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

Practical strategies to improve MRI operations and workflow in pediatric radiology

Magnetic resonance imaging (MRI) is an essential tool in pediatric imaging. It offers detailed, high-contrast images without ionizing radiation, making it particularly suitable for children. Creating an efficient MRI service is challenging given the balancing priorities of image quality and scan time and the overlying logistical challenges, including MRI safety protocols, the need for sedation in certain patient populations, and flexibility to accommodate patients at different phases of care. This paper reviews practical strategies to improve MRI operations and workflows in pediatric radiology, emphasizing protocol standardization and customization, scheduling optimization, and identification of key performance indicators (KPIs). Operational data through dashboards and reports enable continuous quality assessment and improvement, while specialized staff training ensures high imaging and patient safety standards. The strategies outlined in this paper highlight the importance of a comprehensive, patient-centered approach to MRI operations. By prioritizing efficiency, quality, and patient care, radiology departments can improve diagnostic outcomes and patient experience.

Optimizing infant neuroimaging methods to understand the neurodevelopmental impacts of early nutrition and feeding

There is strong evidence proper nutrition is imperative for healthy infant neurodevelopment, providing the neural foundations for later cognition and behavior. Over the first years of life infants are supported by unique sources of nutrition (e.g., human milk, alternative milk sources). It is during this time that the brain undergoes its most drastic changes during postnatal development. Past research has examined associations between infant feeding and nutrition and morphological features of the brain, yet there remains a paucity of information on functional characteristics of neural activity during feeding. Within this article, we discuss how neuroimaging modalities can be optimized for researching the impacts of infant feeding and nutrition on brain function. We review past research utilizing EEG and fNIRS and describe our efforts to further develop neuroimaging approaches that allow for measurement of brain activity during active feeding with greater spatial resolution (e.g., fMRI and OPM-MEG). We also discuss current challenges, as well as the scientific and logistical limitations of each method. Once protocols have been optimized, these methods will provide the requisite insight into the underlying mechanisms of nutritional and feeding impacts on neurodevelopment, providing the missing piece in the field's efforts to understand this essential and ubiquitous part of early life.

Procedural sedation and analgesia in pediatric diagnostic and interventional radiology: An expert DELPHI consensus document developed by the ITALIAN scientific society of anesthesia, analgesia, resuscitation and intensive care (SIAARTI)

BACKGROUND

Children undergoing diagnostic and interventional radiology procedures often require sedation to achieve immobility and analgesia if the procedure is painful. In the past decades, leading scientific organizations have developed evidence-based guidelines for procedural sedation and analgesia in children outside of the operating room. Their recommendations are being applied to procedural sedation in radiology. However, some questions remain open regarding specific aspects contextualized to the radiology setting, such as elective prone sedation, the urgency of the procedure, when venous access or airway protection is required, and others.

AIMS

To address the unresolved issues of procedural sedation and analgesia in pediatric diagnostic and interventional radiology.

METHODS

An expert panel of pediatricians, pediatric anesthesiologists, intensivists, and neuroradiologists selected topics representative of current controversies and formulated research questions. Statements were developed by reviewing the literature for new evidence, comparing expertise and experience, and expressing opinions. Panelists' agreement with the statements was collected anonymously using the DELPHI method.

RESULTS

Twelve evidence-based or expert opinion incorporate are presented, considering risks, benefits, and applicability.

CONCLUSIONS

This consensus document, developed by a multidisciplinary panel of experts involved in the field, provides statements to improve the quality of decision-making practice in procedural sedation and analgesia in pediatric radiology.

Sedation and anesthesia for imaging of the infant and neonate-a brief review

Sedation and anesthesia are often required in order to facilitate collection of high-quality imaging studies free of significant motion artifact for infants and neonates. Provision of safe sedation and anesthesia requires good communication between the ordering provider, radiologist, and anesthesiologist, careful pre-procedural evaluation of the patient, and availability of appropriate and sufficient equipment, drugs, personnel, and facilities. There are many additional factors to be considered for provision of safe sedation or anesthesia for infants and neonates-it is ideal to involve a fellowship-trained pediatric anesthesiologist in the planning and carry-out of these plans. In this review, we discuss some of the basic definitions of sedation and anesthesia, requirements for safe sedation and anesthesia, and many of the germane risks and additional considerations that factor into the delivery of a safe sedation or anesthesia plan for the imaging of an infant or neonate.

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.

White matter microstructure predicts individual differences in infant fear (But not anger and sadness)

We examine neural correlates of discrete expressions of negative emotionality in infants to determine whether the microstructure of white matter tracts at 1 month of age foreshadows the expression of specific negative emotions later in infancy. Infants (n = 103) underwent neuroimaging at 1-month, and mothers reported on infant fear, sadness, and anger at 6, 12, and 18 months using the Infant Behavior Questionnaire-Revised. Levels and developmental change in fear, sadness, and anger were estimated from mother reports. Relations between MRI and infant emotion indicated that 1-month white matter microstructure was differentially associated with level and change in infant fear, but not anger or sadness, in the left stria terminalis (p < 0.05, corrected), a tract that connects frontal and tempo-parietal regions and has been implicated in emerging psychopathology in adults. More relaxed constraints on significance (p < 0.10, corrected) revealed that fear was associated with lower white matter microstructure bilaterally in the inferior portion of the stria terminalis and regions within the sagittal stratum. Results suggest the neurobehavioral uniqueness of fear as early as 1 month of age in regions that are associated with potential longer-term outcomes. This work highlights the early neural precursors of fearfulness, adding to literature explaining the psychobiological accounts of affective development. HIGHLIGHTS: Expressions of infant fear and anger, but not sadness, increase from 6 to 18 months of age. Early neural architecture in the stria terminalis is related to higher initial levels and increasing fear in infancy. After accounting for fear, anger and sadness do not appear to be associated with differences in early white matter microstructure. This work identifies early neural precursors of fearfulness as early as 1-month of age.

Paediatric brain MRI findings following congenital heart surgery: a systematic review

OBJECTIVE

This systematic review aimed to establish the relative incidence of new postoperative brain MRI findings following paediatric congenital cardiac surgery.

DESIGN

To distinguish perioperative changes from pre-existing MR findings, our systematic search strategy focused on identifying original research studies reporting both presurgery and postsurgery brain MRI scans. Patient demographics, study methods and brain MR findings were extracted.

RESULTS

Twenty-one eligible publications, including two case-control and one randomised controlled trial, were identified. Pre-existing brain MRI findings were noted in 43% (513/1205) of neonates prior to surgery, mainly white matter injuries (WMI). Surgery was performed at a median age of 8 days with comparison of preoperative and postoperative MR scans revealing additional new postoperative findings in 51% (550/1075) of patients, mainly WMI. Four studies adopted a brain injury scoring system, but the majority did not indicate the severity or time course of findings. In a subgroup analysis, approximately 32% of patients with pre-existing lesions went on to develop additional new lesions postsurgery. Pre-existing findings were not found to confer a higher risk of acquiring brain lesions postoperatively. No evidence was identified linking new MR findings with later neurodevelopmental delay.

CONCLUSION

This systematic review suggests that surgery approximately doubles the number of patients with new brain lesions.

Real-time motion monitoring improves functional MRI data quality in infants

Imaging the infant brain with MRI has improved our understanding of early neurodevelopment. However, head motion during MRI acquisition is detrimental to both functional and structural MRI scan quality. Though infants are typically scanned while asleep, they commonly exhibit motion during scanning causing data loss. Our group has shown that providing MRI technicians with real-time motion estimates via Framewise Integrated Real-Time MRI Monitoring (FIRMM) software helps obtain high-quality, low motion fMRI data. By estimating head motion in real time and displaying motion metrics to the MR technician during an fMRI scan, FIRMM can improve scanning efficiency. Here, we compared average framewise displacement (FD), a proxy for head motion, and the amount of usable fMRI data (FD ≤ 0.2 mm) in infants scanned with (n = 407) and without FIRMM (n = 295). Using a mixed-effects model, we found that the addition of FIRMM to current state-of-the-art infant scanning protocols significantly increased the amount of usable fMRI data acquired per infant, demonstrating its value for research and clinical infant neuroimaging.

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MRI studies of the infant brain are critical for studying early neurodevelopment.

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Head motion diminishes MRI data quality, which can adversely affect infant imaging.

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We show that real-time head motion monitoring improves fMRI scan quality in infants.

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Being able to monitor motion during fMRI acquisition improves scanning efficiency.