Basics of Pediatric Imaging
John Radtke
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Principles of Pediatric Imaging
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Essential to the success with pediatric
patients and imaging procedures is
remembering:
¾
Understand that children are not small adults
¾
Appreciate their need to be approached at their
level
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Slide 2
Principles of Pediatric Imaging
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The two main areas of problems in
radiographer confidence when imaging
pediatric patients is:
¾
Communication skills
¾
Immobilization techniques
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1
Atmosphere
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Research has shown that that atmosphere of
hospital environment during patient care
affects recovery rate
Pediatric centers should provide an
atmosphere that is appealing and pleasing to
children of all ages
Areas to consider a “comfortable”
atmosphere:
¾
¾
Waiting room
Imaging room
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Exterior Atmosphere
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Waiting Room Atmosphere
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Provide distractions to reduce anxiety
¾
¾
¾
Gender-neutral toys and activities
Books and magazines that appeal to various age
groups. Coloring books and puzzle books work
well with all age groups.
Video disks (DVD) or television:
* It is better to have VCR/DVD movies that are
“G” rated than rely on commercial television
programs
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2
Waiting Room Atmosphere
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Imaging Room Atmosphere
Some Hints:
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Lengthy examinations pass quickly with ageappropriate music or videos playing. Some facilities
have mounted TV or LCD, Plasma monitors in the
ceiling above the patient.
Prepare room before child enters. When child sees a
technologist bringing in equipment it can be alarming
and frightening.
Dimmed or dark rooms frighten younger children
Provide explanation and reassurance if room must be
dim for procedure
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Slide 10
Imaging Room Atmosphere
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Imaging Room Atmosphere
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4
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Approach
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Two patients are usually dealt with in medical
imaging:
¾
¾
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Parent / family members
Child
If child is old enough to comprehend, speak
directly to child
Use age-appropriate language at his/her eye
level when talking to the child
Parent will listen to your explanations and
appreciate special attention given to thier
child
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Slide 14
Approach
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If the child is too young to understand an
exam then explain the examination to parent
Use lay terms and simple sentences
Parents are often stressed and distracted
Simple instructions will aid both parent and
child in understanding the procedure and
what they need to do to help.
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Slide 15
5
Dealing with Agitated Parent
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Fear may be cause of agitation in parents and
children
Remain calm
Speak in a soothing voice
Introduce yourself and escort the parent and child to
a private area:
¾
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Avoid upsetting others in waiting room
Listen to concern without interruption if the parent or
child wishes to address their questions
Provide an explanation and comfort (blankets,
pillows, sips of water (if allowed) etc.)
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Slide 16
Parent Participation in Their Child’s
Exam:
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Depends on:
¾
¾
¾
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Department philosophy or protocols
Wishes of parent and patient (child) some
children don’t want their parents present)
Laws of province or state regarding radiation
protection will also determine if parents will be
allowed in the room with their child
Usually it’s better if only one parent helps:
¾
Prevents overcrowding in our small x-ray rooms
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Parent Participation
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Advantages of letting parents help:
¾
¾
¾
¾
Parent can watch child if radiographer and
radiologists need to attend to equipment, contrast,
IR, etc.
Radiographer may need to leave room to process
film or obtain supplies
Parent can assist with immobilization of the child
Parent who witnesses procedure cannot doubt
professional conduct during the exam
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6
Parent Participation
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Prepared pamphlets in the waiting room are
useful in providing essential instructions and
information about the procedure
¾
z
Also these pamphlets answer many common
questions: How long? Preparation? Etc.
Always provide radiation protection to parents
and children (aprons, contact gonad shielding
etc.) and explain need for it
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Approaching the Child
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z
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Greet parent and patient (child) with warm
smile
Talk to child at their eye level
Introduce yourself and confirm you have
correct patient
State briefly what you are going to do
Suggest child come with you to help with
some “pictures”
¾
Asking allows child to feel in control and/or refuse
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7
Approaching the Child
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Use sincere praise
¾
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Immediate praise needed for young child (age 3-7)
• Example: “You were very still. Thank you!”
Employ distraction techniques:
¾
¾
¾
Ask about school, sports, siblings, pets, etc.
Become familiar with popular cartoons, TV shows,
music, sports figures, etc.
Knowledge of their world builds rapport and
makes them feel more comfortable
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Approaching the Child
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Answer the child’s questions with complete
honesty:
Builds confidence
Establishes your credibility
¾ However, Do not dwell on unpleasantness.
Instead of saying “Oh yeah….this is really going to
hurt”, say “ This injection will probably feel like a
pinch” or something along those lines.
¾
¾
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Slide 23
Age-Specific Needs
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Infant to 6 months = warmth, security, and
nourishment
¾
¾
¾
Infants do not distinguish among caregivers
Infants are startled by loud stimuli
Infants are comforted by pacifier and familiar
objects (Teddy bear or favorite toy)
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8
Age-Specific Needs
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6 months to 2 years = fearful of pain,
separation from parents, and limitations in
movement
¾
¾
¾
These children usually require the most
assertive/aggressive immobilization techniques
Good immobilization techniques are less
disturbing to the child than several adults in lead
aprons trying to physically restrain
Parental participation in this situation is usually
helpful
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Slide 25
Age-Specific Needs
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2 to 4 years = very curious, enjoy fantasy and
games
¾
¾
¾
These children tend to cooperate more readily if
treated like a game
In this age group they respond to praise
An agitated and aggressive child in this age group
will probably not respond to games or other
distraction techniques
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Age-Specific Needs
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5 years = vary widely
¾
¾
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Confident children in this age group respond well
to explanations and behave with advanced
maturity
Scared children in this age group will cling to
parent and act much younger
6 to 8 years = ideal age for inexperienced
radiographers
These children are eager to please
In this age group they are easy to communicate
with
¾ Children in the age group are very modest:
They don’t like to undress in front of parents or
strangers
¾
¾
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9
Age-Specific Needs
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Preteens and adolescents :
They are able to understand what is
happening:
Often worried about recovery or disfigurement
Need clear explanation and questions answered
completely and honestly
¾ Sensitive issues arise during obtaining a history
due to the possibility of pregnancy, since
menstruation onset varies and secondary sex
characteristics.
¾ If possible, a female radiographer should inquire
about menstruation and gynecological history with
female patients in this age group
¾
¾
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Special Needs Patients
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Consider age when approaching patients with
physical and mental disabilities
¾
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Over age 8 = a child seeks autonomy and
independence
Begin the communication with the child first:
¾
¾
If unsuccessful, talk to parents, but continue to
make eye contact with child
Children appreciate being talked to, rather than
being talked about with their parents
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Slide 29
Patient Care: Psychological
Considerations
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Situations to prepare for
¾
¾
¾
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Emergency
Outpatient
Inpatient
Emergency situations are
¾
¾
Emotionally charged: a lot of adrenaline between
parents, child and hospital staff
Confusing – emotions cause distractions
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10
Patient Care: Psychological
Considerations
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In an emergency situation:
Maintain calm in your tone of voice and
manner:
Keep in mind that parents may speak with tone of
anger or urgency that arises usually from fear and
not aggression at you
¾ Communicate with parents and child as to what to
expect during procedure
¾ After the procedure is complete:
(a) explain what may happen next such as going
to other departments, admission into hospital etc.
¾
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Patient Care: Psychological
Considerations
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Outpatient children and parents are probably
the easiest and less stressful to deal with:
¾
¾
¾
Lengthy waiting time while waiting for the
procedure can cause frustration
Communicate with parent and child the cause of
delay
Listen calmly and sincerely to their concerns
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Slide 32
Patient Care: Psychological
Considerations
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Inpatient stress in communication and
psychological interaction are usually due to
the degree of illness: The more critical the
patient the more stressful and intense the
situation.
> Child is fearful due to separation from parents,
strange environment, etc.
> Parents are often trying to juggle work, siblings at
home, and worry about health of the child
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11
Patient Care: Physical Considerations
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Take notes on the following topics:
Specific instructions regarding care and
management of child while in department:
* Lab specimen collection, NPO, etc.
¾ Will a nurse or another health care professional
accompany child?
¾ Will physical limitations influence the way the
examination is performed?
* Handicapped (emotionally or physically)
¾
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Patient Care: Physical Considerations
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z
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Many inpatients are on a 24-hour urine and
stool collection. Make sure you talk to the
nurse before bringing the patient to the
imaging department.
If diaper is changed in department, save it so
floor personnel can weigh and assess the
amount of fluid/solid material. Make sure you
have heavy ply plastic bags for that purpose.
Know policy on IV line management
¾
It is often required to call a nurse or for nurse to
accompany a pediatric patient with an IV
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Patient Care: Physical Considerations
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z
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Practice standard blood and body fluid
precautions. Just because they are children
does not mean they don’t have something
contagious.
Adhere to isolation protocols carefully.
Both policies exist for patient and personnel
protection
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Patient Care: Special Concerns
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Premature infant
Myelomeningocele
Omphalocele and gastroschisis
Epiglottitis
Osteogenesis imperfecta
Suspected child abuse
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Premature Infant
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Greatest danger = hypothermia
To reduce risk of hypothermia, examine
infants in warmer or isolette when possible
¾
Requires use of mobile radiography
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Premature Infant
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When infant must come to department for
procedure
¾
¾
¾
¾
¾
Increase room temperature 20 to 30 minutes
before arrival of child
Prepare infant for procedure in isolette and keep
removal from isolette brief
Use heating pads and heaters – heater must be at
least 2 feet from infant
Warm large bags of IV solutions to serve as hot
water bottles
Monitor infant’s temperature during procedure
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Slide 40
Myelomeningocele
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z
z
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Defined as a congenital defect characterized
by cystic protrusion of the meninges, spinal
cord tissue, and fluid
Occurs as result of spina bifida = cleft in
neural arches of vertebra
Causes varying degrees of paralysis and
hydrocephalus
Procedures should be performed with patient
prone whenever possible
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Slide 41
Myelomeningocele
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14
Myelomeningocele
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Myelomeningocele
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Myelomeningocele
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Modalities used to follow-up care
¾
¾
¾
¾
Ultrasound
Computed Tomography
Magnetic Resonance Imaging
Nuclear Medicine
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Omphalocele and Gastroschisis
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Omphalocele = congenital defect consisting
of herniation covered in a thin, membranous
sac of peritoneum containing bowel and
perhaps liver
Gastroschisis = similar condition but
herniation occurs lateral to umbilicus and the
bowel is not covered by the sac
Herniated bowel contents must be kept warm
and moist
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Omphalocele
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Omphalocele Images
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Omphalocele Images
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Omphalocele Images
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Slide 50
Gastroschisis
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Omphalocele and Gastroschisis
z
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Infants with these conditions are very prone
to hypothermia.
Infant should be accompanied by a nurse of
physician during imaging procedures
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Slide 52
Dealing with the Hypothermic
Pediatric Patient
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z
Warm the patient as quickly as possible
Use “heated” blankets (usually available from
the emergency department)
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Slide 53
Epiglottitis
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z
z
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One of most common causes of acute upper
airway obstruction in children
Treated as an emergency
Peak incidence = 3 to 6 years old
Usually caused by Haemophilus influenzae
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Slide 54
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Epiglottitis
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Epiglottitis
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Symptoms
¾
¾
¾
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Acute respiratory obstruction
High fever
Dysphagia
For radiographic examinations, patient must
be accompanied by physician to monitor
airway at all times
Perform single lateral image without moving
patient’s head or neck
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Slide 56
Osteogenesis Imperfecta
z
z
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“Brittle bone” disease, or OI
Prone to spontaneous fractures or fractures
that occur with minimal trauma
Team approach works best with primary
caregiver positioning patient
¾
¾
Explain procedure and positions simply
Parent or caregiver knows how to move patient
safely
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Osteogenesis Imperfecta
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Best to perform procedure with patient on bed
or stretcher
Technical factors need to be reduced
¾
Best to check first image for quality before
proceeding with remaining images
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Slide 58
Osteogenesis Imperfecta
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Slide 59
Osteogenesis Imperfecta
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Suspected Child Abuse
z
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No universal agreed-upon definition
Described as “the involvement of physical
injury, sexual abuse, or deprivation of
nutrition, care, or affection in circumstances
which indicated that injury or deprivation may
not be accidental or may have occurred
through neglect”
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Suspected child abuse
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Suspected child abuse
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21
Suspected child abuse
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Suspected Child Abuse
z
z
z
Mandatory for health care professionals to
report suspected cases of abuse or neglect
Radiographer should report suspicion to
radiologist or attending physician
Classic x-ray indicators
¾
¾
¾
Posterior rib fractures
Corner fractures
“Bucket-handle” fractures of limbs
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Slide 65
Suspected Child Abuse
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Avoid “babygram” radiograph
z
Skeletal surveys are recommended
¾
¾
Reduced diagnostic quality
Each part centered accurately
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Suspected Child Abuse
Recommended Images
z
z
z
z
AP and lateral skull
AP and lateral
complete spine
AP both humeri
AP both forearms
z
z
z
z
z
AP pelvis
AP both femora
AP both tibiae and
fibulae
AP both feet
AP and lateral ribs
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Slide 67
Protection of the Child
z
From injury
¾
¾
¾
¾
¾
Perform routine safety inspections
Supervise children while in department and during
transport
Use immobilization to prevent falls from table
Inspect immobilization tools
If injury occurs, file report per protocol
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Slide 68
Protection of the Child
z
From unnecessary radiation
¾
¾
¾
Use proper centering, exposure factors,
collimation, and proper filter application
Use of gonad and breast shields – practical tips
provided with each examination in chapter
Effective immobilization to reduce repeats
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Radiation Protection
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Radiation Protection
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Radiation Protection
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Radiation Protection
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Slide 73
Immobilization
z
z
z
Should never be a traumatic, torturous event
for child
Should never cause harm
Good communication strategies required
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Slide 74
Immobilization
z
Aside from regular sponges and sandbags,
three tools are frequently used in pediatrics
¾
¾
¾
Velcro compression band (also called Bucky or
body band)
Strip of reusable Velcro
“Bookends”
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25
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Immobilization
z
Other devices
¾
¾
Pigg-O-Stat
Octagonal infant immobilization cradle
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Slide 79
Pigg-O-Stat
z
z
z
z
Can be used for upright chest, abdomen,
thoracic and lumbar spine
Consists of large support base on wheels,
adjustable seat, and Plexiglas support, or
sleeves.
Mounted on a turntable device that enables
quick rotation from PA/AP to lateral
projections
Requires two persons to use
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Slide 80
Pigg-O-Stat
Child positioned for PA chest
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Octagonal Immobilizer
z
z
z
Initial positioning requires two people
Less comfortable and appears more
traumatic
Child’s fear can be overcome by playing the
“rocket ship” game
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Slide 82
Octagonal Immobilizer
Child positioned in “rocket ship”; note multiple positions allowed by immobilizer
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Slide 83
Common Pediatric Examinations
z
Chest
¾
¾
z
z
z
Newborn to 3-year-old
3- to 18-year-old
Hip
Skull
Limb
¾
¾
¾
Newborn to 2-year-old
Preschoolers
School-age
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Common Pediatric Examinations
z
z
Abdomen
GI and GU procedures
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Slide 85
Chest: Newborn to 3 Years
z
z
z
Good inspiratory image required for accurate
diagnosis
Place child in Pigg-O-Stat using appropriate
sleeve size
Explain to parent assisting that child will
probably cry, but that helps to get an
exposure on inspiration
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Slide 86
Chest: Newborn to 3 Years
z
z
z
Adjust seat height until face fits cutouts on
sleeves
Select proper size IR to include from mastoid
tips to just above iliac crests
Center perpendicular CR to T6-T7
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Chest: Newborn to 3 Years
z
Make exposure on end of inspiration by
¾
¾
¾
¾
Waiting for end of cry – child will gasp
Watching abdomen – extends on inspiration
Watching chest wall – ribs outlined on inspiration
Watching rise and fall of sternum
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Slide 88
Chest: 3 to 18 Years
z
z
z
z
Place patient in seated position
Place IR in extension stand
Child holds sides of stand and rests chin on
top
For lateral – arms raised with head held
between them
¾
Assistance needed
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Slide 89
Hip
z
Most often ordered to assess
¾
¾
¾
z
z
z
Legg-Calvé-Perthes disease
Congenital hip dislocation
Nonspecific hip pain
Both sides examined for comparison
Symmetric positioning critical
Note shielding guidelines in Merrill’s Atlas
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30
Hip
z
z
z
z
Diaper must be removed
Check for rotation of pelvis; pain often causes
child to compensate position
Velcro band and strips used to immobilize
lower limbs in position
Sandbags or assistance used to immobilize
arms
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Skull
z
z
Prepare room in advance
Patients 3 years and younger immobilized
using “bunny” technique
¾
¾
z
Refer to Merrill’s Atlas for illustration
Exception: sleeping child
Head clamp also used for immobilization
¾
¾
Even on sleeping child
Alleviate anxiety by referring to clamp as
“earmuffs”
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Skull
z
Tube angles require modification from adults
¾
On average, a decrease of CR angle by 5 degrees
is needed
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Limb: Newborn to 2 Years
z
z
z
z
Presents greatest challenge
Requires modified “bunny” wrapping
technique
Plexiglas and bookends used to immobilize
limb of interest
Velcro band used for safety
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Limb
Child positioned and immobilized safely
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Limb: Preschoolers
z
z
Best examined seated in parent’s lap
If parent unable to assist, immobilize child as
described for younger children
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Limb: Preschoolers
Child cooperative in parent’s lap
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Limb: School-Age
z
z
Typically managed in same manner as adults
Use good communication skills and
explanations
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Abdomen
z
z
Pigg-O-Stat useful for infants to young
children
For supine patient, immobilize as described
for hip and pelvis
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GI and GU Procedures
z
z
Octagonal immobilizer or modified “bunny”
wrap are useful for younger children
Anxiety lessened by making a game of
immobilization process
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Unique Pediatric Examinations
z
z
z
Bone length
Bone age
Foreign bodies
¾
¾
z
Aspirated
Ingested
Scoliosis
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Bone Length
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Bone Length
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Bone Length
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Bone Length
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Bone Age
z
z
z
z
Used to evaluate degree of skeletal
maturation
Becomes a concern if child’s development is
well behind or well advanced of peers
Standard is AP projection of left hand and
wrist
Protocols for 1- to 2-year-olds often include
AP left knee
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Bone Age
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Bone Age
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Foreign Bodies: Aspirated
z
z
z
z
Common cause of respiratory distress in
children between 6 months and 3 years of
age
Many times, object is radiolucent, requiring
esophageal studies
Lateral soft tissue neck is used
Image obtained easier with mc Infant Head
and Neck Immobilizer
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Foreign Bodies: Aspirated
z
z
PA chest taken on inspiration and expiration
used to check if object is lodged in bronchus
Lateral chest is also taken for location
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Foreign Bodies: Ingested
z
z
Coins are most common ingested foreign
body
Images made of neck, chest, and abdomen to
locate
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Foreign Bodies
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Scoliosis
z
z
z
Defined as “the presence of one or more
lateral-rotary curvatures of spine”
PA or AP projection of entire spine on single
IR
Upright, recumbent, and lateral bending
positions may be used
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Scoliosis
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Advanced Modalities
z
z
z
z
z
z
MRI
Myelography
CT
3D imaging
Interventional radiology
Nuclear medicine
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MRI
z
z
Usually requires child to be heavily sedated
Modality of choice for evaluation of spinal
cord abnormalities
¾
¾
¾
¾
¾
Tethered cords
Lipomyelomeningoceles
Neoplasms
Myelination
Congenital anomalies
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MRI
z
z
z
Also useful for cardiac imaging
Aids in diagnosis of epiphyseal fractures
Provides multiplanar images for surgical
assessments
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Myelography
z
z
Procedure of choice is CT myelography
Used to evaluate weakness in upper limbs
after traumatic birth
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CT
z
Useful in diagnosis and assessment of
¾
¾
¾
¾
¾
z
z
Congenital anomalies
Metastases
Bone sarcomas
Sinus disease
Limb length discrepancies
Faster scanners reducing need for conscious
sedation
Sedation still warranted in some cases
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3D Imaging
z
Revolutionized surgical procedures for
correction of congenital malformations and
trauma
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Interventional Radiology
z
Therapeutic interventions can eliminate need
for surgery
¾
¾
¾
Minimally invasive = reduced risk to patient
Reduces recovery time
Less expensive than surgery
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Nuclear Medicine
z
Direct radionuclide cystogram may be used in
place of VCUG if bladder function is lone
concern
¾
¾
Reduced radiation dose
Does not demonstrate anatomy
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Conclusion
z
z
Pediatric radiography requires experience
and practice to obtain confidence and
competence
Rewards are worth the efforts!
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