Computed Tomography vs. Clinical Observation In Paediatric Headaches

Computed Tomography vs. Clinical Observation In Paediatric Headaches | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Computed Tomography vs. Clinical Observation In Paediatric Headaches Safa Qazafi, Gareth Iball This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7356542/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Paediatric headaches have become a wide concern in the UK, resulting in the increased use of CT scanning. However, global concerns are rising due to the fear of negative impacts of radiation effects on children. This study aims to investigate whether clinical observation can be used to predict the need for CT scanning in order to reduce unnecessary radiation. Secondary research was conducted using five peer-reviewed articles comparing the use of clinical observation vs. CT scanning for paediatric headaches. The main themes discovered were : negative radiation effects associated with CT imaging in paediatric patients, clinical observation as an alternative to CT scanning, and unclear diagnostic guidelines in clinical observations. The results of the thematic analysis suggest that introduction of standard clinical observation before a CT scan can help rule out the use of a CT scan in many cases, however there is a gap in knowledge on what clinical observation is required. Figures Figure 1 Figure 2 Key points Radiation Dose: The number of the single doses received in a given period by a quantified population from exposure. (Materials 1999) Computed tomography (CT): A computerised X-ray imaging technique in which a patient is exposed to X-rays from all around the body. The detected signals are used to produce cross-sectional images. (National Institute of Biomedical Imaging and Bioengineering 2022) Paediatrics: Patients up to the age of eighteen are considered "children" by the European Union, the United Nations, and its Children's Fund. (Strouse et al. 2022) Introduction Over the past few decades, headaches have become a global concern in paediatrics where 58.4% of school children and adolescents are affected (Straube et al. 2013), with girls being affected 3 times more than boys (Fabio Antonaci et al. 2014). Clinical techniques such as blood tests, cerebrospinal fluid examinations and cardiovascular examinations are ways to diagnose headaches (De Luca and Bartleson 2010). Furthermore, diagnostic imaging such as MRI (Magnetic Resonance Imaging) and CT scanning are also the most frequent imaging tests used (Behzadmehr et al. 2018). However, global concerns are rising due to the fear of negative impacts of radiation effects on children (WHO 2015). For example, a report conducted by the World Health Organisation (WHO) (2015) points out that the use of inappropriate medical scans can result in preventable radiation risks especially in children, they suggest a balanced approach which considers full health benefits with minimised risks (Hardell 2017). There are various methods that can be used to avoid unnecessary CT scanning and radiation risks associated with it. One method that has received attention from scholars and researchers is to provide more detailed, standard clinical observation to ensure that children are sent for scanning only if it’s absolutely necessary. The aim of this study is to investigate the existing literature on this topic and find out if there are any potential gaps. In order to achieve this objective, this study aims to address three interrelated objectives: To investigate negative exposure effects of radiation associated with CT imaging in paediatric patients. To investigate the role of good clinical observation for headaches in paediatrics and reducing unnecessary X-ray exposure To provide recommendations based on literature to achieve a balance between safety (minimising radiation exposure) and assuring optimal patient outcomes. The findings can have valuable insights in developing paediatric optimisation guidelines for CT scanning. By examining the balance between minimising radiation exposure and diagnostic precision this paper provides insights on the existing debate on paediatric head scanning and current practices in paediatric radiography. Furthermore, the findings could influence clinical decision-making processes whilst minimising unnecessary exposure and creating a guide to keep up the standards of headache management. Background According to the International Headache Society (IHS) headaches are classified as primary and secondary (Özge et al. 2011). A primary headache is categorised as a migraine, cluster headache or a daily headache which is not caused by a medical condition. Secondary headaches are caused by medical conditions, trauma, infection or overuse of medication (Ahmed 2012). It is important to identify the type of headache, as this will determine which imaging or treatment is given. For example, post trauma headaches would be considered a clinical emergency and therefore require immediate imaging (Mavroudis et al. 2023). Currently the United Kingdom (UK) uses the NICE (National Institution for Health Care and Excellence) guidelines which help classify headaches into primary or secondary. The use of this helps manage and improve the recognition of headaches to reduce delayed investigations (NICE 2012). CT scanning can help rule out the cause of headaches as they can detect many underlying pathologies such as tumours (Holle and Obermann 2013). Furthermore, CT scans have a short acquisition time which enables imaging to be undertaken at a faster rate compared to other modalities such as MRI (Kitai et al. 2007). Altmann et al. (2023) points out that there CT images are higher resolution than many other types of imaging which means that details of bones and soft tissues can be more easily observed. On the other hand, MRI does not use ionising radiation, so there are no associated radiation risks (National Institute of Biomedical imaging and Bioengineering 2019). Table 1 represents the dose given in a medical scan with comparison to typical UK background radiation levels. It is important to understand the equivalence of radiation on children as they are considered to be at higher risk of radiation induced effects. Table 1: Average dose from diagnostic scans and comparison to background radiation. Types of radiation. Average estimated dose. Equivalent to days of background radiation. Natural background radiation 3mSv/per year 365 days Chest x-ray 0.01mSv 1 day CT head 2mSv 8 months CT chest 3mSv 12 months CT abdomen 5mSv 20 months The review of existing literature on the negative impact of exposure to CT scanning has mixed opinions. A retrospective cohort study by Pearce et al. (2012) on children and adults under 22, found that there is a significant correlation between radiation dose from CT scanning and the development of leukaemia and brain tumours. Their findings suggest that participants undergoing a CT scan are 2.82 times more likely to have a brain tumour with an exposed dose of 50-74mGy, and 3.18 times more likely to develop leukaemia with exposed dose of 30mGy. However, the study failed to identify other co-founding factors that can cause this such as medical status, history and environmental exposure. The development of cancer resulting from radiation has been explored by Meulepas et al. (2019). They conducted a nation-wide retrospective cohort study of 168,394 children who received one or more CT scan under the age of 18 years and found out that 84 children had developed brain tumours (malignant and benign). The large sample size of this paper has proven reliability along with a 2-sided statistical test reducing the likelihood of errors, showing the correlation of cancer development throughout childhood. However, it should be noted that this study was undertaken in Dutch hospital, and the associated findings may not be useful to other countries with different guidelines. There is extensive evidence that CT scanning can be avoided through conducting comprehensive clinical observations which can include checking medical history and patient symptoms (Dougeni et al. 2012). Clinical observation is referred to monitoring the patient’s health and recording signs of their status and wellbeing (Faustinella 2020). A study by Behzadmehr et al. (2018) suggests that if proper clinical observation is performed, 75.7% of patients won’t need to go through CT scanning. This includes evaluating the patient’s eyes for papilledema, checking their pulse rate, temperature and undertaking a general examination (Faustinella 2020). Currently, the NICE guidelines have provided advice on managing headaches by using clinical observation such as recording the frequency, severity and duration of headaches, along with monitoring interventions (NICE 2022). However, the guidelines give a lot of information on referring, but it does not specify much information regarding what to do before referrals. Materials and Methods This study undertook a systematic review following the PRISMA guidelines (Ahn and Kang 2018). The 3 data bases that helped retrieved articles was Medline, CINAHL and APA PsycINFO. These databases include a comprehensive, peer reviewed and narrowed literature in healthcare which can address the concerns of the research topic (Melnyk and Fineout-Overholt 2022). Peripheral Boolean operators including AND, OR were utilised along with key terms such as “CT”, “children”, “assessment”. Selection of studies: The studies selected were between 2019-2024 – this date range was chosen to reduce the length of a biased search. A clear detailed inclusion and exclusion criteria can be seen in Table 2 which ensured validity and reliability of the studies (Brennan 2024). The criteria helped ensure that the studies chosen were focused on paediatric CT head scanning and clinical observation. Table 2: inclusion and exclusion criteria: Criteria Inclusion criteria Exclusion criteria Population Children, paediatrics under 18 years with a headache Adults with headaches, and other pathologies. Children with other pathologies. Intervention Comparing the difference between CT scanning and clinical observation on paediatric headaches . Patients that have suffered trauma or with known medical condition. Language All papers written in English Exclude papers not written in English Full text availability Studies accessible to the University of Bradford Studies not accessible to the university of Bradford. Settings No form of restriction n/a Publication date Last 5 years Published before 2019 Screening: The study utilised a PRISMA guide for filtering and obtaining results. A total of 316 records were obtained from Medline, CINAHL and Apa PsycINFO. Covidence was used to remove duplicates. Covidence is a data extraction tool used in systematic reviews to keep track of data and remove duplicates (Purssell and McCrae 2020). After removing 8 duplicates on Covidence, 308 records with similar identities underwent screening on the title and the abstract. This can be seen in Figure 1. Critical appraisal: To ensure quality assessment of the research studies the critical appraisal skills programme (CASP) tool was used. This was crucial in achieving precise research as the accuracy and credibility of results should be assured along with a guarantee of high quality of search (WHIFFIN 2023). The worthiness of the qualitative, quantitative and mixed research papers was found to ensure the best quality of results, which ensured a high-quality review being produced. This also allowed good assessment of evidence which further researchers can utilise. CASP helped address problems, themes, collection process and analysis. Three main themes also appeared which helped provide a base of the discussion and analysis. Analysis: The study provided a 6-stage thematic analysis as created by Braun and Clark (2006), this includes being familiar with the data found, generating initial codes, identifying themes, reviewing themes, defining themes and providing reports (Kiger and Varpio 2020). Similar themes were put into the same category such as barriers of the diagnostic approach of CT scanning, clinical observation and dose. Ethical approval: Ethical approval was granted on October 28 th , 2024. By the Vice Chair of the Humanities, Social and Health Sciences Research Ethics Panel at the University of Bradford. Reference number EC28404. Results This chapter details the articles that were reviewed as a result of our search as well as the main themes that occurred during the systematic review. The main themes included negative radiation effects, importance of clinical observation and following diagnostic protocols in CT. Table 3. Research on Paediatric Headaches: CT scan Utilisation and Results Author and type of study: Sample size: Patients with headache: Patients referred for a CT : Findings and no scanned patient: Etsehiwot Demeke and Mekonnen (2022) (Retrospective cohort study) 443 64 52 -20 scans had no findings. - 9 patients were discharged upon assessment. (Khurana et al. 2023) (Retrospective cross-sectional study) 311 285 173 (was for MRI or CT scan) -169 had no findings. - 112 had clinical observation/assessment. Hanan Azouz et al. 2024) (Cross sectional study) 22,662 164 109 88 had no findings. -55 had clinical observation/assessment. (Costa et al. 2020) ( Retrospective study) 2354 89 6 4 had no findings. -83 had clinical assessment took medication. (Tsze et al. 2019) (Prospective cohort study) 224 197 31 -23 had no findings. -166 had clinical observation/assessment. Total= 25,994 676 414 353 The outcome of the CT scans that were performed is shown in Figure 2. Discussion The analysis of the literature revealed that: There is a correlation between CT scanning in paediatrics and the development of adverse effects in the future such as leukaemia and brain tumours. Psychological impact on children has been found to increase anxiety in the medical environment. Implementing clinical observation can provide a better patient pathway as regular communication and interaction can help provide better choices for the patient and reduce mistakes. One important finding from the review of existing literature is the lack of standard guidance for clinical observation. While the data from most of the articles conclude clinical observation can reduce the necessity of CT scanning, none of the papers have suggested what those observations should look like. For example, while Khurana et al. (2023) found out that appropriate screening and clinical observation will help reduce the number of scanning episodes children go through, they failed to state what type of assessment would be the best and most effective. This also links with the study by Almuqbil et al. (2023), who revealed that CT and MRI scans should only be considered if there are red flags present throughout the clinical observation but has not specified which type of observation clinicians should undertake. Another important finding from the review of existing literature is the impact of parental pressure during clinical observations, and its impact on clinicians to refer children for CT. For example, Madrigal et al. (2022) has revealed that parents with anxiety have low levels of trust towards the clinician and would prefer to make their own medical decisions about their child. This suggest that there is a need to build trust with parents to make them feel at ease, so there is a better understanding between parent and clinicians. This could reduce unnecessary demand on CT imaging, resulting in associated health economic benefits. Theme 1: Negative radiation effects associated with CT imaging in paediatric patients: A wide range of literature that has been published that supports the raised concerns about the correlation between CT scanning and radiation in paediatrics. Many of the papers have also concluded that there has been are small numbers of clinically relevant findings resulting from the use of CT scanning which can be seen in Figure 2. The data shown in this Figure has been derived from the articles used in table 3. Meulepas et al. (2019) found that children under 18 years are more likely to develop a brain tumour risk from CT related radiation. This is due to the increased cell division in children which makes them more vulnerable to developing radiation induced malignancies. Etsehiwot Demeke and Mekonnen (2022) performed a retrospective cross-sectional study on children younger than 14 years and found that radiation exposure links to an increased risk of brain malignancy and leukaemia. Hanan Azouz et al. (2024) also has similar findings based on a 6-month follow up of 164 children who fitted in the headache category with an associated red flag. The results showed that children who have 2 to 3 CT scans before reaching the age of 15 years are 3 times more likely to develop brain tumours and 5 to 7 scans would triple the risk of leukaemia. Aside from the negative exposure effects there has also been data on negative impacts of unnecessary CT scans on children’s mental health. For example, Khurana et al. (2023) pointed out that children’s anxiety and distress increase when they undergo diagnostic scans. Similarly, Callahan (2011) raised concerns that children fear unfamiliar environments such as medical settings. A further article points out that children may become uncooperative due to fear of medical environments and sometimes clinicians may struggle to deal with this situation as it leads to delays (Hayes et al. 2018). A study by Bailey et al. (2016) suggests providing entertainment tools and sedation and claims that using sedative agents has resulted in a 95% success rate of scans as images are clearer due to less patient movement and no repeats. Theme 2: Importance of standard clinical observatio n: Four out of five articles suggested that clinical observation can be used in many cases as an alternative to CT scanning when assessing paediatric headaches. These articles suggest that clinical observation should be used to help distinguish different types of headaches which can alert clinicians as to whether CT scanning is necessary. For example, Costa et al. (2020) conducted a retrospective study of 2,201 children that were admitted due to complaints of headaches. Their findings suggest that in nearly 29% of cases, standard clinical observation resulted in appropriate medication and ruled out the need for a CT scan. They suggest that improvements in standard clinical observation can increase these numbers even higher. These results are consistent with Khosravi et al. (2023) who found out that 74% of CT requests were categorised as unnecessary, indicating that pre-observation, history check and physical examination can reduce the number of CT requests (Eigenbrodt et al. 2021). Khurana et al. (2023) conducted a retrospective study from 90 children reporting headaches and found out that 80% of cases were found to be normal after the CT scanning, suggests that clinical observation could have avoided the unnecessary scanning. Interestingly, the existing literature suggests that external pressures such as parent’s insistence on the need for CT scanning is one of the main reasons that has resulted in unnecessary imaging. Costa et al. (2020) and Etsehiwot Demeke and Mekonnen (2022) have both agreed that advice on follow up education from doctors should be in place, and further explanation should be provided to parents in this situation. Hanan Azouz et al. (2024) also explained that it is necessary that parents are educated upon the negative impacts and radiation as this can lead a reduction in the pressure faced by referrers to provide imaging. Theme 3: following diagnostic protocols in CT : The review of the existing literature suggests that existing diagnostic guidelines are sometimes unclear (WHO 1992). Currently the classification system for headaches in the UK are based on NICE guidelines. The international classification of headache disorders (ICDH-3) categorises primary and secondary headaches and the British National Formulary for children (BNF-C) helps provide guidance on medication use (Lenney 2015). NICE guidelines suggest imaging should only be performed after a neurological assessment if a red flag symptom is present and if not, a CT scan is not necessary (NICE 2012). The study of Tsze et al. (2019) was based in an emergency department and followed the guidelines of the American Academy of Neurology (AAN) and American College of Radiology (ACR) along with established diagnostic protocols in the hospital. According to these guidelines a headache with vomits, or systemic illness or progressive changes would be a red flag and require imaging. However, they point out that these symptoms might be misdiagnosed due to human error or misinterpretation of guidelines. Etsehiwot Demeke and Mekonnen (2022) also point out that sometimes the ACR guidelines are not fully adhered to. Their data showed that 31.3% of the cases were deemed inappropriate especially those that did not have red flag symptoms. This goes against the guidelines, which states to not use imaging if there are no red flags present. The study also mentions paediatrics under 14 years had the highest rates of inappropriate scanning which suggests ACR-AC paediatric guidelines are not followed for this age group. The authors have debated that there is confusion between medical professionals and a lack of guidance which leads to misuse of the guidelines. Study limitations: The studies that were included have several limitations. Firstly, the studies used different types of method, as seen in Table 3. This limitation may lead to heterogeneity in findings, making it difficult for the researchers to compare results directly or draw consistent conclusions (Faber and Fonseca 2014). The number of participants also varied between each of these studies with patient numbers ranging from 224 to 22,662. This affects the generalisability of the results, and limits the strength of the findings for benefitting the wider population (Button et al. 2013). Review limitations : There are also limitations throughout this review. For example, all the studies were written in English, which can cause selection bias. Egger et al. (1997) argues that studies published in English are more likely to have positive findings than studies published in nonother languages. This may lead to an unbalanced view of determining whether clinical observation should be undertaken rather than a CT scan for paediatric headaches. Including non-English language papers and use of translation services could affect the results of this review. Moving forward, reviews that are conducted around this topic should include non-English papers, as this would ensure a broader representation of the published evidence. Secondly a single reviewer performed this literature review. However, the Cochrane Collaboration and Agency for Healthcare Research and Quality (AHRQ) has recommended that a minimum of two independent reviewers should screen the studies to reduce any bias formed or errors. A study by Stoll et al. (2019) has concluded that using a second reviewer can maximise the number of studies found and can reduce random error. However, this study had to be conducted by one student only, due to University guidelines. Conclusion The findings of this review suggest that there can be a correlation between CT scanning in paediatrics and the development of adverse effects in children, and that clinical observations can play an important role in reducing CT referrals. However, the lack of clear clinical guidance and consistent standards for medical observations makes it difficult for practitioners to resist the external pressure from parents, resulting in increases in the referral of children for CT referrals. This highlights the importance of developing standardised paediatric imaging protocols that align with current safety guidelines and adapting these protocols according to individual patient risk and clinical presentation. Furthermore, findings suggest greater integration of education and training for clinicians to reinforce the value of clinical observation. Declarations Contributions and implications for practice and future: It is recommended that clinical guidelines should provide a more structured approach in their referral pathway and should address gaps which have caused confusions in the current pathways. As there is a lack of literature reviews on this topic further research is needed to strengthen this area which can help develop frameworks across hospitals that will result in a successful management of paediatric headaches and will ensure patient safety. The authors report there are no competing interests to declare. References Almuqbil, M., Saud Abdulaziz Alsayed, Amer Mohammed Almutairi, Khalid Mohammed Aladhadh, Abdullah Omar Alghannami and Almutairi, M. (2023) Diagnostic Yield of Neuroimaging for Headache in a Pediatric Emergency Department: A Single Tertiary Centre Experience. 11 (6), 913–913. Altmann, S., Abello, M.A., Ucar, F.A., Kronfeld, A., Bilal Al-Nawas, Mukhopadhyay, A., Booz, C., Brockmann, M.A. and Othman, A.E. 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Tsze, D.S., Ochs, J.B., Gonzalez, A.E. and Dayan, P.S. (2019) Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging. Cephalalgia: An International Journal of Headache 39 (2), 185–196. WHIFFIN (2023) Critical Appraisal Skills in Healthcare: a Practic Al Guide for Evidence-Based Practice . Wiley-Blackwell. World Health Organization (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines . https://www.who.int/publications/i/item/9241544228 Accessed. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7356542","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":499440520,"identity":"7bec2b7c-fab2-4b9a-b188-18420c5c8567","order_by":0,"name":"Safa Qazafi","email":"","orcid":"","institution":"University Of Bradford","correspondingAuthor":false,"prefix":"","firstName":"Safa","middleName":"","lastName":"Qazafi","suffix":""},{"id":499440521,"identity":"421d4ff9-a1e5-4078-bfbe-8901bb478cb5","order_by":1,"name":"Gareth Iball","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYLCCxAYGGT72HiCLTQ5IJIAFDQhp4WHjOQPSYkykFkaQFokcIrXIO/A+YHi4w46HTfLtsQ8/ygzkzNsTGD/8YDhsjEuL4QF2A4bEM8k8bNJ5yTN7zhkYy5x5wCzZw3DYDKeWBjagX9qYgVpyjBl42/4kzpBIYJBmYDhsQ0BLPdBhZ4wZ/7YZgLQw/8anRZ4BrOUw0Ps8xsy8EC1sIFtwOsyAmY3hQOKZ48BAzktmlgH6RYLnYZtlj0E6Tu/Lt7cxPvy5o1qOn/3sYcY3wBCTYE8+fONHhbVhAy5bDjMwHEATA0YTvoiUx2XWKBgFo2AUjAI4AAD5sUfQHYZBWQAAAABJRU5ErkJggg==","orcid":"","institution":"University Of Bradford","correspondingAuthor":true,"prefix":"","firstName":"Gareth","middleName":"","lastName":"Iball","suffix":""}],"badges":[],"createdAt":"2025-08-12 14:01:02","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-7356542/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7356542/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89266842,"identity":"c404db63-c0e5-4f21-bcaa-7c2bacf4ae06","added_by":"auto","created_at":"2025-08-18 08:19:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":319514,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA flow diagram for systematic reviews and Meta-Analyses of search.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7356542/v1/6a96fe152adb27c0acd19251.png"},{"id":89266841,"identity":"f5d424e9-f451-4b76-baf0-fc046f14d48c","added_by":"auto","created_at":"2025-08-18 08:19:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18064,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003epercentage of no findings vs findings in paediatric patients undergoing a CT scan for headache symptoms.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7356542/v1/0bbeae79c4bcfb36b70e2e25.png"},{"id":89270208,"identity":"e5378808-7c0b-4452-b090-ae551ad2b894","added_by":"auto","created_at":"2025-08-18 08:43:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1202969,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7356542/v1/35abbd8a-224d-4e8a-b161-36cf64a8d631.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eComputed Tomography vs. Clinical Observation In Paediatric Headaches\u003c/p\u003e","fulltext":[{"header":"Key points","content":"\u003cul\u003e\n \u003cli\u003eRadiation Dose: The number of the single doses received in a given period by a quantified population from exposure. (Materials 1999)\u003c/li\u003e\n \u003cli\u003eComputed tomography (CT): A computerised X-ray imaging technique in which a patient is exposed to X-rays from all around the body. The detected signals are used to produce cross-sectional images. (National Institute of Biomedical Imaging and Bioengineering 2022)\u003c/li\u003e\n \u003cli\u003ePaediatrics: Patients up to the age of eighteen are considered \u0026quot;children\u0026quot; by the European Union, the United Nations, and its Children\u0026apos;s Fund. (Strouse et al. 2022)\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eOver the past few decades, headaches have become a global concern in paediatrics where 58.4% of school children and adolescents are affected (Straube et al. 2013), with girls being affected 3 times more than boys (Fabio Antonaci et al. 2014). Clinical techniques such as blood tests, cerebrospinal fluid examinations and cardiovascular examinations are ways to diagnose headaches (De Luca and Bartleson 2010). Furthermore, diagnostic imaging such as MRI (Magnetic Resonance Imaging) and CT scanning are also the most frequent imaging tests used (Behzadmehr et al. 2018). However, global concerns are rising due to the fear of negative impacts of radiation effects on children (WHO 2015). For example, a report conducted by the World Health Organisation (WHO) (2015) points out that the use of inappropriate medical scans can result in preventable radiation risks especially in children, they suggest a balanced approach which considers full health benefits with minimised risks (Hardell 2017).\u003c/p\u003e\n\u003cp\u003eThere are various methods that can be used to avoid unnecessary CT scanning and radiation risks associated with\u0026nbsp;it. One method that has received attention from scholars and researchers is to provide more detailed, standard clinical observation to ensure that children are sent for scanning only if it\u0026rsquo;s absolutely necessary. The aim of this study is to investigate the existing literature on this topic and find out if there are any potential gaps.\u0026nbsp;In order to achieve this objective, this study aims to address three interrelated objectives:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTo investigate negative exposure effects of radiation associated with CT imaging in paediatric patients.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTo investigate the role of good clinical observation for headaches in paediatrics and reducing unnecessary X-ray exposure\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eTo provide recommendations based on literature to achieve a balance between safety (minimising radiation exposure) and assuring optimal patient outcomes.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe findings can have valuable insights in developing paediatric optimisation guidelines for CT scanning. By examining the balance between minimising radiation exposure and diagnostic precision this paper provides insights on the existing debate on paediatric head scanning and current practices in paediatric radiography. Furthermore, the findings could influence clinical decision-making processes whilst minimising unnecessary exposure and creating a guide to keep up the standards of headache management.\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eAccording to the International Headache Society (IHS) headaches are classified as primary and secondary (\u0026Ouml;zge et al. 2011). A primary headache is categorised as a migraine, cluster headache or a daily headache which is not caused by a medical condition. Secondary headaches are caused by medical conditions, trauma, infection or overuse of medication (Ahmed 2012). It is important to identify the type of headache, as this will determine which imaging or treatment is given. For example, post trauma headaches would be considered a clinical emergency and therefore require immediate imaging (Mavroudis et al. 2023). Currently the United Kingdom (UK) uses the NICE (National Institution for Health Care and Excellence) guidelines which help classify headaches into primary or secondary. The use of this helps manage and improve the recognition of headaches to reduce delayed investigations (NICE 2012).\u003c/p\u003e\n\u003cp\u003eCT scanning can help rule out the cause of headaches as they can detect many underlying pathologies such as tumours (Holle and Obermann 2013). Furthermore, CT scans have a short acquisition time which enables imaging to be undertaken at a faster rate compared to other modalities such as MRI (Kitai et al. 2007). \u0026nbsp;Altmann et al. (2023) points out that there CT images are higher resolution than many other types of imaging which means that details of bones and soft tissues can be more easily observed. On the other hand, MRI does not use ionising radiation, so there are no associated radiation risks (National Institute of Biomedical imaging and Bioengineering 2019). Table 1 represents the dose given in a medical scan with comparison to typical UK background radiation levels. It is important to understand the equivalence of radiation on children as they are considered to be at higher risk of radiation induced effects.\u003c/p\u003e\n\u003cp id=\"_Toc193980074\"\u003e\u003cstrong\u003e\u003cu\u003eTable 1: Average dose from diagnostic scans and comparison to background radiation.\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"469\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.7179%;\"\u003eTypes of radiation.\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.5641%;\"\u003eAverage estimated dose.\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48.7179%;\"\u003eEquivalent to days of background radiation.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.7179%;\"\u003eNatural background radiation\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.5641%;\"\u003e3mSv/per year\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48.7179%;\"\u003e365 days\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.7179%;\"\u003eChest x-ray\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.5641%;\"\u003e0.01mSv\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48.7179%;\"\u003e1 day\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.7179%;\"\u003eCT head\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.5641%;\"\u003e2mSv\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48.7179%;\"\u003e8 months\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.7179%;\"\u003eCT chest\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.5641%;\"\u003e3mSv\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48.7179%;\"\u003e12 months\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.7179%;\"\u003eCT abdomen\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 27.5641%;\"\u003e5mSv\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 48.7179%;\"\u003e20 months\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003eThe review of existing literature on the negative impact of exposure to CT scanning has mixed opinions. A retrospective cohort study by Pearce et al. (2012) on children and adults under 22, found that there is a significant correlation between radiation dose from CT scanning and the development of leukaemia and brain tumours. Their findings suggest that participants undergoing a CT scan are 2.82 times more likely to have a brain tumour with an exposed dose of 50-74mGy, and 3.18 times more likely to develop leukaemia with exposed dose of 30mGy. However, the study failed to identify other co-founding factors that can cause this such as medical status, history and environmental exposure. The development of cancer resulting from radiation has been explored by Meulepas et al. (2019). They conducted a nation-wide retrospective cohort study of 168,394 children who received one or more CT scan under the age of 18 years and found out that 84 children had developed brain tumours (malignant and benign). The large sample size of this paper has proven reliability along with a 2-sided statistical test reducing the likelihood of errors, showing the correlation of cancer development throughout childhood. However, it should be noted that this study was undertaken in Dutch hospital, and the associated findings may not be useful to other countries with different guidelines.\u0026nbsp;\u003cp\u003eThere is extensive evidence that CT scanning can be avoided through conducting comprehensive clinical observations which can include checking medical history and patient symptoms (Dougeni et al. 2012). Clinical observation is referred to monitoring the patient\u0026rsquo;s health and recording signs of their status and wellbeing (Faustinella 2020). A study by Behzadmehr et al. (2018) suggests that if proper clinical observation is performed, 75.7% of patients won\u0026rsquo;t need to go through CT scanning. This includes evaluating the patient\u0026rsquo;s eyes for papilledema, checking their pulse rate, temperature and undertaking a general examination (Faustinella 2020). Currently, the NICE guidelines have provided advice on managing headaches by using clinical observation such as recording the frequency, severity and duration of headaches, along with monitoring interventions (NICE 2022). However, the guidelines give a lot of information on referring, but it does not specify much information regarding what to do before referrals.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eThis study undertook a systematic review following the PRISMA guidelines (Ahn and Kang 2018). The 3 data bases that helped retrieved articles was Medline, CINAHL and APA PsycINFO. These databases include a comprehensive, peer reviewed and narrowed literature in healthcare which can address the concerns of the research topic (Melnyk and Fineout-Overholt 2022). Peripheral Boolean operators including AND, OR were utilised along with key terms such as \u0026ldquo;CT\u0026rdquo;, \u0026ldquo;children\u0026rdquo;, \u0026ldquo;assessment\u0026rdquo;. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eSelection of studies:\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe studies selected were between 2019-2024 \u0026ndash; this date range was chosen to reduce the length of a biased search. A clear detailed inclusion and exclusion criteria can be seen in Table 2 which ensured validity and reliability of the studies (Brennan 2024). The criteria helped ensure that the studies chosen were focused on paediatric CT head scanning and clinical observation.\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc193980077\"\u003e\u003cstrong\u003e\u003cu\u003eTable 2: inclusion and exclusion\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003ecriteria:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"586\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.256%;\"\u003e\u003cstrong\u003eCriteria\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8874%;\"\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.8567%;\"\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.256%;\"\u003ePopulation\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8874%;\"\u003eChildren, paediatrics under 18 years with a headache\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.8567%;\"\u003eAdults with headaches, and other pathologies. Children with other pathologies.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.256%;\"\u003eIntervention\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8874%;\"\u003eComparing the difference between CT scanning and clinical observation on paediatric headaches .\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.8567%;\"\u003ePatients that have suffered trauma or with known medical condition.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.256%;\"\u003eLanguage\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8874%;\"\u003eAll papers written in English\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.8567%;\"\u003eExclude papers not written in English\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.256%;\"\u003eFull text availability\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8874%;\"\u003eStudies accessible to the University of Bradford\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.8567%;\"\u003eStudies not accessible to the university of Bradford.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.256%;\"\u003eSettings\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8874%;\"\u003eNo form of restriction\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.8567%;\"\u003en/a\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 25.256%;\"\u003ePublication date\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30.8874%;\"\u003eLast 5 years\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.8567%;\"\u003ePublished before 2019\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp id=\"_Toc193980078\"\u003e\u003cstrong\u003e\u003cu\u003eScreening:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study utilised a PRISMA guide for filtering and obtaining results. A total of 316 records were obtained from Medline, CINAHL and Apa PsycINFO. Covidence was used to remove duplicates. Covidence is a data extraction tool used in systematic reviews to keep track of data and remove duplicates (Purssell and McCrae 2020). After removing 8 duplicates on Covidence, 308 records with similar identities underwent screening on the title and the abstract. This can be seen in Figure 1.\u003c/p\u003e\n\u003cp id=\"_Toc193980079\"\u003e\u003cstrong\u003e\u003cu\u003eCritical appraisal:\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo ensure quality assessment of the research studies the critical appraisal skills programme (CASP) tool was used. This was crucial in achieving precise research as the accuracy and credibility of results should be assured along with a guarantee of high quality of search (WHIFFIN 2023). The worthiness of the qualitative, quantitative and mixed research papers was found to ensure the best quality of results, which ensured a high-quality review being produced. This also allowed good assessment of evidence which further researchers can utilise. CASP helped address problems, themes, collection process and analysis. Three main themes also appeared which helped provide a base of the discussion and analysis.\u003c/p\u003e\n\u003cp id=\"_Toc193980080\"\u003e\u003cstrong\u003e\u003cu\u003eAnalysis:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study provided a 6-stage thematic analysis as created by Braun and Clark (2006), this includes being familiar with the data found, generating initial codes, identifying themes, reviewing themes, defining themes and providing reports (Kiger and Varpio 2020). Similar themes were put into the same category such as barriers of the diagnostic approach of CT scanning, clinical observation and dose.\u003c/p\u003e\n\u003cp id=\"_Toc193980081\"\u003e\u003cstrong\u003e\u003cu\u003eEthical approval:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was granted on October 28\u003csup\u003eth\u003c/sup\u003e, 2024. By the Vice Chair of the Humanities, Social and Health Sciences Research Ethics Panel at the University of Bradford. Reference number EC28404.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis chapter details the articles that were reviewed as a result of our search as well as the main themes that occurred during the systematic review. \u0026nbsp;The main themes included negative radiation effects, importance of clinical observation and following diagnostic protocols in CT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 3. \u0026nbsp;Research on Paediatric Headaches: CT scan Utilisation and Results\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"680\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4743%;\"\u003e\u003cstrong\u003e\u003cem\u003eAuthor and type of study:\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0617%;\"\u003e\u003cstrong\u003e\u003cem\u003eSample size:\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4391%;\"\u003e\u003cstrong\u003e\u003cem\u003ePatients with headache:\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.978%;\"\u003e\u003cstrong\u003e\u003cem\u003ePatients referred for a CT :\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.047%;\"\u003e\u003cstrong\u003e\u003cem\u003eFindings and no scanned patient:\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4743%;\"\u003e\u003cstrong\u003e\u003cem\u003eEtsehiwot Demeke and Mekonnen (2022)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e(Retrospective cohort study)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0617%;\"\u003e443\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4391%;\"\u003e64\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.978%;\"\u003e52\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.047%;\"\u003e-20 scans had no findings.\u003cbr\u003e- 9 patients were discharged upon assessment.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4743%;\"\u003e\u003cstrong\u003e\u003cem\u003e(Khurana et al. 2023)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e(Retrospective cross-sectional study)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0617%;\"\u003e311\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4391%;\"\u003e285\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.978%;\"\u003e173 (was for MRI or CT scan)\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.047%;\"\u003e-169 had no findings.\u003cbr\u003e- 112 had clinical observation/assessment.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4743%;\"\u003e\u003cstrong\u003e\u003cem\u003eHanan Azouz et al. 2024)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e(Cross sectional study)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0617%;\"\u003e22,662\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4391%;\"\u003e164\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.978%;\"\u003e109\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.047%;\"\u003e88 had no findings.\u003cbr\u003e-55 had clinical observation/assessment.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4743%;\"\u003e\u003cstrong\u003e\u003cem\u003e(Costa et al. 2020)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e(\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003eRetrospective study)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0617%;\"\u003e2354\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4391%;\"\u003e89\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.978%;\"\u003e6\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.047%;\"\u003e4 had no findings.\u003cbr\u003e-83 had clinical assessment took medication.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4743%;\"\u003e\u003cstrong\u003e\u003cem\u003e(Tsze et al. 2019)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e(Prospective cohort study)\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0617%;\"\u003e224\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4391%;\"\u003e197\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.978%;\"\u003e31\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.047%;\"\u003e-23 had no findings.\u003cbr\u003e-166 had clinical observation/assessment.\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 17.4743%;\"\u003e\u003cstrong\u003e\u003cem\u003eTotal=\u003c/em\u003e\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18.0617%;\"\u003e25,994\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.4391%;\"\u003e676\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.978%;\"\u003e414\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 28.047%;\"\u003e353\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cstrong\u003e\u003cu\u003e\u003c/u\u003e\u003c/strong\u003e\n\u003cp\u003eThe outcome of the CT scans that were performed is shown in Figure 2. \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe analysis of the literature revealed that:\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eThere is a correlation between CT scanning in paediatrics and the development of adverse effects in the future such as leukaemia and brain tumours.\u003c/li\u003e\n \u003cli\u003ePsychological impact on children has been found to increase anxiety in the medical environment.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eImplementing clinical observation can provide a better patient pathway as regular communication and interaction can help provide better choices for the patient and reduce mistakes.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eOne important finding from the review of existing literature is the lack of standard guidance for clinical observation. While the data from most of the articles conclude clinical observation can reduce the necessity of CT scanning, none of the papers have suggested what those observations should look like. For example, while Khurana et al. (2023) found out that appropriate screening and clinical observation will help reduce the number of scanning episodes children go through, they failed to state what type of assessment would be the best and most effective. This also links with the study by Almuqbil et al. (2023), who revealed that CT and MRI scans should only be considered if there are red flags present throughout the clinical observation but has not specified which type of observation clinicians should undertake.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother important finding from the review of existing literature is the impact of parental pressure during clinical observations, and its impact on clinicians to refer children for CT. For example, Madrigal et al. (2022) has revealed that parents with anxiety have low levels of trust towards the clinician and would prefer to make their own medical decisions about their child. This suggest that there is a need to build trust with parents to make them feel at ease, so there is a better understanding between parent and clinicians. This could reduce unnecessary demand on CT imaging, resulting in associated health economic benefits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTheme 1: Negative\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003e\u0026nbsp;radiation effects associated with CT imaging in paediatric patients:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA wide range of literature that has been published that supports the raised concerns about the correlation between CT scanning and radiation in paediatrics. Many of the papers have also concluded that there has been are small numbers of clinically relevant findings resulting from the use of CT scanning which can be seen in Figure 2. The data shown in this Figure has been derived from the articles used in table 3.\u003c/p\u003e\n\u003cp\u003eMeulepas et al. (2019) found that children under 18 years are more likely to develop a brain tumour risk from CT related radiation. This is due to the increased cell division in children which makes them more vulnerable to developing radiation induced malignancies. Etsehiwot Demeke and Mekonnen (2022) performed a retrospective cross-sectional study on children younger than 14 years and found that radiation exposure links to an increased risk of brain malignancy and leukaemia. \u0026nbsp;Hanan Azouz et al. (2024) also has similar findings based on a 6-month follow up of 164 children who fitted in the headache category with an associated red flag. The results showed that children who have 2 to 3 CT scans before reaching the age of 15 years are 3 times more likely to develop brain tumours and 5 to 7 scans would triple the risk of leukaemia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Aside from the negative exposure effects there has also been data on negative impacts of unnecessary CT scans on children\u0026rsquo;s mental health. \u0026nbsp;For example, Khurana et al. (2023) pointed out that children\u0026rsquo;s anxiety and distress increase when they undergo diagnostic scans. Similarly, Callahan (2011) raised concerns that children fear unfamiliar environments such as medical settings. A further article points out that children may become uncooperative due to fear of medical environments and sometimes clinicians may struggle to deal with this situation as it leads to delays (Hayes et al. 2018). A study by Bailey et al. (2016) suggests providing entertainment tools and sedation and claims that using sedative agents has resulted in a 95% success rate of scans as images are clearer due to less patient movement and no repeats.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTheme 2: Importance of standard clinical observatio\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003en:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFour out of five articles suggested that clinical observation can be used in many cases as an alternative to CT scanning when assessing paediatric headaches. These articles suggest that clinical observation should be used to help distinguish different types of headaches which can alert clinicians as to whether CT scanning is necessary. For example, Costa et al. (2020) conducted a retrospective study of 2,201 children that were admitted due to complaints of headaches. Their findings suggest that in nearly 29% of cases, standard clinical observation resulted in appropriate medication and ruled out the need for a CT scan. They suggest that improvements in standard clinical observation can increase these numbers even higher. These results are consistent with Khosravi et al. (2023) who found out that 74% of CT requests were categorised as unnecessary, indicating that pre-observation, history check and physical examination can reduce the number of CT requests (Eigenbrodt et al. 2021). Khurana et al. (2023) conducted a retrospective study from 90 children reporting headaches and found out that 80% of cases were found to be normal after the CT scanning, suggests that clinical observation could have avoided the unnecessary scanning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterestingly, the existing \u0026nbsp;literature suggests that external pressures such as parent\u0026rsquo;s insistence on the need for CT scanning is one of the main reasons that has resulted in unnecessary imaging. Costa et al. (2020) and Etsehiwot Demeke and Mekonnen (2022) have both agreed that advice on follow up education from doctors should be in place, and further explanation should be provided to parents in this situation. Hanan Azouz et al. (2024) also explained that it is necessary that parents are educated upon the negative impacts and radiation as this can lead a reduction in the pressure faced by referrers to provide imaging. \u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc193980087\"\u003e\u003cstrong\u003e\u003cu\u003eTheme 3: following diagnostic protocols in CT\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003e:\u003c/u\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe review of the existing literature suggests that existing diagnostic guidelines are sometimes unclear (WHO 1992). Currently the classification system for headaches in the UK are based on NICE guidelines. The international classification of headache disorders (ICDH-3) categorises primary and secondary headaches and the British National Formulary for children (BNF-C) helps provide guidance on medication use (Lenney 2015). NICE guidelines suggest imaging should only be performed after a neurological assessment if a red flag symptom is present and if not, a CT scan is not necessary (NICE 2012).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study of Tsze et al. (2019) was based in an emergency department and followed the guidelines of the American Academy of Neurology (AAN) and American College of Radiology (ACR) along with established diagnostic protocols in the hospital. According to these guidelines a headache with vomits, or systemic illness or progressive changes would be a red flag and require imaging. However, they point out that these symptoms might be misdiagnosed due to human error or misinterpretation of guidelines. Etsehiwot Demeke and Mekonnen (2022) also point out that sometimes the ACR guidelines are not fully adhered to. Their data showed that 31.3% of the cases were deemed inappropriate especially those that did not have red flag symptoms. This goes against the guidelines, which states to not use imaging if there are no red flags present. The study also mentions paediatrics under 14 years had the highest rates of inappropriate scanning which suggests ACR-AC paediatric guidelines are not followed for this age group. The authors have debated that there is confusion between medical professionals and a lack of guidance which leads to misuse of the guidelines.\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc193980089\"\u003e\u003cstrong\u003e\u003cu\u003eStudy limitations:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies that were included have several limitations. Firstly, the studies used different types of method, as seen in Table 3. This limitation may lead to \u003cstrong\u003eheterogeneity\u003c/strong\u003e in findings, making it difficult for the researchers to compare results directly or draw consistent conclusions (Faber and Fonseca 2014). The number of participants also varied between each of these studies with patient numbers ranging from 224 to 22,662. This affects the generalisability of the results, and limits the strength of the findings for benefitting the wider population (Button et al. 2013).\u0026nbsp;\u003c/p\u003e\n\u003cp id=\"_Toc193980090\"\u003e\u003cstrong\u003e\u003cu\u003eReview limitations\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cu\u003e:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are also limitations throughout this review. For example, all the studies were written in English, which can cause selection bias. Egger et al. (1997) argues that studies published in English are more likely to have positive findings than studies published in nonother languages. This may lead to an unbalanced view of determining whether clinical observation should be undertaken rather than a CT scan for paediatric headaches. Including non-English language papers and use of translation services could affect the results of this review. Moving forward, reviews that are conducted around this topic should include non-English papers, as this would ensure a broader representation of the published evidence.\u003c/p\u003e\n\u003cp\u003eSecondly a single reviewer performed this literature review. However, the Cochrane Collaboration and Agency for Healthcare Research and Quality (AHRQ) has recommended that a minimum of two independent reviewers should screen the studies to reduce any bias formed or errors. A study by Stoll et al. (2019) has concluded that using a second reviewer can maximise the number of studies found and can reduce random error. However, this study had to be conducted by one student only, due to University guidelines.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe findings of this review suggest that there can be a correlation between CT scanning in paediatrics and the development of adverse effects in children, and that clinical observations can play an important role in reducing CT referrals. However, the lack of clear clinical guidance and consistent standards for medical observations makes it difficult for practitioners to resist the external pressure from parents, resulting in increases in the referral of children for CT referrals. This highlights the importance of developing standardised paediatric imaging protocols that align with current safety guidelines and adapting these protocols according to individual patient risk and clinical presentation. Furthermore, findings suggest greater integration of education and training for clinicians to reinforce the value of clinical observation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eContributions and implications for practice and future:\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt is recommended that clinical guidelines should provide a more structured approach in their referral pathway and should address gaps which have caused confusions in the current pathways. As there is a lack of literature reviews on this topic further research is needed to strengthen this area which can help develop frameworks across hospitals that will result in a successful management of paediatric headaches and will ensure patient safety.\u003c/p\u003e\n\u003cp\u003eThe authors report there are no competing interests to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlmuqbil, M., Saud Abdulaziz Alsayed, Amer Mohammed Almutairi, Khalid Mohammed Aladhadh, Abdullah Omar Alghannami and Almutairi, M. (2023) Diagnostic Yield of Neuroimaging for Headache in a Pediatric Emergency Department: A Single Tertiary Centre Experience. 11 (6), 913\u0026ndash;913.\u003c/li\u003e\n\u003cli\u003eAltmann, S., Abello, M.A., Ucar, F.A., Kronfeld, A., Bilal Al-Nawas, Mukhopadhyay, A., Booz, C., Brockmann, M.A. and Othman, A.E. (2023) Ultra-High-Resolution CT of the Head and Neck with Deep Learning Reconstruction\u0026mdash;Assessment of Image Quality and Radiation Exposure and Intraindividual Comparison with Normal-Resolution CT. \u003cem\u003eDiagnostics\u003c/em\u003e 13 (9), Multidisciplinary Digital Publishing Institute1534\u0026ndash;1534.\u003c/li\u003e\n\u003cli\u003eAhmed, F. (2012) Headache disorders: Differentiating and Managing the Common Subtypes. \u003cem\u003eBritish Journal of Pain\u003c/em\u003e 6 (3), 124\u0026ndash;132.\u003c/li\u003e\n\u003cli\u003eAhn, E. and Kang, H. (2018) Introduction to systematic review and meta-analysis. \u003cem\u003eKorean Journal of Anesthesiology\u003c/em\u003e 71 (2), 103\u0026ndash;112.\u003c/li\u003e\n\u003cli\u003eBailey, M.A., Saraswatula, A., Dale, G. and Softley, L. 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(2011) CT dose reduction in practice. \u003cem\u003ePediatric Radiology\u003c/em\u003e 41 (S2), 488\u0026ndash;492.\u003c/li\u003e\n\u003cli\u003eCosta, F.M., Ferreira, I.P., Mascarenhas, I.F., Alves, C.F., Bento, V.A. and Loureiro, H.C. (2020) Diagnosis and Treatment of Headache in a Pediatric Emergency Department. \u003cem\u003ePediatric Emergency Care\u003c/em\u003e 36 (12), 571\u0026ndash;574.\u003c/li\u003e\n\u003cli\u003eDe Luca, G.C. and Bartleson, J.D. (2010) When and How to Investigate the Patient with Headache. \u003cem\u003eSeminars in Neurology\u003c/em\u003e 30 (02), 131\u0026ndash;144.\u003c/li\u003e\n\u003cli\u003eDougeni, E., Faulkner, K. and Panayiotakis, G. (2012) A review of patient dose and optimisation methods in adult and paediatric CT scanning. \u003cem\u003eEuropean Journal of Radiology\u003c/em\u003e 81 (4), e665\u0026ndash;e683.\u003c/li\u003e\n\u003cli\u003eEgger, M., Zellweger-Z\u0026auml;hner, T., Schneider, M., Junker, C., Lengeler, C. and Antes, G. 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Wiley-Blackwell.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (1992) \u003cem\u003eThe ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines\u003c/em\u003e. https://www.who.int/publications/i/item/9241544228 Accessed.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Bradford","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7356542/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7356542/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePaediatric headaches have become a wide concern in the UK, resulting in the increased use of CT scanning. However, global concerns are rising due to the fear of negative impacts of radiation effects on children. This study aims to investigate whether clinical observation can be used to predict the need for CT scanning in order to reduce unnecessary radiation. Secondary research was conducted using five peer-reviewed articles comparing the use of clinical observation vs. CT scanning for paediatric headaches. The main themes discovered were : negative radiation effects associated with CT imaging in paediatric patients, clinical observation as an alternative to CT scanning, and unclear diagnostic guidelines in clinical observations. The results of the thematic analysis suggest that introduction of standard clinical observation before a CT scan can help rule out the use of a CT scan in many cases, however there is a gap in knowledge on what clinical observation is required.\u003c/p\u003e","manuscriptTitle":"Computed Tomography vs. Clinical Observation In Paediatric Headaches","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-18 08:19:02","doi":"10.21203/rs.3.rs-7356542/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1b42616f-6d0f-4e98-9460-d2b90672945c","owner":[],"postedDate":"August 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-18T08:19:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-18 08:19:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7356542","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7356542","identity":"rs-7356542","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}