REPORT

Enhancing
Enhancing nuclear
nuclear safety
safetyExposure of children to ionisingradiation due to diagnostic
medical imaging procedures
performed in France in 2015
2015 ExPRI Paediatric Study
Report No. PSE-SANTE/SER/2018-00004
Health and Environment Unit
Radiological Protection Study and Appraisal
Department

Contents
1

INTRODUCTION .................................................................................... 82

SELECTION OF THE TYPES OF PROCEDURE AND DETERMINATION OF THEIRFREQUENCY ........................................................................................ 9

2.1

Selection of diagnostic imaging procedures for the study ............................................................... 9

2.2

Estimation of the frequency of diagnostic imaging procedures ...................................................... 103

ESTIMATION OF THE DOSES ASSOCIATED WITH DIAGNOSTIC IMAGING
PROCEDURES ..................................................................................... 14

3.1

Dosimetric indicator: effective dose....................................................................................... 14

3.2

Estimation of the mean effective doses associated with each type of procedure ................................ 14

3.3

Uncertainty of the effective dose values ................................................................................. 15

4

EXPOSURE OF THE WHOLE PAEDIATRIC POPULATION IN 2015.......................... 17

4.1

Distribution of exposure by imaging modality ........................................................................... 17

4.2

Frequency of diagnostic imaging procedures by anatomical area explored ........................................ 22

4.3

Distribution of imaging procedures by type of healthcare establishment .......................................... 31

5

PAEDIATRIC POPULATION ACTUALLY EXPOSED IN 2015 ................................. 33

5.1

Characterisation of the exposed population ............................................................................. 33

5.2

Individual effective dose ..................................................................................................... 37

6

COMPARISON WITH THE LITERATURE ........................................................ 39

7

CONCLUSION ...................................................................................... 41

BIBLIOGRAPHIC REFERENCES ........................................................................ 42
APPENDIX 1 LIST OF CCAM CODES BY IMAGING MODALITY AND BY ANATOMICALAREA EXPLORED. ASSOCIATED EFFECTIVE DOSE, FREQUENCY AND
CONTRIBUTION TO THE COLLECTIVE DOSE. ................................................ 44

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Illustrations and tables
Illustrations
Figure 1. Distribution by imaging modality of diagnostic procedures and of the associated effective dose. ............. 17
Figure 2. Frequency of procedures by imaging modality according to the child's age, both sexes combined. .......... 19
Figure 3. Annual mean effective dose per child in µSv by imaging modality and age, both sexes combined. ........... 21
Figure 4. Frequency of conventional radiology procedures by anatomical area according to the child's age(both sexes combined). ...................................................................................................... 24
Figure 5. Frequency of conventional radiology procedures according to anatomical area explored, andchild's age group and sex. ................................................................................................... 25
Figure 6. Frequency of intraoral and extraoral dental radiology procedures according to child's age groupand sex. ......................................................................................................................... 26
Figure 7. Frequency of computed tomography procedures according to anatomical area explored, andchild's age and sex. ........................................................................................................... 27
Figure 8. Frequency of nuclear medicine procedures according to anatomical area explored and child's age
group. ........................................................................................................................... 28
Figure 9. Distribution of procedures between the public and private sectors by child's age group, forconventional radiology and computed tomography..................................................................... 32
Figure 10. Proportion of children who underwent at least one diagnostic procedure in 2015, by age groupand sex .......................................................................................................................... 33
Figure 11. Histogram of the numbers of procedures per child exposed during the year, for each age range. .......... 35
Figure 12. Proportion of children undergoing one or more ultrasound scans of the hips prior to pelvic
girdle X-ray performed under the age of 6 months. .................................................................... 36
Figure 13. Histogram of the cumulative effective dose received by each child exposed during the year, foreach age range................................................................................................................. 38
Figure 14. Classification of CCAM codes by: a) their proportion of the total coded procedures; b) theircontribution to the total annual effective dose. ........................................................................ 45

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Tables
Table I: Anatomical areas associated with each imaging modality and number of CCAM codes actually used. .......... 10
Table II: Number of beneficiaries2 in the 2015 EGB sample by year of birth between 2000 and 2015 .................... 12
Table III. Frequency of procedures by age range according to imaging modality (number of procedures per1000 children in the age range in question) ............................................................................. 18
Table IV. Annual mean effective dose per child by age range and imaging modality (µSv). ................................. 20
Table V. Distribution of imaging procedures by imaging modality and anatomical area explored, expressedas the number of procedures and the frequency of procedures per 1000 children. ............................. 23
Table VI. Distribution between the public sector and private sector of paediatric diagnostic procedures
listed in the EGB sample database in 2015. .............................................................................. 31
Table VII. Statistics for the annual number of procedures per exposed child by age group. ................................ 34
Table VIII. Statistics for effective dose per exposed child by age group......................................................... 37

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RésuméCe rapport a pour objectif d’établir pour l’année 2015 les données relatives à l’exposition des enfants de moins de 16 ans
aux examens d’imagerie médicale diagnostique utilisant les rayonnements ionisants (radiologie conventionnelle, dentaire
et interventionnelle diagnostique, scanographie et médecine nucléaire). L’étude a été réalisée à partir des actes
d’imagerie diagnostique extraits de l’échantillon généraliste des bénéficiaires de l’Assurance maladie, représentatif au
1/97ème de la population française.
Environ 604 actes diagnostiques pour 1000 enfants ont été réalisés en 2015, chiffre en relative stabilité (+1,5 %) par
rapport à l’année 2010. La proportion d’enfants ayant bénéficié d’au moins un acte diagnostique atteint 31 %, en haussede 2 points. La dose efficace annuelle moyenne s’élève à 0,135 mSv par enfant, exposé ou non, en baisse de 25 % par
rapport à l’année 2010, tandis que la dose efficace moyenne par enfant exposé atteint la valeur de 0,43 mSv, en baisse de
34 %. L’exposition est extrêmement hétérogène puisque la moitié des enfants exposés a reçu une dose efficace annuellecumulée inférieure ou égale à 0,02 mSv. Les enfants âgés de moins de 1 an sont, en proportion de l’effectif exposé de leurclasse d’âge, la catégorie la plus exposée, avec une dose efficace annuelle médiane de 0,55 mSv.
L’exposition des enfants aux rayonnements ionisants due aux actes d’imagerie médicale diagnostique a très sensiblement
diminuée entre 2010 et 2015 en France et cela alors que la fréquence moyenne de ces actes est restée relativement
stable sur la même période. Cette baisse de l’exposition est donc exclusivement due à la diminution globale des doses
moyennes par acte d’imagerie médicale, liée à l’amélioration des techniques et des pratiques.

Abstract
The purpose of this report is to establish data for the year 2015 on the exposure of French children aged under 16 years todiagnostic medical imaging procedures involving ionising radiation (conventional and dental radiology, diagnostic
interventional radiology, computed tomography and nuclear medicine). The study was conducted using the échantillon
généraliste des bénéficiaires, a sample on a 1/97th scale of the healthcare consumption of the population covered by themain French health insurance schemes.
Around 604 diagnostic procedures per 1000 children were performed in 2015, a near stable figure (+1.5%) compared to theyear 2010. The proportion of children who had at least one diagnostic procedure was 31%, up by 2 points from 2010. The
annual mean effective dose is 0.135 mSv per child, exposed or not, down 25% from 2010, while the mean effective dose
per exposed child is 0.43 mSv, down 34% from 2010. Exposure is extremely varied among exposed children, since half ofthem received a cumulative annual effective dose of 0.02 mSv or less. Relative to the number of children exposed in theirage group, children aged under 1 year are the most highly exposed category, with a median annual effective dose of
0.55 mSv.
Children's exposure to ionising radiation originating from diagnostic medical imaging procedures decreased markedly inFrance between 2010 and 2015, even though the mean frequency of these procedures remained nearly stable over thesame time period. This reduction in exposure is therefore due solely to an overall decrease in the mean dose per medical
imaging procedure, which is related to improvements in technologies and practices.

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Glossary
ASP

Abdominal X-ray without preparation

ATIH

French Technical Agency for Information on Hospitalisation

CCAM

Common Classification of Medical Procedures

ICRP

International Commission on Radiological Protection

CNAM

French national health insurance scheme

EGB

Representative sample of the French population protected by health insurance

FDG

Fluorodeoxyglucose

HAS

French national health authority

MSA

Social security scheme for agricultural workers

NIR

National registration number (social security number)

DRL

Diagnostic reference level

PMSI

Diagnosis categorisation system for calculating hospital treatment costs

RSI

Social security scheme for the self-employed

SFIPP

French-speaking society for paediatric and prenatal imaging

SFR

French radiology society

SLM

Social security scheme for public sector workers

SNIIRAM

National information system for health insurance schemes

T2A

Activity-based funding system for French hospitals

PET

Positron emission tomography

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1

INTRODUCTION

Medical imaging, though undeniably beneficial in patient treatment, is the main contributor to the French population's
exposure to ionising radiation of artificial origin [1]. It is therefore important to characterise this medical exposure
regularly, as required by the European Union since 1997 [2]. This requirement was reinforced in 2013 by European
Directive 2013/59/Euratom [3], which was recently transposed into French law. Article R1333-67 of the French Public
Health Code, as amended by decree on 4 June 2018, stipulates that "The mean exposure of the population to ionisingradiation by imaging modality, anatomical area, age and sex, linked to medical diagnostic procedures, shall be estimatedand analysed periodically by the Institute for Radiological Protection and Nuclear Safety (IRSN) and shall be the subjectof a public report that can be consulted on IRSN's website."This has been done by IRSN since 2003, when it took part with InVS, the French Institute for Public Health Surveillance(now part of Santé Publique, the French public health agency) in setting up the national ExPRI (Exposure of the Population
to Ionising Radiation) system, which is designed to provide the authorities and professionals with up-to-date data for
exposure of the French population to diagnostic medical imaging procedures. Since 2012 the ExPRI system has been
entirely the responsibility of IRSN. Three reports have been produced on exposure of the French population, at five-year
intervals (2002, 2007 and 2012) [4]–[6]. In 2015 IRSN brought together a team of experts consisting of representatives of
the competent authorities and of relevant learned societies and professional bodies. Among other things, the committee
recommended repeating the special study of exposure of the paediatric population in 2010 because of the particularradiosensitivity and long life expectancy of this section of the population [7].
This report aims to establish data for 2015 on the medical exposure of France's paediatric population due to diagnostic
imaging. First of all it discusses the methods used to select the diagnostic imaging procedures and to estimate theirfrequency of use and the doses associated with them. The results are then presented by imaging modality, by anatomicalarea investigated, by type of procedure and by type of healthcare establishment, for the whole paediatric population. All
the results are characterised by the age and sex of the individuals. Finally, the results are compared with international
data.

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2

SELECTION OF THE TYPES OF PROCEDURE AND DETERMINATION OF
THEIR FREQUENCY

The exposure of children to ionising radiation linked to diagnostic imaging procedures in France is studied, for 2015, using
the following indicators:

the frequency of each type of diagnostic imaging procedure using ionising radiation in 2015 for children aged
under 16 years on the date of the procedure;the share of the population of children actually exposed in 2015, i.e. who underwent at least one diagnostic
imaging procedure using ionising radiation during the year;the contribution of each type of procedure to the mean effective dose per child, for the whole paediatricpopulation;

2.1

the annual effective dose received by the children actually exposed in 2015.

Selection of diagnostic imaging procedures for the study

Only imaging procedures that use ionising radiation for diagnostic purposes are included, i.e.:conventional radiology procedures, including dental radiology;

computed tomography procedures (CT scans);

nuclear medicine procedures for diagnostic purposes;interventional radiology procedures for diagnostic purposes 1.

These procedures are referred to as "diagnostic procedures" in the rest of this report.

2.1.1

Identification of procedures: the Common Classification of Medical Procedures (CCAM)The CCAM is a unique system of reference codes for all technical medical procedures covered by health insurance inFrance. It is used nationally and its use has been mandatory since 31 December 2005 by all general practitioners andmedical specialists working either in the outpatient sector (local doctors' surgeries and health clinics) or in public or
private hospitals (inpatient stays and outpatient consultations). The codes are used for activity pricing and description.
With the CCAM, diagnostic procedures can be unambiguously distinguished from one another. Each type of procedure is
identified by a full description and a code consisting of four letters and three numbers. For example, the CCAM code
ZBQK002 corresponds to the description "Chest X-ray". For the requirements of this study, a keyword search was carriedout on version 49 of the CCAM: 632 different codes were found. Having eliminated therapeutic procedures, biopsies andex-vivo examinations, 401 codes were retained, including 24 new codes that were not covered in the study for 2010 [7].
The use of the codes in the CCAM nomenclature by dental surgeons, which did not apply at the time of the 2010 study,
was becoming widespread in 2015. Consequently, only some dental X-rays are associated with a CCAM code. The rest canstill be identified using a particular service reference (see section 2.2.3 for more details).

1

Radioguided biopsies are not included in this study because representative dosimetric data are rare for these procedures that are highly
dependent on the operator’s skill as well as on the complexity of the intervention.

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2.1.2

Grouping of procedures

The procedures selected for this study were grouped for analysis in two ways:a.

By imaging modality: conventional radiology (excluding
dental), dental radiology, computed tomography, nuclear
medicine and diagnostic interventional radiology.

b.

Table I: Anatomical areas associated with each
imaging modality and number of CCAM codes
actually used.

By anatomical area explored: the anatomical areas
defined in the report are based on radiation protection
criteria, i.e. by looking at the organs situated within theradiation field, using the methodology recommended by

Imaging modality

Number of

Anatomical area

CCAM codes

Conventional radiology

93

Head and neck

8

Chest

13

Abdomen and pelvis

16

Pelvic girdle

10Whole spine

4

procedures concerning the digestive system are included in

Limbs

31

the head and neck, chest or abdomen-pelvis areas,

Other

11

European Radiation Protection Report 154 [8]. For example,
X-rays of the lumbar spine are grouped in the anatomicalarea "abdomen". In the study, some of the anatomical areas
rarely explored in children have been grouped together:

depending on the organ concerned; those concerning the

Dental radiology

22

genitourinary system are grouped into the abdomen-pelvis

Extraoral

5

area. Conversely, procedures concerning the pelvic girdle

Intraoral

17

are grouped in a specific area, because of their particularComputed tomography

37

importance in paediatric radiology. Similarly, procedures

Head and neck13

concerning a section of the spine are included in the areas

Chest and heart4

head and neck, chest or abdomen-pelvis areas, depending

Abdomen and pelvis

5on the part of the spinal column being studied, whereas

Spine

4

those concerning the whole spine have their own special

Limbs

9

Trunk

2

category. In dental radiology, procedures are grouped into
two categories, which are not strictly anatomical areas.
The extraoral category includes procedures where theimage receptor is outside the patient's mouth (panoramic Xray, cone-beam CT, cephalometric projection), whereas
the intraoral category includes procedures where theimage receptor is inside the patient's mouth (periapical,
bitewing and occlusal X-rays).

Nuclear medicine

27

Head and neck3

Chest and heart

4

Abdomen and pelvis

10Whole body

7

Other

3

Diag. interventional radiology

9

Cardiac

1

Table I lists the anatomical areas taken into account for each

Vascular8

imaging modality, and the number of CCAM codes used for this study

All modalities

188(i.e. the codes covering at least one procedure for the sample population in question). A full list of the CCAM codes
included in this study is given in Appendix 1.

2.2

Estimation of the frequency of diagnostic imaging procedures

The frequency of procedures for the "Whole of France" paediatric population was estimated for this study on the basis of
the observed frequency for the paediatric population in SNIIRAM's EGB sample, the database of anonymised data managed
by CNAM containing billing information for healthcare procedures.

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2.2.1

EGB sample

The SNIIRAM order of 20 June 2005 authorised the creation of a national representative sample of 1/97 th of all healthinsurance scheme beneficiaries (general scheme excluding the SLM public sector schemes). This sample is known as the
Échantillon Généraliste des Bénéficiaires or EGB sample. It is a permanent sample of beneficiaries and it links theiradministrative and sociodemographic characteristics to their healthcare "consumption" over time (this consumption may
be zero). A study published in 2009 by Roquefeuil et al. [9] demonstrated the EGB sample's internal validity, i.e. thesample's representativeness and lack of bias in respect of the population protected by the general health insurance
scheme (excluding the SLM schemes) and the reimbursed healthcare consumption of this population:the sex and age distribution of the EGB sample is very similar to that of the population as a whole;the mean reimbursed expenditure per EGB sample beneficiary who underwent at least one healthcare procedure
during the year of study (2007) is very similar to that of the population as a whole.

After that study was carried out, the EGB was extended in 2011 to beneficiaries of the MSA (agricultural) insurance
scheme and the RSI (self-employed) insurance scheme, and then in 2015 to the beneficiaries of 10 SLM (public sector)
schemes. It therefore represents 94.5% of the population covered by a social security scheme in France and will eventuallyencompass all French social security schemes. Its representativeness has therefore been improved since the study by
Roquefeuil et al. The results in this report, calculated on the basis of the paediatric population in the EGB sample for2015, can therefore be extrapolated to the whole population of France with a high degree of confidence.
The EGB sample data is accessed via a secure Internet portal run by CNAMTS. Since the end of 2016, IRSN has had
permanent access by decree for the purposes of its public service missions, particularly the preparation of this report [10].
Approximately 120,000 beneficiaries born between 2000 and 2015 were included in the EGB sample in 2015, regardless ofwhether they were "consumers" or "non-consumers" of healthcare during that period 2. In particular, in the field of interestof this study, these beneficiaries may have undergone one or more diagnostic procedures, or none at all in the year 2015.
The composition of the EGB sample in 2015 for beneficiaries born from 2000 onwards is presented in Table II. The
population was studied by in 5-year age ranges (or by year where the number of procedures was sufficiently high), in
accordance with the recommendations of European Radiation Protection Report 154 [8], with a special class for infants
aged under one year because of the particular morbidity of this age group.

2

In this study, the population of the 2015 EGB sample is calculated only with the beneficiaries of the general healthcare scheme, theagricultural scheme and the self-employed scheme. The beneficiaries of the 10 SLM schemes were incorporated during the year, but theirpast history was not included so their healthcare consumption does not cover 12 months in 2015. Taking them into account would
therefore have introduced bias into the study.

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Table II: Number of beneficiaries2 in the 2015 EGB sample by year of birth
between 2000 and 2015
Year of birth

2.2.2

Total

2015

2010-2014

2005-2009

2000-2004

Boys

3 362

19 68319 93219 20362 180

Girls

3 161

18 79019 031

18 27559 257

Total

6 523

38 47338 96337 478121 437

Procedure count

The healthcare consumption of each beneficiary is periodically fed into the EGB sample from SNIIRAM's billing data. Since
June 2011, SNIIRAM has had reimbursement data for healthcare services (non-hospital healthcare) and data from public
and private hospitals, thanks to the inclusion of additional data from the PMSI programme (diagnosis categorisation systemfor calculating hospital treatment costs) run by ATIH, the French Technical Agency for Information on Hospitalisation. The
CCAM is used to code the procedures performed. Each beneficiary included in the EGB sample is identified by theirencrypted NIR number3, so it is possible to reconstruct healthcare pathways while maintaining patient anonymity,
regardless of whether the care was received in the private or public sector, or at home, at a clinic or in hospital. The EGB
sample therefore enables all diagnostic procedures on the sample's beneficiaries to be counted.
Compared to the study for 2010 [7], the representativeness of the SNIIRAM data available in 2015 has improved in several
respects:


The PMSI data for public hospitals is much more comprehensive. The T2A system (activity-based funding system
for French hospitals), introduced in 2004 and gradually expanded since then, is now almost the only funding
method for medicine, surgery, obstetrics and dentistry at both public and private establishments. All imaging
carried out at these establishments therefore appears in the PMSI and it can therefore be considered in 2015 togive a practically exhaustive picture of hospital activity.



The inclusion of the beneficiaries of the agricultural and self-employed schemes makes the EGB sample more
representative of the diversity of the French population's health habits. This representativeness will be further
improved in future studies by the inclusion of a large number of SLMs, including the student healthcare schemes.

Many private dental healthcare services are associated with CCAM codes, enabling a more detailed description ofthis activity.

The data extracted from the EGB sample for this study can therefore be considered comprehensive enough to describe
population exposure linked to diagnostic procedures performed in the private sector or during stays or outpatient
treatment at public hospitals. Nevertheless, because the EGB is a 1/97 th sample of the population, there may be only very
tiny numbers of some uncommon procedures for children, such as interventional radiology, nuclear medicine, and to alesser extent computed tomography. Extrapolation to the whole population becomes statistically problematic in thesecases.
3

National registration number of physical persons, usually referred to as their social security number. It is unique to each beneficiary.

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2.2.3Extraction of parameters of interest for the study

Queries were made via the SAS Enterprise Guide 7.1 software to the SNIIRAM and PMSI databases to extract all diagnostic
procedures in the EGB sample carried out between 1 January and 31 December 2015 on children aged under 16 years at
the time of the procedure. In practice, because the beneficiary's date of birth is not available in the EGB sample, toprevent re-identification, the beneficiary's age at the time of the diagnostic procedure is calculated to the nearest monthand rounded up, so a child born in February 2014 who underwent a procedure in February 2015 is considered to be aged
12 months at the time of the examination, though their real age could be 11 or 12 months depending on whether theexamination date was before or after their birthday. The diagnostic procedures extracted include:

procedures performed in the private sector, i.e. by "practitioners working in private practice", "full-time hospital
practitioners working privately", and "practitioners working as employees in a private establishment", which
therefore includes procedures performed in doctor's surgeries and private clinics, including dental care with a
CCAM code;procedures performed during hospital stays in public establishments;



procedures performed as outpatient treatments in public healthcare establishments;



procedures performed by dental surgeons in the private sector without a CCAM code.

For each of these procedures, the parameters of interest for this study were:the demographic characteristics of the beneficiary: encrypted NIR, sex, month and year of birth;

the characteristics of the procedure:reference service type4,

healthcare sector (private, dental without CCAM code, public sector inpatient and outpatient),

CCAM code and procedure description, for all procedures except some dental radiology,month and year performed.

The analysis looked at:the frequency of performance in 2015 of each of these types of diagnostic procedure, for children aged 0 to 15
years, according to the two groups defined (imaging modalities and anatomical areas examined), and according
to the age and sex of the beneficiaries;the distribution of imaging procedures between the public and private sectors;the share of the population of children actually exposed in 2015, i.e. who underwent at least one procedure
during the year, characterised by age and sex.

Finally, the exposure of children given at least one pelvic X-ray before they were 6 months old in 2015 was also studied.
This is because the ongoing use of this type of X-ray on very young children, against the recommendations of the French

4

The reference service type is a variable defining the type of healthcare service in SNIIRAM, for procedures performed privately. There
are 10 values of this variable that are associated with radiology procedures. In practice only 4 codes returned a non-zero number ofprocedures (listed by decreasing number of procedures): 1351 (CCAM imaging procedures [excluding ultrasound]), 1331 (X-rays), 9423
(oral disease prevention – 4 X-ray plates) et 9422 (oral disease prevention – 2 X-ray plates). Code 1351 is used for all radiology procedureswith CCAM codes, including dentistry procedures. Codes 1331, 9422 and 9423 are used solely for dental radiology procedures without
CCAM codes.

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national health authority (HAS) [11], is of particular interest to the French-speaking society for paediatric and prenatal
imaging (SFIPP).

3

ESTIMATION OF THE DOSES ASSOCIATED WITH DIAGNOSTIC IMAGING
PROCEDURES

3.1

Dosimetric indicator: effective doseIn accordance with the recommendations of European Radiation Protection Reports°154 [8] and 180 [12], the dosimetricindicator used in this study to assess the exposure of children to ionising radiation linked to diagnostic procedures is theeffective dose (expressed in millisieverts, mSv). Effective dose is an indicator of the risk of long-term damage to health(potential to cause cancers and hereditary effects) linked to exposure to ionising radiation. This indicator is used to assess
the overall risk for the whole body, regardless of whether or not the whole body was exposed, taking account of the typeof radiation (type and energy), and the radiosensitivity of each organ exposed [13]. Because it is calculated using
weighting factors defined for the general population, all ages and sexes combined, the effective dose should not be used
to give an absolute quantification of the risk for a specific population such as the paediatric population, or of course
for estimating the risk to an individual. However, it can be used to compare the relative radiological risks associatedwith the imaging of different anatomical areas or the risks associated with different imaging modalities used for the same
examination. As a standardised indicator, it can also be used for comparisons between different countries and for studying
how the exposure resulting from a particular procedure changes over time.
The effective doses were calculated using the tissue weighting factors defined in International Commission on RadiologicalProtection (ICRP) Publication 103 [13]. The annual individual effective dose is obtained by adding together the effective
doses associated with the different procedures performed on a single patient during the period of interest.

3.2

Estimation of the mean effective doses associated with each type of procedure

Various different sources of available data have been used to associate a mean effective dose with each type ofprocedure:the data sent to IRSN by all imaging services for the update of the radiology and nuclear medicine diagnostic
reference levels [14], [15];

procedure guides prepared by professionals, radiologists, nuclear medicine doctors and dental surgeons [16]–[18];

dosimetric studies performed by IRSN or professional bodies in France [19]–[23];

private communications with professionals [24].

These data are considered to be representative of French practice in radiology and nuclear medicine in 2015. The meaneffective doses by procedure type for 2015 are presented in Appendix 1, categorised by imaging modality, anatomical area
and CCAM code. The doses by procedure type have fallen overall compared to 2010, in line with the reduction in
dosimetric indicators already identified in IRSN's report published in 2016 analysing data related to the update of the
DRLs [15].
It is important to remember that the mean effective doses used for each procedure are for examinations of adults.
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diagnostic procedures in this study. Moreover, the data that are available are heavily dependent on children's body size,
and therefore their age. Additionally, even in cases where exposure parameters specific to children are available, thesmall physical stature of children means that there is less radiation attenuation and that the organ doses received are
therefore not necessarily lower than for adults. Finally, as explained in section 3.1 above, the tissue weighting factors in
ICPR Publication 103 are for the general population, which means that they should not be used to estimate the risk for a
specific population. Because the study is not a risk study but only a study to characterise the exposure of the paediatricpopulation for national and international comparison purposes, it is therefore better to use the effective doses calculated
for adults, as recommended by European Radiation Protection Report 154 [8] and ICRP Publication 103 [13, Paragr. 340],
and as the previous study [7] did.

3.3

Uncertainty of the effective dose values

The main sources of uncertainty when it comes to estimating the mean effective dose by type of procedure were
described and discussed in the report for 2010 [7]. They concern:

the national dispersion of effective doses delivered for a given type of procedure;

inconsistencies that can persist for certain types of procedure between actual clinical practice and the CCAM
classification;the rarity of certain types of procedure, which affects the reliability of their dosimetric assessment.

European Radiation Protection Report 180 [12] estimated the uncertainty of the mean effective doses per procedure
calculated by each of the countries that took part in the Dose Datamed 2 study. The mean uncertainty of this estimate,based on the method proposed by Hart and Wall [25], is in the range 20-40% for all the procedures being looked at.
The uncertainty for the calculation of the annual mean effective doses per child is mainly due to the uncertainty for themean effective doses per procedure, which in this type of study is much higher than the uncertainty for the frequency ofthe procedures or the population count. European Radiation Protection Report 180 [12] considers that the uncertainty ofthe estimates for population dose is between 12% and 25% depending on whether the mean effective doses by type ofprocedure are calculated on the basis of real clinical practice or are estimated from the literature. Because the meaneffective doses by type of procedure in this study are partly calculated on the basis of real data (DRL survey or specificstudies) and partly extrapolated from the literature, the uncertainty of the annual mean effective doses per childcalculated in this study should fall within this range.

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Summary
The 2015 ExPRI Paediatric Study was conducted on the EGB sample, which represents 1/97th of the French population
protected by the CNAM general health insurance scheme, the self-employed scheme and the agricultural scheme. All
diagnostic imaging procedures using ionising radiation (conventional radiology, dental radiology and diagnostic
interventional radiology, computed tomography and nuclear medicine), performed in 2015 on children aged under 16
years at the time of the procedure, were taken into account. The frequency of performance of the procedures wasdetermined for the public and private sectors and was studied on the basis of the child's age and sex. The meaneffective doses associated with each type of procedure were determined and were used to calculate the annual meaneffective dose per child. The share of the population of children actually exposed, i.e. who underwent at least one
procedure during the year, was characterised by age and sex. The number of procedures and the annual individual
effective dose were calculated for the population of children actually exposed.

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4

EXPOSURE OF THE WHOLE PAEDIATRIC POPULATION IN 2015

This chapter describes the results of the study concerning the whole paediatric population studied, regardless of whether
or not a child underwent a diagnostic procedure. The results are given in the form of frequency of performance, i.e. thenumber of procedures per 1000 children in the population studied, and in the form of an annual mean effective dose per
child. Where the information available for the study permits, the main results are interpreted.
A total of 73,325 diagnostic procedures were performed during 2015 on children in the EGB sample aged under 16 years.
When related to the 121,437 children in the EGB sample born between 2000 and 2015, that represents a mean of 604
procedures per 1000 children. The mean effective dose per child in the EGB sample due to diagnostic procedures carriedout during 2015 is 0.135 mSv per child. This mean can be extrapolated to the whole paediatric population of France. It
therefore provides an indicator of the exposure of French children to ionising radiation of medical origin (excluding
therapeutic uses). However, the real exposure of children is extremely diverse because only a fraction of the children in
the sample underwent one or more diagnostic procedures in 2015. This population of children actually exposed will be
studied in chapter 0.

4.1

Distribution of exposure by imaging modality

Figure 1 presents by imaging modality the frequencies of performance of procedures and the distribution of the associatedtotal effective dose for all ages and sexes combined.

a) Frequency of proceduresb) Total effective dose

Figure 1. Distribution by imaging modality of diagnostic procedures and of the associated effective dose.

Conventional radiology accounts for both the majority of procedures performed and the majority of the total effective
dose. Dental radiology is the second largest contributor in terms of frequency of procedures but only the fourth largest for
total effective dose. Conversely, computed tomography is the third most frequent modality, a long way behind dental
radiology, but is in second place for effective dose with a contribution of more than 40%. Nuclear medicine and diagnostic
interventional radiology procedures are infrequent and contribute little to the overall dose of the paediatric population.

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4.1.1Frequency of procedures by imaging modality according to the child's age and sex

The frequencies of procedures vary according to the child's age and, to a lesser extent, sex. Table III shows thefrequencies of procedures by age range and sex, calculated per 1000 children in each age range.
Table III. Frequency of procedures by age range according to imaging modality (number of procedures per 1000
children in the age range in question)
Imaging modality
Sex
Conventional radiology< 1 year

1 to 5 yrs

6 to 10 yrs/1000 child. (%)/1000 child. (%)/1000 child. (%)

11 to 15 yrs/1000 child. (%)

All ages/1000 child. (%)

521 (95.8%)

214 (85.5%)

288 (48.9%)490 (49.3%)

339 (56.2%)

Boys

562 (95.1%)

224 (85.2%)

272 (48.4%)

501 (51.6%)

343 (57.6%)

Girls

476 (96.8%)

204 (85.9%)

305 (49.5%)478 (47%)336 (54.7%)

Dental radiology

0.5 (0.1%)

26.7 (10.7%)289 (49.1%)

478 (48.1%)

249 (41.2%)Boys

0.3 (0.1%)

28.8 (11%)

278 (49.6%)

444 (45.7%)

235 (39.6%)Girls

0.6 (0.1%)

24.6 (10.4%)300 (48.6%)

514 (50.5%)262 (42.8%)

17 (3.2%)

7.6 (3.1%)

11 (1.8%)

24 (2.4%)

14 (2.3%)

22 (3.7%)

8.2 (3.1%)

11 (1.9%)25 (2.5%)

15 (2.5%)

Computed tomography
Boys
Girls

12 (2.5%)

7.0 (3%)

11 (1.7%)

23 (2.2%)

13 (2.2%)

3.4 (0.6%)

1.7 (0.7%)

0.8 (0.1%)

1.8 (0.2%)

1.5 (0.3%)Boys

5.1 (0.9%)

1.5 (0.6%)

0.8 (0.1%)

1.6 (0.2%)

1.5 (0.3%)Girls

1.6 (0.3%)

1.9 (0.8%)

0.9 (0.1%)

1.9 (0.2%)

1.6 (0.3%)

1.5 (0.3%)

0.2 (0.1%)

0.1 (0%)0.1 (0%)0.2 (0%)Boys

1.8 (0.3%)

0.3 (0.1%)

0.1 (0%)0.1 (0%)0.2 (0%)Girls

1.3 (0.3%)

0.1 (0%)0.2 (0%)0.2 (0%)0.2 (0%)543 (100%)250 (100%)

588 (100%)

993 (100%)

604 (100%)Boys

592 (100%)

262 (100%)562 (100%)

971 (100%)

595 (100%)Girls

492 (100%)

238 (100%)

616 (100%)

1017 (100%)

613 (100%)

Nuclear medicine

Diag. interventional radiology

All modalities

Large variations can be observed for different age ranges:
Children aged 1 to 5 years have the lowest frequency of exposure to diagnostic procedures, at around 4 times lessthan children aged 11 to 15 years, who are the most frequently exposed with a frequency of nearly 1 procedure
per child.

Conventional radiology accounts for nearly 96% of diagnostic procedures performed on children aged under 1
year, which makes this age range the one most frequently exposed to this imaging modality.



The conventional radiology and dental radiology proportions are equivalent for children aged 6 years and over.

Girls are exposed slightly more often than boys (1.8%); this trend is enhanced in children aged over 6 years,
mainly because of dental radiology. Conversely, girls aged under 6 years are less often exposed than boys aged
under 6 years, particularly in the under 1 year age range, where the frequency of diagnostic procedures is 10%
higher for boys, mainly due to conventional radiology. This difference between the sexes in very young children isprobably linked to perinatal mortality, which in developed countries is 20% to 30% higher for boys than girls [26].
Indeed, it seems logical to consider that more common perinatal pathologies in small boys translate into a larger
number of imaging procedures.

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These trends can also be observed in Figure 2, which represents the frequency of procedures according to the child's age
and the imaging modality for both sexes combined.

Figure 2. Frequency of procedures by imaging modality according to the child's age, both sexes combined.

It can be seen that:

After the peak observed before the age of 1 year, the frequency of procedures is minimal and fairly stable from 1
to 5 years, with the conventional radiology proportion gradually decreasing in favour of dental radiology. From 6
years of age, the frequency of procedures gradually increases up to 12 years of age, where the maximum isreached with approximately 1100 procedures per 1000 children. It then declines slightly, stabilising at
approximately 1 procedure per child aged 13 to 15 years.

The proportions of conventional and dental radiology are almost the same from 6 years of age, except at 12 yearsof age when an increase in dental procedures produces the maximum observed in the frequency of procedures,for all modalities combined. This peak in procedures is probably related to the compulsory oral disease
prevention examination required at 12 years of age by the Public Health Code [27].

The proportion of computed tomography procedures varies between 1.3% and 3.5%, with maximum values
observed in both the youngest children and the oldest.

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

Nuclear medicine and even more so diagnostic interventional radiology only account for a significant share of thefrequency of procedures in the youngest children.

4.1.2

Mean effective dose by imaging modality according to the child's age and sex

Table IV presents the mean effective dose per child and per imaging modality, by age range and sex.
Table IV. Annual mean effective dose per child by age range and imaging modality (µSv).
Imaging modality
Sex
Conventional radiology< 1 year

1 to 5 yrs

6 to 10 yrsµSv/child (%)µSv/child (%)µSv/child (%)

220 (78.5%)

45 (57.6%)

47 (49.7%)

Boys

243 (75.9%)

44 (54.1%)

Girls

196 (82.3%)

45 (61.7%)-- (0%)

Boys
Girls

Dental radiology

Computed tomography

11 to 15 yrsµSv/child (%)

All agesµSv/child (%)

101 (47%)

72 (53%)44 (46.5%)

86 (42.3%)

67 (49.7%)

50 (53%)118 (51.4%)

77 (56.4%)<1 (0.4%)

3 (3.3%)5 (2.4%)3 (2%)-- (0%)<1 (0.4%)

3 (3.2%)5 (2.4%)3 (1.9%)-- (0%)<1 (0.4%)

3 (3.4%)6 (2.4%)3 (2.1%)50 (17.6%)

27 (34.6%)

40 (42.6%)

101 (46.7%)

55 (40.4%)

Boys

63 (19.8%)

31 (38%)44 (46.6%)

103 (50.5%)

59 (43.4%)

Girls

35 (14.5%)

23 (30.8%)

36 (38.4%)

99 (43.1%)

51 (37.3%)

Nuclear medicine

7 (2.6%)5 (6.6%)4 (3.9%)8 (3.5%)6 (4%)Boys

12 (3.8%)

5 (6.3%)3 (3.4%)9 (4.4%)6 (4.5%)Girls

2 (0.8%)5 (6.8%)4 (4.3%)6 (2.7%)5 (3.6%)

Diag. interventional radiology
Boys
Girls

4 (1.3%)<1 (0.8%)<1 (0.5%)<1 (0.4%)<1 (0.6%)

2 (0.5%)

1 (1.3%)<1 (0.3%)<1 (0.4%)<1 (0.6%)6 (2.4%)<1 (0.4%)<1 (0.8%)<1 (0.4%)<1 (0.7%)280 (100%)

77 (100%)

94 (100%)

216 (100%)

136 (100%)Boys

321 (100%)80 (100%)

94 (100%)

203 (100%)

136 (100%)Girls

238 (100%)

74 (100%)

94 (100%)229 (100%)

137 (100%)

All modalities

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The mean effective dose per child, regardless of sex or imaging modality but by the child's age, is presented in Figure 3.

Figure 3. Annual mean effective dose per child in µSv by imaging modality and age, both sexes combined.

The large variations in the frequency of procedures based on the child's age are confirmed and amplified when assessing
the annual mean effective dose:Children aged under 1 year and children aged 11 to 15 years have the highest annual mean effective dose, at 280µSv per child for the former and 216 µSv for the latter (up to 270-275 µSv for children aged 14 and 15 years).
Conventional radiology is by far the biggest contributor for children aged under 1 year, and gives the highest
mean effective dose for all ages combined (220 µSv), whereas computed tomography is responsible for aroundhalf of the exposure of the oldest age groups. Children aged 1 to 10 years receive mean doses that are 3 to 4
times lower.

Overall, the mean doses of boys and girls are equivalent, though computed tomography scans make a larger
contribution for boys and conventional radiology makes a larger contribution for girls. On the other hand, boys
aged under 1 year receive on average a distinctly higher dose (35%) than girls of the same age, which is linked tothe difference in the frequency of procedures mentioned in the previous section. Conversely, the effective doseof girls aged 11 to 15 years is on average 13% higher than that of boys in the same age range, related entirely toconventional radiology.

With the notable exception of children aged under 1 year, the effective doses linked to conventional radiology
and computed tomography are fairly small and relatively stable for children aged from 1 to 10 years, but they

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then gradually increase up to the ages of 14 and 15 years. The most frequent procedures observed in Figure 2 forchildren aged 12 years are dental procedures, which involve very low doses and therefore have no impact on themean dose per child. The contribution of nuclear medicine to the mean effective dose per child remains low for
all age groups (10 µSv or less). The contribution of diagnostic interventional radiology is only significant forchildren aged under 1 year, but it remains very low.
Summary of results and comparison with the previous study
In France in 2015, approximately 604 diagnostic procedures were carried out per 1000 children aged under 16 years,
which is relatively stable (+1.5%) compared to the figure for 2010. Conventional radiology and dental radiology
account for 56% and 41% of procedures respectively, computed tomography accounts for just over 2%, nuclear
medicine and diagnostic interventional radiology account for less than 1%. This distribution is substantially equivalent
to the distribution for 2010. By age group, it is children aged 11 to 15 years who are the most frequently exposed,with 993 procedures per 1000 children (down 10% on 2010), whereas those aged 1 to 5 years are the least
frequently exposed, with 250 procedures per 1000 children (up 24%). The frequency of procedures on children aged
under 1 year (543 procedures per 1000 children) has fallen by 26% compared to 2010. Girls are exposed slightly
more often than boys, for all age groups combined (+1.8%).
The annual mean effective dose is 0.135 µSv per child; this is down 25% compared to 2010. Conventional radiology
contributes about 53% to this dose, or 72 µSv per child, which is a 53 µSv reduction compared to 2010. CT scans
account for about 40% of the total dose, or 55 µSv per child, which is a slight increase of 7 µSv since 2010. Dental
radiology, nuclear medicine and diagnostic interventional radiology together contribute less than 7%, or 9 µSv, which
is a 2 µSv increase since 2010. Children aged under 1 year have the highest annual mean effective dose: 0.28 mSv
per child. For all age groups combined, the annual mean effective doses of girls and boys are identical.

4.2

Frequency of diagnostic imaging procedures by anatomical area explored

The distribution of the imaging procedures extracted from the EGB sample for 2015 is described in Table V. The number ofprocedures is shown there by imaging modality, broken down by anatomical area. The frequencies of the procedures
performed on the EGB sample population are also given for each sex and for both sexes combined. The results of this table
are broken down by imaging modality in the next few pages.

4.2.1

Conventional radiology

The absolute majority of procedures concern examinations of the limbs, followed by chest X-rays. Boys undergo
conventional radiology procedures overall slightly more often than girls (+0.7%). The difference is mainly due to X-rays ofthe limbs and chest, where there is a significant difference in favour of boys (+1.4% for limbs, +1.1% for the chest).
Conversely, girls more frequently undergo examinations of the pelvic girdle (+0.3%), the abdomen and pelvis (+0.3%) andespecially the whole spine, for which the difference is 1.3%.

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Table V. Distribution of imaging procedures by imaging modality and anatomical area explored, expressed as thenumber of procedures and the frequency of procedures per 1000 children.
Number of

Frequency of procedures

Imaging modality

procedures in

Anatomical area

EGB 2015

Conventional radiology

Overall/1000 child. (%)

Boys/1000 child. (%)

Girls/1000 child. (%)

41210

339.4 (56.2%)

342.9 (57.6%)

335.6 (54.7%)

Head and neck1540

12.7 (3.7%)

13.6 (4%)

11.7 (3.5%)

Chest

8733

71.9 (21.2%)

77.1 (22.5%)

66.5 (19.8%)

Abdomen and pelvis

2124

17.5 (5.2%)

16.3 (4.7%)

18.8 (5.6%)

Pelvic girdle

3046

25.1 (7.4%)

23.6 (6.9%)

26.6 (7.9%)

Whole spine

2673

22.0 (6.5%)

15.8 (4.6%)

28.6 (8.5%)

Limbs

22148

182.4 (53.7%)

189.0 (55.1%)

175.4 (52.3%)

Other

946

7.8 (2.3%)

7.7 (2.2%)

7.9 (2.4%)

30190

248.6 (41.2%)

235.4 (39.6%)

262.5 (42.8%)

Extraoral

10585

87.2 (35.1%)

79.9 (34%)

94.7 (36.1%)

Intraoral

19605

161.4 (64.9%)

155.5 (66%)

167.7 (63.9%)

1714

14.1 (2.3%)

14.8 (2.5%)

13.4 (2.2%)

Head and neck1010

8.3 (58.9%)

8.8 (59.4%)

7.8 (58.3%)

Chest and heart160

1.3 (9.3%)

1.6 (10.7%)

1.0 (7.7%)

Abdomen and pelvis229

1.9 (13.4%)

1.8 (12.5%)

1.9 (14.4%)

Spine

86

0.7 (5%)0.7 (4.9%)

0.7 (5.2%)

Limbs

205

1.7 (12%)1.6 (10.5%)

1.8 (13.6%)

Trunk

24

0.2 (1.4%)

0.3 (2%)0.1 (0.8%)

Nuclear medicine

186

1.5 (0.3%)

1.5 (0.3%)

1.6 (0.3%)

Head and neck4

<0.1 (2.2%)-- (0%)

0.1 (4.3%)

Chest and heart4<0.1 (2.2%)<0.1 (3.2%)<0.1 (1.1%)

Abdomen and pelvis

75

0.6 (40.3%)

0.6 (37.6%)

0.7 (43%)

Whole body97

0.8 (52.2%)

0.9 (58.1%)

0.7 (46.2%)

Other

6

<0.1 (3.2%)<0.1 (1.1%)

0.1 (5.4%)

25

0.2 (<0.1%)

0.2 (<0.1%)

0.2 (<0.1%)

Cardiac2<0.1 (8%)-- (0%)<0.1 (18.2%)

Vascular23

0.2 (92%)

0.2 (100%)

0.2 (81.8%)

603.8 (100%)594.9 (100%)613.2 (100%)

Dental radiology

Computed tomography

Diag. interventional radiology

All modalities

73325

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Figure 4 represents the change in the frequency of procedures by child's age, for each anatomical area explored.

Figure 4. Frequency of conventional radiology procedures by anatomical area according to the child's age(both sexes combined).
This graph shows that the anatomical areas explored vary significantly with the child's age:

Chest X-rays are very frequent in children aged under 1 year, where they account for more than half ofconventional radiology procedures. Their frequency is much lower in older children but they still account for 30
to 50% of conventional radiology procedures in children aged 1 to 5 years, falling to about 10% in children aged
over 10 years.

Conversely, X-rays of limbs are infrequent in children aged under 1 year but are very frequent in older children:
they account for the majority of procedures from the age of 6 years.

The frequency of procedures concerning the pelvic girdle varies little with age, with the notable exception ofchildren aged under 1 year for whom this is the second most frequently explored area with a proportion of about
25%. This will be studied in more detail in a focus on page 35.

Procedures carried out on the whole spine are in a small minority in young children; their proportion gradually
increases until they become as frequent as chest X-rays in children aged 12 years and over.

Procedures carried out on the head and neck remain in a minority, regardless of the children's age, which isconsistent with the small number of recommended indications for this examination [28].

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

The frequency of procedures on the abdomen and pelvis is low from 1 to 9 years, but significantly higher
thereafter and in children aged under 1 year. Abdominal X-rays without preparation (ASPs) form the bulk of
conventional radiology procedures on this area (see Appendix 1). Paediatric indications for ASP are limited as afirst-line examination but remain relatively frequent as a second-line examination after an ultrasound scan [29].

Figure 5 shows by age range the differences in exposure frequency between boys and girls already observed overall in
Table V.

Figure 5. Frequency of conventional radiology procedures according to anatomical area explored, and child's
age group and sex.

It can be seen that:

The higher frequency of chest X-rays among boys is particularly significant in children aged under 1 year andmuch less marked for other age groups. This observation confirms the explanation put forward in section 4.1.1
that the difference is linked to the higher mortality of newborn boys, with respiratory syndromes among the mostcommon perinatal pathologies [26]. The difference in the frequency of limb X-rays between girls and boys is also
very marked for children aged 11 to 15 years.

Certain procedures are performed more frequently on girls, and for X-rays of the pelvic girdle this is particularly
true for children aged under 1 year and to a lesser extent for children aged 11 to 15 years. Girls aged 6 years andover receive X-rays of the whole spine more frequently than boys of the same age; this type of examination isextremely rare in younger children.

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4.2.2

Dental radiology

Table V and Figure 6 can be used to study the frequency of dental radiology procedures according to the sex and age ofthe children.

Figure 6. Frequency of intraoral and extraoral dental radiology procedures according to child's age group 5 andsex.

Overall, about two thirds of dental radiology procedures performed in 2015 on the population studied are intraoral X-rays.
Dental radiology procedures are performed more frequently on girls than on boys, with a difference of 27 procedures per1000 children, of which 15 are extraoral X-rays (panoramic X-ray, cone-beam CT, etc.). This difference is only apparent
from the 6-10 year age group upwards and is particularly significant in children aged 11 to 15 years. The difference canprobably be explained by the fact that orthodontic treatment on girls is more frequent than on boys [30].

4.2.3

Computed tomography

In the case of scans, head and neck examinations are dominant and account for nearly 60% of procedures, for all age
groups combined (see Table V). The frequency of CT scans, for all anatomical areas combined, is 10% higher in boys thanin girls, though girls undergo scans of the limbs or abdomen and pelvis slightly more often than boys.
The frequency of computed tomography procedures by anatomical area explored is shown in Figure 7 according to child's
age and sex.

5Children aged under 1 year are not shown in this graph because for them the number of procedures is insignificant.

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Figure 7. Frequency of computed tomography procedures according to anatomical area explored, and child's
age and sex.

It can be considered that:

differences between boys and girls can be observed in all age groups, but they are particularly marked forchildren aged under 1 year: boys have computed tomography scans almost twice as often as girls, mainly on thehead and neck;

examinations of the head, neck, chest and heart also seem to be significantly more frequent in boys aged 11 to
15 years than girls of the same age.

These observations should, however, be viewed in the light of the fact that relatively few of these scans were identified
for the EGB sample (1,714 in total), which means the statistics are insufficient in some age groups and for some types of
examination.

4.2.4

Nuclear medicine

The number of nuclear medicine procedures extracted from the EGB sample is small; only the frequency of procedures
concerning the whole body (mainly bone scintigraphy and PET scans with FDG) and the abdominal/pelvic area (mainly
renal scintigraphy) can be interpreted statistically. Boys seem to be given whole body examinations slightly more
frequently than girls, and vice versa for examinations of the abdominal/pelvic area, but these differences are probably
not statistically significant. Figure 8 shows that examinations of the abdomen/pelvis are more frequent in young children,
particularly those aged under 1 year, whereas whole body scans are performed mostly on older children, particularly those
aged 11-15 years.

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Figure 8. Frequency of nuclear medicine procedures according to anatomical area explored and child's age
group.

4.2.5

Diagnostic interventional radiology

The number of procedures identified is extremely small, which prevents analysis of these procedures. Vascularexaminations seem to dominate by far, but it is worth remembering that diagnostic interventional cardiology procedures
such as coronary arteriography are commonly combined with therapeutic procedures in children and are therefore notcounted in this study.

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Summary of results and comparison with the previous study
With conventional radiology, more than half of procedures are on the limbs. Children aged over 6 years andespecially boys aged 11 to 15 years are the categories that undergo these procedures most frequently. The chest is
the second most frequently exposed anatomical area, particularly in children aged under 1 year and especially boysin this age range.
With dental radiology, two thirds of examinations carried out in 2015 are intraoral X-rays. Girls undergo dental
radiology procedures significantly more often than boys, particularly extraoral X-rays.
With computed tomography, head and neck examinations are dominant and account for nearly 60% of procedures.
Children aged under 1 year and children aged 11 to 15 years are the most frequently exposed, boys more than girls.
With nuclear medicine, the majority of procedures concern the abdomen and pelvis, particularly for children aged
under 1 year, and the whole body, particularly for children aged 11 to 15 years.
These observations correspond overall to those of the previous study for 2010.

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Focus on the CCAM codes associated with the highest frequencies and the highest doses
The queries run on the EGB sample database for 2015 supplied a total of 73,325 diagnostic imaging procedures performedon children aged under 16 years. Out of this total, 61,219 procedures had a CCAM code (83.5%) and 12,106 did not (16.5%).
The procedures without codes are considered to be intraoral X-rays, as explained in section 2.1.2. A detailed list of the
CCAM codes, with their description, frequency of performance and contribution to the annual mean effective dose per
child is given in Appendix 1. In total, 188 CCAM codes out of the 401 included in this study are represented, i.e. had a nonzero frequency in queries run on the 2015 EGB sample database.
Of the 23 most frequent codes, 5 concern dental radiology and 18 conventional radiology. The most frequently coded
procedure is the dental panoramic radiograph (referred to hereafter as the panoramic X-ray), with a frequency of
performance in the EGB sample of approximately 63 procedures per 1000 children. Then comes the chest X-ray(58 procedures/1000 children), intraoral periapical and/or bitewing X-rays of a sector of 1 to 3 adjacent teeth(38 procedures/1000 children),then

X-rays

of

the

hand

or

finger(31 procedures/1000 children),

the

foot

(21 procedures/1000 children) and the wrist (20 procedures/1000 children). It should be noted that, when all the CCAM
codes related to intraoral periapical and/or bitewing X-rays are grouped together, this becomes the second most frequent
type of radiological examination (61 procedures/1000 children) of the examinations with codes, and therefore the largest
overall since procedures without codes are also intraoral X-rays.
The highest code for computed tomography (CT scan of the skull with injection) is in 24 th place with a performance
frequency of 5 procedures/1000 children. The highest code for nuclear medicine is the whole body bone scintigraphy scanin several stages, in 76th place with 0.5 procedures/1000 children. Finally, there are no codes for diagnostic interventional
radiology in the top 100.
If CCAM codes are ranked by relative contribution to the total effective dose, the procedure contributing most to the
exposure of the paediatric population of the EGB sample in 2015 is the abdominal/pelvic CT scan with injection, which
accounts for 15.7 µSv per child on average. Next come four conventional radiology procedures: abdominal X-ray without
preparation, pelvic girdle (1 view), whole spine (2 views), and oesophageal/gastric/duodenal transit, which contribute
between 7 and 12.4 µSv/child on average. Computed tomography scans of the skull and spine without injection are in 6th
and 7th place. The highest nuclear medicine code is for bone scintingraphy in stages, at 18 th position with a contribution to
the annual mean effective dose per child of 2.1 µSv.
To conclude, it is interesting to note that the 12,106 procedures not coded in the CCAM, which are dental procedures,contribute only 0.39% to the total effective dose, which only represents about 0.5 µSv per child on average in 2015.

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4.3

Distribution of imaging procedures by type of healthcare establishment

The sector performing the diagnostic procedures was analysed using the EGB sample data for 2015, since the available
information includes the type of healthcare facility. Two facility types were identified: private facilities, comprising
doctor's surgeries, private clinics and hospitals and private non-profit facilities (e.g. cancer centres); and public hospital
facilities, for which it is possible to find out whether the examination was performed during an inpatient stay or on an
outpatient basis.
The results of this analysis are shown in Table VI.
Table VI. Distribution between the public sector and private sector of paediatricdiagnostic procedures6 listed in the EGB sample database in 2015.
Distribution of procedures
Imaging modality

Number of

Publicprocedures

Outpatient

Inpatient

Privatetreatment

treatment

Conventional radiology

41 210

51.1%

38.3%

10.5%

Dental radiology

30 190

98.1%

1.8%

0.1%

Computed tomography

1 714

35.1%

27.0%

37.9%

186

30.1%

45.2%

24.7%

73 325

70.0%

23.0%

6.9%

Nuclear medicine
All modalities

Overall, 70% of the procedures counted in this study were performed in the private sector, compared to 30% in the public
sector, of which 23% were on an outpatient basis and 7% during a hospital stay. If dental radiology procedures, which arevery numerous and more than 98% of which are performed in the private sector, are excluded, the distribution is morebalanced: 50.4% in the private sector and 49.6% in the public sector, of which 37.9% are performed on an outpatient basis
and 11.7% during hospital stays.
If dental radiology is excluded, the distribution between the public and private sectors depends heavily on patient age, as
shown in Figure 9 in the case of computed tomography and conventional radiology.

6

The public/private distribution of diagnostic interventional radiology procedures is not shown in this table because it is not statistically
representative.

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Figure 9. Distribution of procedures between the public and private sectors by child's age group, forconventional radiology and computed tomography.

The proportion of conventional radiology procedures performed in the private sector increases with patient age, risingfrom 29% for children aged under 1 year to 58% for children aged 11 to 15 years, i.e. twice as many. For computed
tomography, the private sector proportion is always lower than for conventional radiology but the change as a function ofpatient age is even more marked: the private sector proportion for children aged 11 to 15 years is 17 times larger than forchildren aged under 1 year, for whom the private sector accounts for only 2.7% of procedures. Because scans of young
children are almost always associated with complex pathologies or emergency treatment, they are mainly performed by
specialist hospital departments, which are mostly public.
By comparison with the previous study for 2010 [7], when these figures were calculated only for computed tomography
procedures, the public sector proportion was slightly higher in 2015, at 65% compared to 59%. This increase is due almost
entirely to outpatient treatments. The change by patient age is comparable, with a greater public sector share than in2010 for children aged 6 to 10 years and 11 to 15 years (66% compared to 59% and 54% compared to 39% respectively), buta slightly lower public sector share for younger children (97% compared to 100% for children aged under 1 year and 86%
compared to 91% for children aged 1 to 5 years).

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5

PAEDIATRIC POPULATION ACTUALLY EXPOSED IN 2015

Because the EGB sample data come from the SNIIRAM database for the private sector and the PMSI database for inpatientand outpatient treatments in the public sector, it was possible to determine the share of the population studied that was
actually exposed in 2015, i.e. that underwent at least one imaging procedure using ionising radiation for diagnostic
purposes during the year. For each patient exposed, it was possible to characterise their exposure in terms of the number
and type of procedures.

5.1

Characterisation of the exposed population

Of the 121,437 children aged 0 to 15 years in the EGB sample in 2015, 38,024 or 31.3% underwent one or more diagnostic
procedures in 2015. They are referred to as exposed children or the exposed population in the rest of this report. Figure
10 shows the proportion of children exposed according to sex and age7.

Figure 10. Proportion of children who underwent at least one diagnostic procedure in 2015, by age and sex

The proportion of exposed children varies widely with age and, to a lesser extent, with sex:7



30% of children aged under 1 year underwent one or more procedures.



Between 1 and 5 years, the proportion is relatively stable at around 15%.

The proportion then gradually increases to 50% at the age of 12 years, and then stabilises at around 47%.

Where multiple procedures are carried out, the child's age is calculated on the date of the first diagnostic procedure.

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These results should be compared with the change in the frequency of procedures, shown in Figure 2 on page 19. In
particular, the peaks observed for children aged under 1 year and children aged 12 years are explained by the fact thatthe higher frequencies of procedure in these two age groups are due more to a larger number of children being exposed
than to a larger number of examinations per exposed child. It is highly likely that the very specific case of medical care of
the neonatal population explains why, proportionally, twice as many children aged under 1 year undergo diagnostic
procedures than children aged 1 to 5 years. The high proportion of children aged 12 years exposed is probably due to thecompulsory oral disease prevention examination, as mentioned earlier in section 4.1.1 on page 19.
The differences between boys and girls are less marked than those linked to age. However, it can be seen that from theage of 7 years, the proportion of girls who undergo at least one procedure is significantly higher than the proportion ofboys, except at the age of 15 years. Conversely, boys aged 6 years and under are more frequently exposed than girls of
the same age.
In 2015, the exposed population of the EGB sample underwent a total of 73,325 diagnostic procedures (see Table V on
page 23). The exposed children therefore underwent on average 1.93 procedures. Table VII presents statistical indicators
for the number of procedures per exposed child by age group.
Table VII. Statistics for the annual number of procedures per exposed child by age
group.

< 1 year

1 to 5 yrs

6 to 10 yrs 11 to 15 yrs

All ages

1 960

5 960

12 57017 53438 024

Mean

1.88

1.62

1.88

2.08

1.93

Minimum

1

1

1

1

1

25th percentile

1

1

1

1

1

Median

1

1

1

2

1

75th percentile

2

2

2

3

2

95th percentile

5

4

4

5

5

Maximum

92

25

42

31

92

Number of children
exposed in EGB sample
Number of procedures per child

It shows, for example, that 50% of exposed children underwent only one diagnostic procedure during the year; 75%
underwent one or two procedures and 95% had 5 procedures or fewer. The distribution of the number of procedures per
child is therefore very asymmetrical: the vast majority of children underwent only one procedure during the year,
whereas a very small number of children had a large number of procedures. This is explained by the fact that theprocedures included in the study are both common radiological examinations, such as dental X-rays affecting a large
number of children in the general population, but not recurrent, and more specialised radiological examinations, such as
abdominal/pelvic CT scans, which affect a small number of children and are generally used to monitor a disease.
The distribution of the number of procedures per child, within the exposed population, is shown in Figure 11, according to
the 4 age groups used previously.

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Figure 11. Histogram of the numbers of procedures per child exposed during the year, for each age
range.

This graph shows that, among the exposed children, the oldest tend to undergo a larger number of diagnostic imaging
procedures than the younger children: the 11 to 15-year age group has the smallest rate for a single procedure (45%) andthe highest rates for 2 procedures or more. The exception is the age group of children aged under 1 year: whereas 68% of
this age group undergo only one diagnostic procedure in the year, the rate for 6 to 10 examinations is the same as the rate
for children aged 11-15 years and the rate for more than 10 examinations is much higher than for the other age groups(about 3%). This probably reflects a very specific population requiring high levels of medical care, probably due tocongenital disorders or premature birth.
Among the most frequent examinations performed on children aged under 1 year, X-rays of the pelvic girdle have a special
place. Their frequency is high (31% of all conventional radiology procedures performed on girls aged under 1 year, 20% of
those performed on boys of the same age, see Figure 5) and their appropriateness is questioned [11]. They are analysed indetail in the box on the next page.

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Focus on X-rays of the pelvic girdle in children aged under 6 months
A high frequency of pelvic girdle X-rays in children aged under
1 year was identified in the report for 2010 [7, Fig. 5].
Because the appropriateness of these procedures was alreadyin doubt, the French radiology society (SFR) and SFIPP, in
partnership with paediatricians and orthopaedic surgeons,
have run initiatives to raise awareness regarding appropriate
justification for these X-rays [24]. To diagnose congenital hip
displacements/dysplasia, ultrasound is the recommended
examination method. X-ray is only necessary to monitor
disorders that have already been confirmed [11]. The
frequencies calculated in this report for this age range havefallen significantly: there were 112 procedures per 1000 boys
compared

to

205

in

2010

(a

45%

reduction)and148 procedures per 1000 girls, compared to 250 in 2010 (a41% reduction). This reduction is encouraging but theappropriateness of the remaining procedures is still an issue.
In response to this and to a question from SFIPP, the EGB
sample data were queried on the following basis: for any

Figure 12. Proportion of children undergoing one or more ultrasoundchild who had had at least one pelvic girdle X-ray under the(US) scans of the hips prior to pelvic girdle X-ray performed underage of 6 months during 2015, the number of ultrasoundthe age of 6 months.

89

procedures carried out beforehand was searched. The results of this query are shown in Figure 12. These figures show that only 23% ofchildren who had one or more pelvic girdle X-rays under the age of 6 months were given one or more ultrasound scans beforehand in linewith HAS recommendations [11]. The interpretation of this figure has been refined following discussions with radiologists at the SFR and
SFIPP. Because giving children several X-rays without performing an ultrasound scan first can also be considered justified (if there isconfirmed dislocation seen clinically, which is then monitored by X-ray), the percentage of children for whom X-ray(s) of the pelvic girdle
is(are) theoretically justified is 28%. The remaining 72% of children can be split into several categories:Children for whom an ultrasound examination was not performed before the age of 3 months, as recommended, and for whom
an X-ray is consequently performed later on. This does not correspond to recommended best practice [11].

Children for whom an ultrasound examination was not performed because no ultrasound scanner was available or there was no
trained clinician. In theory this should not happen any more and the relevant learned societies are working to combat it.



X-rays of the pelvic girdle other than to diagnose congenital hip displacement, such as infection, trauma, etc. There is genuine
justification in these cases, but the frequency of this type of indication could only explain a small number of the 72% ofchildren mentioned.

To conclude, the frequency of pelvic X-rays in children aged under 1 year has fallen very significantly since the 2010 study, which showsthat initiatives to raise awareness among professionals have been valuable. But in a large share of cases, possibly as many as 70%, wherechildren had a pelvic X-ray before the age of 6 months, these X-rays, subject to further investigation, could be considered unjustified.

8
9Corresponding to CCAM codes NAQK007, NAQK015, NAQK023, NAQK049, NAQK071, NEQK010, NEQK012 and NEQK035.
Corresponding to CCAM codes NEQM001, PBQM001 to PBQM004.

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5.2

Individual effective dose

Dividing the total effective dose calculated for 2015 by the number of children actually exposed in the EGB sample
population gives a mean individual effective dose of 0.43 mSv. More so than for the number of procedures, the dose
distribution is extremely varied (see Table VIII): half of the exposed population receives a dose of 0.02 mSv or less, 95%
receives 1.6 mSv or less, whereas the remaining 5% receives a dose of 1.6 mSv or more, with a maximum observed in thisstudy of 68 mSv.
Table VIII. Statistics for effective dose per exposed child by age group.
< 1 year

1 to 5 yrs 6 to 10 yrs 11 to 15 yrs

All ages

Number of children
exposed in EGB sample

1 960

5 960

12 57017 53438 024

Mean

0.97

0.49

0.30

0.45

0.43

Minimum

0.00020.00020.00020.00020.0002

25th percentile

0.06

0.005

0.004

0.004

0.004

Median

0.55

0.06

0.012

0.016

0.02

75th percentile

0.6

0.12

0.04

0.06

0.06

95th percentile

2.9

1.5

1.3

1.7

1.6

Maximum

57.8

40.8

56.2

68.0

68.0

Eff. dose/child (mSv)

Figure 13 also illustrates this wide variation in the doses received.

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Figure 13. Histogram of the cumulative effective dose received by each child exposed during the year,
for each age range.
Whereas the vast majority of children aged over 1 year received a cumulative dose well below 0.1 mSv, half of those aged
under 1 year received more than 0.55 mSv. Relative to the number of children exposed in their age group, the youngest
children are the most exposed category. This finding obviously agrees with the finding regarding the number of proceduresfor the same age group (see section 5.1 above). The reasons are therefore the same: high levels of medical care for a very
specific population.
Summary of results and comparison with the previous study
In 2015, about 31% of children aged from 0 to 15 years underwent one or more diagnostic procedures, up 2 points
compared to 2010. This proportion varies from about 15% for children aged 1 to 5 years, to about 30% for children
aged under 1 year and about 45% for those aged 11 to 15 years. The mean number of procedures per exposed child,
which is 1.9 in 2015, is slightly lower than in 2010 (2 procedures per exposed child).
The mean effective dose per exposed child in 2015 was 0.43 mSv, down 34% compared to 2010. Exposure is
extremely varied, since half of exposed children received a cumulative effective dose of 0.02 mSV or less (compared
to 0.025 mSv in 2010) and only 5% of exposed children received more than 1.6 mSv. Relative to the number of
exposed children in their age group, children aged under 1 year are the most exposed, with a mean effective dose ofnearly 1 mSv and a median effective dose of 0.55 mSv.

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6

COMPARISON WITH THE LITERATURE

It is difficult to compare the results of this study with data published in the international literature because there are very
few studies describing exposure of the paediatric population.
European Radiation Protection Report 180 [12] presents an analysis of the Dose Datamed 2 study conducted between 2007
and 2010 in 36 European countries. This is the most comprehensive study to date on exposure of the European population
to ionising radiation, but it is not specific to the paediatric population and presents very few results by patient age range.
In particular, the frequency of procedures and the annual mean effective doses per caput are only given for the whole
population of each country. Distributions by age group and sex are given for 20 radiological examinations, but because thenumber of procedures is not standardised for the population of each age group and sex, the frequencies of the procedures
are not comparable with those presented in this report. Qualitatively, the variation in the number of procedures by
patient age for chest X-rays (Chest graph, p. 148) is comparable to that observed in this study in Figure 5. The highnumber of procedures for children aged 0 to 4 years observed in the European study is consistent with the high frequencyof this type of procedure for children aged under 1 year identified in this study. The higher frequency of this procedurefor boys also appears in the European study data. The same qualitative observations can be made with X-rays of theabdomen and pelvis (Abdomen and Pelvis graphs, p. 151). The graphs for CT scans (p. 154-157) also show that head andneck scans dominate by far in children, which agrees with the results of this study (see Figure 7).
An Irish study published in 2015 [31] provides elements for comparison on computed tomography and nuclear medicine
examinations. This study gives a national frequency of 3.85 CT scans per 1000 children in 2012, which is much lower than
the figure calculated here (14.1, see Table V). However, the Irish study only looks at examinations performed in the
country's 3 paediatric hospitals, so CT scan frequency is probably underestimated, though the authors believe that few
examinations of this kind are performed outside paediatric hospitals. For the record, in France about 35% of paediatric CT
scans are performed in the private sector and the proportion of scans performed in paediatric hospitals compared to thewhole public sector was not estimated. The frequency of nuclear medicine examinations in Ireland, which is 1.53 per1000 children, is almost identical to the frequency calculated for France in this study. The anatomical areas to which the
Irish examinations relate are, for CT scans, head and neck (about 50%), chest (15%) and abdomen (15%), which is very
similar to the French distribution. In nuclear medicine, 70% of examinations concern the kidneys (40% in France) and justover 20% the bones (about 50% in France). Clinical practices in nuclear medicine therefore appear to be very different in
the two countries.
A recent Italian study [32] looks at the change in the use of computed tomography scans in children and adults between
2004 and 2014 in the Lombardy region. Approximately 8.5 CT scans per 1000 children aged 0 to 17 years are counted for2014. This is much higher than the figure in the Irish study, but it is still lower than the figure in this study (see Table V).
In addition, the Italian study gives a frequency of almost zero for children aged under 5 years, unlike our results.
However, it should be pointed out that the Italian study does not include hospitalised patients, which means that theexamination frequency is underestimated, especially for young children, because CT scans are generally associated withhigh levels of medical care, and therefore hospitalisation, in this age range.
This study can also be compared with a study of exposure of the Swiss population, conducted in 2013 [33]. Regarding
conventional radiology, the Swiss study indicates that chest X-rays are in a very large majority for children aged under
5 years, whereas X-rays of the limbs are very dominant for children aged 5 years and over. This matches the findings ofthis study. For computed tomography, the Swiss study shows a significantly higher scan frequency for boys, which agrees
with this study. The anatomical area explored most is the head and neck, particularly for children aged under 5 years andReport No. PSE-SANTE/SER/2018-00004

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to a lesser extent for children aged over 5 years, for whom the chest, abdomen/pelvis and limbs also play a large part.
Once again, these results agree with the results of this study (see Figure 7).
There are many other studies of population exposure but very few of them contain data specific to the paediatricpopulation. Where such data do exist, they are usually not precise enough to be compared reliably with this study. A
Romanian study for 2012 [34] states that the most frequent computed tomography scans on patients aged 0 to 15 years areof the limbs and joints, the head and the cervical spine. These results only partially match the results presented here
because examinations of the abdomen and pelvis are also frequent in this study and those of the head and neck dominate
by a very large margin (see Table V). Another study looks at medical exposure of the South Korean population [35]. The
annual number of diagnostic imaging procedures is presented for 5-year age ranges: it is stable at about 3.8 million forgirls, and varies between 4.7 million for boys aged 1 to 5 years and 6.8 million for boys aged 11 to 15 years. Though notdirectly comparable with the procedure frequencies given in this report per 1000 children, these results neverthelesscontradict the results in Table III, in which similar differences between boys and girls are not observed. One possible
explanation for this contradiction is the small proportion of dental radiology procedures indicated in the Korean study(10.8% for the total population) compared to French practices (33.8% according to [6]). These considerations illustrate thedifficulty of comparing studies of countries with very different medical practices and healthcare systems.
As well as the small amount of available data, the data published in the selected studies therefore vary widely.
Quantitative comparisons with the results of this study are consequently necessarily limited. The qualitative
correspondences observed are sufficient, however, to consider that the results of this study are consistent with thosealready published in other countries. Finally, this comparison highlights the uniqueness of this study: because it uses the
EGB sample, it is the only study able to characterise the population of children actually exposed at a national scale.
Studies that do not have a similar tool available are limited either to describing the exposure of the whole population,with no distinction between exposed and non-exposed children, or to studying a population of patients from a limited
number of healthcare establishments.

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7

CONCLUSION

The 2015 ExPRI Paediatric Study was conducted on the EGB sample, which represents 1/97 th of the French population
protected by the CNAM general health insurance scheme, the self-employed scheme and the agricultural scheme. All
diagnostic imaging procedures using ionising radiation (conventional radiology, dental radiology and diagnostic
interventional radiology, computed tomography and nuclear medicine), performed in 2015 on children aged under 16 years
at the time of the procedure, were taken into account.
In France in 2015, about 604 diagnostic procedures were carried out per 1000 children aged under 16 years, which isrelatively stable (+1.5 %) compared to the figure for 2010. Children aged 11 to 15 years are the most frequently
exposed, with 993 procedures per 1000 children, whereas children aged 1 to 5 years are the least frequently exposed,with 250 procedures/1000 children. Conventional radiology and dental radiology account for 56% and 41% of procedures
respectively, computed tomography accounts for just over 2%, nuclear medicine and diagnostic interventional radiology
account for less than 1%. This distribution is substantially equivalent to the distribution for 2010. Girls are exposed slightly
more often than boys, for all age groups combined (+1.8%). The proportion of children that underwent at least one
diagnostic procedure is 31%, up 2 points compared to 2010. This proportion varies from about 15% for children aged 1
to 5 years to about 45% for those aged 11 to 15 years. The mean number of procedures per exposed child, which is 1.9, isslightly lower than in 2010 (2 procedures per exposed child).
The annual mean effective dose is 0.135 mSv per child, whether exposed or not, down 25% compared to 2010.
Conventional radiology contributes about 53% to this dose, or 72 µSv per child, which is a 53 µSv reduction compared to2010. CT scans account for about 40% of the total dose, or 55 µSv per child, which is a slight increase of 7 µSv since 2010.
Dental radiology, nuclear medicine and diagnostic interventional radiology together contribute less than 7%, or 9 µSv,
which is a 2 µSv increase since 2010. The annual mean effective doses of girls and boys are identical. The mean effective
dose per exposed child is 0.43 mSv, down 34% compared to 2010. Exposure is extremely varied, since half of
exposed children received a cumulative effective dose of 0.02 mSv or less (compared to 0.025 mSv in 2010) and only 5% of exposed children received more than 1.6 mSv. Relative to the number of exposed children in their age group,
children aged under 1 year are the most exposed, with a mean effective dose of nearly 1 mSv and a median effective
dose of 0.55 mSv.
Generally, very few changes are observed in the frequency of diagnostic procedures in 2015 compared to 2010, as regards
both number and distribution by imaging modality. On the contrary, the annual mean effective dose, calculated for thewhole population as for the exposed population, is significantly lower than in the previous study. The fact that thisreduction in children's mean exposure has been observed even though the frequency of imaging procedures is stable
overall means that it is directly linked to the reduction in the mean effective dose by type of procedure, identified
mainly through the analysis of data sent to IRSN for diagnostic reference level purposes. Several explanations related
to better techniques and practices could be associated with this reduction, though it is not possible to determine which
has the most influence. Between 2010 and 2015, a number of technological developments that reduced the dose needed
to produce a high quality image became widespread in radiology departments and clinics: digital image receptors inconventional radiology and iterative reconstruction algorithms in computed tomography are two examples. Awareness has
improved among professionals – both radiologists and radiographers – of the principles for justifying and optimisingexaminations. The involvement of medical physicists in radiology has increased and this has helped to improve practices.
The learned societies concerned have published best practice guides. The authorities have stepped up their involvement,
for example, ASN's action plan to manage the doses delivered to patients during medical imaging, launched in 2011.

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[2] Council Directive 97/43/Euratom of 30 June 1997 on health protection of individuals against the dangers of ionizing
radiation in relation to medical exposure, and repealing Directive 84/466/Euratom, vol. OJ L. 1997.
[3] Council Directive 2013/59/Euratom of 5 December 2013 laying down basic safety standards for protection against
the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom,
96/29/Euratom, 97/43/Euratom and 2003/122/Euratom, vol. OJ L. 2014.
[4] P. Scanff, J. Donadieu, P. Pirard, and B. Aubert, "Exposition médicale de la population française aux rayonnements
ionisants", IRSN - INVS, Apr. 2006.
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actes de diagnostic médical en 2007", IRSN - INVS, March 2010.
[6] "Exposition de la population française aux rayonnements ionisants liée aux actes de diagnostic médical en 2012",
IRSN, PRP-HOM 2014-6, 2014.
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[10] Decree 2016-1871 of 26 December 2016 on the processing of personal data known as the "national health datasystem". 2016.
[11] "Luxation congénitale de la hanche : dépistage", Haute autorité de santé. [Online]. Available at: https://www.hassante.fr/portail/jcms/c_1680275/fr/luxation-congenitale-de-la-hanche-depistage. [Consulted on: 14-Nov-2018].
[12] European Commission and Directorate-General for Energy, Medical radiation exposure of the European population.
Luxembourg: Publications Office, 2015.
[13] International Commission on Radiological Protection. The 2007 Recommendations of the International Commission on
Radiological Protection. French language edition by J.C. Nénot. Paris, Éd. Tec & doc, 2009.
[14] IRSN, "Analyse des données relatives à la mise à jour des niveaux de référence diagnostiques en radiologie et enmédecine nucléaire. Bilan 2011-2012", IRSN, Fontenay-aux-Roses, PRP-HOM/2014-9, 2014.
[15] IRSN, "Analyse des données relatives à la mise à jour des niveaux de référence diagnostiques en radiologie et enmédecine nucléaire Bilan 2013-2015", IRSN, Fontenay-aux-Roses, PRP-HOM 2016-00006, Nov. 2016.
[16] "Guide des Procédures Radiologiques : Critère de Qualité et Optimisation des Doses". [Online]. Available at:
http://www.sfrnet.org/sfr/professionnels/5-referentiels-bonnes-pratiques/guides/guide-proceduresradiologiques/index.phtml. [Consulted on: 14-Nov-2018].
[17] Société française de radiologie (SFR) and Société française de médecine nucléaire et d’imagerie moléculaire, "Guide
du Bon Usage des examens d’imagerie médicale". [Online]. Available at: http://gbu.radiologie.fr/. [Consulted on: 14Nov-2018].
[18] "Guide des indications et des procédures des examens radiologiques en odontostomatologie. Recommandations pourlesprofessionnelsdesanté.",

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[Online].

Availableat:https://www.has-sante.fr/portail/jcms/c_610464/fr/guide-des-indications-et-procedures-des-examens-radiologiques-en-odontostomatologie. [Consulted on: 14-Nov-2018].

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[19] IRSN, "Doses délivrées aux patients en scanographie et en radiologie conventionnelle. Résultats d’une enquête
multicentrique en secteur public.", IRSN, Fontenay-aux-Roses, DRPH/SER 2010-12, 2010.
[20] IRSN, "Doses délivrées aux patients en scanographie. Analyse des recueils de doses de 9 services de radiologie en
France en 2012.", IRSN, Fontenay-aux-Roses, PRP-HOM 2013-12, 2013.
[21] H. J. Brisse and B. Aubert, "Niveaux d’exposition en tomodensitométrie multicoupes pédiatrique : résultats del’enquête dosimétrique SFIPP/IRSN 2007-2008", Journal de Radiologie, vol. 90, no 2, p. 207-215, Feb. 2009.
[22] C. Etard, D. Celier, P. Roch, and B. Aubert, "National survey of patient doses from whole-body FDG PET-CT
examinations in France in 2011", Radiat Prot Dosimetry, vol. 152, no 4, p. 334-338, Jan. 2012.
[23] C. Etard and B. Aubert, "Enquête nationale en médecine nucléaire : radiopharmaceutiques et activités utilisés en2007 dans le secteur public", Médecine Nucléaire, vol. 36, no 2, p. 53-61, Feb. 2012.
[24] "Communications personnelles avec la section radioprotection de la SFR et l’association dentaire française (ADF)",2018-2017.
[25] D. Hart and B. F. Wall, "Radiation exposure of the UK populations from medical and dental X-rays examinations",
NRPB-W4, March 2002.
[26] United Nations, Department of Economic and Social Affairs, Population Division, "Sex Differentials in Childhood
Mortality", United Nations, ST/ESA/SER.A/314, 2011.
[27] Public Health Code - Article L2132-2-1, vol. L2132-2-1. .
[28] "Indications de la radiographie du crâne et/ou du massif facial", Haute autorité de santé. [Online]. Available at:https://www.has-sante.fr/portail/jcms/c_679833/fr/indications-de-la-radiographie-du-crane-et/ou-du-massif-facial.
[Consulted on: 14-Nov-2018].
[29] "Indications et non-indications de la radiographie de l’abdomen sans préparation", Haute autorité de santé. [Online].
Available at: https://www.has-sante.fr/portail/jcms/c_745656/fr/indications-et-non-indications-de-la-radiographiede-l-abdomen-sans-preparation. [Consulted on: 14-Nov-2018].
[30] K.-F. Krey and C. Hirsch, "Frequency of orthodontic treatment in German children and adolescents: influence of age,gender, and socio-economic status", Eur J Orthod, vol. 34, no 2, p. 152-157, Apr. 2012.
[31] M. O’Connor, J. Ryan, and S. Foley, "A review of cross-sectional imaging, ultrasound and nuclear medicine utilization
patterns in paediatric patients in Ireland, 2003–12", BJR, vol. 88, no 1048, p. 20140767, Feb. 2015.
[32] A. Pola et al., "Computed tomography use in a large Italian region: trend analysis 2004-2014 of emergency andoutpatient CT examinations in children and adults", Eur Radiol, vol. 28, no 6, p. 2308-2318, June 2018.
[33] R. Le Coultre, J. Bize, M. Champendal, D. Wittwer, P. Trueb, and F. Verdun, "Exposition de la population suisse aux
rayonnements ionisants en imagerie médicale en 2013", University of Lausanne and University of Applied Sciences andArts Western Switzerland, 2014.
[34] O. Girjoaba and A. Cucu, "Romanian medical exposure to ionising radiation in 2012", Radiat Prot Dosimetry, vol. 165,
no 1-4, p. 137-140, July 2015.
[35] S. Y. Lee, H. S. Lim, J. Lee, and H. S. Kim, "Evaluation of diagnostic medical exposure in Republic of Korea", Radiat
Prot Dosimetry, vol. 168, no 3, p. 388-395, March 2016.

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APPENDIX 1

List of CCAM codes by imaging modality and by anatomicalarea explored. Associated effective dose, frequency andcontribution to the collective dose.

All 188 CCAM codes with a non-zero frequency in this study, representing 61,219 procedures, i.e. 83.5% of the total
procedures in 2015 on the paediatric population of the EGB sample, are listed in Tables IX to XIII below. The codes are
categorised by imaging modality and by anatomical area exposed. The "E/proc." column indicates the effective dose 10
associated with the CCAM code, in mSv. The "Proc. Freq." column gives the procedure frequency expressed as the numberof procedures per 1000 children, and its rank in descending order. The "Emean/child" column indicates the procedure's
contribution to the annual mean dose per child in µSv, calculated for the whole paediatric population of the 2015 EGB
sample, both exposed and non-exposed. N.S. (not significant) is entered where fewer than 10 occurrences of the code
were found. [100+] indicates that the code is ranked in 100th place or more.
The distribution of the CCAM codes according to their frequency of occurrence in this study is shown in Figure 14a. The
top 8 CCAM codes by frequency on their own account for more than half of the total number of coded procedures. The top
20 codes together account for three quarters of the total number of coded examinations. Finally, 165 codes each accountfor less than 1% of the total number of coded procedures, which corresponds to a frequency of less than 5 procedures per1000 children. Together, these infrequent codes account for more than 21% of all coded procedures. The CCAM codes canalso be studied on the basis of their relative contribution to the total effective dose, which is shown in Figure 14b. Half ofthe total effective dose in 2015 is due to the top 8 CCAM codes: 3 computed tomography codes and 5 conventional
radiology codes. The top 20 codes account for three quarters of the total dose and consist of 10 conventional radiology
codes, 9 computed tomography codes and 1 nuclear medicine code. Finally, the 164 codes that each contribute less than
1% to the total dose, which corresponds to an annual mean effective dose per child of 1.4 µSv, together make up 19% of
the total dose, or nearly 26 µSv per child.
Dental radiology procedures without a CCAM code (see section 2.2.3) are not taken into account in either Tables IX to XIII
or Figure 14. To calculate their contribution to the total effective dose, they were considered to be equivalent to one (ortwo or four respectively) intraoral periapical and/or bitewing X-rays of a sector of 1 to 3 adjacent teeth (CCAM code
HBQK389) for the reference service code 1331 (or 9422 or 9423 respectively).

10

It should be remembered that the dose is assessed on the basis of adult examinations for the reasons explained in section 3.2.

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a)

b)

Figure 14. Classification of CCAM codes by: a) their proportion of the total coded
procedures; b) their contribution to the total annual effective dose.

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Table IX. List of CCAM codes for conventional radiology, categorised by anatomical area.

CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

Head and neck
HQQH002

Dynamic radiological swallowing study with recording [Dynamic
pharyngography]

0.06

N.S.

[100+]

N.S.

[100+]

LAQK003

X-ray of the skull and/or facial bones, 1 or 2 views

0.04

5.44

[21]

0.22

[58]

LAQK005

X-ray of the skull and/or facial bones, 3 or more views

0.08

1.51

[48]

0.12

[77]

LBQK001

Unilateral or bilateral temporomandibular joint tomography

0.5

N.S.

[100+]

N.S.

[100+]

LBQK005

Unilateral or bilateral temporomandibular joint X-ray

0.012

0.12

[96]

<0.01

[100+]

LCQK002

Neck soft tissue X-ray

0.06

1.58

[47]

0.09

[82]

LDQK001

X-ray of the cervical segment of the spinal column, 1 or 2 views

0.07

1.01

[58]

0.07

[91]

LDQK002

X-ray of the cervical segment of the spinal column, 3 or more views

0.2

2.93

[34]

0.59

[40]

HEQH001

Oesophageal radiography with opacification using a contrast agent[Oesophageal transit]

1.2

N.S.

[100+]

N.S.

[100+]

HEQH002

Oeso-gastro-duodenal radiography with opacification using a contrast
agent [Oeso-gastro-duodenal transit]

10

0.70

[67]

7.00

[5]

LDQK004

X-ray of the cervical segment and thoracic segment of the spinal
column

0.35

0.39

[79]

0.14

[73]

LEQK001

X-ray of the thoracic segment of the spinal column

0.25

0.96

[61]

0.24

[56]

LJQK001

Thoracic cage X-ray

0.08

0.71

[66]

0.06

[96]

LJQK002

Chest X-ray with thoracic cage X-ray

0.14

0.96

[60]

0.13

[74]

LJQK015

X-ray of the sternum and/or the sternoclavicular joints

0.08

0.44

[77]

0.03

[100+]

MAQK001

Shoulder girdle and/or shoulder X-ray, 3 or 4 views

0.02

2.22

[41]

0.04

[99]

MAQK002

Shoulder girdle and/or shoulder X-ray, 5 or more views

0.03

0.57

[69]

0.02

[100+]

MAQK003

Shoulder girdle and/or shoulder x-ray, 1 or 2 views

0.01

6.33

[19]

0.06

[93]

MEQH001

Shoulder arthrography

0.03

N.S.

[100+]

N.S.

[100+]ZBQK002

Chest X-ray

0.06

57.82

[2]

3.51

[12]

ZBQK003

Dynamic chest radiography, to study respiratory and/or cardiac
function

0.12

0.12

[95]

0.01

[100+]

Chest

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CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

Abdomen and pelvis
HGPH001

Meconium ileus removal from the small intestine by intestinal enema,with radiological monitoring

6

N.S.

[100+]N.S.

[80]

HGQH002

Radiography of the small intestine with contrast medium ingestion[Small-bowel transit]

3.3

N.S.

[100+]

N.S.

[100+]

HHQH001

Radiography of the colon with opacification by contrast medium

9

0.14

[93]

1.26

[27]

HPMP002

Secondary radiological check of the position and/or operation of aperitoneal drain, peritoneal dialysis catheter or peritoneovenous
shunt, with opacification by contrast medium

2.4

N.S.

[100+]

N.S.

[100+]

HZMP002

Secondary radiological check of the position and/or operation of anaso-gastric tube, bile drain or biliary endoprosthesis, with
opacification by contrast medium

2.4

N.S.

[100+]N.S.

[95]

JBQH002

Retrograde pyelography

2.4

N.S.

[100+]

N.S.

[100+]JBQH003

Antegrade pyelography, through a nephrostomy already in place

2.4

N.S.

[100+]

N.S.

[100+]JDQH001

Retrograde urethrocystography

2.4

0.52

[73]

1.25

[29]

JDQH003

Urethrocystography, by percutaneous puncture of the bladder

2.4

N.S.

[100+]N.S.

[81]

JZQH003

Intravenous urography with voiding urethrocystography

2.5

N.S.

[100+]

N.S.

[100+]

LDQK005

X-ray of the cervical segment and lumbar segment of the spinal
column0.95

N.S.

[100+]N.S.

[94]

LEQK002

X-ray of the thoracic segment and lumbar segment of the spinal
column

1.1

2.45

[40]

2.70

[13]

LFQK001

X-ray of the lumbar segment of the spinal column, 4 or more views

1.1

1.11

[56]

1.22

[30]

LFQK002

X-ray of the lumbar segment of the spinal column, 1 to 3 views

0.85

1.99

[42]

1.69

[21]

LGQK001

X-ray of the sacrum and/or coccyx

0.5

0.72

[65]

0.36

[50]

ZCQK002

Abdominal X-ray without preparation

1.2

10.33

[10]

12.42

[2]

NAQK007

Pelvic girdle X-ray, 2 views

1.1

3.62

[30]

3.99

[9]

NAQK015Pelvic girdle X-ray, 1 view

0.55

17.14

[9]

9.43

[3]

NAQK023

Pelvic girdle X-ray, 3 or more views

1.7

0.97

[59]

1.65

[23]

NAQK049

Pelvic girdle X-ray, 1 view, and bilateral X-ray of the coxofemoral
articulation, 1 or 2 views per side

1.2

0.32

[80]

0.39

[48]

NAQK071

Pelvic girdle X-ray, 1 view, and unilateral X-ray of the coxofemoral
articulation, 1 or 2 views

0.85

1.05

[57]

0.90

[33]

NEQH002

Hip arthrography

0.25

N.S.

[100+]

N.S.

[100+]

NEQK010

X-ray of the coxofemoral articulation, 1 or 2 views

0.3

1.45

[50]

0.43

[44]

NEQK012

X-ray of the coxofemoral articulation, 4 or more views

0.75

0.21

[87]

0.15

[66]

NEQK035

X-ray of the coxofemoral articulation, 3 views

0.45

0.30

[82]

0.13

[75]

ZCQK001

Pelvimetry by radiography

0.55

N.S.

[100+]

N.S.

[100+]

PelvisReport No. PSE-SANTE/SER/2018-00004

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CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

Whole spine
LHQK002

Teleoroentgenography of the whole spinal column, 2 views

0.85

9.76

[13]

8.29

[4]

LHQK003

Teleoroentgenography of the whole spinal column, 2 views with
supplementary segment view

1.1

3.71

[29]

4.09

[8]

LHQK004

Teleoroentgenography of the whole spinal column, 1 view

0.4

4.18

[27]

1.67

[22]

LHQK007

X-ray of the whole spinal column

0.85

4.36

[26]

3.71

[10]

MBQK001

Upper arm X-ray

0.001

1.80

[45]

<0.01

[100+]

MCQK001

Forearm X-ray

0.001

8.58

[15]

<0.01

[100+]

MDQK001

Hand or finger X-ray

0.0002

30.82

[4]

<0.01

[100+]

MDQK002

Bilateral hand and/or wrist X-ray, 1 view on a single plate, frontal

0.0002

0.49

[75]

<0.01

[100+]

MFQK001

Elbow X-ray, 3 or more views

0.002

2.67

[37]

<0.01

[100+]

MFQK002

Elbow X-ray, 1 or 2 views

0.001

9.63

[14]

<0.01

[100+]

MGQK001

Wrist X-ray, 3 or more views

0.0004

9.88

[12]

<0.01

[100+]

MGQK002

Dynamic radiographic examination of the wrist for non-dissociative
sprain, 7 specific views

0.0008N.S.

[100+]

N.S.

[100+]

MGQK003

Wrist X-ray, 1 or 2 views

0.0002

20.08

[6]

<0.01

[100+]MZQK001

Unilateral or bilateral teleoroentgenography of the whole arm, frontal

0.002

N.S.

[100+]

N.S.

[100+]MZQK003

X-ray of 2 segments of the arm

0.002

3.38

[31]

<0.01

[100+]MZQK004

X-ray of 3 segments or more of the arm

0.003

0.79

[63]

<0.01

[100+]

NBQK001

Thigh X-ray

0.001

1.91

[44]

<0.01

[100+]

NCQK001

Leg X-ray

0.002

5.69

[20]

0.01

[100+]NDQK001

Unilateral foot X-ray, 1 to 3 views

0.0002

20.75

[5]

<0.01

[100+]NDQK002

Bilateral foot X-ray, 1 to 3 views per side

0.0004

2.94

[33]

<0.01

[100+]NDQK003

Foot X-ray, 4 or more views

0.0004

1.46

[49]

<0.01

[100+]NDQK004

Foot X-ray, 4 or more views, for podometric examination

0.0005

1.26

[55]

<0.01

[100+]

NFQH001

Knee arthrography

0.005

N.S.

[100+]

N.S.

[100+]

NFQK001

Unilateral knee X-ray, 1 or 2 views

0.002

8.47

[16]

0.02

[100+]

NFQK002

Bilateral knee X-ray, 1 or 2 views per side

0.004

1.65

[46]

<0.01

[100+]

NFQK003

Knee X-ray, 3 or 4 views

0.003

10.05

[11]

0.03

[100+]

NFQK004

Knee X-ray, 5 or more views

0.006

4.80

[25]

0.03

[100+]

NGQH001

Ankle arthrography

0.0005N.S.

[100+]

N.S.

[100+]

NGQK001

Ankle X-ray, 1 to 3 views

0.0002

17.28

[8]

<0.01

[100+]

Limbs

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CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

NGQK002

Ankle X-ray, 4 or more views

0.0004

8.00

[18]

<0.01

[100+]NZQK001

Unilateral or bilateral teleoroentgenography of the whole leg, frontal,
bipodal support

0.005

2.64

[38]

0.01

[100+]NZQK003

Bilateral teleoroentgenography of the whole leg, frontal, bipodal
support, one after the other

0.01

0.19

[89]

<0.01

[100+]NZQK005

X-ray of 2 segments of the leg

0.003

5.30

[22]

0.02

[100+]NZQK006

X-ray of 3 or more segments of the leg

0.005

1.42

[51]

<0.01

[100+]

PAQK001

Comparative radiography of the cartilages joining the long bones in
the limbs

0.01

0.13

[94]

<0.01

[100+]

PAQK002

Bone age radiography, after the age of 2 years

0.01

3.86

[28]

0.04

[100+]

PAQK003

Skeletal survey (radiography of the whole body), segment by segment,in children

1.8

0.54

[72]

0.96

[32]

PAQK005

Hemiskeleton bone age radiography, before the age of 2 years

0.01

0.31

[81]

<0.01

[100+]

PAQK007

Bone mineral densitometry on 2 sites, by dual-photon absorptiometry

0.001

0.21

[86]

<0.01

[100+]

PAQK008

Whole body bone mineral densitometry by dual-photon
absorptiometry, for constitutional bone diseases in children

0.001

N.S.

[100+]

N.S.

[100+]

PAQK900

Whole body bone mineral densitometry by dual-photon
absorptiometry, for non-constitutional bone diseases

0.001

N.S.

[100+]

N.S.

[100+]QEQK001

Bilateral mammography

0.36

N.S.

[100+]

N.S.

[100+]QEQK005

Unilateral mammography

0.18

N.S.

[100+]

N.S.

[100+]YYYY163

Hemiskeletal or skeletal survey in adults

1.8

0.25

[85]

0.44

[43]

ZZQK001

Bedside X-ray, 3 or more views

1.4

N.S.

[100+]N.S.

[97]

ZZQK002

Bedside X-ray, 1 or 2 views

0.7

1.97

[43]

1.76

[20]

Other

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Table X. List of CCAM codes for dental radiology.

CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

Extraoral
HBQK002

Dentomaxillary panoramic radiography

0.02

63.14

[1]

1.26

[26]

LAQK001

Cephalometric projection of the skull and facial bones, 2 views

0.026

2.91

[35]

0.08

[89]

LAQK008

Cephalometric projection of the skull and facial bones, 3 views

0.039

0.11

[97]

<0.01

[100+]

LAQK012

Cephalometric projection of the skull and facial bones, 1 view

0.013

19.43

[7]

0.25

[54]

LAQK027

Cone-beam computed tomography [CBCT] of the maxilla, mandible
and/or dental arch

0.1

1.58

[47]

0.16

[62]

HBQK001

Occlusal X-ray

0.025

0.58

[68]

0.01

[100+]HBQK040

Preinterventional or periinterventional intraoral periapical X-rays ona sector of 1 to 3 adjacent teeth with a final X-ray for root canaltreatment

0.008

5.04

[23]

0.04

[100+]HBQK041

Intraoral periapical and/or bitewing X-rays of 14 distinct sectors of 1
to 3 adjacent teeth

0.056

N.S.

[100+]

N.S.

[100+]HBQK046

Intraoral periapical and/or bitewing x-rays of 9 distinct sectors of 1
to 3 adjacent teeth

0.036

N.S.

[100+]

N.S.

[100+]HBQK061

Final intraoral periapical and/or bitewing X-ray of a sector of 1 to 3
adjacent teeth for root canal treatment or periinterventional and/or
final intraoral periapical and/or bitewing X-ray for a procedure otherthan root canal treatment

0.004

2.51

[39]

0.01

[100+]HBQK065

Intraoral periapical and/or bitewing X-rays of 10 distinct sectors of 1
to 3 adjacent teeth

0.04

N.S.

[100+]

N.S.

[100+]HBQK142

Intraoral periapical and/or bitewing X-rays of 8 distinct sectors of 1
to 3 adjacent teeth

0.032

N.S.

[100+]

N.S.

[100+]HBQK191

Intraoral periapical and/or bitewing X-rays of 2 distinct sectors of 1
to 3 adjacent teeth

0.008

8.14

[17]

0.07

[92]

HBQK303

Preinterventional, periinterventional and final intraoral periapical Xrays on a sector of 1 to 3 adjacent teeth for root canal treatment

0.012

2.96

[32]

0.04

[100+]HBQK331

Intraoral periapical and/or bitewing x-rays of 3 distinct sectors of 1
to 3 adjacent teeth

0.012

1.42

[52]

0.02

[100+]HBQK389

Intraoral periapical and/or bitewing X-rays of a sector of 1 to 3
adjacent teeth

0.004

37.64

[3]

0.15

[67]

HBQK424

Intraoral periapical and/or bitewing X-rays of 11 distinct sectors of 1
to 3 adjacent teeth

0.044

N.S.

[100+]

N.S.

[100+]HBQK428

Intraoral periapical and/or bitewing X-rays of 5 distinct sectors of 1
to 3 adjacent teeth

0.02

0.40

[78]

<0.01

[100+]HBQK430

Intraoral periapical and/or bitewing X-rays of 7 distinct sectors of 1
to 3 adjacent teeth

0.028

N.S.

[100+]

N.S.

[100+]HBQK443

Intraoral periapical and/or bitewing X-rays of 4 distinct sectors of 1
to 3 adjacent teeth

0.016

2.79

[36]

0.04

[98]

Intraoral

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CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]HBQK476

Intraoral periapical and/or bitewing X-rays of 12 distinct sectors of 1
to 3 adjacent teeth

0.048

N.S.

[100+]

N.S.

[100+]HBQK480

Intraoral periapical and/or bitewing X-rays of 6 distinct sectors of 1
to 3 adjacent teeth

0.024

N.S.

[100+]

N.S.

[100+]

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Table XI. List of CCAM codes for computed tomography, categorised by anatomical area.

CCAM code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

Head and neck
ACQH002

Computed tomography of the cranium, its contents and thechest, with intravenous contrast medium injection

5.7

N.S.

[100+]N.S.

[60]

ACQH003

Computed tomography of the cranium and its contents, withintravenous contrast medium injection

1.4

0.90

[62]

1.26

[28]

ACQH004

Computed tomography of the cranium, its contents, and thetrunk, with intravenous contrast medium injection

12

N.S.

[100+]N.S.

[36]

ACQK001

Computed tomography of the cranium and its contents,
without contrast medium injection

1.4

4.97

[24]

6.97

[6]

EAQH002

Computed tomography of blood vessels in the brain [Brainangiogram]

2.5

N.S.

[100+]N.S.

[86]

EBQH004

Computed tomography of blood vessels in the head and neck
[Head and neck angiogram]

3.6

N.S.

[100+]N.S.

[59]

EBQH006

Computed tomography of blood vessels in the neck [Neckangiogram]

3.1

N.S.

[100+]N.S.

[88]

LAQK002

Unilateral or bilateral computed tomography of the petrous
part of the temporal bone and the middle ear

1.3

0.56

[70]

0.73

[35]

LAQK009

Computed tomography of the face with computed tomographyof the neck soft tissues

1.8

0.20

[88]

0.36

[51]

LAQK011

Unilateral or bilateral computed tomography of thecerebellopontine angle and/or the internal acoustic meatus[internal auditory canal]

1.2

N.S.

[100+]

N.S.

[100+]

LAQK013

Computed tomography of the face = cone-beam

0.5

1.30

[53]

0.65

[38]

LCQH001

Computed tomography of the neck soft tissues, withintravenous contrast medium injection

4.2

0.16

[91]

0.66

[37]

LCQK001

Computed tomography of the neck soft tissues, without
contrast medium injection

3.3

N.S.

[100+]

N.S.

[100+]

ECQH010

Computed tomography of blood vessels in the chest and/orheart [Chest angiogram]

10

0.15

[92]

1.48

[24]

ECQH011

Computed tomography of blood vessels in the chest and/orheart, with computed tomography of blood vessels in theabdomen and/or pelvis [Chest angiogram with angiogram of
the abdomen/pelvis]

18

N.S.

[100+]N.S.

[34]

ZBQH001

Computed tomography of the chest, with intravenous contrast
medium injection

6.8

0.54

[71]

3.70

[11]

ZBQK001

Computed tomography of the chest, without intravenous
contrast medium injection

4.3

0.58

[68]

2.51

[15]

Computed tomography of blood vessels in the abdomen
and/or pelvis [Abdominal/pelvic angiogram]

19

N.S.

[100+]N.S.

[52]

Chest and heart

Abdomen and pelvis
ELQH002

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CCAM code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

ZCQH001

Computed tomography of the abdomen and pelvis, withintravenous contrast medium injection

12

1.29

[54]

15.71

[1]

ZCQH002

Computed tomography of the abdomen or pelvis, withintravenous contrast medium injection

12

0.21

[87]

2.47

[16]

ZCQK004

Computed tomography of the abdomen and pelvis, without
intravenous contrast medium injection

7.7

0.27

[83]

2.09

[17]

ZCQK005

Computed tomography of the abdomen or pelvis, without
intravenous contrast medium injection

7.7

N.S.

[100+]

N.S.

[39]

LHQH002

Computed tomography of several segments of the spinal
column, with intravenous contrast medium injection

13

N.S.

[100+]

N.S.

[45]

LHQH006

Computed tomography of one segment of the spinal column,
with intravenous contrast medium injection

11

N.S.

[100+]N.S.

[42]

LHQK001

Computed tomography of one segment of the spinal column,
without intravenous contrast medium injection

9.3

0.51

[74]

4.75

[7]

LHQK005

Computed tomography of several segments of the spinal
column, without intravenous contrast medium injection

11

0.12

[95]

1.36

[25]

EMQH001

Computed tomography of the blood vessels in the legs [Legangiogram]

20

N.S.

[100+]N.S.

[61]

MZQH001

Arthrography of the arm with computed tomography [Armarthrogram]

5.8

N.S.

[100+]N.S.

[71]

MZQH002

Unilateral or bilateral computed tomography of an arm
segment, with contrast medium injection

4.8

N.S.

[100+]N.S.

[63]

MZQK002

Unilateral or bilateral computed tomography of an arm
segment, without contrast medium injection

3.8

0.71

[66]

2.69

[14]

NZQH001

Unilateral or bilateral computed tomography of a leg
segment, with contrast medium injection

0.2

N.S.

[100+]

N.S.

[100+]

NZQH002

Arthrography of the leg with computed tomography [Legarthrogram]

3.8

N.S.

[100+]N.S.

[57]

NZQH005

Computed tomography of the hip and leg for computed-aided
design of a bespoke osteoarticular prosthesis

10

N.S.

[100+]N.S.

[87]

NZQK002

Unilateral or bilateral computed tomography of a leg
segment, without contrast medium injection

0.2

0.77

[64]

0.15

[65]

NZQK004

Computed tomography scan to measure leg length

5.5

N.S.

[100+]N.S.

[72]

ZZQH033

Computed tomography of 3 or more anatomical areas, withintravenous contrast medium injection

11

0.18

[90]

1.99

[19]

ZZQK024

Computed tomography of 3 or more anatomical areas,
without contrast medium injection

9.6

N.S.

[100+]

N.S.

[64]

Spine

Limbs

Trunk

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Table XII. List of CCAM codes for nuclear medicine, categorised by anatomical area.

CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

Head and neck
ACQL002

Brain SPECT scan, with dedicated PET camera

3.8

N.S.

[100+]

N.S.

[100+]KCQL001

Thyroid gland scintigraphy with radioactive iodine uptake test

1.8

N.S.

[100+]

N.S.

[100+]KCQL003

Thyroid gland scintigraphy

1.6

N.S.

[100+]

N.S.

[100+]

DAQL009

SPECT myocardial perfusion scan at rest, with SPECT myocardial
perfusion scan after effort or pharmacological stress, ECGsynchronised

11

N.S.

[100+]N.S.

[83]

GFQL002

Lung ventilation/perfusion SPECT

3.5

N.S.

[100+]

N.S.

[100+]GFQL007

Lung perfusion scintigraphy

3.2

N.S.

[100+]

N.S.

[100+]

GLQL002

Alveolar-capillary permeability measurement with radioisotopes

3.8

N.S.

[100+]

N.S.

[100+]

Chest and heart

Abdomen and pelvis
FFQL001

Spleen scintigraphy by injection of a special radiotracer

1

N.S.

[100+]

N.S.

[100+]

HEQL001

Radionuclide detection of gastro-oesophageal reflux

0.6

N.S.

[100+]

N.S.

[100+]

HEQL002

Oesophageal transit scintigraphy with a solid or liquid

0.9

N.S.

[100+]

N.S.

[100+]

HFQL002

Gastric or duodenal transit scintigraphy with a solid or liquid
without pharmacological stress

0.3

N.S.

[100+]

N.S.

[100+]

HFQL004

Gastric or duodenal transit scintigraphy with solids and liquids
without pharmacological stress

0.6

N.S.

[100+]

N.S.

[100+]

JAQL001

Renal glomerular or tubular scintigraphy [Radioisotope renography]
without pharmacological stress

1.3

N.S.

[100+]

N.S.

[100+]

JAQL002

Renal cortical scintigraphy

1

0.26

[84]

0.26

[53]

JAQL003

Renal glomerular or tubular scintigraphy [Radioisotope renography]
with pharmacological stress

1.3

0.12

[96]

0.15

[68]

JAQL005

Renal glomerular or tubular scintigraphy [Radioisotope renography]
without pharmacological stress, with anterograde pyelogram of the
bladder

1.3

N.S.

[100+]

N.S.

[100+]

KEQL001

Adrenal gland scintigraphy

3.2

0.12

[95]

0.40

[47]

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CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

Whole body
PAQL002

Whole body bone scintigraphy in several stages

4.4

0.47

[76]

2.07

[18]

PAQL003

Whole body bone scintigraphy in one pass [late scan]

4.4

0.08

[99]

0.36

[49]

PAQL005

Whole body bone scintigraphy segment by segment in several stages,
without additional image acquisition by a pinhole collimator

4.4

0.09

[98]

0.40

[46]

PAQL007

Bone scintigraphy of a segment in several stages, with additional
image acquisition by a pinhole collimator

4.4

N.S.

[100+]N.S.

[78]

PAQL008

Bone scintigraphy of a segment in several stages, without additional
image acquisition by a pinhole collimator

4.4

N.S.

[100+]N.S.

[70]

PAQL010Whole body bone scintigraphy segment by segment in several stages,
with additional image acquisition by a pinhole collimator

4.4

N.S.

[100+]N.S.

[90]

ZZQL016Whole body SPECT scan, with dedicated PET camera

13

0.08

[99]

1.07

[31]

FEQL002

Platelet life span measurement with radioisotopes

5.5

N.S.

[100+]N.S.

[84]

KGQL001

Measurement of plasma and urine radioisotope clearance

0.04

N.S.

[100+]

N.S.

[100+]KGQL004

Measurement of plasma radioisotope clearance

0.02

N.S.

[100+]

N.S.

[100+]

Other

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Table XIII. List of CCAM codes for diagnostic interventional radiology.

CCAM
code

Procedure description

E/proc.

Proc. freq.

Emean/child

mSv

/1000
child.

[rank]µSv[rank]

9N.S.

[100+]

N.S.

[69]

Cardiac
DDQH012

Coronary arteriography with left ventriculography, by percutaneousarterial catheterisation

Vascular radiology
DFQH001

Selective arteriography of the trunk and/or pulmonary arterybranches, by percutaneous venous catheterisation

5

N.S.

[100+]N.S.

[55]

DFQH002

Hyperselective arteriography of the pulmonary arteries, bypercutaneous venous catheterisation

5

N.S.

[100+]N.S.

[85]

DGQH002

Full arteriography of the abdominal aorta, by percutaneous arterial
catheterisation

12

N.S.

[100+]N.S.

[79]

DGQH006

Full arteriography of the thoracic aorta, by percutaneous arterial
catheterisation

5

N.S.

[100+]

N.S.

[100+]

DHQH006

Full venography of the superior vena cava [Superior vena
cavography], by percutaneous venous catheterisation

5

N.S.

[100+]

N.S.

[100+]

EBQH002

Selective arteriography of 3 or more cervico-cephalic axes, bypercutaneous arterial catheterisation

5

N.S.

[100+]N.S.

[76]

EBQH008

Arteriography of several cervico-cephalic axes, by multiple
percutaneous intra-arterial injections

5

N.S.

[100+]

N.S.

[100+]

EZMH001

Secondary radiological permeability and/or position check of avascular access device or a vascular stent, by contrast medium
injection

0.1

N.S.

[100+]

N.S.

[100+]

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