PEDIATRIC IMAGING

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PEDIATRIC IMAGING





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Principles of Pediatric Imaging


Understanding that children are not just small adults and appreciating that they need to be approached on their level are essential ingredients for successful encounters with children in the imaging department. Radiographers often lack confidence in two main areas of pediatric radiography—pediatric communication skills and immobilization techniques. The basic steps of pediatric radiography can be explained, but they must also be practiced.


Although pediatric imaging and adult radiography have many similarities, including basic positioning and image quality assessment, there are some significant differences. The way to approach the child tops the list of differences. It may help novice pediatric radiographers to think about children of various ages whom they know and to imagine how they would explain a particular radiographic examination to those children. This strategy, along with the descriptions that follow, is quite effective. Working successfully with children requires an open mind, patience, creativity, the willingness to learn, and the ability to look at the world through the eyes of a child.


Another characteristic of pediatric imaging revolves around the increased sensitivity of children to radiation and the imperative need to take steps to reduce the dose administered every time a procedure involving x-radiation is done. The concept of “imaging gently” has been recently introduced in the world of pediatric radiology to increase awareness among radiation workers and to address the growing concerns that parents have regarding radiation exposure.



Atmosphere


The environment in which patients are treated and recover plays a significant role in the recovery process. Research studies have compared the recovery course of patients whose hospital rooms looked out over parks with the recovery course of patients whose view was a brick wall. The patients who faced the park had a much shorter hospital stay than the other patients, and they required considerably less pain medication. With these differences in mind, the patient care center at SickKids (Toronto) was designed and built as an atrium (Fig. 26-1). Each patient room receives natural light, either by facing outside or overlooking the atrium, which receives natural light from the glass roof. Although it is easy to see how children can be amused by Miss Piggy and the barnyard animals that fly across the atrium, the environment does not have to be this elaborate to be appreciated by children. Small measures can be taken at relatively little cost to make a child’s hospital stay more comfortable.




WAITING ROOM


Parents of pediatric patients often arrive at the reception desk feeling anxious. They may be worried about what is involved in a procedure because they have not had the specifics explained to them or because they did not hear all that was explained to them. They also may be worried about the amount of time the care of their child will take, not to mention the outcome.


Feelings of anxiousness and tension are often transferred from parent to child—the child senses a parent’s tension through the parent’s tone of voice or actions. A well-equipped waiting room (this does not have to be expensive) can reduce this tension. Children are attracted to and amused by the toys, leaving the parents free to check in or register and ask pertinent questions.


Gender-neutral toys or activities such as a small table and chairs with crayons and coloring pages are most appropriate. (Children should be supervised to prevent them from putting the crayons in their mouths.) Books or magazines for older children are also good investments. The child life department of the hospital can provide advice and the most appropriate recommendations (Fig. 26-2).




IMAGING ROOM


Time can pass quickly for lengthy procedures if age-appropriate music or videos are available. A child who is absorbed in a video often requires little or no immobilization (other than the usual safety precautions designed to prevent the child from rolling off the table). Charitable and fund-raising organizations often donate televisions, DVD players, and computer games for this purpose.


Experience has shown that children are less likely to become upset or agitated if they are brought into a room that has been prepared before they enter. This preparation should include placement of the image receptor (IR), approximate centering of the tube to the IR, and placement of all immobilization tools likely to be needed at one end of the table and moving the x-ray tube in proximity to where the patient will be positioned.


Young children are often afraid of the dark. They dislike having the lights turned out but are often comfortable with low levels of illumination. Dimming the lights enough to see the collimator light before the child enters can prevent the need to explain why the lights have to be dimmed. Busy radiographers often turn the lights down without explanation, causing unnecessary anxiety.


After the procedure is complete, the radiographer or other imaging professional should take a moment to emphasize, even overemphasize, how helpful the child was and to explain where the child should wait or what the child should do next, ensuring that the parent is comprehending the instructions.



Approach



APPROACHING THE PARENT


No discussion of dealing with children is complete without mentioning ways to approach the parent. Although children are sometimes brought for medical care by someone other than the parents, in this discussion, the caregiver is referred to as the parent.


In many cases, radiographers find that they are dealing with two patients—the child and the parent. They may wonder to whom they should primarily speak. The answer, however, is easy:



• If the child is capable of understanding, direct the explanation to the child and use age-appropriate language (discussed later). The parents will listen and consequently understand what is expected. Communicating in this way puts the parents more at ease and increases their confidence in the radiographer’s skills. They appreciate the fact that their child has been made the focus of attention.


• If the child is too young to comprehend, direct the explanation to the parent, explaining in simple sentences what is going to happen and what is expected of the parent. The importance and value of simple sentences cannot be overemphasized. People in stress-filled situations do not think as clearly as they normally do, and many parents in this setting are under stress. Successful communication involves the use of short sentences repeated once or twice in a soothing tone.




Parent participation


The degree of parent participation depends on the following factors:



The advantages of parental participation can be great for everyone concerned— patients, parents, radiographers, and departmental administrators. Experience has shown that both parents should have the basic procedure explained to them. It is advisable, however, that only one parent be present in the imaging room. The presence of both parents often causes the room to become crowded; it is distracting and can actually lengthen the procedure. Many state or provincial laws permit only one additional person in the room, and this serves nicely as a rationale when the radiographer explains the policy to parents. Posting signs to this effect in strategic locations also can be helpful.


Some parents insist on participating, and many pediatric radiographers advocate parent participation for the following reasons:



This last point illustrates a benefit to parents and to medical personnel. The parent’s presence ensures that no action, explanation, or question is misinterpreted by the child or adolescent. At the same time, the parent can take comfort in seeing that the child is being cared for in a professional manner. Although parental participation is perhaps less controversial now than it was in the past, radiographers can put the situation in perspective by imagining themselves in the position of parents and asking whether they would want to be present. With increasing public knowledge and the ever-present threat of litigation, parents are participating in more procedures.


Informed parents, whether physically present in the imaging room or not, can usually help to explain the procedure to the child. Most hospitals and commercial organizations have prepared pamphlets describing procedures and answering many commonly asked questions.


In some situations, parental presence is not advised. Some children are further agitated by their parents’ presence. Some parents may find certain procedures too disturbing, such as those performed in the interventional suites.


Whenever parents are in the room during a radiographic exposure, they should be protected from scatter radiation. Parents should also be given lead gloves if their hands will be near the primary radiation beam.



APPROACHING THE CHILD


Naturally, good communication is essential to obtaining maximum cooperation. Children should be spoken to at their level in words that they can understand. This is not as difficult as learning a new language, and it can be made even easier if the radiographer keeps a few strategies in mind, as follows:



• Greet the patient and parent in the waiting area with a smile.


• Bend down to talk to the child at the child’s eye level.


• Take a moment to introduce yourself and ensure that you identify the correct patient; then state briefly what you are going to do.


• Suggest, rather than ask, the child to come and help you with some pictures. This firm, yet gentle approach avoids creating the idea that the child has a choice. After all, the patient may be tempted to be emphatic and say “no.”


• Use sincere praise. This is a powerful motivator, no matter what the age of the patient. Praise for young children (3 to 7 years old) should be immediate. Children have short attention spans and often expect to receive rewards immediately. The reward should be linked directly to the task that has been well done. Use phrases such as “You sat very still for me, thank you” or “You took a nice, big breath in for that picture, and I am going to ask you to do it again for the next one.”


• When the outcome will be the same, give children an option: “Would you like Mom to help lift you up on the table, or may I help you?” or “We have two pictures to do. Which would you like first—the one with you sitting down or the one with you lying down?”


• Employ distraction techniques. As radiographers develop confidence in basic radiography skills and adapting these skills for children, they find themselves able to engage in chatter and distraction techniques, making the experience as pleasant as possible for the child. Ask the child about brothers, sisters, pets, school, or friends—the topics are limitless. As homework, watch a few popular children’s cartoons. Communication is improved when the radiographer can build rapport with a child, and learning a few more distraction techniques is helpful.


• Answer all questions truthfully— regardless of their nature. Maintaining honesty is crucial in all communications with children. Confidence and credibility built by the previous strategies can be lost if the truth is withheld. The secret is to not volunteer information too early or dwell on unpleasantness.


The child’s age should greatly influence the approach. Children are unique individuals with unique social styles, but the following guidelines may still prove helpful.




Children 6 months to 2 years old


Children 6 months to 2 years old are particularly fearful of pain, separation from their parents, and limitation of their freedom of movement. Children this age are very disturbed by immobilization and usually require the most assertive immobilization techniques. Experience has shown that it is less disturbing to children to be well immobilized than to have numerous adults in lead aprons trying to hold them in the correct positions.


Although radiographers should be knowledgeable in the art of immobilization for children in this age group (particularly 2-year-olds), one of the most valuable forms of immobilization is natural sleep. The challenge is to complete the entire radiographic sequence without waking the child. This can be done by carefully transferring the child to the table and taking care to maintain warmth, comfort, and safety.


Parental participation is especially valuable with this age group, as it is with children 2 to 4 years old. Radiographers can easily pick up tips for communicating with children by taking cues from parents as they explain procedures to their children. Parents are also helpful because they can act as “babysitters” during the procedure.


NOTE: Chest radiography must be performed while children are awake. Because respirations are generally shallow during sleep, it is impossible to obtain an adequate degree of inspiration.



Children 2 to 4 years old


Preschoolers can test the power of the radiographer’s imagination. They are extremely curious—their favorite question is “Why?” They enjoy fantasy and may readily cooperate if the situation is treated like a game or distraction techniques are used. The following strategies can be useful:



Children 2 to 4 years old can be verbally and physically aggressive. A child who is having a tantrum does not respond to games and distraction techniques. Making the procedure as short as possible through the use of practiced and kind, yet effective, immobilization techniques is the best approach. Young patients generally calm down quickly when they are back in their parents’ arms or resume the activity they were involved in before the examination.



Children 5 years old


A 5-year-old child has typically reached a time that is rich in new experiences. Reactions can differ widely, depending on how at ease the child feels with a given environment. Children in this age group generally want to perform tasks correctly, and they enjoy mimicking adults. When a 5-year-old feels confident, that child will act like a 6-, 7-, or 8-year-old; however, when afraid or worried, that same child may cling to parents and become reticent and uncooperative. Constant reassurance and simple explanations help in such moments. Take a moment to show the child how the collimator light works and let the child turn it on—for a child, this is as much fun as pressing the buttons in an elevator (Fig. 26-3).




School-age children 6 to 8 years old


For a radiographer who is not accustomed to working with children, the perfect group to start with is 6- to 8-year-olds. These children are generally accommodating and eager to please. They are modest and embarrass easily, so their privacy should be protected. These children are the easiest age group with which to communicate; they appreciate being talked through the procedure, which gives them less time to worry about their surroundings or the procedure itself. Anatomic landmarks are easy to locate for positioning, and body habitus evens out nicely—the “big belly” of the toddler disappears. From an imaging standpoint, the bones are maturing, with the increased calcium content enhancing subject contrast (Fig. 26-4).




Adolescents


Image is important to preteens and adolescents. Although they are better able to understand the need for hospitalization, they are upset by interference in their social and school activities. They are particularly concerned that as a result of the injury they may not be able to return to their preinjury state. These patients require, and often demand, clear explanations. Health care workers should not be surprised by the frankness of their questions and should be prepared for some discussion.1


Adolescents want to be treated as adults, and the radiographer must exercise judgment in assessing the patient’s degree of maturity. The radiographer should become familiar with the local statutes regarding consent to understand when children are deemed to be responsible for themselves.2


Sensitive issues, such as the possibility of pregnancy in a postpubescent girl, must be approached discreetly. Honest responses are more likely to be elicited if the girl is alone with the radiographer (i.e., the parent is not present), and the following guidelines are observed:



• Preface the questioning by stating that information of a sensitive nature needs to be obtained for radiation safety.


• Ask a 10-, 11-, 12-, or 13-year-old girl if she has started menstruating. If the response is affirmative, continue by saying that a slightly more sensitive question needs to be asked. Then ask if there is any possibility of pregnancy.


• Simply but tactfully ask girls 14 years and older if there is any chance of pregnancy. Judging from the patient’s expression and response, decide how to continue.


• Differing levels of maturity call for different explanations. If necessary, apologize for the need to ask sensitive questions and assure the patient that the same questions are asked of all girls of this age.


• Follow the questioning with an explanation that it is unsafe for unborn babies to receive radiation.


• If possible, have the questioning performed by a woman.



APPROACHING PATIENTS WITH SPECIAL NEEDS



Children with physical and mental disabilities


The radiographer should consider age when approaching children with physical and mental disabilities. Children older than 8 years with disabilities strive to achieve as much autonomy and independence as possible. They are sensitive to the fact that they are less independent than their peers. The radiographer should observe the following guidelines:



• Direct communication toward the child first. All children appreciate being given the opportunity to listen and respond. Similar to all patients, these children also want to be talked to rather than talked about.


• If this approach proves ineffective, turn to the parents. Generally, the parents of these patients are present and can be very helpful. In strange environments, younger children may trust only one person—the parent. In that case, the medical team can gain cooperation from the child by communicating through the parent. Parents often know the best way to lift and transfer the child from the wheelchair or stretcher to the table. Children with physical disabilities often have a fear of falling and may want only a parent’s assistance.


• After introducing yourself, briefly explain the procedure to the child.


• Place the wheelchair or stretcher parallel to the imaging table, taking care to explain that you have locked the wheelchair or stretcher and will be getting help for the transfer. These children often know the way they should be lifted—ask them. They can tell you which areas to support and which actions they prefer to do themselves.


Finally, children with spastic contractions are often frustrated by muscle movements that are counterproductive to the intended action. Gentle massage should be used to help relax the muscle, and a compression band should be applied to maintain the position.


Communicating with a child who has a mental disability can be difficult, depending on the severity of the disability. Some patients react to verbal stimuli. Loud or abrupt phrases can startle and consequently agitate them.



Patient Care: Psychological Considerations


Although pediatric patients have many of the same psychological characteristics as adults, some factors are worthy of mention to prepare the radiographer better for interactions with children and their parents.



EMERGENCY PATIENT


When an accident happens, emotions run high, thought processes are clouded, and the ability to rationalize is often lost. For the parents of a child who has been injured, another powerful factor is often involved—guilt. As parents try to absorb information about the child’s condition, they also ask themselves how they could have let the accident happen. Dealing with these questions often prevents parents from hearing or understanding all that is being explained. In addition, fearing that permanent damage has been done, the child can feel extremely traumatized by a relatively minor injury. The radiographer should observe the following guidelines in dealing with emergency patients and their parents:



• Greet the patient and parents, and then describe the procedure using short, simple, and often-repeated sentences.


• When patients and parents speak with a tone of urgency and frustration, this usually stems from fear; maintain a calm perspective in these situations to ensure a smooth examination.


• Increase the level of confidence the parents and child have in your abilities with frequent reassurance presented in a calming tone. (The reassurance referred to here is reassurance that the radiographer knows how to approach the situation, not reassurance that all will be well with respect to the injury.)


• In emergency examinations, as with any other examination, ensure that only one caregiver is giving the child instructions and explanations. (Caregivers include parents, nurses, physicians, and radiographers, all of whom may be present.) Much greater success is achieved when only one person speaks to the child.


• After completing the procedure, ensure that you have the parents’ attention. Speaking slowly, give clear instructions about where to wait and what to expect.





Patient Care: Physical Considerations



GENERAL MEASURES


Depending on the level of care being provided, children may arrive in the imaging department with chest tubes, intravenous (IV) infusions (including central venous lines), colostomies, ileostomies, or urine collection systems. Usually these children are inpatients, but in many instances outpatients (particularly in interventional cases) arrive in the department with various tubes in situ (e.g., gastrostomy or gastrojejunostomy tube placements). The radiographer must be aware of the purpose and significance of these medical adjuncts and know the ways to care for a patient with them (see Figs. 26-46 and 26-47).




A competent and caring radiographer takes note of the following:



Many inpatients are on a 24-hour urine and stool collection routine. Medical personnel who change diapers on these patients should save the old diaper for the ward or floor personnel to weigh or assess.


Hospital policy and the availability of nursing staff within the imaging department determine the amount of involvement the radiographer has with the management of IV lines. The radiographer must be able to assess the integrity of the line and must know the measures to take in the event of problems.1



ISOLATION PROTOCOLS AND STANDARD BLOOD AND BODY FLUID PRECAUTIONS


Prevention of the spread of contagious disease is of primary importance in a health care facility for children. Microorganisms are most commonly spread from one person to another by human hands. Careful handwashing is the most important precaution, but it is often the most neglected. In addition, all equipment that comes in contact with the radiographer and patient during isolation cases must be washed with an appropriate cleanser.


The premise of standard blood and body fluid precautions is that all blood and body fluids are to be considered infected. The U.S. Centers for Disease Control and Prevention recommend that health care workers practice blood and body fluid precautions when caring for all patients. These precautions are designed to protect patients and medical personnel from the diseases spread by infected blood and body fluids. All blood and body fluids, including secretions and excretions, must be treated as if they contain infective microorganisms. Working under this assumption, personnel can protect themselves not only from patients in whom a known infective organism is present but also from the unknown. The management of patients in isolation varies according to the type of organism or preexisting condition, the procedure itself (some can alternatively be performed with a mobile unit), and hospital or departmental policies. Decisions regarding when to bring an infectious patient to the department also often depend on the condition of other patients who may be in the vicinity. Patients with multiresistant organisms should not be close to immunocompromised patients.


The radiographer should follow all precautions outlined by the physician and nursing unit responsible for the child. Respiratory, enteric, or wound precautions for handling a patient are usually instituted to protect staff members and other patients. Isolation procedures are instituted to protect a patient from infection. Protective isolation is used with burn victims and patients with immunologic disorders. The protective clothing worn by staff members may be the same in either situation, but the method of discarding the clothing would be different.1



Patient Care: Special Concerns


As with most pediatric examinations, a collaborative team approach produces the best results. Cooperation among all caregivers and the child provides for a smooth examination. A few special situations that warrant individual mention are discussed in the following sections.



PREMATURE INFANT


One of the greatest dangers facing a premature and sometimes a full-term neonate is hypothermia (below normal body temperature). Thermoregulation, the balance of heat losses and gains, is crucial to the care and survival of a premature infant. The sources of heat loss—evaporation, convection, conduction, and radiation—are greater in the preterm infant. Premature infants have a greater surface area compared with body mass. They are incapable of storing the fat needed for warmth, and they have increased metabolic rates.


To avoid hypothermia, premature infants should be examined within the infant warmer or isolette whenever possible. General radiography must be performed with a portable or mobile unit. (See Chapter 28 for a discussion of mobile radiography.) The radiographer should take great care to prevent the infant’s skin from coming in contact with IRs. Covering the IR with one or two layers of a cloth diaper (or equivalent) works well; however, the material should be free of creases because these produce significant artifacts on neonatal radiographs.


When a premature infant is brought to the imaging department for gastrointestinal (GI) procedures or various types of scans, the radiographer should observe the following guidelines:



• Elevate the temperature in the room 20 to 30 minutes before the arrival of the infant. The ambient temperature of the imaging room is usually cool compared with the temperature of the neonatal nursery.


• When increasing the temperature is impossible, prepare the infant for the procedure while the infant is still in the isolette and remove the infant for as brief a period as possible.


• Use heating pads and radiant heaters to help maintain the infant’s body temperature; however, these adjuncts are often of limited usefulness because of necessary obstructions such as the image intensifier. If heaters are used, position them at least 3 ft (1 m) from the infant.


• Place large bags of IV solutions, prewarmed by soaking in a sink of warm water, beside the infant to serve as small hot water bottles.


• Monitor the infant’s temperature throughout the procedure, and keep the isolette plugged in to maintain the appropriate temperature.


Because of the risk of infection to infants in the neonatal intensive care unit (NICU), most units insist on adherence to isolation protocols such as gowning and handwashing.


NOTE: Neonatal refers to newborn. Although premature infants constitute the highest percentage of patients in NICUs, all of the infants in these units are not premature. Full-term infants experiencing distress are also cared for in NICUs.


The radiographer must take care when positioning an infant from the NICU. Many of these infants can tolerate only minimal handling without their heart rates becoming irregular.



MYELOMENINGOCELE


A myelomeningocele is a congenital defect characterized by a cystic protrusion of the meninges and the spinal cord tissue and fluid. It occurs as a result of spina bifida, a cleft in the neural arches of a vertebra. It can be recognized by fetal ultrasonography at the 17th or 18th week of gestation. Myelomeningoceles may cause varying degrees of paralysis and hydrocephalus. The higher the location of the myelomeningocele, the worse the neurologic symptoms.


Patients with myelomeningoceles are cared for in the prone position. Whenever possible, radiographic examinations of these patients should be performed using the prone position until the defect has been surgically repaired and the wound healed. The primary imaging modalities used in the investigation and follow-up care of myelomeningoceles include ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) (Fig. 26-5).





EPIGLOTTITIS


Epiglottitis is one of the most dangerous causes of acute upper airway obstruction in children and must be treated as an emergency. Its peak incidence occurs in children 3 to 6 years old. Epiglottitis is usually caused by Haemophilus influenzae, and the symptoms include acute respiratory obstruction, high temperature, and dysphasia (inability to swallow or difficulty in swallowing). When epiglottitis is clinically suspected, the radiographer observes the following steps:




OSTEOGENESIS IMPERFECTA


Osteogenesis imperfecta (OI) is a disease characterized by brittle bones. The approach and management need to be altered significantly in the imaging department to accommodate patients with OI. Children with OI are prone to spontaneous fractures or fractures that occur with minimal trauma. Although OI can vary in severity, patients with this disease need to be handled with extreme care by an experienced radiographer (Fig. 26-7).



Children with OI are almost always accompanied by a key caregiver—usually a parent. Experience has shown that these patients are best handled with a team approach in an unhurried atmosphere. The team comprises the patient, parent (caregiver), and radiographer, with the radiographer observing the following guidelines:




SUSPECTED CHILD ABUSE


Although no universal agreement exists on the definition of child abuse, the radiographer should have an appreciation of the all-encompassing nature of this problem. Child abuse has been described as “the involvement of physical injury, sexual abuse or deprivation of nutrition, care or affection in circumstances, which indicate that injury or deprivation may not be accidental or may have occurred through neglect.”1 Although diagnostic imaging staff members are usually involved only in cases in which physical abuse is a possibility, they should realize that sexual abuse and nutritional neglect are also prevalent.


It is mandatory in all states and provinces in North America for health care professionals to report suspected cases of abuse or neglect. The radiographer, while preparing or positioning the patient, may be the first person to suspect abuse or neglect (Fig. 26-8). The first course of action for the radiographer should be to consult a radiologist (when available) or the attending physician. After this consultation, the radiographer may no longer have cause for suspicion because some naturally occurring skin markings mimic bruising. If the radiographer’s doubts persist, the suspicions must be reported to the proper authority, regardless of the physician’s opinion. Recognizing the complexity of child abuse issues, many health care facilities have developed a multidisciplinary team of health care workers to respond to these issues. Radiographers working in hospitals have access to this team of physicians, social workers, and psychologists for the purposes of reporting their concerns; others are advised to work through their local Children’s Aid Society or appropriate organization.



Plain image radiography, often the initial imaging tool, can reveal characteristic radiologic patterns of skeletal injury. Clear evidence of posterior rib fractures, corner fractures, and bucket-handle fractures of limbs are considered classic indicators of physical abuse (Fig. 26-9). All imaging modalities play a role in the investigation of suspected child abuse. After plain radiography, nuclear medicine is often the next investigative tool of choice (Fig. 26-10). CT with three-dimensional reconstruction has contributed to differentiating cases of actual abuse from accidental trauma (Fig. 26-11). The presence of numerous fracture sites at varied or multiple stages of healing can also indicate long-term or ongoing abuse. These cases are often viewed by nonradiologic staff members (e.g., lawyers) and imaging professionals. Evidence of injury must be readily apparent, especially because pediatric fractures at an early age can remodel totally over time, providing no clear evidence of earlier fractures.





The radiographer’s role is to provide physicians with diagnostic radiographs that show bone and soft tissue equally well. Referring physicians depend on the expertise of the diagnostic imaging service for the detection of physical abuse, and radiologists are able to estimate the date of the injury based on the degree of callus formation or the amount of healing.


The radiographer observes the following guidelines when dealing with a case of possible child abuse:


Mar 4, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on PEDIATRIC IMAGING
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