"Feed-and-wrap" technique versus deep sedation for neonatal magnetic resonance imaging: a retrospective comparative study

OBJECTIVES

Neonatal MRI is usually performed under deep sedation, which is challenging-especially in low-weight premature patients. In addition, long-term side effects, such as neurotoxicity, are of concern. An alternative to sedation is to induce natural sleep by feeding and immobilising the child, the "feed-and-wrap" technique (FWT). The objective of this study was to evaluate differences in image quality between neonates examined under sedation and by using the FWT during the first four months of life.

MATERIALS AND METHODS

We retrospectively assessed image quality (based on a 4-point semiquantitative scale) of all MRI examinations in neonates performed at our institution between July 2009 and August 2022. Differences in image quality between examinations under sedation versus FWT were evaluated.

RESULTS

We included 432 consecutive patients, 243 (56%) using sedation and 189 (44%) using the FWT. Corrected age and body weight (mean ± SD: 3.7 ± 1.1 versus 4.5 ± 1.3 kg, p < 0.001) were significantly lower in the FWT group. The overall success rate in the FWT group was 95%. Image quality was slightly lower when using the FWT (mean ± SD: 3.7 ± 0.43 versus 3.96 ± 0.11, p < 0.001). Multivariate analysis showed a higher risk of acquiring sequences with diagnostic limitations in the FWT group (p < 0.001), increasing with corrected age (p = 0.048).

CONCLUSION

The FWT is a highly successful method to perform MRI scans in term and preterm neonates. Overall image quality is only slightly lower than under sedation. Especially in immature low-weight preterm patients, the FWT is a reliable option to perform MRI studies without exposing the child to risks associated with sedation.

CLINICAL RELEVANCE STATEMENT

The "feed-and-wrap" technique enables high-quality MRI examinations in neonates, including low-weight premature patients. Deep sedation for diagnostic MRI procedures in this age group, which has the risk of short- and long-term complications, can often be avoided.

KEY POINTS

Deeply sedating neonates for MR examinations comes with risks. Image quality is only slightly lower when using the "feed-and-wrap" technique. The "feed-and-wrap" technique is feasible even in low-weight premature infants.

The effect of video-based education program applied before children's pediatric Magnetic Resonance Imaging (MRI) on anxiety in Turkey: A randomized controlled study

OBJECTIVE

This study is a randomized controlled trial conducted to examine the effects of a Turkish video-based education program on scanned image quality and child and parent anxiety during Magnetic Resonance Imaging (MRI).

DESIGN AND METHODS

The study was conducted with 66 children aged between 4 and 15 years at Zonguldak Bulent Ecevit University Health Practice and Research Hospital, between January 2019 and December 2019. A video-based educational program was applied to an intervention group before MRI.

RESULTS

The video-based education program reduced children's anxiety and fear (p < 0.001). The study also showed a significant reduction in parental stress (p < 0.001). The image quality in the intervention group was better than that in the control group (control group: 3.24 ± 1.20; intervention group: 4.18 ± 0.81) (p = 0.001). Significantly fewer children refused to enter the MRI room in the intervention group than in the control group (p < 0.05).

CONCLUSION

Child-friendly and video-based educational programs can be organized for children and parents in diagnostic and treatment procedures for children in hospitals.

PRACTICE IMPLICATIONS

MRI scans can be uncomfortable for children and require transport to a better-equipped hospital for sedation. They can also cause financial loss for children and their parents and disrupt facility workflow. An educational program to adjust the children and their families will improve the scanning process and its success rate.

Strategies to perform magnetic resonance imaging in infants and young children without sedation

Given the increasing use of MRI in the pediatric population, the need for sedation in MRI performed in young children is a topic of growing importance. Although sedation is generally tolerated well by children, the financial and operational impacts of anesthesia on MRI workflow, as well as potential adverse effects of anesthetic medications, highlight the need to perform MRI in children without sedation whenever possible. This review focuses on current techniques to facilitate non-sedation MRI in children, including exam preparation with MRI simulation; asleep but not sedated techniques; awake and relaxed techniques using certified child life specialists, animal-assisted therapy, a child-friendly environment and in-scan entertainment; and non-sedated MRI protocol modifications such as shorter scan time, prioritizing sequences, reducing motion artifact, noise reduction, limiting use of gadolinium, employing an open MRI and modifying protocols.

The Feasibility of Magnetic Resonance Imaging Without General Anesthesia Using the "Bundle and Scan" Technique for Infants With Sensorineural Hearing Loss

OBJECTIVE

The purpose of this study is to determine the feasibility of magnetic resonance imaging (MRI) without general anesthesia (GA) for infants being evaluated for sensorineural hearing loss (SNHL) using the bundle and scan technique.

STUDY DESIGN

Retrospective study.

SETTING

Pediatric tertiary care hospital.

PATIENTS

All infants who underwent MRI using the bundle and scan technique as part of the diagnostic workup for unilateral or bilateral SNHL between June 2016 to April 2019 were included.

MAIN OUTCOME MEASURE

The primary outcome was the proportion of clinically useful images produced.

RESULTS

We reviewed 21 bundle and scan MRI examinations in infants being evaluated for SNHL. Patients had a median age of 10 (range: 6-25) weeks at the time of MRI. Motion artifact was noted in 38% (8/21) of cases. Eighty-six percent (18/21) of the magnetic resonance images produced using the bundle and scan technique were of diagnostic quality and/or sufficient for surgical planning for cochlear implantation. Repeat imaging with GA was required for three cases (14%) as the initial images were not clinically useful. All patients requiring GA had unilateral SNHL. All patients with bilateral SNHL successfully underwent MRI without GA using the bundle and scan technique.

CONCLUSION

The results of our study demonstrate that it is feasible to perform MRI using the bundle and scan technique in the majority of young infants being evaluated for SNHL. This has the potential to help determine cochlear implant candidacy earlier, reduce exposure to GA, and reduce healthcare costs.

Non-pharmacological strategies to obtain usable magnetic resonance images in non-sedated infants: Systematic review and meta-analysis

BACKGROUND

Although the use of sedation is commonly practiced to keep infants still while receiving magnetic resonance imaging, non-pharmacological strategies are a potential alternative.

OBJECTIVES

The purpose of this study was to determine the success rate of obtaining usable magnetic resonance images in infants with the sole use of non-pharmacological strategies.

DESIGN

Systematic literature review and meta-analysis SETTING: A search was conducted in PubMed, CINAHL and Cochrane Library.

PARTICIPANTS

Human infants from birth to 24 months of age who did not receive any sedation or anesthesia during magnetic resonance imaging METHOD: Articles that reported the success rate of obtaining usable images were included.

RESULTS

Of the 521 non-duplicate articles found, 58 articles were included in the systematic review with sample sizes ranging from 2-457, an average success rate of 87.8%, and an average scan time of 30 min. The most common non-pharmacological technique included feeding and swaddling infants before imaging to encourage infants to sleep during the scan. Meta-analysis performed on 53 articles comprising 3,410 infants found a success rate of 87%, but significant heterogeneity was found (I² = 98.30%). It was more difficult to obtain usable images solely with non-pharmacological techniques if infants were critically ill or a structural magnetic resonance imaging of the brain was required.

CONCLUSION

Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most but not all infants. Tweetable abstract: Non-pharmacological techniques are effective for obtaining usable magnetic resonance imaging scans in most infants.

Feed and Swaddle: An Alternative to Infant Sedation for Craniofacial Imaging

Objective:

The gold standard for diagnosis of craniosynostosis is a clinical examination and motionless head computed tomography (CT). Computed tomography sedation is associated with increased cost, resource utilization, medical, and possible developmental risks. This study investigates whether a “feed and swaddle” protocol can be used to achieve diagnostic quality craniofacial imaging without the use of infant sedation.

Design:

Prospective cohort study.

Setting:

Tertiary academic medical center.

Patients:

Ninety patients <18 months of age undergoing evaluation for craniosynostosis from 2012 to 2018.

Interventions:

A feed and swaddle protocol.

Main Outcome Measures:

Diagnostic level imaging without the use of infant sedation.

Results:

Eighty-five (94%) achieved a diagnostic quality craniofacial CT scan using the “feed and swaddle” method. Mean patient age was 24.0 ± 10.0 weeks. Craniosynostosis was diagnosed in 74% of patients. Mean age of patients with successful completion of a CT scan was 23.7 ± 9.6 weeks, compared to 27.2 ± 17.1 weeks for unsuccessful completion. Mean weight for the successful group was 15.6 ± 2.9 pounds and 15.9 ± 2.5 pounds for the unsuccessful group. Mean travel distance was 59.2 ± 66.5 miles for successful patients and 66.5 ± 61.5 miles for unsuccessful patients. For the unsuccessful patients, there were no delays in surgical planning or scheduling.

Conclusion:

The “feed and swaddle” protocol described here is an effective alternative to infant sedation for motionless craniofacial CT imaging.

Feed and Wrap MRI Technique in Infants

The feed and wrap technique refers to the use of feeding and swaddling to induce natural sleep in infants. It can be used prior to an magnetic resonance imaging (MRI) scan, avoiding sedation or anesthesia. We performed a retrospective review of feed and wrap MRI scans in infants 3 months or younger over a 2-year period at our center (279 scans) to evaluate the efficacy of this technique. Of scan results reviewed, 79% addressed the clinical question, 20% partially addressed the clinical question, and 1% were technically inadequate. History of preterm birth (odds ratio [OR] = 2.368; P = .032) and spine MRI (OR = 2.821; P = .001) were associated with a less-successful scan outcome. The feed and wrap technique can be used successfully in infants undergoing MRI; however, it may be less successful in preterm infants and those requiring spinal MRI. A standardized technique performed by experienced personnel may avoid anesthesia and sedation in infants who require MRI.

Childhood extracranial neoplasms: the role of imaging in drug development and clinical trials

Cancer is the leading cause of death in children older than 1 year of age and new drugs are necessary to improve outcomes. Imaging is crucial to the drug development process and assessment of therapeutic response. In adults, tumours are often assessed with CT using size criteria. Unfortunately, techniques established in adults are not necessarily applicable in children due to differing pathophysiology, ability to cooperate and increased susceptibility to ionising radiation. MRI, in particular quantitative MRI, has to date not been fully utilised in children with extracranial neoplasms. The specific challenges of imaging in children, the potential for functional imaging techniques to inform upon and their inclusion in clinical trials are discussed.

Practical planning to maintain premature infants' safety during magnetic resonance imaging: a systematic review

BACKGROUND

Magnetic resonance imaging (MRI) makes a significant contribution to diagnose brain injury in premature infants and is a diagnostic procedure that requires the infant to be taken out of the controlled environment established for growth and development. To ensure safe procedures for these vulnerable patients, practical planning and surveillance are paramount.

PURPOSE

This systematic review summarizes and evaluates the literature reporting on practical planning to maintain required safety for premature infants undergoing MRI.

METHODS

Literature identified through various search strategies was screened, abstracted, appraised, and synthesized through a descriptive analysis. Thirteen research studies, 2 quality improvement projects, and 10 other documents, including practice guidelines, general reviews and articles, a book chapter, and an editorial article, were retained for in-depth review.

CONCLUSIONS

Various procedures and equipment to ensure the safety of premature infants during MRI have been developed and tested. Although the results are promising and increasingly consistent, our review suggests that more research is needed before conclusive recommendations for the use of magnetic resonance-compatible incubators, the "feed-and-sleep" approach to avoid sedation, or the specific noise-cancelling ear protection for the premature infants' safety during MRI can be established.

The challenges of neonatal magnetic resonance imaging

Improved neonatal survival rates and antenatal diagnostic imaging is generating a growing demand for postnatal MRI examinations. Neonatal brain MRI is now becoming standard clinical care in many settings, but with the exception of some research centres, the technique has not been optimised for imaging neonates and small children. Here, we review some of the challenges involved in neonatal MRI, including recent advances in overall MR practicality and nursing practice, to address some of the ways in which the MR experience could be made more neonate-friendly.

Paediatric MRI under sedation: is it necessary? What is the evidence for the alternatives?

To achieve diagnostic images during MRI examinations, small children need to lie still to avoid movement artefact. To reduce patient motion, obviate the need for voluntary immobilisation or breath-holding and therefore obtain high-quality images, MRI of infants is frequently carried out under sedation or general anaesthesia, but this is not without risk and expense. However, many other techniques are available for preparing children for MRI, which have not been fully evaluated. Here, we evaluate the advantages and disadvantage of sedation and anaesthesia for MRI. We then evaluate the alternatives, which include neonatal comforting techniques, sleep manipulation, and appropriate adaptation of the physical environment. We summarize the evidence for their use according to an established hierarchy. Lastly, we discuss several factors that will influence the choice of imaging preparation, including patient factors, imaging factors and service provision. The choice of approach to paediatric MRI is multi-factorial, with limited scientific evidence for many of the current approaches. These considerations may enable others to image children using MRI under different circumstances.