Ionizing radiation from computed tomography versus anesthesia for magnetic resonance imaging in infants and children: patient safety considerations

A Correction to this article is available

This article has been updated


In the context of health care, risk assessment is the identification, evaluation and estimation of risk related to a particular clinical situation or intervention compared to accepted medical practice standards. The goal of risk assessment is to determine an acceptable level of risk for a given clinical treatment or intervention in association with the provided clinical circumstances for a patient or group of patients. In spite of the inherent challenges related to risk assessment in pediatric cross-sectional imaging, the potential risks of ionizing radiation and sedation/anesthesia in the pediatric population are thought to be quite small. Nevertheless both issues continue to be topics of discussion concerning risk and generate significant anxiety and concern for patients, parents and practicing pediatricians. Recent advances in CT technology allow for more rapid imaging with substantially lower radiation exposures, obviating the need for anesthesia for many indications and potentially mitigating concerns related to radiation exposure. In this review, we compare and contrast the potential risks of CT without anesthesia against the potential risks of MRI with anesthesia, and discuss the implications of this analysis on exam selection, providing specific examples related to neuroblastoma surveillance imaging.

This is a preview of subscription content, access via your institution.

Fig. 1

Change history

  • 25 January 2018

    The published version of this article incorrectly lists Dr. Joseph P. Cravero in the Department of Radiology at Boston Children’s Hospital. Dr. Cravero’s correct affiliation is given below.


  1. 1.

    Miglioretti DL, Johnson E, Williams A et al (2013) The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr 167:700–707

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Smith-Bindman R, Lipson J, Marcus R et al (2009) Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 169:2078–2086

    Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Brenner DJ, Elliston CD, Hall EJ, Berdon WE (2001) Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 176:289–296

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Brody AS, Frush DP, Huda W, Brent RL (2007) Radiation risk to children from computed tomography. Pediatrics 120:677–682

    Article  PubMed  Google Scholar 

  5. 5.

    Frush DP, Donnelly LF, Rosen NS (2003) Computed tomography and radiation risks: what pediatric health care providers should know. Pediatrics 112:951–957

    Article  PubMed  Google Scholar 

  6. 6.

    Schroeder AR, Duncan JR (2016) Overuse of medical imaging and its radiation exposure: who’s minding our children? JAMA Pediatr 170:1037–1038

    Article  PubMed  Google Scholar 

  7. 7.

    Little MP, Wakeford R, Tawn J et al (2009) Risks associated with low doses and low dose rates of ionizing radiation: why linearity may be (almost) the best we can do. Radiology 251:6–12

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Preston DL, Ron E, Tokuoka S et al (2007) Solid cancer incidence in atomic bomb survivors: 1958–1998. Radiat Res 168:1–64

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation, National Research Council (2006) Health risks from exposure to low levels of ionizing radiation: BEIR VII phase. National Academies Press, Washington, DC, p 2

    Google Scholar 

  10. 10.

    American Association of Physicists in Medicine (2011) Position statement. Radiation risks from medical imaging procedures. Accessed 5 Oct 2017

  11. 11.

    Paterson N, Waterhouse P (2011) Risk in pediatric anesthesia. Paediatr Anaesth 21:848–857

    Article  PubMed  Google Scholar 

  12. 12.

    Cravero JP (2009) Risk and safety of pediatric sedation/anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol 22:509–513

    Article  PubMed  Google Scholar 

  13. 13.

    Morray JP (2002) Anesthesia-related cardiac arrest in children. An update. Anesthesiol Clin North Am 20:1–28

    Article  Google Scholar 

  14. 14.

    Davidson AJ, Disma N, de Graaff JC (2016) Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 387:239–250

    Article  PubMed  Google Scholar 

  15. 15.

    DiMaggio C, Sun LS, Kakavouli A et al (2009) A retrospective cohort study of the association of anesthesia and hernia repair surgery with behavioral and developmental disorders in young children. J Neurosurg Anesthesiol 21:286–291

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    FDA Drug Safety Communication (2017) FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. Accessed 5 Oct 2017

  17. 17.

    Flick RP, Katusic SK, Colligan RC et al (2011) Cognitive and behavioral outcomes after early exposure to anesthesia and surgery. Pediatrics 128:e1053–e1061

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Wilder RT, Flick RP, Sprung J et al (2009) Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology 110:796–804

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Brenner DJ, Hall EJ (2007) Computed tomography — an increasing source of radiation exposure. N Engl J Med 357:2277–2284

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Townsend BA, Callahan MJ, Zurakowski D, Taylor GA (2010) Has pediatric CT at children’s hospitals reached its peak? AJR Am J Roentgenol 194:1194–1196

    Article  PubMed  Google Scholar 

  21. 21.

    Bachur RG, Levy JA, Callahan MJ et al (2015) Effect of reduction in the use of computed tomography on clinical outcomes of appendicitis. JAMA Pediatr 169:755–760

    Article  PubMed  Google Scholar 

  22. 22.

    Menoch MJA, Hirsh DA, Khan NS et al (2012) Trends in computed tomography utilization in the pediatric emergency department. Pediatrics 129:e690–e697

    Article  PubMed  Google Scholar 

  23. 23.

    Larson DB, Johnson LW, Schnell BM et al (2011) National trends in CT use in the emergency department: 1995–2007. Radiology 258:164–173

    Article  PubMed  Google Scholar 

  24. 24.

    Lee J, Kirscher J, Pawa S et al (2010) Computed tomography use in the adult emergency department of an academic urban hospital from 2001 to 2007. Ann Emerg Med 56:591–596

    Article  PubMed  Google Scholar 

  25. 25.

    Broder J, Warshauer DM (2006) Increasing utilization of computed tomography in the adult emergency department, 2000–2005. Emerg Radiol 13:25–30

    Article  PubMed  Google Scholar 

  26. 26.

    Lam DL, Larson DB, Eisenberg JD et al (2015) Communicating potential radiation-induced cancer risks from medical imaging directly to patients. AJR Am J Roentgenol 205:962–970

    Article  PubMed  Google Scholar 

  27. 27.

    Frush DP, Mercado-Dean M.-G. (2016) Misunderstanding about radiation risks from medical imaging abounds. AAP news. Accessed 5 Oct 2017

  28. 28.

    Doss M (2014) Letter to the editor: no increased risk of cancer from CT. AJR Am J Roentgenol 202:W410

    Article  PubMed  Google Scholar 

  29. 29.

    Pearce MS, Salotti JA, Little MP et al (2012) Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 380:499–505

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Mathews JD, Forsythe AV, Brady Z et al (2013) Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ 346:f2360

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Berrington de Gonzalez A, Salotti JA, McHugh K et al (2016) Relationship between pediatric CT and subsequent risk of leukaemia and brain tumors: assessment of the impact of underlying conditions. Br J Cancer 114:388–394

    Article  PubMed  Google Scholar 

  32. 32.

    Harvey HB, Brink JD, Frush DP (2015) Informed consent for radiation risk from CT is unjustified based on the current scientific evidence. Radiology 275:321–325

    Article  PubMed  Google Scholar 

  33. 33.

    Ozasa K, Shimizu Y, Suyama A et al (2012) Studies of the mortality of atomic bomb survivors, report 14, 1950–2003: an overview of cancer and noncancer diseases. Radiat Res 177:229–243

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Tubiana M, Feinendegen LE, Yang C, Kaminski JM (2009) The linear no-threshold relationship is inconsistent with radiation biologic and experimental data. Radiology 251:13–22

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Hendee WR, O’Connor MK (2012) Radiation risks of medical imaging: separating fact from fantasy. Radiology 264:312–321

    Article  PubMed  Google Scholar 

  36. 36.

    Aurengo A, Averbeck D, Bonnin A et al (2005) Dose-effect relationships and estimation of the carcinogenic effects of low doses of ionizing radiation. National Academy of Medicine, Paris

    Google Scholar 

  37. 37.

    Tubiana M (2005) Dose-effect relationship and estimation of the carcinogenic effects of low doses of ionizing radiation: the joint report of the Académie des sciences (Paris) and the Académie Nationale de Médecine. Int J Radiat Oncol Biol Phys 63:317–319

    Article  PubMed  Google Scholar 

  38. 38.

    Hendee WR (2013) Policy statement of the International Organization for Medical Physics. Radiology 267:326–327

    Article  PubMed  Google Scholar 

  39. 39.

    Nagasawa H, Little JB (1999) Unexpected sensitivity to the induction of mutations by very low doses of alpha-particle radiation: evidence for a bystander effect. Radiat Res 15:552–557

    Article  Google Scholar 

  40. 40.

    Mothersill C, Seymour CB (2006) Radiation-induced bystander effects and the DNA paradigm: an “out of field” perspective. Mutat Res 597:5–10

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Puskin JS (2009) Perspective on the use of LNT for radiation protection and risk assessment by the U.S. Environmental Protection Agency. Dose Response 7:284–291

    Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Boice JD Jr (2015) Radiation epidemiology and recent paediatric computed tomography studies. Ann IRCP 44:236–248

    Google Scholar 

  43. 43.

    Siegel JA, Sacks B, Pennington CW, Welsh JS (2017) Dose optimization to minimize radiation risk for children undergoing CT and nuclear medicine imaging is misguided and detrimental. J Nucl Med 58:865–868

    Article  PubMed  Google Scholar 

  44. 44.

    Siegel JA, Pennington CW, Sacks B (2016) Subjecting radiological imaging to the linear no-threshold hypothesis: a non sequitur of non-trivial proportion. J Nucl Med 58:1–6

    Article  PubMed  Google Scholar 

  45. 45.

    Feinendegen LE (2005) Evidence for beneficial low level radiation effects and radiation hormesis. Br J Radiol 78:3–7

    CAS  Article  PubMed  Google Scholar 

  46. 46.

    Lell M, Wildberger JE, Alkadhi H et al (2015) Evolution in computed tomography: the battle for speed and dose. Investig Radiol 50:629–644

    Article  Google Scholar 

  47. 47.

    Foster KR, Moulder JE, Budinger TF (2017) Will an MRI examination damage your genes? Radiat Res 187:1–6

    CAS  Article  PubMed  Google Scholar 

  48. 48.

    Gonzalez LP, Pignaton W, Kusano PS et al (2012) Anesthesia-related mortality in pediatric patients: a systematic review. Clinics 67:381–387

    Article  PubMed  PubMed Central  Google Scholar 

  49. 49.

    Faraoni D, Zurakowski D, Vo D et al (2016) Post-operative outcomes in children with and without congenital heart disease undergoing noncardiac surgery. J Am Coll Cardiol 67:793–801

    Article  PubMed  Google Scholar 

  50. 50.

    Ramamoorthy C, Haberkern CM, Bhananker SM et al (2010) Anesthesia-related cardiac arrest in children with heart disease: data from the pediatric perioperative cardiac arrest (POCA) registry. Anesth Analg 110:1376–1382

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Scherrer PD, Mallory MD, Cravero JP et al (2015) The impact of obesity on pediatric procedural sedation-related outcomes: results from the pediatric sedation research consortium. Paediatr Anaesth 25:689–697

    Article  PubMed  Google Scholar 

  52. 52.

    Tiret L, Desmonts JM, Hatton F, Vourc'h G (1986) Complications associated with anaesthesia – a prospective survey in France. Can Anaesth Soc J 33:336–344

    CAS  Article  PubMed  Google Scholar 

  53. 53.

    Cohen MM, Cameron CB, Duncan PG (1990) Pediatric anesthesia morbidity and mortality in the perioperative period. Anesth Analg 70:160–167

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Havidich JE, Beach M, Dierdorf SF et al (2016) Preterm versus term children: analysis of sedation/anesthesia adverse events and longitudinal risk. Pediatrics 137:e20150463

    Article  PubMed  Google Scholar 

  55. 55.

    Tay CL, Tan GM, Ng SB (2001) Critical incidents in paediatric anaesthesia: an audit of 10 000 anaesthetics in Singapore. Paediatr Anaesth 11:711–718

    CAS  Article  PubMed  Google Scholar 

  56. 56.

    Murat I, Constant I, Maud'huy H (2004) Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period. Paediatr Anaesth 14:158–166

    Article  PubMed  Google Scholar 

  57. 57.

    Cravero JP, Blike GT, Beach M et al (2006) Incidence and nature of adverse events during pediatric sedation/anesthesia for procedures outside the operating room: report from the pediatric sedation research consortium. Pediatrics 118:1087–1096

    Article  PubMed  Google Scholar 

  58. 58.

    Cravero JP, Beach ML, Blike GT et al (2009) The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the pediatric sedation research consortium. Anesth Analg 108:795–804

    CAS  Article  PubMed  Google Scholar 

  59. 59.

    Mallory MD, Baxter AL, Yanosky DJ, Cravero JP (2011) Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med 57:462–468

    Article  PubMed  Google Scholar 

  60. 60.

    Brambrink AM, Back SA, Riddle A et al (2012) Isoflurane-induced apoptosis of oligodendrocytes in the neonatal primate brain. Ann Neurol 72:525–535

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Creeley C, Dikranian K, Dissen G et al (2013) Propofol-induced apoptosis of neurones and oligodendrocytes in fetal and neonatal rhesus macaque brain. Br J Anaesth 110:i29–i38

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  62. 62.

    Creeley CE, Dikranian KT, Dissen GA et al (2014) Isoflurane-induced apoptosis of neurons and oligodendrocytes in the fetal rhesus macaque brain. Anesthesiology 120:626–638

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  63. 63.

    Hansen HH, Briem T, Dzietko M et al (2004) Mechanisms leading to disseminated apoptosis following NMDA receptor blockade in the developing rat brain. Neurobiol Dis 16:440–453

    CAS  Article  PubMed  Google Scholar 

  64. 64.

    Schenning KJ, Noguchi KK, Martin LD et al (2017) Isoflurane exposure leads to apoptosis of neurons and oligodendrocytes in 20- and 40-day old rhesus macaques. Neurotoxicol Teratol 60:63–68

    CAS  Article  PubMed  Google Scholar 

  65. 65.

    Wang C, Sadovova N, Fu X et al (2005) The role of the N-methyl-D-aspartate receptor in ketamine-induced apoptosis in rat forebrain culture. Neuroscience 132:967–977

    CAS  Article  PubMed  Google Scholar 

  66. 66.

    Zou X, Sadovova N, Patterson TA et al (2008) The effects of L-carnitine on the combination of, inhalation anesthetic-induced developmental, neuronal apoptosis in the rat frontal cortex. Neuroscience 151:1053–1065

    CAS  Article  PubMed  Google Scholar 

  67. 67.

    Jevtovic-Todorovic V, Hartman RE, Izumi Y et al (2003) Early exposure to common anesthetic agents causes widespread neurodegeneration in the developing rat brain and persistent learning deficits. J Neurosci 23:876–882

    CAS  PubMed  Google Scholar 

  68. 68.

    Liu F, Patterson TA, Sadovova N et al (2013) Ketamine-induced neuronal damage and altered N-methyl-D-aspartate receptor function in rat primary forebrain culture. Toxicol Sci 131:548–557

    CAS  Article  PubMed  Google Scholar 

  69. 69.

    Hansen TG, Pedersen JK, Henneberg SW et al (2011) Academic performance in adolescence after inguinal hernia repair in infancy: a nationwide cohort study. Anesthesiology 114:1076–1085

    Article  PubMed  Google Scholar 

  70. 70.

    Anand KJ, Coskun V, Thrivikraman KV et al (1999) Long-term behavioral effects of repetitive pain in neonatal rat pups. Physiol Behav 66:627–637

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  71. 71.

    Anand KJ, Hall RW (2007) Controversies in neonatal pain: an introduction. Semin Perinatol 31:273–274

    CAS  Article  PubMed  Google Scholar 

  72. 72.

    Anand KJ, Palmer FB, Papanicolaou AC (2013) Repetitive neonatal pain and neurocognitive abilities in ex-preterm children. Pain 154:1899–1901

    Article  PubMed  Google Scholar 

  73. 73.

    Anand KJ, Scalzo FM (2000) Can adverse neonatal experiences alter brain development and subsequent behavior? Biol Neonate 77:69–82

    CAS  Article  PubMed  Google Scholar 

  74. 74.

    Taddio A, Katz J (2005) The effects of early pain experience in neonates on pain responses in infancy and childhood. Paediatr Drugs 7:245–257

    Article  PubMed  Google Scholar 

  75. 75.

    Wagner LK (2014) Should risk from medical imaging be assessed in the absence of benefit and vice versa. Pediatr Radiol 44:414–417

    Article  PubMed  Google Scholar 

  76. 76.

    Slovis T (2002) The ALARA concept in pediatric CT: myth or reality? Radiology 223:5–6

    Article  PubMed  Google Scholar 

  77. 77.

    Children’s Oncology Group (2017) Response and biology-based risk factor-guided therapy in treating younger patients with non high-risk neuroblastoma. In: study ANBL1232

    Google Scholar 

  78. 78.

    Children’s Oncology Group (2017) Comparing two different myeloablation therapies in treating young patients who are undergoing a stem cell transplant for high-risk neuroblastoma. In: study ANBL0532

    Google Scholar 

  79. 79.

    Children’s Oncology Group (2017) Iobenguane I-131 or Crizotinib and standard therapy in treating younger patients with newly-diagnosed high-risk neuroblastoma or ganglioneuroblastoma. In: study ANBL1531

    Google Scholar 

  80. 80.

    Owens C, Li BK, Thomas KE, Irwin MS (2016) Surveillance imaging and radiation exposure in the detection of relapsed neuroblastoma. Pediatr Blood Cancer 63:1786–1793

    CAS  Article  PubMed  Google Scholar 

  81. 81.

    McHugh K, Roebuck DJ (2014) Pediatric oncology surveillance imaging: two recommendations. Abandon CT scanning, and randomize to imaging or solely clinical follow-up. Pediatr Blood Cancer 61:3–6

    Article  PubMed  Google Scholar 

  82. 82.

    Brisse HJ, McCarville MB, Granata C et al (2011) Guidelines for imaging and staging of neuroblastic tumors: consensus report from the International Neuroblastoma Risk Group project. Radiology 261:243–257

    Article  PubMed  Google Scholar 

  83. 83.

    Hiorns M, Owens C (2011) Radiology of neuroblastoma in children. Eur Radiol 11:2071–2081

    Article  Google Scholar 

  84. 84.

    Sauvat F, Brisse H, Magdeleinat P et al (2006) The transmanubrial approach: a new operative approach to cervicothoracic neuroblastoma in children. Surgery 139:109–114

    Article  PubMed  Google Scholar 

  85. 85.

    Siegel MJ, Ishwaran H, Fletcher BD et al (2002) Staging of neuroblastoma at imaging: report of the radiology diagnostic oncology group. Radiology 223:168–175

    Article  PubMed  Google Scholar 

  86. 86.

    Gauguet JM, Pace-Emerson T, Grant FD et al (2017) Evaluation of the utility of 99m Tc-MDP bone scintigraphy versus MIBG scintigraphy and cross-sectional imaging for staging patients with neuroblastoma. Pediatr Blood Cancer 64(11)

  87. 87.

    Kushner BH (2004) Neuroblastoma: a disease requiring a multitude of imaging studies. J Nucl Med 45:1172–1188

    PubMed  Google Scholar 

  88. 88.

    Weiser DA, Kaste SC, Siegel MJ, Adamson PC (2013) Imaging in childhood cancer: a Society for Pediatric Radiology and Children’s oncology group joint task force report. Pediatr Blood Cancer 60:1253–1260

    Article  PubMed  PubMed Central  Google Scholar 

  89. 89.

    Huda W (2015) Radiation risks: what is to be done? AJR Am J Roentgenol 204:124–127

    Article  PubMed  Google Scholar 

  90. 90.

    Barry MJ, Edgman-Levitan S (2012) Shared decision making — the pinnacle of patient-centered care. N Engl J Med 366:780–781

    CAS  Article  PubMed  Google Scholar 

  91. 91.

    Probst MA, Kanzaria HK, Schriger DL (2014) A conceptual model of emergency physician decision making for head computed tomography in mild head injury. Am J Emerg Med 32:645–650

    Article  PubMed  PubMed Central  Google Scholar 

  92. 92.

    MacDonald RJ, McDonald JS, Kallmes DF et al (2015) Intracranial gadolinium deposition after contrast-enhanced MR imaging. Radiology 275:772–782

    Article  Google Scholar 

  93. 93.

    Stojanov D, Aracki-Trenkic A, Benedeto-Stojanov D (2016) Gadolinium deposition within the dentate nucleus and globus pallidus after repeated administrations of gadolinium-based contrast agents — current status. Neuroradiology 58:433–441

    Article  PubMed  Google Scholar 

  94. 94.

    Kanda T, Fukusago T, Matsuda M et al (2015) Gadolinium-based contrast agent accumulates in the brain even in subjects without severe renal dysfunction: evaluation of autopsy brain specimens with inductively coupled plasma mass spectroscopy. Radiology 276:228–232

    Article  PubMed  Google Scholar 

  95. 95.

    Kanda T, Ishii K, Kawaguchi H et al (2014) High signal intensity in the nucleus and globus pallidus on unenhanced T1-weighted MR images: relationship with increasing cumulative dose of a gadolinium-based contrast material. Radiology 270:834–841

    Article  PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Michael J. Callahan.

Ethics declarations

Conflicts of interest


Additional information

A correction to this article is available online at

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Callahan, M.J., MacDougall, R.D., Bixby, S.D. et al. Ionizing radiation from computed tomography versus anesthesia for magnetic resonance imaging in infants and children: patient safety considerations. Pediatr Radiol 48, 21–30 (2018).

Download citation


  • Anesthesia
  • Children
  • Computed tomography
  • Ionizing radiation
  • Magnetic resonance imaging
  • Neuroblastoma
  • Sedation