Paediatric radiology is one of the most sensitive and critical areas of modern medicine. The radiological imaging techniques used in childhood play a crucial role in diagnosis and treatment planning. However, the biggest problem in this age group is the high sensitivity to the biological effects of ionising radiation. Compared to adults, children are more susceptible to the short and long-term effects of radiation due to their higher cell proliferation, progressive organ development, and longer life expectancy.

The increasing use of computed tomography (CT) has raised significant concerns in the paediatric population. Millions of paediatric CT scans are performed each year in the United States and Europe, most of which are indicated for trauma, acute abdominal and thoracic pathologies. If the dose is not optimised for children, cumulative exposure becomes a risk factor for secondary malignancies later in life.

Therefore, the basic approach in paediatric radiology is based on the “As Low As Reasonably Achievable” (ALARA) principle. ALARA means that the lowest possible radiation dose is used that still enables an accurate diagnosis. It is not only a technical requirement, but also an ethical obligation. Nowadays, in addition to the ALARA principle, iterative reconstruction algorithms, spectral CT, artificial intelligence–based optimisation systems, and personalised protocols have been integrated into paediatric imaging to further minimise radiation exposure

When choosing an imaging modality, the diagnostic benefit should always be weighed against the radiation risk:

Ultrasound (US) and magnetic resonance imaging (MRI) are the modalities of first choice as they do not contain ionising radiation.

Computed tomography (CT) should be reserved for necessary clinical situations, especially emergencies, and must be performed with low-dose protocols.

PET/CT and PET/MRI are of great benefit in oncology and metabolic diseases, but should be used with caution due to their significant radiation exposure.

Several international initiatives have been launched to improve paediatric imaging techniques. The Image Gently Alliance in the United States and EuroSafe Imaging in Europe are leading the way in promoting dose reduction strategies, raising parental awareness, and providing professional training modules for clinicians.

The biological effects of radiation include DNA damage, impaired cell proliferation, negative effects on growth and development, and an increased risk of cancer later in life. For this reason, the principle of “choosing the method that causes the least harm to the child” should apply to any paediatric imaging examination

Looking to the future, advances such as AI-assisted automated protocol optimisation, radiomics, nanotechnology-based contrast agents, and personalised imaging strategies are expected to make paediatric radiology safer, more effective, and more patient-centred. These developments are critical to protecting children's health and reducing the long-term risk of radiation-induced malignancies.