Merrill's Chapter 22: Pediatric Imaging

• Pediatric imaging is covered in Chapter 22 of Merrill's.

The Pediatric Patient

• Each pediatric patient and their caregiver are unique.
• The approach and attitude of the medical imaging technologist (MIT) greatly impacts the child.
• Children reach the age of understanding at different times.
• Most 2- to 3-year-old children can be talked through a diagnostic test without immobilization.
• Introductions to both the patient and the parent/caregiver are essential.
• Building a rapport with the patient is important.
• All of this needs to be accomplished in a short time.

First Impressions

• Obtain pertinent information regarding the child's condition before meeting them.
• Be aware of what the child has been told about the test by doctors, family, or friends.
• Explain the procedure, what needs to be done by the child, and the parent's potential role.
• Be honest and use non-scary language.
• Repeat instructions as needed and offer a private changing space.
• Relay any delays.
• Delays should be communicated as makes the parent feel taken care of.
• Encourage questions and educate the parents about the procedure.

Psychology

• Pediatric patients can be: sad, nervous, scared, or in pain
• Explanations need to be short and to the point.
• Engage with the parent by reassuring the patient and giving examples.
• Encouraging the patient is important.
• Avoid lying to the child.

Needs

• Considerations for pediatric patients encompass their physical needs: they may be tired, hungry, and may need changing.

Qualities and skill of a caregiver

• Important qualities in pediatric healthcare givers includes: patient, good communicator, emphatic, organized, creative, and detachment.

Radiology Examinations

• Increase the room temperature 10-15 minutes prior in bedside exams as this will enable the patient to get to a comfortable temperature before the procedure.
• The ICU nursing term will accompany the patient in radiology department exams.
• Medical information of the patient should be noted, along with any additional instructions from nursing staff.
• Suction and oxygen must always be available, and the room needs to be well stocked.
• Keep the patient in the incubator/warmer until just before the procedure.

Patient Immobilization

• Patient immobilization devices help with pediatric imaging.
• The Universal Octostop allows stable positioning at every 45-degree interval.
• It features isocentric rotation and stability in all positions.
• There are adapted head cushions.
• Velcro straps and blankets ensure fast immobilization.

Toddlers Series

• Lower leg projections required for a toddler's series includes: AP and lateral of the affected leg and lateral of the unaffected led for comparison.
• Spiral fractures of the Tibia are often caused by falling when children are at the learning age.

Chest and Abdomen imaging

• Patients should remove clothes when preparation for CXR and Abdomen images.
• Place child on the IR.
• Have parent hold child with arms up if possible and necessary.
• In the event that parents are not available to hold the child, note it.
• Head should be tilted back
• Immobilize as required.
• Pigg-o-Stat is commonly used to immobilize infants and children up to around 5 years of age for abdomen and erect chest procedures
• Some examples of pediatric immobilizers is Tama-em board, Posi-Tot, and Papoose board
• Technologist must view child from viewing station
• Ensure that lead gloves and shields are appropriately prepared.

Exam techniques

• For an AP chest exam, center the CR to mid-thorax at the mammillary nipple line.
• Rotation should be avoided.
• Collimate exposure to chest margins.
• Ensure inspiration by catching a crying baby and using this opportunity.
• Adult kVp range is 110-120 with a grid.
• Baby kVp range is 75-85 without a grid.
• A recumbent position is required for lateral chest exam.
• Tam-em board is needed as immobilization aid.
• CR should be located to at mid-coronal point at the mammillary line.
• Rotation should be avoided .
• For Chest Exam Erect: Use upright AP
• Pigg-O-Stat is often used
• Direct CR to mid-thorax at the mammillary line
• No rotation should be present
• Ensure that 11-month-old child is able to sit upright.

Evaluation Criteria

• With PA and AP chests, ensure no rotation.
• Arm should be extended and elevated
• Lungs should be expanded
• Motion should be avoided
• There should be optimal exposure
• Ensure that there is a marker
• For the examination of the Lateral Chest, rotation should be avoided.
• Arm should be elevated
• Lungs should be fully expanded as motion should be avoided
• There should be optimal exposure along with an accurate marker.

Soft Tissue Neck Exam

• Common Indications include foreign bodes, laryngotracheal bronchitis or Croup, epiglottis, and adenoid hypertrophy
• It is contraindicated for patients with epiglottitis when the supine position is used, as blocks airways.
• Diagnostic quality of this exam requires: instructions, proper neck extension, exposure and immobilization.

Croup

• Croup is generally a viral infection and occurs to Children from 1-3 years old
• The trachea becomes swollen which may lead to obstructive patterns.
• This swelling is localized to the subglottic portion of the trachea

Croup & laboured breathing

• Edema causes laboured breathing and dry cough that sounds like a seal barking. This is termed stridor.
• Stridor also makes high-pitched sound when breathing happens through a narrow or partly blocked airway. Usually loudest on breathe in.
• Possible fever is also present.
• Treatment with antibiotics is used for those infected.
• AP Inspiration is taken with added filtration (Cu filter0
• Lateral inspiration & expiration and no filter
• Phonations may be done
• High kVp technique required
• Patients with Croup will show an AP projection that shows walls of the subglottic larynx are convex with narrowing of an hourglass shape.
• This radiographic appearance is called steeple sign or pencil sign.

Scheuermann's Disease

• Adolescent Kyphosis
• Vertebral body does not develop
• Wedge shape vertebrae
• Forward curve > 40° in adolescents
• This also requires an Upright lateral T spine for diagnosis.

C- Spine Trisomy 21 - Down Syndrome

• Trisomy 21 - Down Syndrome is a genetic disorder.
• Presence of all or part of a third copy of chromosome 21 is present.
• Physical growth delays will be seen as well as Characteristics facial features
• This includes moderate intellectual disability along with the need for Flexion/extension lateral c-spine images.
• These images are used to r/o subluxation due to high incidence of atlantoaxial instability

Congenital Heart Disease (CHD)

• It is caused by abnormal heart structure (defect) present at birth.
• There are two types: Cyanotic congenital heart disease and Acyanotic congenital heart disease
• Acyanotic CHD: Cyanotic impacts the heart by reducing the amount of oxygen delivered to the body
• Acyanotic CHD: Blood features enough oxygen, however it is pumped throughout the body abnormally. As a result, the defects don't interfere with the amount of oxygen or blood delivered to the body.

Cardiac Congenital Anomalies include:

• Atrial Septal Defect
• Patent Foramen Ovale (PFO)
• Ventricular Septal Defect
• Patent Ductus Arteriosus
• Coarctation of Aorta
• Tetralogy of Fallot
• Septal Defect - Right to left sided heart
• Blood is shunted from the low-pressure pulmonary circulation to the high-pressure LT sided systemic circulation
• Blood has not gone to lungs yet
• Blood is shunted into LT atrium, bypasses lungs and gets sent to systemic circulation. Magnitude of the shunt depends on
• Size of the defect
• Differences in pressure on the two sides based on hemodynamic studies.

Patent Foramen Ovale - PFO

• It is generally an atrial Septal Defect and is considered one because of failure of the foramen ovale at birth.
• Patent Foramen Ovale allows Permits free communication between the 2 atria
• Normally, tissue forms around the opening to seal it and it becomes the fossa ovalis
• Should close within minutes of first breath. However, it can take up to 24 months.
• In particular, in 20% of people the flap does not close
• The flap may eventually close when it can reopen with pressure in RT atrium rises
• Mixing of blood from the systemic and pulmonary circulations is possible
• Usually doesn't Cause normal complications.
• It is Hemodynamically stable
• People may not even know they have it
• Possible complications: Fatigue, Cyanotic, Linked to strokes and migraines with aura small blood clots in the heart, traveling through the Patent Foramen Ovale (travel to Lt Atrium)
• PFO can be detected by echocardiogram or a Transesophageal echo, MRI, CT
• For Atrial Septal Closure (ASD) procedure, a non-surgically is used and an implantable PFO Occluder is performed

Ventricular Septal -Left to Right Ventricular Shunt

• Always moves from Right to left because left ventricular pressure is higher than in the right.
• Blood is recirculated in the lungs and causes increased pulmonary load
• Surgery is needed as there is a large opening.

Patent Ductus Arteriosus

• Results due to failure of ductus arteriosus
• Also results in the movement of blood from the left to a right shunt
• Blood from higher pressure is moved to a lower pulmonary artery, causing an increased pulmonary flow
• There is also an increased amount of blood that returns to ventricle and Left atrium
• The increases load causes increased loads to both the Pulmonary and Rt Atrium/Ventricle

Coarctation of the Aorta

• As this is the narrowing and constriction of the artery, the overall blood supply and pressure is higher compared to the normal
• Classified Patient normally features a normal blood pressure, however legs may indicate reduced blood pressure.
• Decreased blood flow will occur through the area.
• Collateral circulation is ultimately constructed.
• This is frequently seen in hypertension of children
• Localization of the site of obstruction of obstruction is visible using Aortography. Any associated cardiac malformations are identified.
• Treatment through surgically or by PTA/Stent placements

Tetralogy of Fallot

• It is generally characterized by a Blue Baby Syndrome
• Ventricular septal defect (VSD)
• Overriding aorta
• Pulmonary stenosis
• Right ventricular hypertrophy

Enlargement

• Enlargement of the right ventricle also occurs.
• Thus causes movement of the heart, resulting to the appearance of curvature

Imperforate Anus

• Anal atresia or Imperforate Anus
• The severity of the spectrum ranges from a membranous separation to complete absence
• The condition is observed when the anus is occluded by and has not been formed by
• Imaging is visible through the use of the lateral rectum x-ray and horizontal beam technique. This will have the child prone with there bum up in there
• With the use of air, the air will rise to the highest point with measurements
• To indicate the opening, A metal marker is used where paste should be
• For diagnosis, surgical procedures are performed as well.

Intussusception

• Also known as telescoping and features Diminished colonic stool in the bowel
• Common among with those age 3
• As the Blood supply is not able to travel appropriately, necrosis occurs
• This is made common as it is indicated through ileocecal junction (90%)
• With 60% of males being indicated, the disorder leads to mechanical bowel obstruction
• Clinical: Stools, mucous, diarrhea, vomiting
• BRBPR is also associated
• The enema is used to facilitate a high percentage of success

VCUG - Voiding Cystourethrogram

• Indications: evaluate vesicoureteral reflux or Recurrent tract infection with boys being affected
• This procedure is performed before IVU
• Assesses ureters, bladder, and urethra anatomy
• A Special prep is not required, instead prepare child
• Preparation needed is lodging CM for cystography, Intravenous stand, Sterile tray and Urine specimen container
• Ensure 8f feeding with balloon, and catheters
• Clean Skin and fistula
• The room should be table. CM and clamp
• This will enable easier access to equipment
• The catheter should be Void, along with balloon being set
• Full images taken and
• Full examination to be performed

Effective points during test

• Avoid Using older equipment in area for use
• Test tube should only be accessible with test only
• Try to be as possible and try empty the bladder

How the radiocopic technique is done

• Mom can stay with child
• Cover can be in the way
• Towel may be used

Effective ways to communicate with child during Post-test session

• The Burning sensations is natural and pain will get better over time
• Test results processed online immediately

IOS

• Is used for deformities such as such scoliosis and more
• Low beam and effective beam. Used to assess areas of both the body and spine simultaneously. Will generate an in depth detailed summary of any potential issues.