Imaging Overutilization in Pediatrics: Risks and Solutions

Deepti Verma, MS3, Penn State College of Medicine, contributed this piece.

Developments in imaging have revolutionized pediatric medicine, enabling earlier diagnoses and generating greater diagnostic precision than ever before. However, with these steps forward has also come the underhanded confrontation of imaging overutilization as imaging has slowly become the lens  through which many pediatric illnesses come into focus. According to studies in the New England Journal of Medicine and the Journal of the American Medical Association, national trends in engagement of advanced imaging has grown steadily over the years  where pediatric CT use increased substantially from the 1990s through the early 2010s, with some estimates showing a 2–3× increase before recent stabilization efforts. While this trend signifies the remarkable progress we have made in technology, it raises eyebrows on the value, safety, and the overall sustainability of pediatric imaging. 

In many clinical settings, the inclination to “just order the scan” is often driven by good intention. Diagnostic ambiguity is more than prevalent in a population that cannot clearly express their symptoms, and imaging often provides reassurance to both clinicians and families. However, this tradition of precaution can lead to snowballing effects. Every unnecessary CT exposes a child to ionizing radiation, and MRIs may require sedation , lengthy wait times, and increased cost without improving/changing outcomes. For patients with chronic conditions who undergo repeated studies, the summative burden can be substantial. 

When the clinical picture feels blurred, clinicians instinctively turn to the imaging lens in hopes of sharpening the view - but a lens used reflexively can distort as much as it clarifies. In many cases, we are refocusing the lens rather than reassessing the child in front of us. These additional scans often attempt to tighten a picture that was never out of focus to begin with. These patterns in imaging overutilization are not due to lack of effort or skill– it is due to system design. Time limitations, proactive medicine, and the pressure to accelerate diagnosis all contribute to overuse. The hunt of a clearer image can paradoxically obscure the broader clinical story. In high acuity environments (such as the ED), radiologists comprise a pivotal position in assessing imaging utility. Radiology intrinsically bridges departments, and thus, radiologists see the patterns of ordering behavior that individual clinicians cannot. This focal point places this specialty at the center of any effort to improve imaging stewardship and to “recalibrate” how this lens is used.

A good starting point is defining value in the realm of pediatric imaging as being the appropriate study being done at the appropriate time for the appropriate reason. The American College of Radiology’s Appropriateness Criteria and the Image Gently campaign  have provided influential frameworks. When radiologists take the lead in implementing these guidelines into clinical pathways and coordinate with pediatric and emergency medicine colleagues to create evidence based algorithms for common presentations (appendicitis, minor head trauma etc.) the impact can be instant. 

Imaging overutilization can also happen due to the lack of opportunity of specialties to interact with radiologists. Establishing routine multidisciplinary rounds and open-door consultation systems can help integrate radiology into the decision-making process rather than the final step of confirmation. 

Medical students and residents often receive limited formal training in imaging appropriateness, and early exposure to radiology is often observational rather than analytical. Introducing curriculum tweaks that teach when not to order an imaging study is as valuable as teaching how to interpret one. 

Families may equate more imaging with better care and declining a study can sometimes be perceived as neglect. Radiologists can help shape patient-facing communication by developing educational materials that explain the risks and benefits of imaging in plain language. When parents understand that “less” can mean “safer,” they can be more likely to support evidence based limitations.

Imaging overutilization in pediatrics sits at the juncture of culture, policy, and education, and radiology has the expertise to navigate all three. By leading stewardship initiatives and embedding appropriateness into everyday workflow , radiologists can demonstrate that high-value care is united with high-quality imaging. As the field continues to evolve, radiology’s leadership will be defined not only by what it can see but by the wisdom of knowing when not to look.