Pediatric Ultrasound Committee

For Parents and Families

Ultrasound is a way of non-invasively making pictures using high frequency sound. Sound waves travel into your body and bounce off internal structures. The different ways in which to those sound waves bounce back allows an image to be created. Unlike radiography (x-rays), ultrasound makes images without using ionizing radiation. Because of the way images are made by ultrasound, ultrasound excels at looking at soft tissue and fluid filled structures but is less good at looking at air-filled structures like lung or dense structures like bone.
Ultrasound plays an indispensable role in taking care of children with a broad spectrum of illnesses, in both the outpatient and inpatient setting.  The lack of ionizing radiation makes ultrasound an imaging technique of choice in children. The portability of ultrasound makes it a valuable tool in the assessment of critically ill patients. One other advantage is that ultrasound can be done without sedation even in difficult situations.
Ultrasound can not only look at structure but can also look at blood flow using a technique called Doppler. Newer ultrasound techniques are allowing doctors to evaluate tissue hardness which can predict the presence and severity of some diseases.
Some examples of the many uses of ultrasound in pediatric patients are shown in the following figure.
peds-ultrasound2.png(A) This image shows a normal newborn brain. The openings in the skull of a newborn baby allow imaging of the brain that is not possible in older patients. Head ultrasounds are commonly performed to look for brain hemorrhage, which is an unfortunate, but common, complication of prematurity.
(B) This image shows a complex mass within a testicle (cluster of black circles). The colors in the image show blood flow in both the normal testicle and the mass.The mass was removed surgically and turned out to be a specific type of cancer that required additional non-surgical therapy.
(C) This image shows an inflamed appendix (i.e. appendicitis). The colors in this image show the increased blood flow to the inflamed appendix. Urgent surgery was performed, and the patient went home the next day.
(D) This image shows a mass in the patient’s jaw (gray ovoid structure). A biopsy was performed and showed a cancer that had spread to the jaw, needing immediate treatment.

(Images courtesy of UCSF Benioff Children’s Hospital)


Ultrasound works the same in children and adults, however ultrasound turns out to be much more useful in children due to their smaller size.  Also, because children are more susceptible to the potential long-term effects of ionizing radiation, doctors will often choose ultrasound over other imaging tests whenever feasible.  One example of this is that in children, ultrasound is far more commonly used to look for appendicitis (and is more often successful), whereas in adults CT is preferred.

Diagnostic ultrasound for children is essentially risk free.  Unlike x-ray or CT, there is no ionizing radiation. The level of energy used by diagnostic ultrasound to create images is very carefully controlled by the government and the manufacturers of the machines.

For further information on the safety of ultrasound, the FDA has put together an excellent summary for consumers.

For the most part, ultrasounds are performed by sonographers.  Sonographers have an associate’s or bachelor’s degree in sonography, and their full time job is performing ultrasound examinations of patients.  In some instances, the physician will perform the ultrasound on her/his own.
Only a physician is allowed to interpret the ultrasound images, and in general, that will be a radiologist.  A radiologist is a physician who has completed a 4-year undergraduate degree, a 4-year medical school degree, a 1-year medical internship, a 4-year radiology residency and frequently a 1-year radiology fellowship (that’s a total of 14 years of education beyond high school).  A radiologist’s full time job is interpreting images, usually across all imaging modalities, as well as performing image-guided procedures.   
Click
here (link pending) for more information about the qualifications required for ultrasound interpretation
Point-of-care ultrasound is the use of ultrasound by non-radiologists when taking care of patients in any setting. The setting could be in a clinic office, an emergency room, an inpatient bedroom, or even an operating room. Ultrasound has so many applications, that many physicians have found it helpful to help their daily care of patients, either for diagnosing problems, or to help guide therapies.


Useful Information

Comments

The links provided here are primarily to sources outside SPR. Please notify us at spr@acr.org should you chance upon a broken link.  Thank you!

General education

Emerging technologies

  1. Acoustic Radiation Force Impulse (ARFI): Also known as quantitative elastography, ARFI allows for a quantitative assessment of the stiffness of a tissue. While ARFI has been in active clinical use Europe and Asia for several years, this technology has only recently become FDA approved for several ultrasound manufacturers. There is a large and growing body of data related to the clinical and diagnostic value of ARFI. 
  2. Superb Microvascular Imaging (SMI): This technique allows small low-flow vessels to be seen that previously were inaccessible to older ultrasound technology. 
  3. Ultrasound Contrast: There are a variety of products that use microbubbles as a contrast medium for ultrasound studies. Visit the Contrast-Enhanced US webpage for the latest FDA status.  At this time of the use of these agents is FDA approved in the United States only for echocardiograms. This FDA ban is expected to be lifted within the next few years, as evidenced by recent FDA downgrading of prior black-box warnings for ultrasound contrast agents. 

Vendor Information

POC US Information

More information about current use of point-of-care ultrasound can be found at this downloadable document. If you have information to share about your institution, please contact US Committee Chair, Dr. Monica Epelman.

Sonographer Templates

The SPR Ultrasound Committee has developed several ultrasound templates to be used by sonographers and pediatric radiologists.  We developed these templates as tools to improve communication between sonographers and radiologists.  We acknowledge that every institution has variations in their protocol, and our templates are not intended to alter your own institution’s practice.  In fact, we have designed the templates with the expectation that every institution will make modifications to meet their individual needs.  

As such, the templates are all formatted as single-page PowerPoint slides, which makes editing very easy.  If you have suggestions for improvement, please e-mail Andrew.Phelps@ucsf.edu with your suggestions.  We hope you find these helpful!


SPR US Template - Thyroid

US Curriculum for Fellows

The SPR ultrasound committee has developed an ultrasound curriculum for pediatric radiology fellows. The curriculum can be downloaded HERE. This curriculum is intended to provide guidance and documentation for pediatric radiology fellowship directors. The core of this curriculum is the hands-on scanning experience. We feel that it is imperative for pediatric radiologists to be experts both in interpretation and performance of ultrasound.

Ultrasound Training Pathways and Opportunities

Many non-radiologists are using portable ultrasound equipment in their clinic and at patient’s bedside. It is in the patients’ best interest that clinicians have proper training in the use of ultrasound. Therefore, some medical schools have already introduced ultrasound into their curriculum. If your medical school does not offer such formal ultrasound training, then you are encouraged to reach out to your radiology department to determine what educational opportunities are available. Even if it does not exist, you can work with your dean to create an ultrasound clerkship elective.
  1. Radiology Residency  - Ultrasound training is required in all radiology residencies, as mandated by the ACGME. However, the amount of hands-on scanning varies from program to program. For those hospital that have 24/7 sonographer coverage, it behooves the radiology resident to actively pursue scanning opportunities. For radiologists to be considered the experts in ultrasound imaging, radiologists must be experts in the physics of ultrasound, the performance of scans, and the interpretation of images.
  2. Radiology Fellowships - For graduating radiology residents, there are several programs that offer 1-year ultrasound fellowships. The majority of programs, however, will incorporate the ultrasound training into abdominal imaging, women’s imaging, pediatric or mammography fellowships.
  3. Non-Radiology Pathways - The term “point-of-care” ultrasound has been coined to describe non-radiologists using ultrasound in daily clinical management. Almost every specialty can find a use for ultrasound in their practice, either for diagnosis or procedural guidance. As a result, ultrasound training has become incorporated into some non-radiology residencies. In addition, dedicated imaging fellowships (e.g. “emergency ultrasound fellowship”) are available for non-radiologists.
Becoming a sonographer requires an associate or bachelor’s degree in sonography, professional certification, and usually a state license. More information about careers in sonography can be found through the American Registry for Diagnostic Medical Sonographers.

Ultrasound Commitee

Roster

Monica Epelman, MD, Chair
Andrew S. Phelps, MD, Vice Chair
Christian L. Carlson, MD
Tushar Chandra, MBBS, MD
Harris L. Cohen, MD
Ricardo Faingold, MD
Rachelle Goldfisher, MD
Kerri Highmore, MD
Melanie Levin, MD
Harriet Paltiel, MD
Michele Retrouvey, MD
Erica L. Riedesel, MD
Henrietta Rosenberg, MD
Cicero T. Silva, MD
Judy H. Squires, MD
Neil Vachhani, MD
Dayna M. Weinert, MD
Jonathan R. Wood, MD
Richard D. Bellah, MD, Advisory 

SPR Unknown US Cases

All cases can be found at the SPR Unknown Case page.

Case 133: Authors: Alexander Rich MD, Nathan Miller MD, Harris L. Cohen MD, University of Tennessee Health Science Center

Case 129: Authors: Monica Epelman MD and Carolina Guimaraes MD, Nemours Children's Hospital

Case 134: Authors: Yeamie Kousari MD and Richard Bellah MD, Children's Hospital of Philadelphia

Case 127: Authors: Daniel Rosenbaum MD and Richard Bellah MD, Children’s Hospital of Philadelphia

Case 125: Authors: Summer Kaplan MD and Richard Bellah MD, The Children's Hospital of Philadelphia