“Doctor, do all these X-rays hurt?”
This is one of the most frequent questions when discussing X-rays in children.
And it's a fair question.
X-rays use ionizing radiation. Therefore, they are not an examination to be done "just to see." In children, moreover, even greater caution is needed: growing tissues are more sensitive than those of adults, and a child has many more years of life ahead of them [1].
That said, the fear of radiation needs to be put into proper perspective.
An X-ray performed with a correct indication, pediatric protocols, and modern equipment generally involves very low doses. In most pediatric orthopedic situations, the diagnostic benefit far outweighs the theoretical risk [1,2].
The question is not “do X-rays hurt?”
The correct question is:
“Is this X-ray really necessary?”
In medicine, no examination is completely "neutral." Even an examination without radiation can have limitations, time constraints, costs, the need for sedation, or the risk of providing unhelpful information.
For X-rays, the reasoning is as follows:
- if the examination does not change the child's management, it is better to avoid it
- if the examination can confirm a diagnosis, guide therapy, or prevent an error, then it may be appropriate
- if an equally valid alternative without radiation exists, such as ultrasound or magnetic resonance imaging, it should be considered [1,2]
This principle is called "justification": every radiological exposure must have a clinical reason.
The second principle is "optimization": when an X-ray is needed, it should be performed with the lowest possible dose compatible with a useful image [1,2].
Why are X-rays performed in pediatric orthopedics?
In pediatric orthopedics, X-rays are often a simple, quick, and very informative examination.
They can be used to evaluate:
- a suspected fracture
- limb alignment
- healing after trauma
- hip dysplasia
- scoliosis
- a foot or knee deformity
- the correct positioning of internal fixation devices or post-operative braces
Clinical examination remains fundamental, but in many cases, it is not enough.
A simple example: if a child falls and cannot bear weight, the examination can provide a lot of guidance. But if we suspect a fracture, the X-ray can completely change the management: cast, brace, follow-up, possible reduction, weight-bearing times.
In these cases, not performing an X-ray "for fear of radiation" can be riskier than performing it.
How much radiation does a child really receive?
Here, great care must be taken, because the numbers can vary based on:
- anatomical region
- number of projections
- child's age and body size
- equipment used
- technical protocol
- need to repeat the image or not [1,3]
However, some comparisons help to understand the order of magnitude.
All of us absorb a small amount of natural radiation every day: from the ground, from the air, from cosmic rays, from some foods. In the United Kingdom, for example, the average natural exposure is estimated to be around 2.7 mSv per year [4].
In comparison, many standard X-rays have very low doses.
| Example | Indicative Dose | Practical Comparison |
|---|---|---|
| Hand or foot X-ray | <0.001 mSv | less than a few hours of natural background radiation [3] |
| Chest X-ray | approximately 0.014-0.1 mSv, depending on source and technique | from a few days to about 10 days of natural radiation [3,4] |
| Transatlantic flight | approximately 0.08 mSv | often more than many simple X-rays [4] |
| Knee or ankle CT scan | often in the order of tenths or hundredths of mSv with modern protocols | much lower than many trunk CT scans; highly dependent on the protocol [11] |
| Head CT scan | approximately 1.4-1.6 mSv | months of natural radiation [3,4] |
| Chest CT scan | approximately 6-6.6 mSv | several years of natural radiation [3,4] |
This table should not be read as a "calculator" valid for every child. It serves to provide a proportion.
The message is: a simple X-ray of a limb is not automatically comparable to a CT scan, but not all CT scans are the same either.
A chest or abdominal CT scan has a very different radiological impact than a highly targeted CT scan of the knee or ankle. In musculoskeletal CT scans of the lower limbs, especially with modern protocols and limited fields, the effective dose can be relatively low, particularly for the knee and ankle [11].
The point is not to demonize CT scans.
The point is to use them when they are truly necessary.
The example of air travel
The comparison with air travel can greatly help parents.
When we fly at high altitudes, we are less protected by the atmosphere and receive a small dose of cosmic radiation. A transatlantic flight can expose one to a dose of around 0.08 mSv [4].
This value is higher than the indicative dose of many simple X-rays, for example, of the hand, foot, or other extremities [3,4].
Naturally, this does not mean that "then X-rays don't matter." It means that we must think in realistic terms.
An unnecessary X-ray should be avoided.
A useful X-ray, however, should not be more frightening than taking a plane for a vacation.
Are children really more sensitive?
Yes.
This point is important and should not be hidden.
The FDA emphasizes three reasons why pediatric radiation protection requires more attention:
- children are more radiosensitive than adults
- using "adult" settings on a child can lead to an unnecessary dose
- children have a longer life expectancy, and thus a longer time horizon for potential late effects [1].
For this reason, pediatric X-rays must be performed with specific protocols for age, body size, and anatomical region [1,2].
It is also why it makes no sense to ask "how many X-rays can be done at most?".
There is no magic number.
What matters much more is understanding:
- which X-rays were performed
- on which part of the body
- with what indication
- with what dose
- if they were truly necessary
- if some can be avoided or replaced in the future
The ALARA principle: low dose, but useful image
In pediatric radiology, the ALARA principle is often used: "As Low As Reasonably Achievable," meaning the lowest dose reasonably achievable [1,2].
However, be careful: ALARA does not mean "bad image just to use less dose."
It means using the minimum dose necessary to obtain a diagnostic image.
A too poor X-ray may not answer the clinical question and force a repeat of the examination. This would be the opposite of radiation protection.
To truly reduce the dose, the following are needed:
- correct indication
- projections limited to those necessary
- precise collimation, i.e., the radiographic field restricted to the area to be studied
- adequate immobilization in young children
- pediatric protocols
- image quality control [2,6]
“But why don't you always use a lead apron anymore?”
This question is becoming increasingly frequent.
For many years, lead shields were used almost automatically. Today, however, many scientific societies have revised this practice.
The reason is simple: with modern equipment, routine shielding often adds little in terms of real protection and, if poorly positioned, can cover an important part of the image or interfere with automatic exposure systems [2,7,8].
The practical risk is having to repeat the X-ray.
And repeating an X-ray means increasing the dose, not reducing it.
For this reason, the use of lead is no longer automatic today: it must be decided on a case-by-case basis, depending on the type of examination and the area to be studied [2,7].
This may seem counterintuitive to parents, but it is one of the most important changes in modern radiology.
X-ray, CT, MRI, and ultrasound: they are not the same thing
It is useful to distinguish them clearly.
X-rays use ionizing radiation, but usually at a low dose.
CT scans use ionizing radiation and, in many regions, involve a higher dose than an X-ray. Therefore, they should be reserved for more selected indications.
That said, it is important not to create alarm about CT scans.
A targeted CT scan of a lower limb, for example, the knee or ankle, can have a much lower dose than a CT scan of the chest, abdomen, or pelvis. In a 2025 study on musculoskeletal CT scans of the lower limbs, the introduction of protocols with tin-prefiltration reduced the median effective dose by 71% for the knee and 60% for the ankle, reaching approximately 0.06 mSv and 0.02 mSv respectively in the analyzed examinations [11].
So, CT scans are not "always dangerous."
They are a more demanding examination than X-rays, to be used judiciously, but in some orthopedic situations, they are extremely useful: complex joint fractures, surgical planning, bone malformations, three-dimensional evaluation of deformities, or cases where X-rays do not answer the clinical question.
Ultrasound does not use ionizing radiation and is very useful in many pediatric contexts, for example, in the infant hip or in some soft tissue evaluations.
Magnetic resonance imaging does not use ionizing radiation, but it requires more time, cooperation, and sometimes sedation in younger children.
So, there is no "best examination" in absolute terms.
There is the examination most suitable for the clinical question.
When can an X-ray be avoided?
Sometimes it can be avoided or postponed.
For example, in some minor traumas with a completely reassuring examination, minimal pain, preserved function, and absence of significant clinical signs, it may be reasonable to observe the child.
The same applies to some non-specific, transient pains, without trauma, without significant limping, and without alarm signals.
But there are situations where X-rays are often necessary:
- significant pain after trauma
- inability to bear weight
- obvious deformity
- suspected fracture
- persistent pain
- progressive worsening
- scoliosis in growth
- post-operative checks
- monitoring of known orthopedic conditions
The decision should not depend solely on the fear of radiation, but on a complete clinical evaluation.
“My child has already had many X-rays: should I worry?”
This is one of the most understandable fears.
The answer, however, cannot be the same for everyone.
A child with progressive scoliosis, hip dysplasia, a complex fracture, or surgery may need repeated check-ups.
In these cases, the goal is not "zero X-rays."
The goal is to perform only the useful ones, at the right time, with correct technique and optimized dose.
It can be useful to keep or make available previously performed examinations, to avoid unnecessary duplication [1].
What can a parent ask?
A parent does not have to become an expert in radiation protection.
However, they can ask some very sensible questions:
- can this X-ray change the treatment?
- are there any previous examinations that are already useful?
- can ultrasound or MRI be used?
- does the center use pediatric protocols?
- how many projections are really necessary?
These are legitimate questions.
A doctor should be able to explain why an examination is needed, not perceive it as a challenge.
The final message
X-rays in children should not be taken lightly.
But they should not be viewed with excessive fear either.
An unnecessary X-ray should be avoided.
A necessary X-ray, performed correctly, is a safe and often fundamental tool for treating a child well.
In pediatric orthopedics, the true balance is this: use images when they are truly needed, use the lowest possible dose, and do not let the fear of radiation lead to missing important diagnoses.
References
[1] U.S. Food & Drug Administration. Pediatric X-ray Imaging. Updated and available at: https://www.fda.gov/radiation-emitting-products/medical-imaging/pediatric-x-ray-imaging
[2] International Atomic Energy Agency. Radiation protection of children in radiology. Available at: https://www.iaea.org/resources/rpop/health-professionals/radiology/children
[3] RadiologyInfo.org / American College of Radiology / Radiological Society of North America. Radiation Dose from X-Ray and CT Exams. Available at: https://www.radiologyinfo.org/en/info/safety-xray
[4] UK Health Security Agency. Ionising radiation: dose comparisons. Available at: https://www.gov.uk/government/publications/ionising-radiation-dose-comparisons/ionising-radiation-dose-comparisons
[5] UK Health Security Agency. Radiographic and simple fluoroscopic X-ray imaging: patient doses. Published 8 July 2025. Available at: https://www.gov.uk/government/publications/radiographic-and-simple-fluoroscopic-x-ray-imaging-patient-doses
[6] Image Gently Alliance. Digital Radiography Educational Materials — Back to Basics. Available at: https://www.imagegently.org/Procedures/Digital-Radiography/Educational-Materials
[7] American Association of Physicists in Medicine. AAPM Position Statement on the Use of Patient Gonadal and Fetal Shielding. 2019. Available at: https://www.aapm.org/org/policies/details.asp?id=468&type=PP
[8] Brink JA, Miller DL. Patient shielding in diagnostic imaging: discontinuing a legacy practice. AJR Am J Roentgenol. 2019;212(4):755-757. DOI: https://doi.org/10.2214/AJR.18.20508
[9] Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatrics. 2013;167(8):700-707. DOI: https://doi.org/10.1001/jamapediatrics.2013.311
[10] Decreto Legislativo 31 luglio 2020, n. 101. Attuazione della direttiva 2013/59/Euratom in materia di protezione contro i pericoli derivanti dall’esposizione alle radiazioni ionizzanti. Available at: https://www.normattiva.it/eli/id/2020/08/12/20G00121
[11] Marth T, Kajdi GW, Stern C, Sutter R. Implementing tin-prefiltration in routine clinical CT scans of the lower extremity: impact on radiation dose. Skeletal Radiology. 2025;54:1915-1925. DOI: https://doi.org/10.1007/s00256-025-04897-3
Disclaimer: content for general informational purposes. It does not replace a medical evaluation.
