Pediatric Imaging
Mosby items and derived items © 2007, 2003, 1999 by Mosby, Inc., an affiliate of Elsevier Inc.
Principles of Pediatric Imaging

Essential to success with pediatric patients



Understanding that children are not small adults
Appreciating their need to be approached at their
level
Two main areas of problems in radiographer
confidence

Communication skills
 Immobilization techniques
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Slide 2
Atmosphere



Research has shown that atmosphere of
patient care affects recovery rate
Pediatric centers should provide an
atmosphere that is appealing and pleasing to
children of all ages
Areas to consider


Waiting room
Imaging room
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Slide 3
Waiting Room Atmosphere

Provide distractions to reduce anxiety

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Gender-neutral toys and activities
Books and magazines that appeal to various age
groups
Video or television
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Slide 4
Imaging Room Atmosphere



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Lengthy examinations pass quickly with ageappropriate music or videos playing
Prepare room before child enters
Dimmed or dark rooms frighten younger
children
Provide explanation and reassurance if room
must be dim for procedure
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Slide 5
Approach

Two patients are usually dealt with


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Parent
Child
If child is old enough to comprehend, speak
directly to child
Use age-appropriate language at his/her eye
level
Parent will listen and appreciate special
attention given to child
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Slide 6
Dealing with Agitated Parent


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Fear may be cause of agitation
Remain calm
Speak in a soothing voice
Introduce yourself and escort to private area



Avoid upsetting others in waiting room
Listen to concern without interruption
Provide explanation and comfort
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Slide 7
Parent Participation

Depends on




Department philosophy or protocols
Wishes of parent and patient
Laws of province or state regarding radiation
protection
Usually better if only one parent helps

Prevents overcrowding in room
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Slide 8
Approaching the Child



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Greet parent and patient 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

Asking allows child to refuse
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Slide 9
Approaching the Child

Use sincere praise


Immediate praise needed for young child (age 3-7)
• Example: “You were very still. Thank you!”
Employ distraction techniques

Ask about school, sports, siblings, pets, etc.
 Become familiar with popular cartoons, TV shows,
music, sports figures, etc.
 Knowledge of their world builds rapport
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Slide 10
Age-Specific Needs

Infant to 6 months = warmth, security, and
nourishment
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Do not distinguish among caregivers
Startled by loud stimuli
Comforted by pacifier and familiar objects
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Slide 11
Age-Specific Needs

6 months to 2 years = fearful of pain,
separation from parents, and limitations in
movement



Usually require most assertive immobilization
techniques
Good immobilization techniques are less
disturbing than several adults in lead aprons trying
to physically restrain
Parental participation helpful
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Slide 12
Age-Specific Needs

2 to 4 years = very curious, enjoy fantasy and
games
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Cooperate readily if treated like a game
Respond to praise
Agitated and aggressive child will not respond to
games or other distraction techniques
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Slide 13
Age-Specific Needs

5 years = vary widely
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Confident children respond well and with
advanced maturity
Scared children will cling to parent and act much
younger
6 to 8 years = ideal age for inexperienced
radiographers
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
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Eager to please
Easy to communicate with
Very modest
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Slide 14
Age-Specific Needs

Preteens and adolescents = able to
understand
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
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Often worried about recovery
Need clear explanation and questions answered
Sensitive issues arise due to possibility of
pregnancy, since menstruation onset varies
If possible, female radiographer should inquire
about menstruation with this age group
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Slide 15
Special Needs Patients

Consider age when approaching patients with
physical and mental disabilities


Over age 8 = child seeks autonomy and
independence
Begin communication with child

If unsuccessful, talk to parents, but continue to
make eye contact with child
 Children appreciate being talked to, rather than
being talked about
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Slide 16
Patient Care: Psychological
Considerations

In emergency situations, maintain calm in
tone and manner



Keep in mind that parents may speak with tone of
anger, urgency – usually from fear and not
aggression at you
Communicate what to expect during procedure
After procedure, explain what may happen next
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Slide 17
Patient Care: Psychological
Considerations

Outpatient is probably easiest, less stressful

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Lengthy waiting time can cause frustration
Communicate cause of delay
Listen calmly and sincerely
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Slide 18
Patient Care: Psychological
Considerations

Inpatient is stressful due to degree of illness


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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Slide 19
Patient Care: Physical Considerations

Take notes on the following
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
Specific instructions regarding care and
management of child while in department
Will a nurse or another health care professional
accompany child?
Will physical limitations influence the way the
examination is performed?
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Slide 20
Patient Care: Physical Considerations



Practice standard blood and body fluid
precautions
Adhere to isolation protocols carefully
Both exist for patient and personnel
protection
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Slide 21
Patient Care: Special Concerns
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Premature infant
Myelomeningocele
Omphalocele and gastroschisis
Epiglottitis
Osteogenesis imperfecta
Suspected child abuse
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Slide 22
Premature Infant
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
Greatest danger = hypothermia
To reduce risk of hypothermia, examine
infants in warmer or isolette when possible

Requires use of mobile radiography
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Slide 23
Premature Infant

When infant must come to department for
procedure

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 24
Myelomeningocele
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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 25
Myelomeningocele

Modalities used to follow-up care
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
US
CT
MRI
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Slide 26
Myelomeningocele
Omphalocele and Gastroschisis



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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Slide 28
Omphalocele and Gastroschisis


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 29
Epiglottitis




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 30
Epiglottitis

Symptoms

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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 31
Epiglottitis
Osteogenesis Imperfecta



“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


Explain procedure and positions simply
Parent or caregiver knows how to move patient
safely
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Slide 33
Osteogenesis Imperfecta


Best to perform procedure with patient on bed
or stretcher
Technical factors need to be reduced

Best to check first image for quality before
proceeding with remaining images
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Slide 34
Suspected Child Abuse


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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Slide 36
Suspected Child Abuse



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



Posterior rib fractures
Corner fractures
“Bucket-handle” fractures of limbs
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Slide 37
Suspected Child Abuse
Recommended Images
Avoid “babygram” radiograph
Reduced diagnostic quality
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AP and lateral skull
AP and lateral
complete spine
AP both humeri
AP both forearms

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AP pelvis
AP both femora
AP both tibiae and
fibulae
AP both feet
AP and lateral ribs
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Slide 38
Protection of the Child
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From injury
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
Perform routine safety inspections
Supervise children while in department and during
transport
Use immobilization to prevent falls from table
Inspect immobilization tools
From unnecessary radiation


Use proper centering, exposure factors,
collimation, and proper filter application
Use of gonad and breast shields – practical tips
provided with each examination in chapter
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Slide 39
Immobilization
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Should never be a traumatic, torturous event
for child
Should never cause harm
Good communication strategies required
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Slide 40
Immobilization

Aside from regular sponges and sandbags,
three tools are frequently used in pediatrics
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Velcro compression band (also called Bucky or
body band)
Strip of reusable Velcro
“Bookends”
Other devices

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Pigg-O-Stat
Octagonal infant immobilization cradle
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Slide 41
Pigg-O-Stat
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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 42
Pigg-O-Stat
Child positioned for PA chest
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Slide 43
Octagonal Immobilizer
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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 44
Octagonal Immobilizer
Child positioned in “rocket ship”; note multiple positions allowed by immobilizer
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Slide 45
Common Pediatric Examinations
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Chest
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Hip
Skull
Limb
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Newborn to 3-year-old
3- to 18-year-old
Newborn to 2-year-old
Preschoolers
School-age
Abdomen
GI and GU procedures
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Slide 46
Chest: Newborn to 3 Years
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
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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 47
Chest: Newborn to 3 Years
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
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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Slide 48
Chest: Newborn to 3 Years

Make exposure on end of inspiration by
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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 49
Chest: 3 to 18 Years
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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

Assistance needed
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Slide 50
Hip
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Most often ordered to assess
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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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Slide 51
Hip




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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Slide 52
Skull


Prepare room in advance
Patients 3 years and younger immobilized
using “bunny” technique



Refer to Merrill’s Atlas for illustration
Exception: sleeping child
Head clamp also used for immobilization

Even on sleeping child
 Alleviate anxiety by referring to clamp as
“earmuffs”
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Slide 53
Skull

Tube angles require modification from adults

On average, a decrease of CR angle by 5 degrees
is needed
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Slide 54
Limb: Newborn to 2 Years

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
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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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Slide 55
Limb
Child positioned and immobilized safely
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Slide 56
Limb: Preschoolers
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
Best examined seated in parent’s lap
If parent unable to assist, immobilize child as
described for younger children
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Slide 57
Limb: Preschoolers
Child cooperative in parent’s lap
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Slide 58
Limb: School-Age


Typically managed in same manner as adults
Use good communication skills and
explanations
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Slide 59
Abdomen


Pigg-O-Stat useful for infants to young
children
For supine patient, immobilize as described
for hip and pelvis
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Slide 60
GI and GU Procedures


Octagonal immobilizer or modified “bunny”
wrap are useful for younger children
Anxiety lessened by making a game of
immobilization process
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Slide 61
Unique Pediatric Examinations


Bone age
Foreign bodies
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Aspirated
 Ingested

Scoliosis
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Slide 62
Bone Age




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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Slide 63
Foreign Bodies: Aspirated
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


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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Slide 64
Foreign Bodies: Aspirated


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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Slide 65
Foreign Bodies: Ingested


Coins are most common ingested foreign
body
Images made of neck, chest, and abdomen to
locate
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Slide 66
Scoliosis
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


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
Refer to Chapter 8 in Merrill’s Atlas
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Slide 67
MRI


Usually requires child to be heavily sedated
Modality of choice for evaluation of spinal
cord abnormalities








Tethered cords
Lipomyelomeningoceles
Neoplasms
Myelination
Congenital anomalies
Also useful for cardiac imaging
Aids in diagnosis of epiphyseal fractures
Provides multiplanar images for surgical
assessments
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Slide 68
Myelography


Procedure of choice is CT myelography
Used to evaluate weakness in upper limbs
after traumatic birth
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Slide 69
CT

Useful in diagnosis and assessment of







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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Slide 70
Interventional Radiology

Therapeutic interventions can eliminate need
for surgery



Minimally invasive = reduced risk to patient
Reduces recovery time
Less expensive than surgery
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Slide 71
Nuclear Medicine

Direct radionuclide cystogram may be used in
place of VCUG if bladder function is lone
concern


Reduced radiation dose
Does not demonstrate anatomy
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Slide 72