# Contextual dimensions of pediatric tuberculosis imaging: radiation exposure, access, and system capacity in high- and low-resource settings

## TL;DR

This study compares pediatric tuberculosis imaging practices and radiation exposure in high-resource Spain and low-resource Mozambique to improve safe and equitable diagnosis.

## Contribution

The study provides empirical evidence on imaging practices and radiation doses in pediatric tuberculosis across different resource settings.

## Key findings

- Spanish children received multiple chest X-rays and CT scans, with lung doses below diagnostic reference levels.
- Mozambican children had fewer X-rays and much lower radiation doses due to limited equipment and protocols.
- Spain showed structured dose optimization, while Mozambique faced challenges with equipment and non-physician interpretation.

## Abstract

Pediatric tuberculosis diagnosis relies heavily on imaging, yet access, equipment standards, and dose monitoring differ widely across health systems. Evidence describing how these contextual factors influence imaging use and radiation exposure in children remains scarce.

To describe pediatric tuberculosis imaging practices and estimated radiation doses across two distinct resource settings, Spain (hospital-based, high-resource) and Mozambique (primary care-based, low-resource), to inform strategies for safe, equitable, and context-appropriate imaging.

A descriptive mixed-methods study combined retrospective data of children (<16 years) diagnosed with tuberculosis (Spain 2015–2021; Mozambique 2018–2021) with complementary surveys of imaging providers. In Spain, chest X-ray and computed tomography parameters were extracted from digital imaging and communications in medicine files to estimate organ-specific doses using the National Cancer Institute dosimetry systems for radiography and computed tomography. In Mozambique, dose estimates were based on standardized pediatric protocols and site survey parameters due to limited digital data. Surveys captured information on imaging access, guideline use, and professional training.

Imaging data were available for 84 Spanish and 83 Mozambican children. In Spain, children underwent multiple chest X-rays (mean four per child) and computed tomographies (mean three per child), resulting in cumulative lung doses up to ~20 mGy cm2, remaining below diagnostic reference levels. In Mozambique, most children had one or two chest X-rays, with cumulative lung doses <0.05 mGy cm2. Survey findings indicated structured dose optimization and quality assurance practices in Spain, versus limited equipment and predominantly non-physician interpretation in Mozambique.

Context-appropriate improvements in pediatric imaging such as strengthened infrastructure, training, dose monitoring, and quality assurance are essential to ensure safe exposure and equitable, reliable tuberculosis diagnosis for children.

The online version contains supplementary material available at 10.1007/s00247-026-06535-z.