Children With Chronic Diseases May Accumulate Surprisingly High Radiation Doses From Medical Imaging

Children living with chronic illnesses often need scan after scan to monitor their conditions, guide treatments, and check for complications. Each individual image may seem harmless, but a new narrative review published in Pediatric Radiology warns that these exposures add up. An international team of pediatric radiology researchers led by Ance Eimane of Riga Stradins University and Ilze Apine of Children’s Clinical University Hospital in Riga systematically examined the medical literature to determine just how much ionizing radiation children with non-cancer chronic diseases receive over the course of their care. The results suggest that for some patient groups, cumulative effective doses from diagnostic imaging can climb into the same range associated with meaningful long-term cancer risk, prompting a renewed call for stricter radiation protection in this vulnerable population.

The review team searched three major biomedical databases, SCOPUS, PubMed, and Web of Science, and identified 129 records for consideration. After screening, 41 studies met the criteria for inclusion and provided usable data on disease type, imaging modalities, and reported radiation dose metrics. The populations covered were diverse: children with congenital heart disease, scoliosis, cystic fibrosis, inflammatory bowel disease, esophageal atresia, osteogenesis imperfecta, spina bifida, hydrocephalus, urological conditions, bleeding disorders, craniosynostosis, cleft palate, asthma, pulmonary hypertension, and organ transplant recipients, among others. This breadth is important, because the authors found that radiation exposure was not uniform across conditions but was strongly influenced by the specific diagnosis, the age at which imaging began, the severity of the disease, and the imaging modalities that each disease trajectory demands.

One of the clearest technical findings of the review is that the modality mix matters enormously. Plain radiography, the conventional X-ray, was by far the most frequently performed examination across nearly all chronic disease groups. However, radiographs deliver relatively small doses per examination, and the review concluded that they were not the dominant contributors to cumulative burden. Instead, computed tomography and fluoroscopy, both of which involve substantially higher dose outputs and, in the case of fluoroscopy, prolonged real-time exposure, accounted for the majority of the cumulative effective dose reported in the included studies. In some patient groups, cumulative doses from these higher-yield modalities exceeded 20 to 50 millisieverts, thresholds that radiation protection specialists regard as significant when accumulated during childhood.

The biological rationale for concern lies in the interaction between ionizing radiation and growing tissue. Effective dose, measured in millisieverts, is a calculated quantity that weights absorbed dose by the radiation sensitivity of the organs exposed, allowing comparison across different types of examinations. Pediatric patients are more sensitive to radiation-induced carcinogenesis than adults for several reasons: their tissues are actively dividing, their longer life expectancy leaves more time for radiation-induced cancers to manifest, and stochastic effects, meaning probabilistic DNA damage that may lead to malignancy decades later, do not have a known safe threshold in the linear no-threshold framework commonly used for protection purposes. A child with a chronic disease diagnosed in infancy may therefore face decades of potential risk following exposures delivered in the first years of life.

Several disease-specific patterns emerged from the included literature. Children with congenital heart disease, particularly those requiring staged surgical palliation or interventional cardiac catheterization, consistently appeared among the most heavily exposed groups, because cardiac fluoroscopy and CT angiography are central to both diagnosis and treatment. Studies cited in the review estimated cumulative doses during staged single-ventricle palliation and documented measurable chromosomal DNA damage in exposed children. In scoliosis management, repeated spinal radiographs required for curve monitoring, combined with intraoperative imaging, produced substantial cumulative exposure, prompting the development of low-dose slot-scanning systems that reduce dose compared with standard radiographs. Children with inflammatory bowel disease frequently underwent CT during acute flare-ups before magnetic resonance enterography became the preferred alternative, and retrospective cohorts documented cumulative doses high enough to raise malignancy concerns.

Other chronic conditions illustrated subtler but still meaningful exposure pathways. Infants with esophageal atresia undergo repeated contrast studies and fluoroscopic procedures in the first months of life, and one French study cited in the review explicitly asked how low these cumulative doses could realistically be pushed. Children with spina bifida and shunt-treated hydrocephalus accumulated exposure through serial imaging of the brain and spine, while pediatric stone disease generated exposure through fluoroscopy-guided procedures such as percutaneous nephrolithotomy and shockwave lithotripsy. Even conditions considered lower risk, such as developmental dysplasia of the hip, appeared in the literature, with one study reassuringly concluding that repeated pelvic radiographs during harness treatment carry very low radiation risk. Meanwhile, pediatric cleft palate patients showed a three- to five-fold increase in cumulative radiation exposure from dental radiology compared with age- and gender-matched peers.

Organ transplant recipients represent another group highlighted by the review. Children receiving heart transplants accumulated considerable exposure within the first post-transplant year through echocardiography-adjacent imaging, catheterization, and CT surveillance for complications such as rejection, infection, and vascular stenosis. A cohort study of pediatric transplant recipients more broadly documented diagnostic imaging exposure that was markedly elevated compared with healthy children. Similarly, children with osteogenesis imperfecta, the brittle bone disorder, required serial skeletal radiographs throughout childhood to monitor fractures and surgical interventions, with one cited study estimating associated lifetime cancer risk from these cumulative exposures.

What emerges from the synthesis is not a reason for alarm or for avoiding medically necessary imaging, the authors emphasize, but rather a roadmap for safer practice. The review calls for evidence-based referral guidelines specific to pediatric chronic disease populations, so that clinicians weigh the diagnostic yield of each examination against its dose contribution within the context of a child’s total imaging history. It also highlights the importance of standardized imaging protocols optimized for children, including weight- and age-based parameter adjustment, substitution of ultrasound or magnetic resonance imaging where diagnostically equivalent, and the use of dose modulation technologies in CT. Equally critical is dose reporting: recording cumulative effective dose in the patient record so that ordering physicians can see the full picture rather than evaluating each request in isolation. Principles such as ALARA, keeping exposure as low as reasonably achievable, and its extensions emphasizing appropriate use and avoiding unnecessary procedures, are framed as essential operational standards rather than abstract ideals.

The authors also point toward the practical infrastructure needed to make dose stewardship routine. Electronic health record integration of dose-tracking systems, standardized dose metrics across institutions, and education of referring clinicians about the relative doses of different modalities all feature in the review’s recommendations. International collaborative efforts, such as the HARMONIC project cohort studies on radiation exposure in children with congenital heart disease cited within the review, exemplify the kind of multinational, disease-stratified data collection the field needs to quantify risk precisely and track the impact of protection measures over time. The review itself was a literature-based analysis, so no individual patient data were collected, and no ethics approval was required.

For families, the message is one of partnership rather than fear. Parents of children with chronic diseases can and should ask whether each proposed imaging examination is necessary, whether a lower-dose alternative is available, and whether the child’s cumulative imaging history has been considered. For the medical community, the review consolidates more than a decade of evidence into a single argument: the child with a chronic disease is not a series of isolated imaging encounters but a single, longitudinally exposed patient whose total radiation burden deserves active management. As imaging technology continues to advance and dose reduction becomes increasingly feasible, the findings serve as both a benchmark of current exposure levels and a challenge to ensure that the children who depend most on medical imaging are also the best protected from its long-term consequences.

Subject of Research: Cumulative ionizing radiation exposure from medical imaging in pediatric patients with chronic diseases

Article Title: Cumulative ionizing radiation exposure in pediatric patients with chronic diseases: a narrative review

Article References: Eimane, A., Francavilla, M., Grigorjevs, A., Granata, C., Limantoro, I., Olteanu, B.-S., Sofia, C., Nievelstein, R. A., Kardos, M., Kasznia-Brown, J., Salerno, S., & Apine, I. (2026). Cumulative ionizing radiation exposure in pediatric patients with chronic diseases: a narrative review. Pediatric Radiology. https://doi.org/10.1007/s00247-026-06785-x

Image Credits: AI Generated

DOI: 10.1007/s00247-026-06785-x

Keywords: pediatric radiology, cumulative radiation dose, ionizing radiation, CT, fluoroscopy, radiation protection, chronic disease, effective dose, congenital heart disease, scoliosis, medical imaging, ALARA