Impact on child and parent anxiety level of a teddy bear-scale mock magnetic resonance scanner

A survey of non-sedate practices when acquiring pediatric magnetic resonance imaging examinations

BACKGROUND

Improving access to magnetic resonance imaging (MRI) in childhood can be facilitated by making it faster and cheaper and reducing need for sedation or general anesthesia (GA) to mitigate motion. Some children achieve diagnostic quality MRI without GA through the use of non- practices fostering their cooperation and/or alleviating anxiety. Employed before and during MRI, these variably educate, distract, and/or desensitize patients to this environment.

OBJECTIVE

To assess current utilization of non-sedate practices in pediatric MRI, including variations in practice and outcomes.

MATERIALS AND METHODS

A survey-based study was conducted with 1372 surveys emailed to the Society for Pediatric Radiology members in February 2021, inviting one response per institution.

RESULTS

Responses from 50 unique institutions in nine countries revealed 49/50 (98%) sites used ≥ 1 non-sedate practice, 48/50 (96%) sites in infants < 6 months, and 11/50 (22%) for children aged 6 months to 3 years. Non-sedate practices per site averaged 4.5 (range 0-10), feed and swaddle used at 47/49 (96%) sites, and child life specialists at 35/49 (71%). Average success rates were moderate (> 50-75%) across all sites and high (> 75-100%) for 20% of sites, varying with specific techniques. Commonest barriers to use were scheduling conflicts and limited knowledge.

CONCLUSION

Non-sedate practice utilization in pediatric MRI was near-universal but widely variable across sites, ages, and locales, with room for broader adoption. Although on average non-sedate practice success rates were similar, the range in use and outcomes suggest a need for standardized implementation guidelines, including patient selection and outcome metrics, to optimize utilization and inform educational initiatives.

Child-centredness in paediatric magnetic resonance imaging: Information needs and experiences of children requiring magnetic resonance imaging and their parents

BACKGROUND

Assessing patient experiences is essential to provide high quality health-care. The objectives of this study were to examine (1) child- and parent-reported information status before magnetic resonance imaging (MRI), (2) experiences during an MRI and (3) needs and suggestions for improvement.

METHODS

Children (≥8 years) and parents answered questionnaires (before and after planned MRI examination) covering mental condition, information status/needs, preparation for MRI, and potential stressors. Before MRI n = 132 accompanying parents and n = 91 children provided data (after MRI: n = 93 parents; n = 71 children). The mean age of the children undergoing MRI was 10.5 years (SD = 4.9). Children had on average seven previous MRIs before our survey (Range: 1-33). Twenty-three percent of the children were to be sedated during the examination.

RESULTS

Parents and children reported low to medium levels of burden, high knowledge and high information status. For the children, most stressful factors during the MRI were boredom and noise. Main information resources were the radiologists or self-searches. Parents of children with their first MRI reported higher anxiety levels in their children and stated a worse information status (main information source: self-searches/internet). Parents reported needs regarding organization of the MRI (e.g., reduction of waiting times), age-appropriate information and communication during the MRI. Children wished to visit the MRI room prior the examination (44%) and to get more information (44%). Children suggested improvements such as better sound quality of films/music, more transparency about the procedure, being in contact with a parent and shorter examinations.

CONCLUSION

Results suggest that preparation, information provision and care is perceived positively by families. Needs and suggestions for improvement were, for example, higher transparency of procedures, better communication and reduction of stress. Findings indicate that preparation in routine-care should follow an individualized child-focused approach, should focus on families without previous MRIs and should address children with high anxiety levels.

Nonpharmacological Interventions to Reduce Sedation and General Anesthesia in Pediatric MRI: A Meta-analysis

CONTEXT

Nonpharmacological strategies are increasingly used in pediatric procedures, but in pediatric MRI, sedation and general anesthesia are still commonly required.

OBJECTIVES

To evaluate the effectiveness of nonpharmacological interventions in reducing use of sedation and general anesthesia in pediatric patients undergoing MRI, and to investigate effects on scan time, image quality, and anxiety.

DATA SOURCES

We searched Ovid Medline, CINAHL, Embase, and CENTRAL from inception through October 10, 2022.

STUDY SELECTION

We included randomized controlled trials and quasi-experimental designs comparing the effect of a nonpharmacological intervention with standard care on use of sedation or general anesthesia, scan time, image quality, or child and parental anxiety among infants (<2 years), children, and adolescents (2-18 years) undergoing MRI.

DATA EXTRACTION

Standardized instruments were used to extract data and assess study quality.

RESULTS

Forty-six studies were eligible for the systematic review. Limited to studies on children and adolescents, the meta-analysis included 20 studies with 33 873 patients. Intervention versus comparator analysis showed that nonpharmacological interventions were associated with reduced need for sedation and general anesthesia in the randomized control trials (risk ratio, 0.68; 95% confidence interval, 0.48-0.95; l2 = 35%) and nonrandomized studies (risk ratio, 0.58; 95% confidence interval, 0.51-0.66; l2 = 91%). The effect was largest among children aged 3 to 10 years when compared with older children and adolescents aged 11 to 18 years.

LIMITATIONS

There was substantial heterogeneity among nonrandomized studies.

CONCLUSIONS

Nonpharmacological interventions must be considered as standard procedure in infants, children, and adolescents undergoing MRI.

Factors and Labor Cost Savings Associated with Successful Pediatric Imaging without Anesthesia: a Single-Institution Study

RATIONALE AND OBJECTIVES

In pediatric imaging, sedation is often necessary to obtain diagnostic quality imaging. We aim to quantify patient and imaging-specific factors associated with successful pediatric scans without anesthesia and to evaluate labor cost savings associated with our institutional Scan Without Anesthesia Program (SWAP).

MATERIALS AND METHODS

Patients who participated in SWAP between 2019-2022 were identified. Chart review was conducted to obtain sociodemographic and clinical information. Radiology database was used to obtain scan duration, modality/body part of examination, and administration of contrast. Mann-Whitney U and Chi-Square tests were used for univariate analysis of factors associated with success. Multivariate logistic regression was used to evaluate independent contributions to success. Associated hospital labor cost savings were estimated using salary information obtained through publicly available resources.

RESULTS

Of 731 patients, 698 had successful and 33 had unsuccessful scans (95% success rate). In univariate analysis, older age, female sex, absence of developmental delay, and administration of contrast were significantly associated with successful scans. Multivariate analyses revealed that older age, female sex, and absence of developmental delay were significant independent factors lending toward success. Imaging-related factors were not associated with outcome in multivariate analysis. Estimated labor cost savings were $139,367.80 per year for the medical center.

CONCLUSION

SWAP had an overall success rate of 95%. Older age, absence of developmental delay, and female sex were independently significantly associated with successful outcome. Cost analysis reveals substantial labor cost savings to the institution compared with imaging under anesthesia.

French survey of sedation practices for pediatric magnetic resonance and computed tomography imaging

BACKGROUND

Pediatric magnetic resonance imaging (MRI) and computed tompgraphy (CT) require patient immobility and therefore often require sedation or general anesthesia of patients. Consensus on these procedures is lacking in France.

OBJECTIVE

Thus, the aim of this study was to describe the current sedation practices for pediatric MRI and CT in France.

MATERIAL AND METHODS

From January 2019 to December 2019, an online questionnaire was delivered by electronic mail to a representative radiologist in 60 pediatric radiology centers registered by the French-speaking pediatric and prenatal imaging society. Questions included protocols, drugs used, monitoring and side effects.

RESULTS

Representatives of 40 of the 60 (67%) radiology centers responded to the survey. Among them, 31 performed sedation including 17 (55%) centers where radiologists performed sedation without anesthesiologists present during the procedure. The premedication drugs were hydroxyzine (n = 8, 80%) and melatonin (n = 2, 20%), Sedation drugs used for children ages 0 to 6 years old were pentobarbital (n = 9, 60%), midazolam (n = 2, 13%), chloral hydrate (n = 2, 13%), diazepam (n = 1, 6.5%) and chlorpromazine (n = 1, 6.5%). A written sedation protocol was available in 10/17 (59%) centers. In 6/17 (35%) centers, no monitoring was used during the procedures. Blood pressure monitoring and capnography were rarely used (< 10%) and post-sedation monitoring was heterogeneous. No life-threatening adverse effect was reported, but 6 centers reported at least one incident per year.

CONCLUSION

For half of the responding radiology centers, radiologists performed sedation alone in agreement with the local anesthesiology team. Sedation procedures and monitoring were heterogenous among centers. Adjustment and harmonization of the practices according to the capacity of each center may be useful.

Effectiveness of training before unsedated MRI scans in young children: a randomized control trial

BACKGROUND

Young children requiring clinical magnetic resonance imaging (MRI) may be given general anesthesia. General anesthesia has potential side effects, is costly, and introduces logistical challenges. Thus, methods that allow children to undergo awake MRI scans are desirable.

OBJECTIVES

To compare the effectiveness of mock scanner training with a child life specialist, play-based training with a child life specialist, and home book and video preparation by parents to allow non-sedated clinical MRI scanning in children aged 3-7 years.

MATERIALS AND METHODS

Children (3-7 years, n=122) undergoing clinical MRI scans at the Alberta Children's Hospital were invited to participate and randomized to one of three groups: home-based preparation materials, training with a child life specialist (no mock MRI), or training in a mock MRI with a child life specialist. Training occurred a few days prior to their MRI. Self- and parent-reported functioning (PedsQL VAS) were assessed pre/post-training (for the two training groups) and pre/post-MRI. Scan success was determined by a pediatric radiologist.

RESULTS

Overall, 91% (111/122) of children successfully completed an awake MRI. There were no significant differences between the mock scanner (89%, 32/36), child life (88%, 34/39), and at-home (96%, 45/47) groups (P=0.34). Total functioning scores were similar across groups; however, the mock scanner group had significantly lower self-reported fear (F=3.2, P=0.04), parent-reported sadness (F=3.3, P=0.04), and worry (F=3.5, P=0.03) prior to MRI. Children with unsuccessful scans were younger (4.5 vs. 5.7 years, P<0.001).

CONCLUSIONS

Most young children can tolerate awake MRI scans and do not need to be routinely anesthetized. All preparation methods tested, including at-home materials, were effective.

Initial Evidence for Positive Effects of a Psychological Preparation Program for MRI "iMReady" in Children with Neurofibromatosis Type I and Brain Tumors-How to Meet the Patients' Needs Best

To provide an effective alternative to sedation during MRI examinations in pediatric cancer and NF1 patients, the aims of the present study were to (1) exploratively evaluate a behavioral MRI training program, to (2) investigate potential moderators, as well as to (3) assess the patients' well-being over the course of the intervention. A total of n = 87 patients of the neuro-oncology unit (mean age: 6.83 years) underwent a two-step MRI preparation program, including training inside the scanner, and were recorded using a process-oriented screening. In addition to the retrospective analysis of all data, a subset of 17 patients were also analyzed prospectively. Overall, 80% of the children receiving MRI preparation underwent the MRI scan without sedation, making the success rate almost five times higher than that of a group of 18 children that opted out of the training program. Memory, attentional difficulties, and hyperactivity were significant neuropsychological moderators for successful scanning. The training was associated with favorable psychological well-being. These findings suggest that our MRI preparation could present an alternative to sedation of young patients undergoing MRI examinations as well as a promising tool for improving patients' treatment-related well-being.

Effectiveness of mock scanners and preparation programs for successful magnetic resonance imaging: a systematic review and meta-analysis

This review aimed to summarise the effectiveness of preparation programs for magnetic resonance imaging (MRI) in children using mock scanners and the success rates by systematically reviewing the current literature. We initially identified 67 articles using the search terms "MRI," "mock" and "child" on online databases. All studies involving a preparation programme for MRI on children ages 18 years or younger, healthy children and those with medical diagnoses were included. The authors extracted data on study design, participant data, details of the MRI protocol and the total numbers of patients who underwent preparation programs and were scanned while awake, without sedation or general anesthesia. Twenty-three studies were included in this review. Preparation programs included in-home and hospital/research facility components; these consisted of a mock scanner, explanatory booklets, recorded MRI scan sounds and other educational materials. The success rate of MRI after the preparation programme reported in each study ranged from 40% to 100%. When all participants from studies that specifically assessed the efficacy of preparation programs were combined, participants who underwent a preparation programme (n = 196) were more likely to complete a successful MRI than those who did not undergo a preparation programme (n = 263) (odds ratio [OR] = 1.98). Our results suggest that preparation programs may help reduce the risk of children failing MRI scans.

Interventions and methods to prepare, educate or familiarise children and young people for radiological procedures: a scoping review

Children attending hospital for radiological procedures can experience uncertainty, anxiety and distress; this can result in sub-optimal experiences for children, poor scan quality and the need for radiological procedures to be rescheduled or sedation to be used. The preparation and education of children before clinical procedures has been shown to have a positive influence on procedural outcomes. This scoping review aimed to locate and examine the evidence relating to non-invasive interventions and methods to prepare, educate and familiarise children for radiological procedures within a healthcare setting. A comprehensive search strategy identified 36 articles. A narrative synthesis approach was adopted to make sense of the key findings. Studies investigated a range of radiological procedures (MRI, plain radiographs, CT, fluoroscopy and Micturating cystourethrogram) using a wide range of interventions (smartphone applications, storybooks, videos, mock scanners) which varied by method, mode of delivery and target audience. The outcomes used to evaluate the value and impact of the interventions are wide, varied and inconsistently applied making it difficult to judge which interventions offer the optimal impact on scan quality, scan completion and children’s experiences. This review highlights that there is a need to further understand which specific elements of the non-invasive interventions ‘work best’ for children. There is a need for consistency on the outcomes measured and for these measures to include child-centred outcomes alongside scan quality and length of radiological procedure.

Functional MRI research involving healthy children: Ethics, safety and recommended procedures

AIM

This specific review aims to expose clinicians, researchers and administrators in hospitals to the importance, procedures and safety of fMRI studies to promote the increased utilisation of such studies in different geographical places worldwide. The child's brain is developing rapidly, both structurally and functionally. These functional changes can only be detected using functional scans generated from an MRI machine and referred to as a functional MRI (fMRI). This method may be used clinically in complex medical and surgical conditions (e.g., epilepsy surgery), but these days are often used for research purposes. However, due to ethical and logistical considerations, fMRI in the paediatric population is not widely and equally used in different geographical places.

CONCLUSIONS

The benefits of using this method to define the functional changes occurring in the developing brain are discussed in this review, along with desensitisation methods recommended when working with this vulnerable population in research and even in a clinical setting.

The Effect of Virtual Reality Game Preparation for Children scheduled for MRI (IMAGINE): a Randomized Controlled Trial Protocol (Preprint)

Background

It is known that magnetic resonance imaging (MRI) procedures generate fear and anxiety. Children may become restless during scanning, which results in movement artifacts requiring the MRI procedure to be repeated with sedation. Few studies seem to have looked at the effect of immersive virtual reality (IVR) on anxiety in children scheduled for MRI scans and how to identify which children are more responsive.

Objective

The aims of this study are 3-fold: develop an algorithm of predictability based on biofeedback, address feasibility and acceptability of preprocedural IVR game preparation for anxiety management during MRI procedures, and examine the efficacy of IVR game preparation compared with usual care for the management of procedural anxiety during MRI scans.

Methods

This study will have 2 phases. We will first conduct a field test with 10 participants aged 7 to 17 years to develop a predictive algorithm for biofeedback solution and to address the feasibility and acceptability of the research. After the field test, a randomized controlled trial will be completed using a parallel design with 2 groups: an experimental group (preprocedural IVR game preparation) and a usual care group (standard care as per the radiology department’s protocol) in an equal ratio of 49 participants per group for 98 participants. Recruitment will be carried out at a hospital in Quebec, Canada. The experimental group will receive a preprocedural IVR game preparation (IMAGINE) that offers an immersive simulation of the MRI scan. Participants will complete a questionnaire to assess the acceptability, feasibility, and incidence of side effects related to the intervention and the biofeedback device. Data collected will include sociodemographic and clinical characteristics as well as measures of procedure-related anxiety with the French-Canadian version of the State-Trait Anxiety Inventory for Children (score 1-3) and the Children’s Fear Scale (score 0-4). Physiological signs will be noted and include heart rate, skin conductance, hand temperature, and muscle tension. Measures of the level of satisfaction of health care professionals, parents, and participants will also be collected. Analyses will be carried out according to the intention-to-treat principle, with a Cronbach α significance level of .05.

Results

As of May 10, 2022, no participant was enrolled in the clinical trial. The data collection time frame is projected to be between April 1, 2022, and March 31, 2023. Findings will be disseminated through peer-reviewed publications.

Conclusions

Our study provides an alternative method for anxiety management to better prepare patients for an awake MRI procedure. The biofeedback will help predict which children are more responsive to this type of intervention. This study will guide future medical practice by providing evidence-based knowledge on a nonpharmacological therapeutic modality for anxiety management in children scheduled for an MRI scan.

Trial Registration

ClinicalTrials.gov NCT04988516; https://clinicaltrials.gov/ct2/show/NCT04988516

International Registered Report Identifier (IRRID)

PRR1-10.2196/30616

An update on pediatric sedation techniques in nonoperating room locations

PURPOSE OF REVIEW

To review advancements in care for pediatric patients in nonoperating room settings.

RECENT FINDINGS

Advances in patient monitoring technology, utilization of Child Life specialists, and alternative staffing models are helping anesthesia providers meet the rising demand for coverage of pediatric nonoperating room anesthesia (NORA) cases. The Wake Up Safe and Pediatric Sedation Research Consortium registries are exploring outcome measures regarding the safety of pediatric anesthesia in off-site locations and have reported an increased risk for severe respiratory and cardiac adverse events when compared to OR anesthesia sites. Additionally, malpractice claims for NORA have a higher proportion of claims for death than claims in operating rooms.

SUMMARY

Pediatric NORA requires thorough preparation, flexibility, and vigilance to provide safe anesthesia care to children in remote locations. Emerging techniques to reduce anesthetic exposure, improve monitoring, and alternative staffing models are expanding the boundaries of pediatric NORA to provide a safer, more satisfying experience for diagnostic and interventional procedures.

Imaging sedation and anesthesia practice patterns in pediatric radiology departments - a survey of the Society of Chiefs of Radiology at Children's Hospitals (SCORCH)

BACKGROUND

There are few data describing practice patterns related to the use of sedation/anesthesia for diagnostic imaging in pediatric radiology departments.

OBJECTIVE

To understand current practice patterns related to imaging with sedation/anesthesia in pediatric radiology departments based on a survey of the Society of Chiefs of Radiology at Children's Hospitals (SCORCH) in conjunction with the American College of Radiology's Pediatric Imaging Sedation and Anesthesia Committee.

MATERIALS AND METHODS

A multi-question survey related to imaging with sedation/anesthesia in pediatric radiology departments was distributed to SCORCH member institutions in January 2019. A single reminder email was sent. Descriptive statistical analyses were performed.

RESULTS

Of the 84 pediatric radiology departments, 23 (27%) completed the survey. Fifty-seven percent of the respondents self-identified as academic/university-affiliated and 13% as a division/section in an adult radiology department. Imaging sedation (excluding general anesthesia) is commonly performed by pediatric anesthesiologists (76%) and intensive care unit physicians (intensivists, 48%); only 14% of departments expect their pediatric radiologists to supervise imaging sedation. Ninety-six percent of departments use child life specialists for patient preparation. Seventy percent of departments have preparatory resources available on a website, including simulation videos (26%) and audio clips (17%). Nearly half (48%) of the departments have a mock scanner to aid in patient preparation. Imaging sedation/anesthesia is most often scheduled at the request of ordering clinicians (65%), while 57% of departments allow schedulers to place patients into imaging sedation/anesthesia slots based on specified criteria.

CONCLUSION

Imaging sedation/anesthesia practice patterns vary among pediatric radiology departments, and understanding current approaches can help with standardization and practice improvement.

Gentle Touch: Noninvasive Approaches to Improve Patient Comfort and Cooperation for Pediatric Imaging

Pediatric imaging presents unique challenges related to patient anxiety, cooperation, and safety. Techniques to reduce anxiety and patient motion in adults must often be augmented in pediatrics, because it is always mentioned in the field of pediatrics, children are not miniature adults. This article will review methods that can be considered to improve patient experience and cooperation in imaging studies. Such techniques can range from modifications to the scanner suite, different ways of preparing and interacting with children, collaborating with parents for improved patient care, and technical advances such as accelerated acquisition and motion correction to reduce artifact. Special considerations for specific populations including transgender patients, neonates, and pregnant women undergoing fetal imaging will be described. The unique risks of sedation in children will also be briefly reviewed.

Normal volumetric and T1 relaxation time values at 1.5 T in segmented pediatric brain MRI using a MP2RAGE acquisition

OBJECTIVES

This study introduced a tailored MP2RAGE-based brain acquisition for a comprehensive assessment of the normal maturing brain.

METHODS

Seventy normal patients (35 girls and 35 boys) from 1 to 16 years of age were recruited within a prospective monocentric study conducted from a single University Hospital. Brain MRI examinations were performed at 1.5 T using a 20-channel head coil and an optimized 3D MP2RAGE sequence with a total acquisition time of 6:36 min. Automated 38 region segmentation was performed using the MorphoBox (template registration, bias field correction, brain extraction, and tissue classification) which underwent a major adaptation of three age-group T1-weighted templates. Volumetry and T1 relaxometry reference ranges were established using a logarithmic model and a modified Gompertz growth respectively.

RESULTS

Detailed automated brain segmentation and T1 mapping were successful in all patients. Using these data, an age-dependent model of normal brain maturation with respect to changes in volume and T1 relaxometry was established. After an initial rapid increase until 24 months of life, the total intracranial volume was found to converge towards 1400 mL during adolescence. The expected volumes of white matter (WM) and cortical gray matter (GM) showed a similar trend with age. After an initial major decrease, T1 relaxation times were observed to decrease progressively in all brain structures. The T1 drop in the first year of life was more pronounced in WM (from 1000-1100 to 650-700 ms) than in GM structures.

CONCLUSION

The 3D MP2RAGE sequence allowed to establish brain volume and T1 relaxation time normative ranges in pediatrics.

KEY POINTS

• The 3D MP2RAGE sequence provided a reliable quantitative assessment of brain volumes and T1 relaxation times during childhood. • An age-dependent model of normal brain maturation was established. • The normative ranges enable an objective comparison to a normal cohort, which can be useful to further understand, describe, and identify neurodevelopmental disorders in children.