Reducing variation in pediatric computed tomography decisions - Children's National

In a busy emergency department, ordering a CT scan can feel like the fastest path to clarity. For a child with trauma to the head from a fall or from a sports injury, or abdominal pain after a fall or a motor vehicle crash, imaging with CT scans can quickly rule out serious injuries. But CT scans also expose children to ionizing radiation which poses a long-term risk for cancer, so in many cases, the safest care is careful observation rather than CT scanning. That tension has long shaped pediatric emergency medicine: how to balance speed and certainty with safety, especially for children.

A new multicenter study published in Pediatrics looks at that question through an additional, critical lens. It examines whether a child's perceived race or ethnicity is associated with CT use after minor blunt head or abdominal trauma, and whether standardized clinical prediction rules help make care more consistent and equitable.

Why consistency matters

Decisions in emergency medicine happen quickly and often with incomplete information. Even when clinicians are acting with the best intentions, nonclinical factors can influence how risk is interpreted. Prior research has shown differences in CT use by race and ethnicity in pediatric trauma, raising concerns that variability in decision-making can contribute to inequities in care. Evidence-based clinical prediction rules are designed to reduce that variability. Developed through the Pediatric Emergency Care Applied Research Network, or PECARN, these tools help clinicians identify children at very low risk of serious injuries, where CT imaging is unlikely to add value.

What the study found

The study analyzed data from six pediatric Level 1 trauma centers, including more than 17,000 children evaluated for minor head trauma and more than 6,800 evaluated for blunt abdominal trauma. All clinicians were given a form with the PECARN CT rules on them to help inform their management of the injured patient. Researchers adjusted for injury severity, age, sex, site and social deprivation to focus on whether differences in CT use remained after accounting for clinical risk. For children with blunt abdominal trauma, CT use was similar across racial and ethnic groups. For minor blunt head trauma, CT use was also largely similar, with one exception. Hispanic children younger than 2 years were less likely to receive a head CT compared with the reference group. Among children 2 years and older, no significant differences were observed. The findings contrast with earlier studies that identified disparities in CT use and suggest that standardized decision support can reduce variation in care.

An accompanying editorial highlighted the importance of applying the PECARN rules to all injured patients to ensure this equitable care.

What's next

The study was led by Nisa S. Atigapramoj, MD, of UCSF Benioff Children's Hospital, and senior-authored by Nathan Kuppermann, MD, MPH, chief academic officer at Children's National Hospital and a national leader in pediatric emergency medicine research. "Dr. Atigapramoj and the study team set out to ask an important question about consistency in care," said Kuppermann. "What we see here is that when clinicians use objective, evidence-based prediction rules, like those developed through PECARN, they can reduce unnecessary imaging and help ensure children are evaluated based on clinical risk rather than subjective factors and receive safe and equitable care."

The lower CT use observed among Hispanic children younger than 2 years raises important questions that warrant further study, including how communication, language barriers and assessment of preverbal children may influence imaging decisions. Overall, the findings reinforce a broader lesson for pediatric emergency care. When evidence leads, variability narrows. Tools like the PECARN prediction rules not only help protect children from unnecessary radiation, but they also support more consistent care in some of the most time-pressured clinical settings.

Read the full study, "Perceived Race and Ethnicity on CT use in Children With Minor Head or Abdominal Trauma " and accompanying editorial, "Standardizing Clinical Care to Reduce Disparities", in Pediatrics.