Pediatric Imaging
What is pediatrics?
• Branch of medicine dealing with medical care of
infants, children, and adolescents
• For our purposes- anyone under 18 years old
• Some hospitals say under 21 years
• Some say under 13, with 13-17 considered
“adolescent” or “teen”
Important!
When you are at your clinical site:
• Do not get signed off, do not work alone
on any pediatric pt until you are in your 4th
semester
• You may work with a tech on any pedi
case up to that point…..
2 main areas where working with Peds differs
from adults:
– Immobilization
techniques
– Communication skills
Dealing with children
• Children are not small adultsneed to be approached at their
level!
– Use age-appropriate language
– at their eye level
• If child old enough to
comprehend, speak directly to
child (Parent will listen and appreciate special
attention given to child)
• Maintain honesty!
Atmosphere
• Environment is everything!
• Waiting room - child friendly
– Music, books or videos
• Imaging room also should be child
friendly
• Dim rooms frighten little kids!
Use distraction techniques when working with children
Ask about school,
sports, siblings, pets,
etc.
Knowledge of their world
builds rapport
• Become familiar with
popular cartoons, TV
shows, music, sports
figures, etc.
Dealing with Parents
Often two pts to deal with: child and parent
Parents
• Introduce yourself to parents
• Give your title and your duties
• Be prepared to answer questions from
parents!
Communicating with Parent
• If child too young to understand, explain exam to
parent
• Use non-medical terminolgy
• Keep it simple
• Don’t assume English is spoken or understood!
• Answer questions with complete honesty
Parent Participation
If parent willing to
help, can be very
useful
– Immobilizing child
– Comforting child
– Frees up tech to
leave room, focus
on other aspects of
exam
– Presence reassures
nothing
unprofessional is
occuring!
Usually better if only one parent helps
– More space
– less confusion
– Prevents divorce!
• Provide shielding for parent
Dealing with Agitated Parent
•
Escort to x-ray room
– Avoid upsetting others in waiting room
•
Speak in a soothing voice
•
Listen to concerns without interruption
•
Provide explanation and comfort, especially re: radiation
protection
–
Parents - tone of anger, urgency – usually fear and not aggression at you
- After procedure, explain what may happen next
Remain Calm!!
• No matter what
happens, keep
smiling!
Age Specific Needs
Infant to 6 months
Warmth, security, and
nourishment
– Do not distinguish
among caregivers
– Startled by loud stimuli
– Comforted by pacifier
and familiar objects
6 months to 2 years
Fearful of pain, separation from parents
Limitations in movement
Require most assertive immobilization!
Parental participation helpful
But good immobilization techniques better than several
adults in lead aprons trying to physically restrain
2 to 4 years
Very curious- enjoy
fantasy, games
Cooperate readily if treated like a game
Love praise
Agitated and aggressive child will not respond to
games or other distraction techniques
5 years
Vary widely
Confident children
respond well and with
advanced maturity
Scared children will cling
to parent and act
much younger
6 to 8 years
Ideal for inexperienced
tech
– Eager to please
– Easy to communicate
with
– Very modest
Preteens and adolescents
Able to understand
Worried about recovery
Need clear explanation
Sensitive pregnancy issues arise
If possible, female tech should inquire about
menstruation
Outpatient Vs Inpatient
Radiographing outpatient children is easier, less stressful
than inpatient
Pt not as sick
But--- lengthy waiting time – frustration
• Communicate cause of delay
• Let parent vent: listen calmly and sincerely
Outpatient vs. Inpatient cont’d
• Inpatient is more stressful due to degree of
illness
– Child fearful - separation from parents,
strange environment
– Parents - juggling work, siblings at home, and
worried!
Immobilizing Pt.
• Should never be
traumatic, torturous
event for child!
• Never cause harm!
• Good communication!
Shielding And Immobilization Devices
• Shielding should be
used religiously!
• Velcro compression
band
• Bookend
• Sandbag
Pigg-o-Stat
Immobilization
Cross-Table Lateral Chest X-Ray
Why should grids should not be used on children?
Immobilization
AP Chest X-Ray
Immobilization - Skull Film
Immobilization Technique
Using Blankets
Papoose
Special Concerns Regarding Pediatrics
• Omphalocele congenital defect
herniation covered in thin,
membranous sac of
peritoneum containing
bowel and perhaps liver
• Gastroschisis similar but herniation
occurs lateral to umbilicus
and bowel not covered by
sac
• Herniated bowel contents
must be kept warm and
moist!
Epiglottitis
• One of most dangerous
causes of upper airway
obstruction in children
• Usually bacterial infection
• Soft tissue neck films
may be necessary
• Do not move child’s head
or neck!
• Peak incidence between
ages 3 - 6
• Support child in
upright position
Myelomeningocele
• Protrusion of spinal cord and
meninges (3 layers around CNS- dura
mater, arachnoid mater, pia mater)
through vertebra
• Result of spina bifida (birth defect
involving incomplete development of spinal
cord or its coverings)
• May cause varying degrees of
paralysis
• Higher up spine- worse
symptoms
• Can be recognized by fetal
sono in 17/18 week
Croup
• Airway is infected and inflamed
• Usually caused by flu virus
• Peak incidence is 6 mos. - 3
yrs.
• Usually requires chest film and
soft tissue neck films
• Narrowing of trachea will be
present on film
Osteogenesis Imperfecta
• Bone malformation
– Very brittle bones
• Prone to spontaneous
fractures
• Must be handled with
care!
Osteogenesis Imperfecta cont’d
Be aware of changes in
technical factors!
Generally cut mAs in half
If possible, view prior films
No universal definition of Child Abuse
It includes:
• Physical injury-suspected not accidental or
through neglect
• Sexual abuse
• Deprivation of nutrition, care or affection
Child Abuse
cont’d
• Suspected child abuse must be reported by
law!
• Report suspicious situations to radiologist or
attending!
• Treat parents non-judgmentally with respect and
courtesy!
– Innocent until proven guilty
– Don’t jeopardize their relationship with health
care providers
Child Abuse cont’d
At least 10% of children under 5
years old brought into ER with
alleged accidents have actually
suffered nonaccidental
trauma!
Forces needed to break a bone in
an infant or young child are
enormous
Any fx in this age group indicates
a major traumatic event, not
just a fall from a low height
Shaken infant syndrome
Child is held around chest
and violently shaken back
and forth
Causes extremities and
head to flail back and
forth in whiplash
movement
Shaken infant syndrome con’t
• Intracranial injury occurs as result
of severe angular acceleration,
deceleration and direct impact as
head strikes solid object
•
Chest is compressed resulting in
rib fxs
• Arms and legs move about in
whiplash movement resulting in
typical 'corner' or 'bucket-handle'fxs
Corner fracture
• Small piece of bone is
avulsed due to shearing
forces on fragile growth
plate
. often subtle• Fx.s are
likelihood of detection directly
related to quality of
radiologic studies!
Bucket Handle Fx. are suspect!
Elbow
Images for suspected abuse
No babygrams!
Typical exams
– Ap, lateral skull
– AP, lateral complete
spine
– AP both humeri
– AP both radii and
ulnae
- AP pelvis
- AP both
femora
- AP both tibfib
- AP both feet
-AP, lateral CXR
for ribs
Premature Infant
• Requires use of mobile
radiography
• Extreme care in handling
• Shielding!
• Greatest danger –
hypothermia
– To reduce risk of hypothermia,
examine infants in warmer or
isolette when possible
8.6 ounces
2 types of Isolettes
Open bed
Enclosed With portholes
(note:
moveable overhead warmer)
If premature infant must come to department for
procedure– Increase room temperature 20 to 30 minutes before
arrival of child
– Prepare infant for procedure in isolette - 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
Radiographing Peds
Slide 50
Chest: Newborn to 3 Years
• Good inspiratory image
required for accurate
diagnosis
• Place child in Pigg-O-Stat
using appropriate sleeve
size
• Explain to parent child will
probably cry, but helps to
get exposure on
inspiration
Getting a deep breath
Make exposure at end of inspiration
– Wait for end of cry – child will gasp
– Synchronize your breathing with child’s
– Watch abdomen – extends on inspiration
– Watch chest wall –
- rise and fall of sternum
- ribs outlined on inspiration
Chest: 3 to 18 Years
• Place pt in seated position
• Child holds sides of stand and rests chin
on top
• For lateral – arms raised with head held
between them
– Assistance may be needed
Hips
• Diaper removed!
• Check for rotation of pelvis- pain causes child to
compensate position
• Velcro band and strips used to immobilize lower
limbs in position
• Sandbags or assistance used to immobilize
arms
Hips
• Both sides examined
for comparison
• Symmetric positioning
critical
• Shield!
cont’d
Skull
• Velcro
• Head clamp
– Even on sleeping child
– Alleviate anxiety by
referring to clamp as
“earmuffs”
Unique Features Of Pediatric Pt.
Growth plates
Epiphyseal Fractures
Salter-Harris types
Type 1 - Directly through
growth plate
Type 2 - Through growth
plate, into metaphysis
Type 3 - Through growth
plate, into epiphysis
Type 4 - Through
metaphysis, across
growth plate, into
epiphysis
Type 5 - Crushing of all,
or part of growth plate
Type 4
Type 5
Limb: Newborn to 2 Years
• Greatest challenge!
• Requires modified
“bunny” wrapping
technique
• Plexiglas and
bookends used to
immobilize limb of
interest
Limb: Preschoolers
• Best examined
seated in parent’s lap
• If parent unable to
assist, immobilize
child as described for
younger children
Limb: School-Age
• Typically managed in
same manner as
adults
• Use good
communication skills
and explanations
Special Pediatric Examinations
Bone Age
Evaluate degree of skeletal maturation
• Determines skeletal age
vs.chronological age
• Concern if child’s
development is well
behind or well advanced
of peers
• Left hand and wrist
• 1- to 2-year-olds often
use AP left knee
Aspirated Foreign Body
• Aspirated (lodged
in
larynx or trachea)
•
Common 6 months to 3 years
– AP/Lateral 8X10 soft
tissue neck
– PA chest taken on
inspiration and expiration
used to check if object
lodged in bronchus
Ingested Foreign Body
Use 14X17 film if both
chest and abdomen will fit
(not considered
“babygram”)
If object is radiolucent,
may require esophageal
studies
Scoliosis
• Defined as “presence of one or
more lateral-rotary curvatures of
spine”
• 6 feet SID
• 14 X 36 cassette
• Use breast shields on females
• Why is it taken PA?
– saves radiation exposure to
breasts
AP, Lateral
Full Spine
Luque Instrumentation
CXR w/Central Venous Catheter
Used to:
Administer medication or fluids, obtain blood tests
Directly obtain cardiovascular measurements
such as the central venous pressure
Ventricular-Peritoneal Shunt