Child’s Play
By Keith Loria
Radiology Today
Vol. 23 No. 4 P. 20

A Look at the Latest Trends in Pediatric MRI

Because pediatric patients come in a range of sizes, from tiny infants to large teens, each with different anatomy, radiologists who are tasked with MR imaging of pediatric patients must keep in mind that MRI sequences will vary depending on age, size, and life stage. Jeffrey Miller, MD, a pediatric radiologist at Phoenix Children’s Hospital, notes that there’s a saying in the pediatric radiology community: “Children are not just small adults!” The more time he spends in the field, the more Miller feels this is a true statement.

“The challenges with pediatric scanning are across the board,” he says. “You can be scanning a newborn that is smaller than your house pet, all the way up to a regular-size child that could be bigger than a lot of adults. So, we have to be able to provide different imaging protocols to do the appropriate imaging.”

There are also the issues of some children being too young to communicate, unable to hold their breath for any substantial period of time, or simply unable to understand what’s happening, causing them to be anxious and fidgety, which makes it virtually impossible to do a proper scan. Often with young children, things such as patient history and understanding what’s happening to them can be difficult. For this reason, pediatric imaging needs to provide more information than what would be needed for an adult.

“Fortunately, a lot of the imaging is normal, but when it’s not normal, the abnormalities that we’re trying to identify in imaging are very complex,” Miller says. “So, we need to not only be able to provide the standard imaging info but also be able to try to understand what’s happening with advanced techniques and provide other information that could be helpful to the clinician.”

That’s why many companies are investing in tools and programs that can improve the success rate of MRI among pediatric patients.

“Remember, children are often uncooperative, and there’s a good proportion of kids who don’t want to be there and are unhappy and scared. The challenge is: What are you going to do to get them through the examination? Because they have to have it,” Miller says. “An alternative is anesthesia or sedation—that’s a safe option in skilled hands, but there is an added risk and some parents are apprehensive about that. We have to be able to provide alternatives, when possible.”

Ioannis Panagiotelis, chief marketing officer for GE Healthcare, notes that the latest MR equipment for pediatric patients offers faster speeds, improved image quality, wider and more comfortable coils that cause less distress for patients, and AI power, which improves accuracy, image sharpness, and noise ratio.

“At the same time, it is enabling shorter scan times up to 50%,” he says. “This increases the confidence in the diagnosis.”

Preparation and Education
One of the hottest topics within pediatric MR is reducing the need for sedation.

“Pediatric patients are more prone to movement, and they are anxious about going into the bore, so if we can’t do a scan fast enough and keep them calm and still, one of the measures we take is sedation,” says Jackie Morley, product manager of Siemens Healthineers MR. “We want to cut that down and provide the ability to go through an MR exam without sedation.”

That can be accomplished, she notes, with patient preparation and faster, motion-robust scanning.

“So, it doesn’t just start with the system. It starts with preparation and education leading up to the actual scan,” Morley says. “We want to make sure we take time to explain what the patients are going to go through so they are comfortable and we have the best chance of completing the exam. We don’t want to stop halfway through.”

As part of the education, Siemens Healthineers uses a miniscanner—a tabletop unit akin to a toy Barbie scanner—that lets children see what the experience will be like. They are allowed play with it.

“There are two buttons on top of the system,” Morley says. “One will play a conventional MRI sound, so they know what it will sound like, and the other button on the mock scanner plays our quiet sequences; we can reduce the sound pressure up to 99%. This helps with our success rate and keeping people calm.”

Julia Dmitrieva, key opinion leader engagement leader, strategic marketing precision diagnosis at Philips, says the latest data show an expected growth of 23% in pediatric MRI examinations over the next decade, and it’s vital to think about anxiety reduction for pediatric patients as well as their parents. To address this need, Philips offers its Pediatric Coaching Solution,which uses augmented reality, gamification, and “buddy system” techniques to engage and guide children through their entire MRI scan journey, from the home to the hospital.

To prepare for the MRI scan, children are provided with a mobile app that familiarizes them and their parents with an MRI procedure in a playful way—such as an online coloring book—and also introduces them to a virtual “buddy” they can role-play with to perform an MRI scan. The app also uses augmented reality to allow the child to explore the MRI system at home before entering the hospital.

“When children enter a hospital, you want it to be a nonscary experience, but they are already leaving their home and don’t know what to expect,” Dmitrieva says. “They can feel claustrophobic in the MRI, then there’s the noise, so we want to make sure our pediatric patients aren’t scared and know what to expect.”

Phoenix Children’s Hospital utilizes the Philips app that pediatric patients can interact with on their phone, which Miller says creates a child-friendly, nonthreatening experience. The hospital also has a miniature MRI scanner children can play with prior to the exam.

“When they get to the MRI scanner room itself, there’s the ambient experience that we rely on quite a bit to continue the distraction effort,” Miller says. “We have projection screen capabilities to project warm colors on the wall and soothing images. Then, once they get in the scanner, patients have the ability to watch movies and videos to distract them during that time.”

Even the LEGO Foundation is working to help, offering LEGO MRI scanners to help children cope with the uncertainty of having an MRI scan. The scanner was developed with a learning-through-play approach and is a means for clinicians to facilitate both role-play and dialogue so that children feel safe and can build confidence and resilience before the MRI journey takes place, reducing stress and anxiety.

Keep Calm and Carry On
GE Healthcare offers its Adventure Series for MR, which is designed to make imaging more inviting for pediatric patients, thanks to themed imaging rooms. The modules use characters, visuals, and hands-on activities to enhance the imaging experience for both children and their parents. Some examples include a safari or space theme.

“This is an excellent use to optimize the whole experience and lessen the anxiety,” Panagiotelis says. “The whole scanner room, including the scanner, is integrated, so it’s very popular. These visuals definitely add to helping the examination go smoothly.”

Siemens Healthineers partners with Comfort Health Solutions, who provide coverings that can be applied to the cover of the MRI system, and wall coverings that can be applied to the walls of the MRI scan room.

“As soon as the patient walks in, they may see an aquarium or a jungle or something that is fun and childlike, to start relaxing the nerves and anxiety right at the beginning of it all,” Morley says. “We offer that as a first step to help distract the patient, and it eases the level of anxiety to get into the scans itself.”

For the scan, Siemens Healthineers has an in-bore entertainment system called Innovision that also plays a role in keeping patients calm.

“Innovision is an audio and visual entertainment system that can start as soon as the patient gets on the table, even before they enter the bore, so they can be immersed in a video or listen to music,” Morley says. “It’s something that’s not just comforting to them but also provides a distraction. This lets us carry out a scan with as little movement as possible, to keep the pediatric patient entertained throughout the scan.”

Besides providing patient entertainment, the display keeps patients informed about their remaining scan time. Another feature is the patient display, which makes the bore appear larger, mitigating claustrophobic feelings. The Innovision solution includes comfort pillows made of memory foam that reduce scan noise and deliver clear audio signals to the patient. Patients can also hear voice commands from the MRI technologist, due to an integrated audio system and specialized ear plugs.

In addition, Siemens Healthineers’ MRI systems offer technology that helps accomplish fast scans and reduce the need for sedation. For example, one of its newest systems, Deep Resolve, utilizes AI-powered image reconstruction technology that uses targeted denoising and convolutional neural networks to generate high-resolution images from low-resolution input. Patients are in the bore for shorter periods of time and the image quality is comparable to what would have been achieved with a longer scan time.

Siemens Healthineers’ Pediatric 16 coil is also designed to facilitate pediatric imaging. Morley explains that the coil has a cradle that allows technologists to prepare a patient in a room outside of the magnet room and help them get the patients comfortable with what they are going to feel. The technologist can then quickly and easily connect the coil to the table when the patient goes in for head and neck imaging.

“It is smoothly integrated into the patient table with DirectConnect technology and can be combined with other Tim 4G coils for whole-body imaging,” she says.

Speed is of utmost importance in pediatric imaging, Miller says. “You don’t want unstable patients to be in the scanner any longer than necessary,” he says. “When you have children who are apprehensive, getting them out as fast as possible is a value.”

It is also important to consider that these tools help technologists as well.

“It can sometimes be really stressful to work with sick kids—it reminds the technologists of their own kids, and they’re dealing with children, parents, and family members who are often stressed,” Miller says. “We need it to be as easy as possible for the technologist so they can get through the situation and without undue burden.”

— Keith Loria is a freelance writer based in Oakton, Virginia. He is a frequent contributor to Radiology Today.