CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

This chapter presents a review of existing literature relevant to the study. It covers conceptual,
empirical, and theoretical perspectives on radiation protection, particularly in the context of
pediatric radiology and radiotherapy. The chapter begins by exploring key concepts such as
ionizing radiation, radiation protection, pediatric sensitivity to radiation, and the roles of
radiographers. Empirical studies are also examined to understand existing gaps in knowledge and
practice, followed by a review of relevant theoretical frameworks guiding radiation safety. The
chapter concludes with an appraisal of literature that highlights the need for the present study.

2.1 Conceptual Review

2.1.1 Concept of Ionizing Radiation

Ionizing radiation refers to electromagnetic or particulate radiation with sufficient energy to

detach electrons from atoms, thereby ionizing them and inducing molecular and cellular changes
in biological tissues (International Atomic Energy Agency [IAEA], 2018). In clinical medicine,
the most common sources of ionizing radiation include diagnostic imaging modalities such as X-
rays, computed tomography (CT), and fluoroscopy, as well as therapeutic applications like
external beam radiotherapy and brachytherapy (UNSCEAR, 2020). These technologies are
indispensable in modern healthcare, providing critical diagnostic insights and effective cancer
treatments. However, they also carry inherent risks, particularly when misused or administered
without adherence to strict radiation protection standards.

Despite the clinical value of ionizing radiation, its application—especially in pediatric

populations—must be approached with heightened caution. This is primarily due to the increased
radiosensitivity of children’s developing tissues and organs, coupled with their longer life
expectancy, which allows more time for radiation-induced effects such as malignancies to
manifest (Brenner & Hall, 2007; ICRP, 2007). For instance, studies have shown that pediatric
patients are several times more vulnerable to radiation-induced cancer than adults exposed to the
same dose (Pearce et al., 2012). This risk is exacerbated in repeated imaging or therapeutic
procedures, which may cumulatively lead to significant biological burden if protective strategies
are not rigorously applied.

One of the major concerns in pediatric radiology is the inadvertent overexposure that can occur
when adult-based imaging protocols are inappropriately scaled down for children. CT scans, in
particular, contribute a disproportionate share of medical radiation exposure, and pediatric
patients often receive higher doses than necessary due to fixed scanner settings or insufficient
protocol adjustments (Frush et al., 2013). Additionally, in low- and middle-income countries,
inadequate access to pediatric-specific equipment and limited staff training further compound the
risk of unsafe practices (Ofori et al., 2020).

The importance of radiation protection in pediatric imaging and therapy is therefore underscored
by international efforts such as the “Image Gently” campaign, which advocates for tailored
protocols, the use of non-ionizing alternatives when possible, and increased awareness among
healthcare professionals (Goske et al., 2008). Effective radiation protection involves multiple
strategies, including proper shielding of radiosensitive organs, judicious justification of every
radiologic examination, optimization of exposure parameters according to the child’s size and
clinical need, and the ongoing education and certification of radiographers in pediatric safety
standards (IAEA, 2018; WHO, 2016).

In radiotherapy, although the intent is curative or palliative, ensuring that only the target tissues
receive the prescribed dose while sparing surrounding normal tissues is critical. Advances such
as image-guided radiotherapy (IGRT), intensity-modulated radiotherapy (IMRT), and proton
therapy have enhanced the precision of pediatric cancer treatment. Nevertheless, without
rigorous adherence to planning protocols, even these technologies can pose significant long-term
risks, such as secondary neoplasms or developmental disorders (Vasconcelos et al., 2021).

In light of these issues, it becomes evident that both diagnostic and therapeutic applications of
ionizing radiation in pediatric care require a well-structured framework of safety protocols,
continuous monitoring, and personnel competency. The ethical imperative to "first, do no harm"
is especially pertinent when dealing with vulnerable populations such as children, making the
study and enforcement of pediatric radiation protection not only a scientific necessity but a moral
obligation.
The biological effects of ionizing radiation stem from its capacity to break chemical bonds and
damage DNA, leading to mutations, cell death, or carcinogenesis (Hall & Giaccia, 2019). Acute
exposure may result in deterministic effects such as skin erythema or organ dysfunction, while
chronic or repeated low-dose exposures elevate the risk of stochastic outcomes, including
malignancies and genetic alterations (ICRP, 2007). In pediatric populations, these risks are
substantially heightened. Children’s tissues are more radiosensitive due to their higher rates of
cellular proliferation and organ development, and because they have a longer post-exposure
lifespan, the probability of late-onset effects—such as secondary cancers—increases (Brenner &
Hall, 2007; Pearce et al., 2012).

Furthermore, the biological impact of ionizing radiation in children is not limited to

carcinogenesis. Sub-lethal DNA damage can lead to genomic instability, impaired tissue growth,
and disruptions in neurocognitive development, particularly when critical organs such as the
brain, thyroid, or gonads are exposed during sensitive developmental windows (Mertens et al.,
2008; Ron et al., 2012). Studies have shown that even low-dose radiation, when delivered to
specific anatomical regions during childhood, can have profound consequences on endocrine
function, fertility, and psychological well-being later in life (UNSCEAR, 2013).

Unlike deterministic effects, which have dose thresholds and predictable clinical manifestations,
stochastic effects follow a probabilistic model, implying that there is no safe threshold below
which radiation is guaranteed to be harmless (ICRP, 2007). This uncertainty necessitates a
precautionary approach in pediatric imaging and therapy. Radiation-induced malignancies such
as leukemia, brain tumors, and thyroid cancer have been observed with increased incidence in
pediatric cohorts exposed to diagnostic and therapeutic radiation (Mathews et al., 2013). For
example, Pearce et al. (2012) reported a statistically significant association between cumulative
radiation dose from childhood CT scans and subsequent development of leukemia and brain
tumors.

These findings underscore the urgent need for rigorous implementation of radiation protection
principles such as justification—ensuring each radiologic or therapeutic procedure is clinically
warranted—and optimization—tailoring exposure parameters to the child’s size, age, and clinical
indication (IAEA, 2018). Moreover, consistent application of shielding techniques, proper
patient positioning, and periodic equipment quality control checks are essential safeguards
against unintended radiation exposure.

The heightened vulnerability of pediatric patients to ionizing radiation also places a

responsibility on healthcare providers to pursue continuing education and training focused on
pediatric radiology and radioprotection protocols. Lack of awareness or inadequate knowledge
among radiographers and other imaging professionals can lead to preventable errors, unnecessary
repeat scans, and suboptimal safety practices (Ofori et al., 2020). As such, integrating pediatric-
specific content into radiography curricula and ongoing professional development programs is a
critical component of ensuring long-term patient safety.

Therefore, the biological risks posed by ionizing radiation in children are well-established,
compelling the medical community to prioritize protective strategies in every phase of imaging
and therapeutic care. Fostering a culture of radiation safety—supported by evidence-based
policies, continuous training, and inter-professional collaboration—is essential in mitigating both
the immediate and long-term consequences of pediatric radiation exposure.

Moreover, the effective dose required for diagnostic adequacy in children is generally lower than
in adults, yet adult-based protocols are often mistakenly applied, leading to overexposure (Frush
et al., 2013). For instance, studies have shown that children undergoing CT scans are more likely
to receive disproportionately higher doses relative to their size and diagnostic needs, particularly
in settings where pediatric-specific protocols and equipment are lacking (Goske et al., 2008;
Ofori et al., 2020). In therapeutic contexts, improper shielding or inadequate treatment planning
can lead to unintended irradiation of healthy tissues, causing growth abnormalities, hormonal
imbalances, or cognitive delays in young patients (Vasconcelos et al., 2021).

This misapplication of adult imaging or treatment protocols in pediatric care reflects a broader
systemic challenge: the underrepresentation of child-specific considerations in routine
radiological practice. Despite the availability of international guidelines such as those from the
Image Gently Alliance and the International Commission on Radiological Protection (ICRP),
implementation remains inconsistent, especially in low-resource settings where access to
pediatric-optimized equipment and trained personnel is limited (ICRP, 2013; Strauss & Goske,
2011). As a result, many children are subjected to unnecessarily high radiation doses, which not
only increase immediate risks but also contribute to the cumulative radiation burden over time—
a critical concern given the increasing reliance on imaging for medical decision-making in
pediatrics.

Furthermore, in therapeutic radiology, especially in the treatment of childhood cancers, precision

is paramount. Yet, outdated equipment or poor-quality assurance mechanisms can compromise
the accuracy of dose delivery, exposing adjacent organs and tissues to unintended radiation. This
is particularly concerning in the case of developing brain tissue, endocrine glands, and
reproductive organs, where even minimal radiation spillage can result in lifelong impairments
(Vasconcelos et al., 2021; Mertens et al., 2008). Inaccurate beam collimation, poor
immobilization techniques, and a lack of individualized treatment planning have all been cited as
contributors to overexposure and radiation-induced complications in pediatric radiotherapy
(UNSCEAR, 2020).

Moreover, these technical shortcomings are often compounded by a lack of multidisciplinary

collaboration in treatment planning and monitoring. In pediatric radiotherapy, input from
radiation oncologists, medical physicists, pediatricians, and radiographers is essential to ensure
that doses are accurately calculated, delivered, and documented. However, in many clinical
environments, communication gaps and insufficient protocol standardization hinder this
collaborative process, leading to suboptimal patient outcomes (IAEA, 2018).

To address these challenges, there is a pressing need for systemic reform that encompasses
equipment upgrades, staff training, policy enforcement, and quality assurance mechanisms.
Pediatric-specific dose reference levels (DRLs), regular audits, and continuing education
programs are essential tools for bridging the gap between existing knowledge and actual clinical
practice (Frush et al., 2013; Ofori et al., 2020). Equally important is the institutional commitment
to fostering a culture of safety—one in which radiation protection is not treated as an optional
protocol, but as a fundamental aspect of pediatric healthcare delivery.

While the benefits of ionizing radiation in diagnosing and treating pediatric conditions are
undeniable, the risks associated with improper use are profound and preventable. Enhancing
radiation protection in pediatric settings requires not only technical adjustments and protocol
revisions but also a paradigm shift toward prioritizing child-centered care at every level of
radiological practice. Given these concerns, the use of ionizing radiation in pediatric care must
be guided by the ALARA (As Low As Reasonably Achievable) principle and supported by
rigorous training, appropriate technology, and strict compliance with international safety
guidelines (WHO, 2016). Thus, understanding and mitigating the biological impacts of ionizing
radiation remains a central priority in pediatric radiology and oncology.

2.1.2 Concept of Radiation Protection

Radiation protection refers to a systematic framework of practices, protocols, and technologies

aimed at minimizing the adverse health effects associated with exposure to ionizing radiation.
These measures are implemented to protect not only patients but also healthcare professionals
and the general public. The primary goal is to reduce radiation doses to levels that are as low as
reasonably achievable, while still ensuring that the clinical benefits of imaging or therapy are
maintained (International Commission on Radiological Protection [ICRP], 2007). This
framework is especially crucial in medical contexts where ionizing radiation is frequently used
for diagnostic and therapeutic purposes.

Key components of radiation protection include shielding of radiosensitive organs, routine

calibration and maintenance of equipment, the application of dose-limiting protocols, and strict
adherence to the ALARA principle—“As Low As Reasonably Achievable.” The ALARA
principle emphasizes the importance of minimizing radiation exposure by considering economic
and societal factors without compromising diagnostic accuracy or therapeutic effectiveness
(European Commission, 2014). Equally important are the principles of justification and
optimization. Justification ensures that any radiological procedure is medically warranted, while
optimization ensures that once a procedure is justified, all efforts are made to keep radiation
doses within safe limits (World Health Organization [WHO], 2016).

In pediatric radiology and radiotherapy, the implementation of radiation protection protocols

demands particular vigilance. Due to their smaller body size, rapidly dividing cells, and longer
life expectancy, children are significantly more sensitive to ionizing radiation than adults
(Brenner & Hall, 2007). Therefore, even relatively low radiation doses can increase the risk of
stochastic effects such as cancer and hereditary disorders later in life. As such, dose optimization
in pediatric settings must be tailored to age, size, and clinical need to avoid overexposure (Frush
et al., 2013).
International regulatory bodies such as the ICRP and WHO have issued comprehensive
guidelines to improve radiation safety in medical imaging, particularly for pediatric patients.
These include the use of child-specific imaging protocols, dedicated pediatric equipment, and
education programs for radiology staff (ICRP, 2013; WHO, 2016). For example, the ICRP
recommends the establishment of diagnostic reference levels (DRLs) specific to pediatric age
groups to serve as benchmarks for acceptable dose ranges in clinical settings (ICRP, 2007).

Furthermore, professional initiatives such as the Image Gently Alliance have played a vital role
in raising awareness and providing resources to encourage safe imaging practices for children.
These initiatives promote the development of child-friendly imaging protocols, emphasize the
importance of communication among healthcare providers, and encourage parents to ask about
radiation exposure during medical imaging (Strauss & Goske, 2011).

Ultimately, radiation protection in pediatric healthcare is not merely a technical issue—it is an

ethical obligation. Healthcare providers must ensure that every exposure is justified, every
procedure is optimized, and every effort is made to protect the most vulnerable population from
preventable harm. Continuous education, policy enforcement, and international collaboration
remain indispensable to achieving this goal in both diagnostic and therapeutic radiological
practice.

An integral yet sometimes underemphasized aspect of effective radiation protection is personnel

training and competence. Radiographers, radiologists, and other healthcare workers must be
thoroughly trained in radiation safety principles, pediatric anatomy and physiology, as well as in
the appropriate operation of imaging equipment tailored for children. Lack of proper knowledge
or skill can result in incorrect positioning, repeat imaging, or excessive exposure, particularly in
children who may be less cooperative or more anxious during procedures (Tzedakis et al., 2010).
Periodic continuing education, certification programs, and adherence to professional standards
help ensure that healthcare workers remain competent in their roles and updated on best practices
in radiation protection.

Moreover, the design of radiological facilities contributes significantly to radiation protection.

Shielded walls, proper room layouts, leaded glass viewing windows, and controlled access areas
all play essential roles in minimizing occupational exposure to staff and inadvertent exposure to
the public. In pediatric departments, the environment should be made child-friendly to minimize
anxiety and movement, which can reduce the need for sedation and repeat scans, thereby further
lowering radiation exposure (Seuri et al., 2013).

Technological advancement has also provided tools to support pediatric radiation protection.
Dose-reduction technologies, such as automatic exposure control, pulsed fluoroscopy, and
iterative reconstruction algorithms in CT, allow for lower radiation doses without compromising
image quality (Kalra et al., 2014). The integration of Picture Archiving and Communication
Systems (PACS) and Radiology Information Systems (RIS) also enables tracking of cumulative
radiation doses, which is vital for long-term dose monitoring in children who may undergo
multiple imaging sessions over time.

Policy and institutional support form another pillar of effective radiation protection. Hospitals
and imaging centers must have clear, enforceable radiation safety protocols and quality
assurance programs. Institutional audits, peer reviews, and compliance checks with international
safety standards ensure that protocols are not only in place but are also followed. Leadership
commitment to patient safety, including investment in pediatric-specific equipment and staff
training, reinforces a culture of radiation safety.

In summary, radiation protection is a multifaceted discipline that blends technical precision,

clinical justification, regulatory guidance, and ethical responsibility. Its importance in pediatric
healthcare cannot be overstated, given the lifelong implications of early radiation exposure.
Through the synergy of technological innovation, continuous professional education,
institutional policy, and international collaboration, it is possible to maintain a high standard of
care while safeguarding children from unnecessary radiation risks.

2.1.3 Concept of Paediatric Radiology and Radiotherapy

Paediatric radiology is a specialized branch of diagnostic radiology that is dedicated to imaging

and diagnosing illnesses in neonates, infants, children, and adolescents. Unlike adult radiology,
pediatric imaging must account for the dynamic anatomical and physiological changes associated
with growth and development. These differences necessitate the use of pediatric-specific imaging
protocols, techniques, and equipment that are designed to minimize radiation exposure while
maintaining diagnostic accuracy (Mettler et al., 2013).
Children are particularly vulnerable to the effects of ionizing radiation due to their smaller body
size, rapidly dividing cells, and longer expected lifespan during which radiation-induced effects
may manifest. As such, pediatric radiology emphasizes adherence to the ALARA (As Low As
Reasonably Achievable) principle. This includes adjusting imaging parameters such as tube
current and voltage based on the child’s size, employing shielding where appropriate, and using
modalities that do not involve ionizing radiation (e.g., ultrasound or MRI) when feasible (Frush
et al., 2013; Brady et al., 2018).

In practice, radiographers play a vital role in optimizing image acquisition while ensuring patient
safety. They must be skilled in using child-appropriate immobilization techniques to reduce
motion artifacts, which can lead to repeat exposures and unnecessary dose escalation (Goske et
al., 2008). Additionally, communication with the child and caregivers is crucial to easing
anxiety, improving cooperation, and thereby improving the quality of the imaging process.

Paediatric radiotherapy, on the other hand, involves the use of ionizing radiation for therapeutic
purposes, particularly in the management of pediatric malignancies such as brain tumors,
Hodgkin’s lymphoma, and leukemia. This form of treatment demands a high level of precision
and multidisciplinary collaboration, as the goal is to effectively eradicate cancerous cells while
sparing as much healthy tissue as possible. This is particularly important in children, whose
developing organs and systems are highly radiosensitive (Merchant et al., 2008).

The long-term risks associated with pediatric radiotherapy include cognitive dysfunction,
endocrine disorders, growth abnormalities, and an increased lifetime risk of secondary cancers.
These risks underscore the importance of meticulous treatment planning, which typically
involves advanced imaging for accurate tumor delineation, image-guided radiotherapy (IGRT)
for real-time precision, and the use of technologies like intensity-modulated radiation therapy
(IMRT) and proton beam therapy that allow better sparing of surrounding healthy tissues
(Vasconcelos et al., 2021; Paulino et al., 2014).

Moreover, protective strategies such as customized shielding, positioning aids, and dosimetric
verification must be employed throughout the treatment process. Radiographers and radiation
therapists are instrumental in these efforts, ensuring each session adheres strictly to prescribed
protocols. They also monitor the child’s response to treatment and contribute to modifications
when necessary to maintain therapeutic efficacy while minimizing harm.
In both diagnostic and therapeutic contexts, radiographers serve not only as technical experts but
also as patient advocates, ensuring that children receive the highest standard of care with the
lowest possible radiation risk. As frontline personnel, their adherence to best practices in
pediatric imaging and therapy is pivotal in achieving optimal clinical outcomes and safeguarding
long-term health.

Beyond the technical delivery of pediatric imaging and radiotherapy, radiographers are also
responsible for maintaining open communication with patients and their families. This is
especially important when working with children, who may not fully understand the procedures
or be able to articulate discomfort or fear. Radiographers must employ age-appropriate
communication strategies, provide reassurance, and collaborate closely with pediatric nurses and
child life specialists to reduce anxiety, which in turn improves cooperation and reduces the need
for repeat imaging (Strahlenschutzkommission, 2012). When sedation or anesthesia is required,
close coordination with anesthesiologists is essential to ensure the child's safety throughout the
imaging or treatment procedure.

In addition, pediatric radiology and radiotherapy often demand strong interdisciplinary

collaboration. Optimal care outcomes are achieved through the concerted efforts of radiologists,
radiation oncologists, medical physicists, pediatricians, nurses, and radiographers. Each
professional brings a unique perspective and expertise that contributes to the comprehensive
evaluation, planning, and execution of procedures. For example, medical physicists are integral
to treatment planning in radiotherapy, ensuring accurate dose calculations and equipment
calibration, while pediatric oncologists oversee treatment regimens and monitor systemic effects
(Delaney et al., 2005).

Globally, there has been increasing advocacy for the development and implementation of
pediatric-specific radiation safety initiatives. Campaigns such as Image Gently and Radiation
Safety of Children by the International Atomic Energy Agency (IAEA) have been instrumental
in raising awareness about the risks of ionizing radiation in children and promoting best practices
among healthcare professionals (Image Gently Alliance, 2022; IAEA, 2018). These campaigns
emphasize education, protocol standardization, equipment modifications, and quality assurance
measures aimed at reducing unnecessary exposure.
Despite these efforts, disparities remain in the availability of pediatric radiology and
radiotherapy services, particularly in low- and middle-income countries (LMICs). Limited access
to specialized equipment, insufficient training, and lack of adherence to international guidelines
often result in suboptimal pediatric care and increased radiation risks (World Health
Organization [WHO], 2016). Therefore, continuous professional development and international
cooperation are essential to bridge these gaps and ensure equitable, safe, and effective radiation-
based care for children worldwide.

In conclusion, pediatric radiology and radiotherapy are highly specialized fields requiring
tailored protocols, skilled personnel, and robust safety measures to accommodate the unique
vulnerabilities of children. Radiographers, as key players in this system, must combine technical
expertise with compassionate care and active participation in multidisciplinary teams to achieve
diagnostic and therapeutic success while upholding the highest standards of radiation protection.

2.1.4 Role of Radiographers in Radiation Protection

Radiographers are highly trained healthcare professionals who specialize in performing

diagnostic imaging procedures and administering therapeutic radiation treatments. Their role
transcends the technical act of image acquisition or dose delivery; they are pivotal in ensuring
the safety and protection of patients from unnecessary or excessive radiation exposure, with
particular emphasis on vulnerable populations such as pediatric patients (Kanal & Zeman, 2018).
Given the heightened radiosensitivity of children, radiographers must exercise meticulous care in
tailoring imaging protocols and radiation therapy regimens to the unique needs of each child.

In diagnostic radiology, radiographers are responsible for accurate patient positioning, selecting
exposure parameters that align with pediatric dose reduction principles, and implementing
protective measures such as shielding and collimation to limit the irradiated area (Brady et al.,
2015). They must also minimize the need for repeat exposures by ensuring optimal first-time
image quality. This requires not only technical proficiency but also an understanding of the
anatomical and physiological differences in children, as well as the ability to manage patient
movement and anxiety through effective communication techniques (Bruno et al., 2018). These
steps are crucial in adhering to the ALARA (As Low As Reasonably Achievable) principle,
which guides radiation safety practice by emphasizing the minimization of radiation dose while
achieving diagnostic objectives (ICRP, 2007).

In therapeutic contexts, radiographers have additional responsibilities that include preparing and
applying immobilization devices designed specifically for pediatric patients to ensure precise and
reproducible treatment positioning. They assist in treatment simulation, verify treatment plans,
monitor dose delivery throughout the treatment course, and ensure adherence to institutional and
international radiation safety standards (Mackenzie et al., 2020). Given the long-term risks
associated with radiation therapy in children, careful monitoring and documentation by
radiographers contribute to minimizing late effects such as growth disturbances and secondary
malignancies (Mitchell et al., 2016).

Continuous professional development is another critical aspect of a radiographer’s role in

radiation protection. Radiographers must remain informed of the latest guidelines, technological
advancements, and best practices in pediatric radiation safety. This commitment involves
participating in regular training, engaging with professional bodies such as the International
Society of Radiographers and Radiological Technologists (ISRRT), and advocating for the
implementation of pediatric-specific protocols and quality assurance programs within their
clinical settings (UNSCEAR, 2020). Their proactive involvement helps to foster a culture of
safety and vigilance in radiation use.

Moreover, radiographers serve as key communicators with children and their caregivers, helping
to alleviate fears and improve cooperation during procedures. By providing clear explanations
tailored to a child's developmental level and addressing parental concerns, radiographers
facilitate smoother procedures that reduce motion artifacts and the likelihood of repeated
exposures (Strahlenschutzkommission, 2012). This holistic approach combines technical skill
with compassionate care, reinforcing the radiographer’s integral role in radiation protection.

Radiographers are not only implementers of imaging and therapeutic procedures but also crucial
contributors to radiation safety culture within healthcare systems. Their role is multidimensional,
demanding a strong grasp of radiological physics, human anatomy—particularly pediatric
variants—and safety standards. In pediatric radiology and radiotherapy, their interventions begin
well before the actual procedure and extend beyond its completion. For instance, before initiating
any diagnostic procedure, radiographers must assess the clinical justification of the exam,
confirm that the benefits outweigh the risks, and verify that no alternative imaging modality—
such as ultrasound or MRI, which do not involve ionizing radiation—could be used instead
(Image Gently Alliance, 2019; WHO, 2016).

One of the most essential contributions of radiographers is their advocacy for protocol
standardization and equipment calibration tailored to pediatric needs. Many imaging centers still
rely on adult-based protocols that can inadvertently expose children to higher doses than
necessary. Radiographers are in a prime position to push for the development and
implementation of pediatric-specific protocols, such as automatic exposure control adjusted for
patient size, weight-based dose modulation, and use of child-optimized filters or detectors (Frush
et al., 2013; Vassileva et al., 2020). They are also responsible for routinely checking that imaging
equipment is functioning within safety parameters, as faulty calibration can significantly increase
exposure risks.

In the therapeutic arena, radiographers are actively involved in treatment planning and
verification. Pediatric patients, due to their small body size and variable anatomy, require precise
contouring of the tumor volume and meticulous planning to avoid surrounding organs at risk
(Sharma et al., 2017). Radiographers collaborate closely with radiation oncologists, medical
physicists, and pediatric oncologists to ensure that treatment fields are accurate and that any
deviation from planned parameters is identified and corrected. They also participate in daily
patient setup and verification using image-guided radiotherapy (IGRT), reducing the risk of
geographic misses and unintentional irradiation of healthy tissues (ICRP, 2013).

Moreover, radiographers are instrumental in patient and family education. Communicating the
necessity, safety measures, and procedural steps of a radiation-based intervention in a clear,
compassionate, and age-appropriate manner helps to build trust and reduce anxiety in children
and their caregivers. This cooperation can significantly decrease the likelihood of motion during
procedures, thereby improving image quality and minimizing the need for repeats (Caruso et al.,
2018). In this context, effective communication is a protective tool, supporting both patient
safety and procedural efficacy.

Radiographers also serve as mentors and trainers for junior colleagues, students, and
interdisciplinary staff. Through workshops, safety briefings, and on-the-job coaching, they
promote awareness of pediatric radiation risks and protective strategies. Their leadership ensures
that radiation safety remains an organizational priority, not merely a procedural afterthought.
Professional bodies such as the International Society of Radiographers and Radiological
Technologists (ISRRT), the American Society of Radiologic Technologists (ASRT), and
regional health authorities increasingly recognize and support this expanded role, emphasizing
the need for continued education and institutional support (IAEA, 2022).

In summary, radiographers hold a central and multifaceted role in the radiation protection
ecosystem—particularly within pediatric care, where precision and caution are paramount. Their
responsibilities span technical operations, safety compliance, communication, patient education,
and advocacy for evidence-based practices. By applying child-specific imaging protocols,
ensuring accurate treatment delivery, and fostering institutional cultures of safety and
accountability, radiographers significantly mitigate radiation risks while supporting optimal
diagnostic and therapeutic outcomes. As both frontline practitioners and safety ambassadors,
their commitment to radiation protection is indispensable to ensuring the health and long-term
well-being of pediatric patients exposed to ionizing radiation.

2.1.5 Paediatric Sensitivity to Ionizing Radiation

Children are considerably more sensitive to ionizing radiation than adults, a fact that has been
consistently supported by scientific research and international health bodies (UNSCEAR, 2013;
ICRP, 2013). This heightened vulnerability is due to a combination of biological, physiological,
and developmental factors that make pediatric patients more susceptible to both the immediate
and long-term effects of radiation exposure. One of the primary biological reasons is the high
rate of cellular division in growing tissues. Actively dividing cells are more radiosensitive
because ionizing radiation can disrupt DNA replication, leading to mutations, cell death, or
abnormal cell proliferation, which increases the risk of malignancies (Hall & Giaccia, 2012).

Another critical factor is the longer life expectancy of children. The extended period between
exposure and potential manifestation of stochastic effects, such as cancer or genetic mutations,
increases the likelihood that such effects will develop (Brenner & Hall, 2007). For instance,
studies have shown that the lifetime risk of developing radiation-induced cancer is several times
higher for children than for adults exposed to the same dose (Mathews et al., 2013). This risk is
not hypothetical; epidemiological data, particularly from atomic bomb survivors and medical
radiation exposure studies, demonstrate a clear link between childhood radiation exposure and
increased cancer incidence later in life (UNSCEAR, 2013).

In addition, the smaller body size of pediatric patients often leads to a proportionally greater
volume of tissue being irradiated during imaging or therapy sessions. For example, a CT scan of
the abdomen in a small child may result in exposure to nearly all abdominal organs
simultaneously, unlike in adults where organ separation and body mass offer some degree of
spatial protection (Frush et al., 2003). Furthermore, due to their lower body weight and thinner
tissue layers, scattered radiation can travel more easily within a child’s body, thereby affecting
multiple organ systems and compounding the risk of systemic effects (Vassileva et al., 2020).

Given these significant risks, rigorous radiation protection measures must be observed in all
pediatric radiologic and therapeutic practices. The use of non-ionizing imaging modalities such
as ultrasound and MRI should be prioritized whenever clinically appropriate, as these
technologies do not involve exposure to ionizing radiation (WHO, 2016). When ionizing
modalities are unavoidable, adherence to the ALARA (As Low As Reasonably Achievable)
principle becomes even more critical. This involves customizing protocols to the individual
child’s size, age, and clinical needs—an approach supported by pediatric imaging initiatives like
the Image Gently Alliance (2019), which advocates for dose awareness and optimization.

Advanced dose-reduction strategies should also be employed. These include automatic exposure
control, tube current modulation, high-pitch scanning, and the use of protective shielding for
radiosensitive organs such as the thyroid, gonads, and breast tissue (Goske et al., 2008).
Radiographers must be particularly vigilant in ensuring that such measures are implemented
consistently, as even minor lapses in protocol adherence can result in unnecessary exposure and
potential harm.

Moreover, clear documentation and dose tracking are essential to maintaining a history of a
child's exposure over time. Institutions are encouraged to adopt radiation dose monitoring
systems and integrate electronic health records that alert practitioners when cumulative dose
thresholds are approached (ICRP, 2013). This proactive approach aids in clinical decision-
making and fosters interdepartmental collaboration in minimizing radiation burdens.
Equally important is the role of education and training. Radiographers, radiologists, and referring
physicians must be continuously educated on pediatric radiation risks and the latest dose-
reduction technologies. Parental counseling is also vital. When caregivers understand the
potential risks and safety measures in place, they are more likely to cooperate during procedures,
thus reducing the likelihood of repeat scans due to patient motion or non-compliance (Caruso et
al., 2018).

Given these considerable risks, the ethical responsibility of healthcare professionals, especially
radiographers, becomes even more profound in pediatric care settings. The use of ionizing
radiation in children should be strictly justified, meaning that every procedure must present more
benefit than harm. This involves a careful evaluation of the clinical need, potential alternatives,
and expected outcomes of each imaging or therapeutic session (ICRP, 2013). In cases where
imaging is essential, justification must not only rely on diagnostic need but must also include an
assessment of prior imaging history to avoid unnecessary repeats or redundant procedures
(UNSCEAR, 2013).

Radiographers, radiologists, and referring clinicians are thus expected to work collaboratively to
determine the appropriateness of each exam. Adherence to international guidelines, such as those
provided by the Image Gently Alliance, the International Atomic Energy Agency (IAEA), and
the World Health Organization (WHO), forms the bedrock of ethical pediatric imaging and
treatment protocols. These frameworks emphasize justification, optimization, dose limitation,
and the use of size- and age-specific reference dose levels (Image Gently, 2019; WHO, 2016).

Moreover, special attention must be paid to communication strategies when dealing with
children and their caregivers. Effective communication helps in gaining the trust and cooperation
of the child, which significantly reduces motion artifacts, avoids the need for sedation, and
minimizes the likelihood of repeat exposures (Caruso et al., 2018). When children understand, to
the extent possible, what is expected of them and feel reassured by the staff, they are more likely
to remain still and cooperative during procedures. Additionally, educating caregivers about the
need for the procedure, safety measures in place, and long-term follow-up can help alleviate
anxiety and foster informed decision-making.

Technological advancement has also introduced opportunities for improving pediatric radiation
safety. Modern imaging equipment now includes pediatric-specific software and hardware
configurations that allow for automatic dose adjustment based on body size and anatomical
region (Vassileva et al., 2020). Innovations such as iterative reconstruction in CT, pulsed
fluoroscopy, and adaptive radiotherapy techniques have been shown to significantly reduce dose
while maintaining image quality and treatment effectiveness (Goske et al., 2008). However, the
mere availability of such technologies is not enough. Radiographers and technical staff must be
proficient in their use and consistently apply them to achieve meaningful reductions in pediatric
radiation exposure.

Equally important is the institutional culture surrounding radiation safety. Facilities that
prioritize radiation protection will typically have structured pediatric protocols, dose-tracking
systems, regular audits, and continuous professional development programs for staff.
Encouraging a safety-first mindset across all levels of the radiology and radiotherapy
departments not only improves practice but also strengthens compliance with local and
international standards. Audit trails, peer reviews, and morbidity-mortality meetings serve as
internal feedback mechanisms to ensure quality improvement and reduce errors (ICRP, 2013).

Finally, the issue of equity must not be overlooked. Children in low- and middle-income
countries (LMICs) are often at a greater disadvantage due to outdated equipment, lack of
standardized protocols, limited access to trained professionals, and weak regulatory oversight.
This can lead to inappropriate imaging practices with poorly optimized radiation doses (WHO,
2016). Therefore, global efforts to improve pediatric radiation safety must include capacity
building, resource allocation, and international collaborations to support underserved regions.
Programs like the IAEA’s Radiation Protection of Patients (RPOP) initiative aim to bridge these
gaps through education, equipment donation, and protocol development tailored to local needs.

In conclusion, children’s unique physiological and developmental attributes make them

particularly vulnerable to the harmful effects of ionizing radiation. Their increased
radiosensitivity, combined with a longer latency window for radiation-induced diseases and a
greater risk of systemic exposure due to body size, necessitates a carefully regulated and patient-
specific approach to imaging and radiotherapy. Through justification of procedures, optimization
of dose, technological innovation, continuous professional training, and robust communication
with caregivers, healthcare professionals—especially radiographers—play a pivotal role in
safeguarding pediatric patients. As radiation use continues to grow in modern healthcare,
sustaining a culture of safety and global equity in pediatric radiation protection remains not only
a clinical imperative but a moral one.

2.1.5 Best Practices in Paediatric Radiation Protection

The implementation of best practices in paediatric radiation protection is critical to ensuring the
safety and well-being of children undergoing diagnostic imaging or radiotherapy. Because of
their heightened sensitivity to ionizing radiation, children require tailored approaches that
balance diagnostic or therapeutic efficacy with minimization of radiation exposure (Brenner &
Hall, 2007; ICRP, 2013). Best practices in this context are guided by a combination of
international guidelines, evidence-based clinical protocols, technological innovations, and
professional competencies that emphasize justification, optimization, and protection.

Justification of Procedures

Justification is the cornerstone of radiation protection, particularly in pediatric care. It mandates

that no radiological procedure should be carried out unless the benefits significantly outweigh
the potential risks (ICRP, 2007). This requires thorough clinical evaluation by the referring
physician in collaboration with radiologists or radiation oncologists to ensure that imaging or
treatment is necessary for diagnosis or patient management. In the pediatric context, it is
especially important to consider alternative modalities that do not involve ionizing radiation,
such as ultrasound and magnetic resonance imaging (MRI), before opting for procedures like
computed tomography (CT) or radiotherapy (WHO, 2016). Studies have shown that many
pediatric CT scans are not clinically indicated and could be replaced with safer alternatives
(Pearce et al., 2012; Miglioretti et al., 2013).

Optimization of Dose

Once a procedure is justified, the next best practice involves optimizing the dose to be "As Low
As Reasonably Achievable" (ALARA), without compromising diagnostic image quality or
therapeutic effectiveness (Frush et al., 2013). Dose optimization in children requires age- and
size-specific protocols. For example, CT imaging should use adjusted tube voltage, current
modulation, and pitch settings appropriate to the child’s body size (Goske et al., 2008). In
radiotherapy, advanced planning systems such as intensity-modulated radiation therapy (IMRT)
and proton therapy allow for precise dose distribution, sparing healthy tissues while targeting
tumors (Vasconcelos et al., 2021). Moreover, radiographers and physicists must engage in
regular calibration and quality control of machines to ensure accurate dose delivery (IAEA,
2018).

Use of Shielding and Immobilization

Proper use of physical shielding and immobilization devices is another best practice in pediatric
radiation protection. Gonadal and thyroid shields, where applicable, help reduce exposure to
radiosensitive organs (Seuri et al., 2016). Although recent debates suggest a move away from
routine shielding due to advancements in dose modulation, in pediatric populations—especially
in resource-limited settings—shielding remains a valuable dose-reduction tool when used
correctly (AAPM, 2019). Immobilization devices, such as papoose boards or vacuum cushions,
are essential to reduce motion artifacts during imaging or therapy, thereby minimizing the need
for repeat procedures and the associated cumulative radiation dose (Caruso et al., 2018).

Protocol Standardization and Equipment Modification

Institutions that cater to pediatric populations should develop standardized imaging and
treatment protocols that are distinct from adult protocols. These protocols should incorporate
pediatric-specific exposure parameters, positioning techniques, and procedural workflows.
Additionally, imaging and radiotherapy equipment should include pediatric settings and
functionalities. For example, digital radiography systems should have low-dose pediatric
exposure presets, and radiotherapy linear accelerators should support small-field dosimetry and
precise beam shaping (Vassileva et al., 2020). Facilities lacking these technologies are advised to
retrofit or replace outdated equipment to align with modern safety standards.

Education and Continuous Professional Development

Best practices also involve ongoing education and training for all professionals involved in
pediatric imaging and radiotherapy. Radiographers, radiologists, and medical physicists must be
regularly updated on advances in radiation protection, changes in international recommendations,
and emerging evidence in pediatric radiology (WHO, 2016). Institutions should promote
continuous professional development (CPD) activities, certification programs, and peer-learning
platforms to reinforce a culture of safety. The Image Gently Alliance and campaigns like
Eurosafe Imaging provide a wealth of educational resources tailored to pediatric safety (Image
Gently, 2019).

Communication and Informed Consent

Effective communication with both pediatric patients and their caregivers is a non-negotiable
component of best practices. Before any procedure, caregivers should be informed about the
need for the examination, the risks and benefits involved, and the measures in place to protect the
child (Caruso et al., 2018). Engaging caregivers in this way enhances cooperation, reduces
anxiety, and supports informed consent. When children are developmentally capable, using
child-friendly explanations and visual aids can foster trust and facilitate compliance during
procedures.

Audit, Monitoring, and Dose Tracking

Institutions should implement routine audits of pediatric imaging and therapy practices to
identify areas for improvement. Monitoring tools such as dose registries, quality indicators, and
incident reporting systems help track performance and ensure adherence to established protocols
(ICRP, 2013). Dose tracking software integrated with PACS (Picture Archiving and
Communication Systems) can provide real-time feedback on cumulative exposure and trigger
alerts when dose thresholds are approached or exceeded. These practices not only improve
patient safety but also support institutional accreditation and accountability.

Global and National Frameworks

The application of these best practices is supported by a range of international and national
frameworks. The International Atomic Energy Agency (IAEA), through its Radiation Protection
of Patients (RPOP) platform, provides practical guidance and training modules on pediatric
radiation safety. Similarly, the International Commission on Radiological Protection (ICRP) and
the World Health Organization (WHO) offer detailed reports and policy frameworks that
emphasize pediatric-specific considerations (ICRP, 2013; WHO, 2016). National regulatory
bodies are expected to adopt these recommendations and adapt them to local contexts through
legislation, professional guidelines, and public awareness campaigns.
In addition to the foundational practices of justification, optimization, and shielding,
technological innovation continues to play a significant role in advancing pediatric radiation
protection. For instance, the advent of automated exposure control (AEC) systems in digital
imaging helps adjust radiation output based on patient size and the density of the body part being
examined. This ensures that only the necessary radiation is delivered to achieve diagnostic-
quality images (Seuri et al., 2016). Similarly, in radiotherapy, image-guided radiation therapy
(IGRT) and adaptive planning systems provide real-time imaging and treatment adjustments,
significantly reducing margins and unintentional dose to surrounding healthy tissues
(Vasconcelos et al., 2021). These technologies contribute to dose reduction while maintaining or
enhancing clinical outcomes.

Moreover, the integration of Artificial Intelligence (AI) and machine learning is beginning to
influence pediatric imaging. AI-based tools can assist in protocol selection, automated organ
contouring, and dose estimation, further personalizing care for children and ensuring adherence
to best practices (Kim et al., 2021). While still emerging, these tools hold promise for reducing
operator error and standardizing high-quality care across different clinical settings.

Another important area in best practices is interdisciplinary collaboration. Pediatric radiation

protection cannot be executed effectively in isolation. It requires coordination between
radiologists, radiation oncologists, medical physicists, radiographers, pediatricians, and nurses.
Multidisciplinary teams ensure that every aspect of the patient’s care—from clinical evaluation
to post-procedure follow-up—considers radiation safety. This collaboration is particularly
important in complex cases, such as those involving multiple imaging sessions or combined
modality treatments like chemotherapy and radiotherapy (Goske et al., 2008).

The establishment of safety culture within healthcare facilities also underpins best practices in
pediatric radiation protection. A strong safety culture encourages transparent reporting of near
misses, encourages feedback loops, and emphasizes continuous improvement (ICRP, 2009).
Institutions must foster environments where staff feel empowered to advocate for pediatric-
specific considerations, speak up about potential risks, and share innovations that enhance patient
safety.

Importantly, public awareness and parental engagement form an emerging frontier in pediatric
radiation protection. Educational campaigns such as the Image Gently Alliance have been
instrumental in informing both professionals and the public about the need to "child-size"
imaging (Goske et al., 2012). Such initiatives not only reduce unnecessary imaging referrals but
also empower caregivers to ask informed questions, seek second opinions, and make better
health decisions for their children.

In resource-constrained settings, implementation of best practices faces unique challenges,

including limited access to pediatric equipment, inadequate staff training, and low awareness of
radiation risks (Ofori et al., 2020). Nevertheless, low-cost strategies—such as protocol
adjustments, enhanced staff training, and engagement in regional safety networks—can
significantly improve radiation protection practices even in low-income environments (IAEA,
2018). Tailoring global guidelines to local realities, through policy reform and capacity building,
is essential to ensure equity in radiation safety for children worldwide.

Lastly, research and quality improvement efforts are integral to sustaining best practices.
Ongoing studies assessing the long-term outcomes of pediatric radiation exposure inform risk
models and shape future guidelines (Pearce et al., 2012). Similarly, continuous audit cycles and
quality improvement initiatives help refine institutional practices and promote adherence to
international standards.

In summary, best practices in pediatric radiation protection encompass a comprehensive

framework that includes justification, dose optimization, shielding, protocol standardization,
technological innovations, staff training, interdisciplinary collaboration, safety culture
development, and parental engagement. These practices are supported by international regulatory
frameworks and professional campaigns such as Image Gently and the ICRP’s pediatric
recommendations. By prioritizing child-specific needs in all aspects of radiation use, healthcare
providers can significantly mitigate radiation-related risks while ensuring that the diagnostic and
therapeutic benefits are fully realized for pediatric patients.

2.2 Empirical Review

2.2.1 Studies on Compliance with Radiation Protection Protocols

Numerous empirical studies have highlighted varying degrees of compliance with radiation
protection guidelines, particularly among radiology departments. In a multicenter study
conducted across European pediatric hospitals, Miglioretti et al. (2013) found that despite
widespread awareness of the ALARA principle, there were inconsistencies in the application of
dose-reduction strategies and the use of appropriate shielding in pediatric imaging. The study
showed that high patient volume, outdated equipment, and inadequate training were contributing
factors to non-compliance.

In sub-Saharan Africa, Ofori et al. (2020) conducted a cross-sectional study among radiographers
in Ghana and revealed that although the majority of respondents were familiar with radiation
protection principles, only 58% routinely used gonadal shielding during pediatric examinations.
The study attributed this gap to limited access to protective materials, lack of institutional
enforcement of protocols, and inadequate pediatric-specific training.

Similarly, Adekanmbi and Oyesiku (2018) explored compliance among radiology personnel in
Nigerian tertiary hospitals. Their study found that while radiographers demonstrated good
knowledge of radiation hazards, compliance with safety protocols—such as patient dose
recording, beam collimation, and the use of immobilization devices—was moderate to low. The
authors emphasized that institutional support, including regular audits and provision of standard
operating procedures, significantly influenced compliance levels.

Compliance challenges are not limited to developing countries. Donnelly et al. (2013) assessed
pediatric CT practices in the United States and found that only 42% of institutions had specific
protocols for different pediatric age groups. Facilities with dedicated pediatric radiologists and
well-trained technologists exhibited higher compliance levels. This finding reinforces the
importance of specialized training and human resource allocation in achieving optimal protection
outcomes.

In therapeutic contexts, Vasconcelos et al. (2021) studied pediatric oncology centers in Brazil
and reported significant discrepancies in radiation dose monitoring and documentation. Their
results suggested that non-compliance was often unintentional, stemming from staffing shortages
and inadequate integration of quality assurance processes. Radiotherapy centers that
implemented electronic treatment verification systems and regular team briefings demonstrated
better adherence to safety norms.
Furthermore, Elshami et al. (2020) surveyed diagnostic radiographers in the United Arab
Emirates and found that compliance was positively correlated with continuing professional
education, access to radiation monitoring tools, and the presence of institutional radiation safety
officers. Radiographers who had undergone recent training on dose optimization techniques were
more likely to adjust exposure settings based on patient age and size, especially for pediatric
imaging.

A systematic review by Frantzen et al. (2012) also showed that compliance with radiation
protection guidelines is higher in institutions with strong safety cultures and active radiation
protection committees. These organizational structures foster accountability, continuous
learning, and routine evaluation of imaging practices, which collectively enhance adherence to
safety standards.

While compliance rates vary globally, the findings consistently point to the role of education,
institutional policy, and resource availability as critical determinants. Pediatric settings, due to
their vulnerability, demand even stricter adherence to radiation protection protocols. Empirical
studies underscore the need for sustained investments in personnel training, infrastructure, and
the enforcement of safety standards across all imaging and therapeutic procedures involving
children.

In addition to institutional and individual-level factors, technological advancements also

influence compliance with radiation protection protocols. For instance, the integration of
automatic exposure control (AEC) systems and dose tracking software in radiological equipment
has been associated with improved compliance in pediatric imaging (Strauss & Goske, 2011).
These systems help optimize radiation doses by adjusting exposure parameters according to
patient size and clinical requirements, reducing the reliance on manual calculations that may lead
to errors.

However, despite the availability of such technologies, their underutilization remains a concern,
particularly in resource-limited settings. According to a survey by Nworgu and Okoye (2019)
among radiology departments in Nigerian public hospitals, over 70% of facilities lacked modern
imaging equipment with dose-saving features. Even in centers where such tools were available,
radiographers reported insufficient training on their effective use, highlighting a disconnect
between technology availability and practical application.
Compliance is also closely linked to the presence of structured protocols and institutional
guidelines. In a study by Ghasemi et al. (2021), healthcare institutions that maintained
standardized operating procedures and regular quality assurance checks reported higher
adherence to radiation protection measures. The study emphasized the importance of
departmental leadership and enforcement of protocol use, particularly during high-demand
procedures such as CT and fluoroscopy.

Another key area examined in the literature is the impact of continuing professional development
(CPD) and radiation safety training on compliance levels. Abubakar et al. (2020), in their cross-
sectional study among radiographers in Northern Nigeria, found a significant association
between recent participation in radiation protection workshops and proper application of
shielding techniques, beam collimation, and exposure factor adjustment in pediatric imaging.
CPD programs were identified as critical in reinforcing theoretical knowledge and translating it
into daily practice.

Moreover, studies have also investigated the psychological and attitudinal aspects influencing
compliance. Elshami and Abuzaid (2022) explored the attitudes of radiographers towards
pediatric radiation protection in Gulf countries and found that although knowledge was generally
high, there was variability in attitudes toward risk perception and patient advocacy.
Radiographers who perceived pediatric patients as highly vulnerable were more diligent in
applying protective measures compared to those who viewed standard protocols as sufficient.

In addition to radiographer-related factors, physician involvement has also been identified as

influential. A study by Larson et al. (2015) revealed that pediatricians and referring physicians
who had adequate knowledge of radiation risks were more likely to request imaging only when
clinically justified, thereby promoting compliance with the justification principle. The study
further recommended the integration of radiation protection education into medical curricula to
foster a multidisciplinary approach to safety.

In therapeutic radiology, compliance with radiation protection is equally vital. A retrospective

audit by Zhang et al. (2020) in pediatric oncology centers in China evaluated the use of image-
guided radiation therapy (IGRT) and found that institutions adhering strictly to International
Atomic Energy Agency (IAEA) protocols demonstrated significantly fewer adverse outcomes
and better dose conformity. The study reinforced the role of international standards in guiding
local practices and ensuring safety.

Furthermore, collaborative initiatives such as the Image Gently Alliance and the IAEA’s Smart
Card project have contributed to improving compliance globally by raising awareness and
providing tools for dose tracking and optimization (Goske et al., 2012). However, empirical
assessments of their uptake in low- and middle-income countries suggest that implementation
remains suboptimal due to lack of funding, training, and policy enforcement (Ofori et al., 2020).

Finally, patient and caregiver education has emerged as an underexplored but important
dimension of compliance. Studies by Zarb et al. (2014) suggest that when parents are informed
about the risks of radiation exposure and the protective measures in place, they are more likely to
participate actively in ensuring adherence—such as by helping to minimize motion during
procedures or asking questions about shielding.

In conclusion, Empirical studies on compliance with radiation protection protocols reveal a

multifaceted challenge influenced by equipment availability, professional knowledge,
institutional policies, technological capacity, and attitudinal dispositions of both radiographers
and referring physicians. Despite global efforts to promote pediatric radiation safety, compliance
remains inconsistent, particularly in low-resource settings.

Common gaps include poor utilization of dose-reduction technologies, inadequate pediatric-

specific training, absence of standardized protocols, and low enforcement of safety regulations.
However, facilities that invest in continuing professional development, implement structured
quality assurance programs, and foster interdisciplinary collaboration demonstrate significantly
higher compliance.

To improve global and local adherence to pediatric radiation protection standards, sustained
efforts are required in training, technological upgrades, institutional governance, and patient-
centered communication. The role of radiographers remains central, but optimal compliance
must be supported by systemic, policy-driven approaches that prioritize pediatric safety across
the imaging and therapeutic spectrum.
2.2.2 Studies on Knowledge and Training of Radiographers

Knowledge and training are essential determinants of radiographers' ability to implement and
uphold radiation protection standards, especially when dealing with vulnerable populations such
as children. Empirical studies have consistently demonstrated that radiographers who possess
adequate knowledge and receive continuous training in radiation safety are more likely to apply
best practices and adhere to pediatric-specific protocols.

For example, a cross-sectional study by Ekpo et al. (2018) involving radiographers in Nigerian
teaching hospitals revealed a significant gap in knowledge regarding the biological effects of
ionizing radiation on pediatric patients. While a majority of respondents demonstrated basic
awareness of general protection principles, only 38% were familiar with dose optimization
strategies specific to children. The study concluded that formal training on pediatric radiation
safety was rarely provided during professional development programs, suggesting the need for
more targeted education.

Similarly, Alotaibi et al. (2021) conducted a survey across several Gulf countries to assess
radiographers’ knowledge of radiation doses in pediatric imaging. Their findings showed that
only a minority of participants could correctly estimate dose ranges for common pediatric
procedures such as chest X-rays and CT scans. Notably, radiographers who had attended recent
radiation protection workshops scored significantly higher, highlighting the impact of training on
knowledge retention and practical application.

In a related study, Ibhadode and Eze (2017) examined the correlation between professional
experience and knowledge of radiation protection among radiographers in tertiary hospitals.
Contrary to expectations, years of experience did not significantly correlate with better
knowledge scores. Instead, frequent participation in structured training sessions and refresher
courses was a stronger predictor of adequate radiation safety knowledge. This underscores the
importance of continuing professional development (CPD) in maintaining current knowledge
amidst evolving technologies and protocols.

A notable study by Johnston et al. (2016) conducted in the United Kingdom focused on
evaluating the efficacy of training modules delivered through e-learning platforms. The study
reported that radiographers who completed online courses on pediatric imaging exhibited
improved performance in areas such as dose selection, justification of procedures, and
communication with pediatric patients. The authors advocated for the integration of flexible,
scalable training models into radiology departments to reach more practitioners.

Moreover, several empirical works have drawn attention to the inadequacies in undergraduate
curricula with regard to pediatric radiation protection. A survey by Obed et al. (2019) found that
most radiography training programs in Sub-Saharan Africa did not offer specialized coursework
on pediatric imaging or radiation sensitivity in children. As a result, new graduates entered the
workforce underprepared for the unique demands of pediatric radiology and radiotherapy. The
authors recommended curriculum reforms and the introduction of pediatric-specific modules
across training institutions.

The importance of interdisciplinary training has also emerged as a crucial theme in recent
literature. According to Akinlade et al. (2020), radiographers who participated in multi-
professional workshops that included pediatricians, oncologists, and medical physicists
demonstrated better understanding of holistic patient care and collaborative safety practices. The
study emphasized that training should not be limited to technical skills but also incorporate
communication, teamwork, and ethical decision-making in pediatric care.

Training is not only important for knowledge acquisition but also for changing attitudes and
promoting a safety culture. Elshami and Abuzaid (2022) found that radiographers who had
undergone simulation-based training were more likely to report incidents, advocate for shielding,
and question unjustified imaging requests. This finding supports the notion that hands-on,
practice-oriented training contributes significantly to behavior modification and proactive safety
engagement.

In addition, international initiatives such as the IAEA’s "Radiation Protection of Patients"

(RPoP) project and the Image Gently Campaign have been instrumental in providing online
resources, training materials, and certification programs focused on pediatric radiation safety
(Goske et al., 2013). Empirical evaluations by IAEA (2020) indicate that institutions adopting
these resources report improved protocol compliance, increased awareness, and greater staff
confidence in handling pediatric cases.
Also, international initiatives such as the International Atomic Energy Agency’s (IAEA)
Radiation Protection of Patients (RPoP) project and the Image Gently Campaign have played
pivotal roles in enhancing pediatric radiation safety worldwide. The IAEA’s RPoP project
provides a comprehensive framework aimed at supporting healthcare facilities in developing and
implementing optimized radiation protection policies, particularly emphasizing pediatric care
due to the increased sensitivity of children to ionizing radiation (IAEA, 2020). The initiative
offers extensive resources, including training modules, technical documents, and protocol
guidelines tailored for low-, middle-, and high-income countries, facilitating equitable access to
best practices across diverse healthcare settings.

The Image Gently Campaign, launched in 2007 by the Society for Pediatric Radiology in the
United States, specifically targets radiation dose reduction in pediatric imaging. This
multidisciplinary campaign focuses on raising awareness among radiologists, technologists,
referring physicians, and parents about the risks of unnecessary radiation exposure in children
and the importance of applying pediatric-specific protocols (Goske et al., 2013). The campaign
advocates for adjusting imaging techniques according to the child’s size and clinical indication,
encouraging alternative modalities without ionizing radiation such as ultrasound and MRI where
appropriate, and promoting the ALARA principle to minimize dose without compromising
diagnostic quality.

Empirical evaluations of institutions adopting these programs have shown marked improvements
in protocol compliance and dose optimization. For instance, a longitudinal study by Mettler et al.
(2018) demonstrated that hospitals participating in the Image Gently initiative reduced pediatric
CT radiation doses by an average of 40% over a five-year period, without significant loss in
image quality or diagnostic confidence. Similarly, the IAEA’s technical cooperation projects
have documented enhanced staff knowledge, increased implementation of pediatric-specific
protocols, and improved patient safety metrics in developing countries (IAEA, 2020).

Moreover, these initiatives encourage the integration of radiation dose tracking systems and audit
processes to monitor and continually improve radiation safety practices. Real-time dose
monitoring technologies and dose registries, supported by both IAEA guidelines and the Image
Gently framework, enable institutions to benchmark performance, identify outliers, and
implement corrective actions promptly (Miglioretti et al., 2016). Such data-driven approaches
have been shown to foster a culture of safety and accountability among radiographers and
radiologists alike.

Training and awareness campaigns provided by these international programs also emphasize
effective communication strategies tailored to pediatric patients and their caregivers. Educating
families about the risks and benefits of imaging procedures builds trust, reduces anxiety, and
facilitates informed consent—critical components of patient-centered care (Applegate et al.,
2014).

In addition, involving radiographers in these educational efforts empowers them to advocate for
patient safety actively and reinforces the ethical imperative of minimizing unnecessary radiation
exposure. The success of these programs has catalyzed the development of numerous regional
and national guidelines that incorporate pediatric-specific radiation protection standards. For
example, the European Commission’s Radiation Protection No. 118 guidelines and the American
College of Radiology (ACR) Appropriateness Criteria both draw heavily on these international
initiatives to shape clinical practice recommendations (European Commission, 2019; ACR,
2021). These guidelines provide detailed protocols on dose adjustment, equipment calibration,
patient positioning, and quality assurance tailored to pediatric populations.

However, despite the widespread availability of such resources, challenges remain in universal
adoption and sustained implementation. Factors such as limited infrastructure, lack of funding,
insufficient training opportunities, and resistance to change can impede progress, particularly in
resource-limited settings (Patel et al., 2020). Addressing these barriers requires coordinated
efforts involving policymakers, healthcare leaders, and international organizations to prioritize
pediatric radiation safety within broader health system strengthening initiatives.

Furthermore, technological advancements continue to evolve, offering new tools that enhance
radiation protection. Innovations like digital radiography with automatic exposure control,
iterative reconstruction algorithms in CT imaging, and proton therapy in radiotherapy allow for
significant dose reductions while maintaining or improving diagnostic and therapeutic efficacy
(Smith-Bindman et al., 2019; Paganetti, 2018). Integrating these technologies with the principles
advocated by the RPoP project and Image Gently can further optimize pediatric radiation safety.
In summary, international initiatives such as the IAEA’s Radiation Protection of Patients and the
Image Gently Campaign provide essential frameworks, training, and resources that have
substantially improved pediatric radiation protection globally. Their holistic approach—
encompassing protocol optimization, education, communication, dose monitoring, and advocacy
—addresses both technical and human factors influencing safety. Continued expansion and
adaptation of these programs, alongside supportive policies and technological integration, are
vital to overcoming existing challenges and safeguarding children from the potential harms of
ionizing radiation in medical care. Empirical studies affirm that radiographers’ knowledge and
training are fundamental to ensuring radiation protection in pediatric radiology and radiotherapy.
Gaps in undergraduate education, limited access to continuing education, and inadequate
institutional support often contribute to suboptimal practice. However, targeted interventions—
such as structured CPD programs, e-learning modules, interdisciplinary workshops, and
international collaborations—have demonstrated significant improvements in radiographers’
competence and commitment to pediatric safety. To build a resilient pediatric radiation
protection culture, it is crucial to institutionalize regular training, enforce curriculum reforms,
and encourage knowledge-sharing platforms. Equipping radiographers with both technical
knowledge and critical thinking skills will not only enhance patient outcomes but also align
radiological practices with global safety standards.

2.3 Theoretical Framework

2.3.1 The ALARA Framework

The ALARA principle—an acronym for As Low As Reasonably Achievable—is a foundational

theoretical framework in the field of radiation protection. Rooted in the precautionary principle,
ALARA emphasizes minimizing exposure to ionizing radiation while achieving the necessary
diagnostic or therapeutic objective. The principle operates under the assumption that no level of
radiation exposure is entirely risk-free, especially for sensitive populations such as children,
whose developing tissues are more susceptible to stochastic effects such as carcinogenesis
(ICRP, 2007; Frush et al., 2013).
ALARA is not just a technical concept but a regulatory and ethical obligation integrated into the
operational standards of radiology and radiotherapy practice. It is anchored on three key
strategies: justification, optimization, and dose limitation. Justification requires that any
radiological procedure should be warranted based on its potential health benefits outweighing its
risks. Optimization involves adjusting imaging or treatment parameters to ensure minimal
radiation exposure without compromising diagnostic quality or therapeutic efficacy. Dose
limitation, while more applicable to occupational and public exposure, reinforces the need for
monitoring and control measures to keep exposure within prescribed safety limits (IAEA, 2014;
Martin, 2006).

In pediatric imaging and therapy, ALARA holds even greater significance. Studies have shown
that children exposed to ionizing radiation—particularly through repeated CT scans or poorly
planned radiotherapy—have an increased risk of developing long-term health issues such as
secondary malignancies or endocrine disorders (Mathews et al., 2013; Vasconcelos et al., 2021).
Consequently, applying ALARA in pediatric contexts necessitates child-specific protocols that
consider variables such as age, weight, body region, and clinical indication. These include
reducing milliampere-seconds (mAs), using automatic exposure control (AEC), shielding
radiosensitive organs, and opting for alternative modalities like ultrasound or MRI when
appropriate (Goske et al., 2008; Strauss & Kaste, 2006).

The ALARA framework also promotes a culture of safety and accountability among
radiographers, who are the front-line enforcers of radiation protection protocols. Radiographers
must not only understand the technical aspects of dose reduction but also engage in proactive
communication with patients, caregivers, and other healthcare providers to ensure that every
exposure is justified and optimized. Continuous professional development and adherence to
updated guidelines from regulatory bodies such as the ICRP, WHO, and national radiological
societies are essential for sustaining ALARA-based practices (Seeram, 2019; ICRP, 2021).

Moreover, ALARA has been increasingly supported by technology-driven innovations such as

dose monitoring software, automated alert systems, and AI-assisted imaging protocols. These
tools aid in real-time tracking and analysis of radiation doses, thereby reinforcing compliance
with ALARA principles and allowing institutions to identify patterns, assess risks, and
implement improvements efficiently (Miglioretti et al., 2016).
In educational and policy frameworks, ALARA serves as a guiding principle in training curricula
for radiographers and medical physicists, as well as in the formulation of institutional policies
and audit systems. Its adaptability across diagnostic and therapeutic radiology, and its emphasis
on continuous optimization and ethical responsibility, make it a suitable theoretical anchor for
studies evaluating radiation protection practices—particularly in vulnerable groups like pediatric
patients.

Also, in educational and policy frameworks, ALARA serves as a guiding principle not only in
the formulation of curricula for radiologic science but also in shaping national and institutional
standards for patient safety. In radiographer education, the principle is embedded in modules that
teach radiation physics, protection principles, dose monitoring, and pediatric-specific
considerations (Seeram, 2019). Training institutions emphasize the ethical and technical
dimensions of ALARA, instilling a safety-first mindset in students from the onset of their
professional development. Through simulation exercises, case-based learning, and hands-on
clinical experiences, students are taught to critically evaluate each exposure scenario, customize
technical parameters, and assess risks versus benefits—skills that are especially important when
dealing with pediatric patients.

On the policy side, the ALARA principle has informed various legislative and regulatory
guidelines. For example, organizations such as the International Commission on Radiological
Protection (ICRP), the World Health Organization (WHO), the International Atomic Energy
Agency (IAEA), and national regulatory authorities mandate that healthcare institutions adopt
ALARA-compliant protocols for diagnostic and therapeutic procedures. These bodies provide
periodic updates to ensure that practices align with current evidence and technological
advancements. The European Basic Safety Standards (EU-BSS, 2013) and Nigeria’s Nuclear
Safety and Radiation Protection Regulations (NNRA, 2003), for instance, emphasize dose
optimization, equipment quality assurance, and regular personnel training—all in alignment with
ALARA tenets.

Despite its widespread endorsement, implementation of ALARA principles still faces several
challenges. One major issue is the variability in awareness and adherence levels among
radiographers, particularly in low- and middle-income countries where access to training, dose
monitoring equipment, and pediatric-specific imaging technology is limited (Ofori et al., 2020;
Adeniji-Sofoluwe et al., 2022). In such settings, adult protocols may be inappropriately used for
children, leading to excessive radiation doses. Additionally, some healthcare professionals may
prioritize diagnostic speed and image quality over dose minimization, especially in high-volume
hospitals, thus undermining ALARA’s optimization mandate (Frush et al., 2013).

Another practical difficulty lies in balancing ALARA with diagnostic or therapeutic

effectiveness. Excessive dose reduction can compromise image quality, leading to misdiagnosis,
delayed treatment, or repeat imaging—which ironically increases cumulative exposure.
Therefore, applying ALARA in pediatrics requires a nuanced, evidence-based approach that
ensures diagnostic adequacy while minimizing risk. This underscores the need for ongoing
research, protocol auditing, and feedback systems that allow radiographers to refine their
techniques and respond to evolving clinical demands (Miglioretti et al., 2016).

Technological innovations continue to play a critical role in reinforcing the ALARA framework.
Digital radiography systems, dose-saving algorithms, automatic exposure control (AEC), and
software-integrated dose tracking solutions now provide real-time dose feedback, alerting
radiographers when thresholds are exceeded. These innovations are essential for maintaining
ALARA compliance, particularly in pediatric radiology where precision is paramount.
Furthermore, the integration of artificial intelligence (AI) into imaging workflows allows for
improved patient positioning, optimized imaging protocols, and reduced scan times, thereby
minimizing unnecessary exposure (Kalra et al., 2020).

Another central dimension of ALARA is interdisciplinary collaboration. Achieving ALARA

objectives, especially in pediatric radiology and radiotherapy, requires the coordinated efforts of
radiologists, radiographers, medical physicists, oncologists, and pediatricians. This teamwork
ensures that every decision—ranging from modality selection to treatment planning—is
grounded in a child’s unique clinical context. Effective communication within this
multidisciplinary team, coupled with shared decision-making with caregivers, ensures that
radiation protection is not an isolated technical goal but a holistic clinical priority (Strauss &
Kaste, 2006).

Moreover, continuous professional development (CPD) is integral to maintaining ALARA

standards in a fast-evolving medical landscape. Radiographers must engage in regular
workshops, certification programs, and peer-learning sessions to stay updated on best practices,
new technologies, and revised regulatory guidelines. Professional bodies and accrediting
institutions play a crucial role in promoting these opportunities and evaluating their outcomes in
clinical settings.

In pediatric oncology, the ALARA principle is especially critical given the long-term risks of
radiation-induced sequelae. Here, ALARA is operationalized through meticulous treatment
planning that employs techniques like conformal radiotherapy, proton therapy, and image-guided
radiation therapy (IGRT) to target tumors precisely while sparing surrounding healthy tissue.
Shielding, immobilization, and motion management are also used to prevent geometric miss and
avoid repeated exposures—thereby adhering to the ALARA model while ensuring therapeutic
success (Vasconcelos et al., 2021; Chawla et al., 2012).

In summary, the ALARA framework remains the cornerstone of radiation protection theory and
practice. It serves as a multidimensional guide encompassing technical, ethical, clinical,
educational, and policy-driven aspects of radiation safety. Particularly in pediatric imaging and
therapy, where vulnerability to ionizing radiation is high, the conscientious application of
ALARA principles ensures that the benefits of medical radiation are realized with minimal long-
term harm. Its continued relevance lies in its adaptability—encouraging innovation, education,
and vigilance in protecting the most sensitive patient populations.

2.3.2 The Risk-Benefit Analysis Model

The Risk-Benefit Analysis (RBA) Model is a decision-making framework commonly employed

in healthcare to evaluate whether the benefits of a medical intervention outweigh the potential
risks. In the context of radiation protection, especially in pediatric radiology and radiotherapy,
the RBA model provides a critical theoretical underpinning for assessing the justification of
imaging procedures or therapeutic interventions involving ionizing radiation (ICRP, 2007).

At its core, the RBA model operates on the ethical principle of non-maleficence—"do no
harm"—and the practical necessity of justification, a cornerstone of radiation protection.
According to the International Commission on Radiological Protection (ICRP, 2007), no
radiation procedure should be conducted unless it yields more good than harm. In pediatric cases,
where patients are biologically more radiosensitive and have a longer post-exposure life
expectancy, the threshold for justification becomes significantly higher (Goske et al., 2013). This
model encourages practitioners to thoroughly evaluate whether an imaging or therapeutic
procedure is absolutely necessary, or if a non-radiating alternative (e.g., ultrasound or MRI)
might achieve the same clinical outcome.

In pediatric imaging, risk-benefit analysis is especially pertinent because of the cumulative

lifetime risk of radiation-induced malignancies. Children’s cells are rapidly dividing and thus
more susceptible to genetic mutations from ionizing radiation, while their longer lifespan
increases the window during which adverse effects may manifest (Brenner & Hall, 2007). The
RBA model, therefore, insists that benefits such as early disease detection, accurate diagnosis, or
effective treatment must be weighed against both immediate and long-term risks like secondary
cancers, cognitive delays, and organ toxicity (Miglioretti et al., 2013).

One strength of the RBA model is its applicability across diverse clinical scenarios. In routine
diagnostic imaging, for instance, it prompts radiographers and clinicians to ask: Is this imaging
procedure necessary? Will it impact clinical management? Can the same result be obtained
through a non-radiologic modality? In therapeutic settings, particularly in treating pediatric
cancers, the model guides oncologists and medical physicists in tailoring radiation doses,
choosing the most precise delivery methods, and employing patient-specific planning tools
(Paulino & Fowler, 2005). Each step—from imaging requisition to post-treatment review—is
governed by a calculated consideration of trade-offs between potential harm and intended
benefit.

Moreover, the RBA model supports individualized care planning, ensuring that decisions are not
generalized but are tailored to each child’s clinical condition, medical history, and developmental
stage. This person-centered approach aligns with modern pediatric care models, which
emphasize shared decision-making between healthcare providers, patients, and caregivers.
Through the lens of RBA, parents or guardians are engaged in informed discussions about the
necessity, risks, and expected outcomes of radiation-based procedures, enhancing transparency
and ethical accountability (Tappin et al., 2016).

In terms of institutional application, hospitals and radiology departments are encouraged to

embed RBA principles into their clinical governance structures. For example, imaging request
forms might include a section requiring justification based on benefit-risk evaluation. Radiology
review boards may adopt protocols that scrutinize pediatric imaging requests, particularly for
repeat or high-dose procedures. Decision-support systems integrated into radiology information
systems (RIS) can prompt clinicians to reconsider or confirm procedures based on RBA logic
(Paterson et al., 2014).

However, implementing the RBA model consistently in practice faces several challenges. One
major issue is the lack of quantitative tools to precisely measure long-term risks, especially in
children. While dose monitoring tools are increasingly available, translating dose values into
tangible risk profiles remains complex. Additionally, time pressures in clinical settings can
sometimes lead to automatic approvals of imaging requests without thorough analysis. There is
also a variability in practitioner awareness and understanding of risk-benefit dynamics,
especially in resource-limited settings where training and continuing education may be
insufficient (Ofori et al., 2020).

Another challenge lies in overestimation or underestimation of risks, which can lead to either
avoidance of necessary procedures or overexposure to radiation. In some cases, fear of litigation
or parent anxiety may prompt unnecessary imaging “just to be safe,” while in other instances,
poor knowledge of pediatric radiation sensitivity may lead to unjustified exposures. Therefore,
the RBA model must be supported by robust professional training, access to evidence-based
protocols, and an organizational culture that values justification as a safety imperative (Seeram,
2019).

Furthermore, the RBA framework is closely linked to the ALARA principle, as both seek to
ensure radiation exposure is justified and minimized. While ALARA focuses on dose
optimization, RBA deals more fundamentally with whether a procedure should be done at all.
Together, they form a synergistic approach: RBA determines the if, and ALARA determines the
how much (ICRP, 2007; Frush et al., 2013).

Technological advancements have also enhanced the application of RBA in clinical settings.
Decision-support software can automatically flag high-risk procedures or suggest alternative
modalities based on patient age, weight, and clinical indications. Dose-reporting systems and
registries allow departments to monitor trends, identify deviations, and benchmark their practices
against national or international standards—all of which strengthen the RBA process (Kalra et
al., 2020).
In summary, the Risk-Benefit Analysis Model is a foundational theoretical framework that
supports ethical, evidence-based, and patient-centered decision-making in pediatric radiation
protection. By systematically evaluating the potential advantages of radiation exposure against
its inherent risks, the model empowers radiographers and clinicians to make informed, judicious
choices that prioritize the child’s long-term health and well-being. As pediatric imaging and
therapy continue to evolve with new technologies and clinical demands, the risk-benefit analysis
remains a critical tool in achieving safe, effective, and responsible radiation practice.

2.4 Appraisal of Literature

The review of existing literature has offered a multifaceted understanding of paediatric radiation
protection, highlighting the theoretical underpinnings, best practices, and empirical realities of
radiographic and radiotherapeutic procedures in paediatric populations. Several patterns and
critical insights emerge from the conceptual, empirical, and theoretical reviews presented in the
preceding sections.

To begin with, the conceptual review outlined the unique vulnerabilities of children to ionizing
radiation, particularly due to their higher cellular replication rates and longer life expectancy,
which increase the likelihood of long-term radiation-induced complications (Brenner & Hall,
2007; Miglioretti et al., 2013). The reviewed literature emphasized the need for stringent
protective measures, including individualized dose protocols, proper immobilization, and the
adoption of non-ionizing imaging alternatives wherever possible (Goske et al., 2013; Strauss et
al., 2015). The essential role of radiographers in applying these principles—through correct
positioning, exposure control, and patient engagement—was repeatedly emphasized.

In the empirical review, two major themes emerged: compliance with radiation protection
protocols and the knowledge/training of radiographers. Research findings have shown variable
levels of compliance among radiographers, often influenced by institutional policy, availability
of protective equipment, workload pressures, and organizational culture (Ofori et al., 2020;
Aweda et al., 2021). Notably, gaps were observed in adherence to international safety standards,
particularly in low- and middle-income countries, where regulatory enforcement and continuous
training are often lacking. The literature also revealed inconsistencies in radiographers'
knowledge regarding paediatric-specific protection protocols, which correlates strongly with the
availability and frequency of in-service training and professional development programs
(Seeram, 2019; Ajibola et al., 2018). These findings suggest a pressing need for standardized,
continuous education modules focused on paediatric safety, especially given the evolving nature
of imaging technologies and international safety standards.

The theoretical frameworks discussed—namely the ALARA principle and the Risk-Benefit
Analysis Model—provided valuable lenses through which radiographers and institutions can
interpret, evaluate, and guide paediatric imaging practices. ALARA supports the drive to
optimize dose levels, encouraging radiographers to constantly innovate and adapt their
techniques to minimize exposure (ICRP, 2007; Frush et al., 2013). Meanwhile, the Risk-Benefit
Analysis Model reinforces the ethical obligation to justify all radiation procedures by ensuring
that diagnostic or therapeutic benefits clearly outweigh the risks (Tappin et al., 2016). Together,
these frameworks enhance clinical decision-making by embedding safety considerations into
everyday radiographic routines.

Despite these strengths, gaps and inconsistencies remain in the literature. Many studies are cross-
sectional and lack longitudinal follow-up, making it difficult to assess the long-term effects of
interventions such as staff training or policy updates. Additionally, most empirical studies focus
on urban tertiary hospitals, with less representation from rural or low-resource settings. This
creates a geographical and contextual gap in understanding how radiation protection is
implemented across diverse clinical environments. Furthermore, the voices of caregivers and
paediatric patients are often absent in empirical assessments, which limits the literature's capacity
to reflect patient-centered perspectives on radiation safety.

Another observed limitation is the lack of standardized metrics for evaluating compliance and
knowledge across different institutions. Without uniform benchmarks or tools for assessment, it
is challenging to compare findings or make generalizable conclusions. This suggests a need for
the development and widespread adoption of validated instruments to measure paediatric
radiation safety practices, knowledge, and compliance consistently across healthcare facilities.

Moreover, policy implementation remains a significant challenge, particularly in developing

countries where health systems may struggle with resource constraints, limited access to modern
imaging equipment, and insufficient regulatory oversight. In such contexts, even when
radiographers possess theoretical knowledge of safety principles, practical application may be
hindered by infrastructural or systemic limitations.

In terms of research implications, future studies should consider longitudinal designs to monitor
changes in compliance and knowledge over time. There is also a need to explore the impact of
tailored training interventions, caregiver education, and multidisciplinary team collaboration on
the effectiveness of paediatric radiation protection. Qualitative research methods could also be
employed to capture deeper insights into the barriers and facilitators influencing radiographers’
practices, including organizational culture, leadership attitudes, and staff morale.

In conclusion, the appraisal of literature reveals that while considerable progress has been made
in understanding the principles and practices of paediatric radiation protection, significant
challenges persist in ensuring consistent application, particularly in low-resource settings. There
is a clear consensus on the heightened vulnerability of children to ionizing radiation and the
pivotal role of radiographers in minimizing exposure. However, gaps in training, compliance,
policy implementation, and standardized assessment tools continue to limit the full realization of
safety objectives. Future research and policy should prioritize targeted interventions that bridge
these gaps, promote continuous professional development, and institutionalize safety cultures
grounded in the ALARA and Risk-Benefit Analysis models.
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