Diagnostic x-ray exams irradiate the patient to produce an x-ray pattern in space, which is captured and processed into a visible image, followed by clinical interpretation. Diagnostic-quality images at a well-managed radiation dose are required. Improvements to image receptors and image processing algorithms have resulted in improved images at reduced dose levels. However, careful management of x-ray production via design or configuration changes of the imaging device also affect patient dose. This initial dose management step is the focus of this discussion. Imaging equipment vendors, in general, have produced quality images of adults at reasonably managed patient doses. This achievement required teamwork between leading adult hospital staff members and representatives of the imaging equipment vendor within the adult hospital. Most manufacturers have had less opportunity to develop similar optimized configurations for pediatric imaging, the imaging of patients ranging from 2–200 kg between 0–21 y of age. Challenges: The wider dynamic range of patient thicknesses in the pediatric size range compared to the adult range of only 45–140 kg challenges automatic control features. In recent years reduction of patient dose as opposed to proper management has been stressed. The principal objectives of end users and vendors, respectively, are patient care and the bottom line. This too often hampers (if not prevents) a productive working relationship between the vendor and the end user. Too many end users rely too heavily on their equipment vendor to solve imaging/dose concerns. The vendors have an important role to play in this challenge but should not be the sole solution. Qualified medical physicists need an understanding of the design of the imaging device, an understanding that many vendors do not support out of proprietary concerns. The performance of the equipment should be judged based on data acquired with better tools. Solutions: Multiple equipment configurations are needed—each designed to excel at a reduced size of patients. Dose reductions that significantly impact image quality must be rejected. Radiologists and their qualified medical physicists should develop target patient doses (size based) for their unique imaging equipment and preferred level of quantum mottle. Once target doses are established as a function of patient size, vendor application specialists and design engineers should leverage the equipment’s strengths and weaknesses to best achieve desired results. The qualified medical physicist should function as an interpreter between the end user and the vendor’s design engineers. Are the radiologists’ and technologists’ expectations of the vendor reasonable and vice versa? While better tools are being developed, vendors may hesitate to make them available or charge excessive dollars for these new features to further slow their adoption. Conclusion: The challenges and solutions require the radiologist, technologist, qualified medical physicist, and vendor representatives to work as a team to manage patient dose and maintain image quality. The installed imaging device will be only as successful as the working relationship between the parties. These challenges and conflicts must continually be overcome to provide the best patient care.
