While the role of ultrasound in adult medicine continues to diminish in an era of faster and better MRI machines, its role in pediatric medicine continues to rise. The ability to image children without sedation, lack of radiation, higher resolution, better contrast and lower cost all contribute to the utility of this modality. With reimbursement changes, the pressure to utilize and maximize sonography will increase as insurance carriers and hospitals start sharing the cost of expensive modalities and workups. As the payers start collecting more data and holding care providers responsible for their utilization, the pressure will increase further.
Because CT scans involve not insignificant amount of radiation and MRIs require sedation, ultrasound serves as a gateway modality that is used to screen patients before they go on to CT or MRI. Without perfecting sonography, it is difficult if not impossible to build a sizeable CT or MRI business especially in pediatric setting. In practice all three modalities have a complimentary role, though in practice most cases can be safely managed simply with single ultrasound or serial follow up ultrasounds to monitor a known disease process.
It is no doubt that more innovations in acoustic imaging are being approved by the FDA and being rolled out in the community, allowing both radiologists and other clinicians in providing better care, faster, often at a cheaper cost.
Having briefly touched upon the integral and increasing role of sonography in pediatric medicine, it would be prudent to highlight some applications of this modality that are often forgotten or less thought about: * A neonate or infant with persistent vomiting often gets an evaluation with upper GI series, which rightfully is used to rule out malrotation. However, overwhelming majority of these infants do not have malrotation, but rather suffer from gastroesophageal reflux or pyloric stenosis. In the appropriate age group, it is always prudent to first start with pyloric ultrasound to rule it out and then go to upper GI series if symptoms persist. * Many children having foreign bodies of various types prompting a plain film evaluation. However, it is important to remember that plain films only detect radiopaque foreign bodies whereas ultrasound can detect essentially all types of foreign bodies and characterize them better. Many pediatric surgeons utilize the same modality in order to find and remove such foreign bodies. * A child with flank pain often ends up with CT of the abdomen and pelvis without contrast to assess for renal and collecting system calculi; however a combination of single abdominal plain film and renal ultrasound can give just as much information in children that are typically small and thin allowing both of these modalities to detect much more pathology. Additionally serial urenal ltrasound can safely be performed to follow these patients over time to assess for passage of calculi and resolution of hydronephrosis. * A patient with right upper quadrant pain will often get evaluated with right upper quadrant or gallbladder ultrasound, however, one must keep in mind that pain from epigastrium or right lower quadrant may refer to the right upper quadrant. Additionally, children often have difficulty localizing their pain and often complain of pain in different quandrants at different points in time. As such a complete abdominal ultrasound is always indicated especially since the cost difference between limited and complete abdominal ultrasound is little to none depending on the insurance status of the patient * A female with lower abdominal pain will often be evaluated with either abdominal or pelvic ultrasound, however, both are often necessary to evaluate the appendix, ovaries, urinary bladder, ipsilateral ureter and ipsilateral kidney. Ruling out appendicitis is often not as clinically useful as ruling out acute pathology with essentially all of the organs that could be causing such pain. Such children can then be safely followed clinically without further imaging.
There are many other indications of sonography that are beyond the scope of this article and are difficult for clinicians to remember. That is why clinicians should never hesitate to call their pediatric radiologist when there is a question about appropriate modality. This type of rapport also enables a clinicians to inform the radiologists regarding all of the relevant clinical information, leading to a clinically pertinent interpretation and thus improved quality of care.