Clinical features of radiation exposure in children
- Joseph Y Allen, MD
Joseph Y Allen, MD
- Assistant Professor of Pediatrics
- Medical Director, Texas Children's Hospital West Campus Emergency Center
- Baylor College of Medicine
- Erin E Endom, MD
Erin E Endom, MD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
- Section Editor
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Physicians who treat children who are exposed to radiation must understand the biologic effects of the various types of radiation in order to determine which patients are at risk for radiation injury, to manage patients with radiation exposure, and to minimize the risk of contamination of hospital equipment and personnel.
The types of radiation exposure and the clinical features and presentation of radiation injury in children will be presented here. The management of radiation injury in children and clinical features and management in adults are discussed separately. (See "Management of radiation exposure in children following a nuclear disaster" and "Biology and clinical features of radiation injury in adults" and "Treatment of radiation injury in the adult".)
A basic understanding of radiation physics is necessary for the management of radiation exposure and injury. Radiation is the transfer of energy through space; it occurs in ionizing and nonionizing forms.
Nonionizing radiation — Nonionizing radiation lacks the energy to facilitate the release of electrons from target tissues . Examples of nonionizing radiation include radio waves, microwaves, infrared light, visible light, and ultraviolet rays. Nonionizing radiation does not penetrate human tissue, poses no risk of contamination, and is easily shielded by sunscreens, glasses, clothing, or any other barrier. Nonionizing radiation causes damage to the cells it contacts through direct transfer of thermal energy; sunburn is a classic example .
Ionizing radiation — Ionizing radiation is released by atoms that have an excess of energy, mass, or both (unstable atoms). These atoms emit the excess energy (eg, gamma rays) or mass (eg, alpha particles) to become stable . Ionizing radiation damages human tissue in several ways. It interacts directly with targets such as mRNA, DNA, and proteins, breaks their covalent bonds, and irreversibly destroys their structure . Ionizing radiation also bombards free water to remove an electron and generate H2O+ cations, which quickly decay to highly reactive free radicals that disrupt adjacent cellular architecture and genomic information . Ionizing radiation causes severe cellular disruption that usually results in cell death. However, most cell types do not manifest evidence of damage until mitosis occurs, and several divisions may ensue before actual cell death.
- Vyas DR, Dick RM, Crawford J. Management of radiation accidents and exposures. Pediatr Emerg Care 1994; 10:232.
- Mettler FA, Royal HD, Drum DE. Radiation accidents. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1033.
- Reeves GI. Radiation injuries. Crit Care Clin 1999; 15:457.
- Conklin JJ, Walker RI, Hirsch EF. Current concepts in the management of radiation injuries and associated trauma. Surg Gynecol Obstet 1983; 156:809.
- Guidance for Radiation Accident Management. www.orau.gov/reacts/guidance.htm. (Accessed on July 06, 2015).
- Champlin RE, Kastenberg WE, Gale RP. Radiation accidents and nuclear energy: medical consequences and therapy. Ann Intern Med 1988; 109:730.
- American Academy of Pediatrics Committee on Environmental Health. Radiation disasters and children. Pediatrics 2003; 111:1455.
- Jarrett, DG. Medical Management of radiological casualities. Military Medical Operations Office. Armed Forces Radiobiology Research Institute. Bethesda, MD 1999. (www.afrri.usuhs.mil).
- Asch SM. Radiation exposure. In: Pediatric Emergency Medicine: Concepts and Clinical Practice, Barkin RM, Caputo GL, Jaffe DM et al (Eds), Mosby, St. Louis 1997. p.522.
- Linnemann RE. Medical experience and preparedness for handling radiation injuries. J Med Assoc Ga 1989; 78:95.
- Shannon BE, Jenkins JL, Braen GR. Radiation Injury. In: Manual of Emergency Medicine, Lippincott Williams & Wilkins, Philadelphia 2000. p.435.
- Gale RP. Immediate medical consequences of nuclear accidents. Lessons from Chernobyl. JAMA 1987; 258:625.
- Ricks, RC, Berger, ME, Holloway, EC, Goans, RE. REAC/TS Radiation Accident Registry: Update of Accidents in the United States. Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge Institute for Science and Education, Oak Ridge, TN.
- Jacob P, Kenigsberg Y, Zvonova I, et al. Childhood exposure due to the Chernobyl accident and thyroid cancer risk in contaminated areas of Belarus and Russia. Br J Cancer 1999; 80:1461.
- Boice JD Jr. Radiation epidemiology: a perspective on Fukushima. J Radiol Prot 2012; 32:N33.
- Tsubokura M, Gilmour S, Takahashi K, et al. Internal radiation exposure after the Fukushima nuclear power plant disaster. JAMA 2012; 308:669.
- Watanobe H, Furutani T, Nihei M, et al. The thyroid status of children and adolescents in Fukushima Prefecture examined during 20-30 months after the Fukushima nuclear power plant disaster: a cross-sectional, observational study. PLoS One 2014; 9:e113804.
- Shimura H, Suzuki S, Fukushima T, et al. Prevalence of thyroid nodular lesions in children and adolescents. Fukushima J Med Sci 2014; 60:196.
- Upton AC. Health impact of the Three Mile Island accident. Ann N Y Acad Sci 1981; 365:63.
- Fong F, Schrader DC. Radiation disasters and emergency department preparedness. Emerg Med Clin North Am 1996; 14:349.
- Roberts L. Radiation accident grips Goiânia. Science 1987; 238:1028.
- U.S. Nuclear Reactors. www.eia.doe.gov/cneaf/nuclear/page/nuc_reactors/reactsum.html. (Accessed on July 06, 2015).
- Akashi M, Hirama T, Tanosaki S, et al. Initial symptoms of acute radiation syndrome in the JCO criticality accident in Tokai-mura. J Radiat Res 2001; 42 Suppl:S157.
- Tanaka SI. Summary of the JCO criticality accident in Tokai-mura and a dose assessment. J Radiat Res 2001; 42 Suppl:S1.
- Gerusky TM. Three Mile Island: assessment of radiation exposures and environmental contamination. Ann N Y Acad Sci 1981; 365:54.
- Testimony Before the Permanent Subcommittee on Investigations of the Senate Committee on Government Affairs by the Director of Central Intelligence, John M. Deutch, March 20, 1996. www.odci.gov/cia/public_affairs/speeches/1996/dci_testimony_032096.html.
- Moysich KB, Menezes RJ, Michalek AM. Chernobyl-related ionising radiation exposure and cancer risk: an epidemiological review. Lancet Oncol 2002; 3:269.
- Noshchenko AG, Zamostyan PV, Bondar OY, Drozdova VD. Radiation-induced leukemia risk among those aged 0-20 at the time of the Chernobyl accident: a case-control study in the Ukraine. Int J Cancer 2002; 99:609.
- Cotterill SJ, Pearce MS, Parker L. Thyroid cancer in children and young adults in the North of England. Is increasing incidence related to the Chernobyl accident? Eur J Cancer 2001; 37:1020.
- Tronko MD, Bogdanova TI, Komissarenko IV, et al. Thyroid carcinoma in children and adolescents in Ukraine after the Chernobyl nuclear accident: statistical data and clinicomorphologic characteristics. Cancer 1999; 86:149.
- Contis G, Foley TP Jr. Depression, suicide ideation, and thyroid tumors among ukrainian adolescents exposed as children to chernobyl radiation. J Clin Med Res 2015; 7:332.
- Anzai K, Ban N, Ozawa T, Tokonami S. Fukushima Daiichi Nuclear Power Plant accident: facts, environmental contamination, possible biological effects, and countermeasures. J Clin Biochem Nutr 2012; 50:2.
- Akabayashi A, Hayashi Y. Mandatory evacuation of residents during the Fukushima nuclear disaster: an ethical analysis. J Public Health (Oxf) 2012; 34:348.
- Mettler FA Jr, Voelz GL. Major radiation exposure--what to expect and how to respond. N Engl J Med 2002; 346:1554.
- Rutherford, MW, Seward, JP. Radiation injuries and illnesses in pediatric emergency medicine. Clin Pediatr Emerg Med 2001; 2:141.
- Forrow L, Sidel VW. Medicine and nuclear war: from Hiroshima to mutual assured destruction to abolition 2000. JAMA 1998; 280:456.
- Finch SC. Landmark perspective: Acute radiation syndrome. JAMA 1987; 258:664.
- Broad, WJ. Georgian Region, Race to Recover Nuclear Fuel. The New York Times, Feb 1, 2002.
- Becker SM. Psychosocial assistance after environmental accidents: a policy perspective. Environ Health Perspect 1997; 105 Suppl 6:1557.
- Darte JM, Little WM. Management of the acute radiation syndrome. Can Med Assoc J 1967; 96:196.
- Rowley MJ, Leach DR, Warner GA, Heller CG. Effect of graded doses of ionizing radiation on the human testis. Radiat Res 1974; 59:665.
- Saenger EL. Radiation accidents. Ann Emerg Med 1986; 15:1061.
- Preston DL, Cullings H, Suyama A, et al. Solid cancer incidence in atomic bomb survivors exposed in utero or as young children. J Natl Cancer Inst 2008; 100:428.
- Kamiya K, Ozasa K, Akiba S, et al. Long-term effects of radiation exposure on health. Lancet 2015; 386:469.
- Farahati J, Demidchik EP, Biko J, Reiners C. Inverse association between age at the time of radiation exposure and extent of disease in cases of radiation-induced childhood thyroid carcinoma in Belarus. Cancer 2000; 88:1470.
- Saenko V, Ivanov V, Tsyb A, et al. The Chernobyl accident and its consequences. Clin Oncol (R Coll Radiol) 2011; 23:234.
- Shibata Y, Yamashita S, Masyakin VB, et al. 15 years after Chernobyl: new evidence of thyroid cancer. Lancet 2001; 358:1965.
- Goans RE, Holloway EC, Berger ME, Ricks RC. Early dose assessment following severe radiation accidents. Health Phys 1997; 72:513.
- Goans RE, Holloway EC, Berger ME, Ricks RC. Early dose assessment in criticality accidents. Health Phys 2001; 81:446.
- US Department of Health and Human Services, Radiation Event Medical Management. Dose Eliminator - Lymphocyte Depletion Kinetics. Available online at: http://www.remm.nlm.gov/ars_wbd.htm#lymphocyte (Accessed on February 12, 2008).
- Jones F. Neuropsychiatric casualties of nuclear, biological, and chemical warfare. In: Textbook of Military Medicine, Zajtchuck R (Ed), Surgeon General, Washington DC 1995. p.98.
- Dubois A, Walker RI. Prospects for management of gastrointestinal injury associated with the acute radiation syndrome. Gastroenterology 1988; 95:500.
- RADIATION PHYSICS
- Nonionizing radiation
- Ionizing radiation
- - Particulate
- - Nonparticulate
- Measures of radiation
- LAWS OF RADIOSENSITIVITY
- SOURCES OF RADIATION EXPOSURE
- Background radiation
- Medical exposure
- Industrial exposure
- Nuclear reactors
- Nuclear weapons
- TYPES OF RADIATION EXPOSURE
- - External
- - Internal
- - Partial-body
- - Whole-body
- - Fetal exposure
- ACUTE RADIATION SYNDROME
- Prodromal phase
- Latent phase
- Overt illness phase
- - Hematopoietic
- - Gastrointestinal
- - CNS syndrome