opportunity for improvement
in CT practice and protocol use for children in less
resourced countries. This survey provides critical baseline
data for ongoing quality improvement efforts by the IAEA.
Creation of multinational networks by the IAEA, with
defined plans of action and a framework for the collection of
data, appears to be a very effective mechanism.
Acknowledgments The work was undertaken as part of technical
cooperation projects of the International Atomic Energy Agency. The
authors wish to thank their respective governments for their nomina-
tion to participate in the study and acknowledge the contribution of
members of the team for their cooperation and understanding, in
particular: Zoran Trajkovski, Jasminka Joseva, N. Naman, C.
Kalambo, A. Pilly, Shady Khazzam, Julius Ziliukas, Edis Ciuksys,
Inga Cibulskaite, Hashim Al Awadhi, Noirin M. Neligan, Jacek
Janaczek, Fatima Al Kaabi, Wadha M. Al-Shamsi, Mohammad Abu
Srour, Alfan S. Al Ameri, Sara Booz, Juan Manuel Herrera Moya,
Eur Radiol
Dean Pekarovič, Ethen Jamnik, Dimitrij Kuhelj, Andrias
Hambardzumyan, Marianna Harutunyan, Lusine Hakobyan, Fredy J.
Gomez, Leila Sadri, Marianna Frik-Amelin, Shaid Kamal, Dr.
Muzafar, Samia Saadi, Fouzia Meddad, Ahmed Merad, Rima Dib,
Ali Rahanjam, Mohd Ahmed Elhallag, Laila Musabeh Mohad
Almuhairi, Suresh Kamath, Tatan Saefuddin, Kukuh Nurcahyo,
Damayanti Sekarsari, Olivera Ciraj-Bjelac, Djordje Lazarevic, Marcos
Ely de Andrade, Nada Hassan, Einas Hamed, Ali Abdelrazeg and
Alejandro Nader.
Co-authors in alphabetical order* Jamila Salem Al Suwaidi
(UAE), Danijela Arandjic (Serbia), Adnan Beganovic
(Bosnia&Herzegovina), Tony Benavente (Peru), Tadeusz Bieganski
(Poland), Simone Dias (Brazil), Leila El-Nachef (Lebanon), Dario
Faj (Croatia), Mirtha E. Gamarra-Sánchez (Paraguay), Juan Garcia
Aguilar (Mexico), Vesna Gershan (Former Yugoslav Republic of
Macedonia), Eduard Gershkevitsh (Estonia), Edward Gruppetta
(Malta), Alexandru Hustuc (Republic of Moldova), Sonja Ivanovic
(Montenegro), Arif Jauhari (Indonesia), Mohammad Hassan Kharita
(Syria), Siarhei Kharuzhyk (Belarus), Nadia Khelassi-Toutaoui
(Algeria), Hamid Reza Khosravi (Iran), Desislava Kostova-Lefterova
(Bulgaria), Ivana Kralik (Croatia), Lantao Liu (China), Jolanta
Mazuoliene (Lithuania), Patricia Mora (Costa Rica), Wilbroad
Muhogora (Tanzania), Pirunthavany Muthuvelu (Malaysia), Denisa
Nikodemova (Slovakia), Leos Novak (Czech Republic), Aruna S.
Pallewatte (Sri Lanka), Mohamed Shaaban (Kuwait), Esti Shelly
(Israel), Karapet Stepanyan (Armenia), Eu-Leong Harvey J. Teo
(Singapore), Naw Thelsy (Myanmar), Pannee Visrutaratna
(Thailand), Areesha Zaman (Pakistan), Dejan Zontar (Slovenia)
*Except first author, the coordinator of the study (placed as second author),
and a consultant (at third place), all other authors’ names have been
arranged alphabetically by their family name. Only one principal contrib-
utor from each participating team in a country region has been included as
an author, although many members were involved in the study.
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