Children are different from adults when it comes to disease – presentation and treatment. Diagnosing these diseases and disorders are difficult and challenging. “Paediatric diseases form a unique spectrum of pathology and require specialised understanding, including from the imaging perspective. The advances in paediatric imaging parallel the growth of the paediatric sub-specialities, such as paediatric surgery, cardiology, neurology, pulmonology, etc.,” says Dr Arjun Kalyanpur, Chief Radiologist and CEO, Teleradiology Solutions, Bangalore.
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“Paediatric imaging requires greater sensitivity on the part of the radiologist to radiation dose and safety.”Non-intimidating painless techniques take precedence over sophisticated diagnostic procedures, which is why paediatric imaging is popular among paediatricians. Assistance in accurate diagnosis without pain is the most attractive trait of radiology. No wonder that it is the most sought after technique in this age group. “Imaging as a diagnostic modality is one of the most frequently ordered investigations. This is for the simple reason that it is non – invasive and painless, which is such an important issue in paediatrics,” says Dr Krishan Chugh, Director & HOD, Paediatric ICU, Fortis Memorial Research Institute.
Gaining insights
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“Equipment and exposure settings designed for adults may result in excessive radiation exposure if used on smaller patients.”All the imaging modalities, including X-ray, ultrasonography, CT scan, MRI and PET scan are used in children for diagnosis and getting more information for treatment planning, depending on the illness. Each of these imaging modalities have pros and cons, for example X-ray, CT scan and PET scan involve ionising radiation. Ultrasound and MRI are radiation-free but ultrasound has limited visibility of certain areas while MRI takes long time (about one hour). For MRI, and in certain cases, CT scan, smaller children are put under sleep/anaesthesia for the test. “We, as paediatric healthcare workers, always do risk benefit analysis and decide about what imaging test to use that will provide the best answer for a particular illness and no harm to the child. For some illnesses, for e.g. pneumonia, simple X-ray is all that is required for the diagnosis while for others like cancers, CT scan, MRI, PET scan or a combination of all may be required to obtain the information so that appropriate therapy can be given to the child,” says Dr Govind Chavhan, Pediatric Radiologist. The Hospital for Sick Children and Assistant Professor, Medical Imaging University of Toronto.
Recent advances
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“Radiation exposure from imaging puts children at a extremely small but definite risk of cancer development later in life.”Paediatric imaging is evolving rapidly. Research and studies are focusing on efforts to make radiology safe, child friendly and cost effective. Some of the notable advancements are in the application of 3D data obtained from the modality and styling it to harvest added information. “There are numerous ongoing advancements in each of these imaging modalities with attempt to get more information in shorter test time, less radiation doses and avoiding or minimising anaesthesia time,” says Dr Chavhan. “Apart from these, 3D imaging data is now used in surgical planning and during actual surgery (for e.g. 3D CT scan or MRI is displayed during brain surgeries in the operation theatre and the surgeon knows how deep is the tumour and in what direction he has to go). 3D data is also used for creating synthetic material 3D models for heart, skull and other bones that can be used for understanding anatomy and virtual surgery can be practised beforehand on these models,” he adds.
Another area in which it is seeing rapid growth is in MRI. Most children with complex congenital heart disease are now imaged on MRI instead of CT in most specialised paediatric imaging centres.
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“Paediatric imaging centres are now designed with child-friendly colours to make the place look less intimidating for the young child.”“Motion compensation techniques combined with faster and higher strength MRI scanners allow imaging of neonates and young infants without sedation using a ‘feed and wrap’ technique and even moving foetuses in utero in greater detail than ever before,” explains Dr Sanjay P Prabhu, Assistant Professor of Radiology, Harvard Medical School and Director, Advanced Image Analysis Lab; Pediatric Neuroradiologist, Boston Children’s Hospital “
The availability of ‘baby MRI’ scanners suitable for installation next to the neonatal unit and MRI-safe equipment allows young, sick and often very prematurely born infants to be transported to MRI scanner without disrupting vital treatment that the child needs,” he adds.
Children-friendly
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“Training in paediatric radiology in India is inadequate. This translates into inadequate and perhaps poor care.”The benefits of imaging goes hand in hand with patient preparation. Technically it’s the same as adult guidelines, but reducing fear and acclimatisation techniques enhance the paediatric patient experience. “Patient preparation depends upon the investigation ordered. For e.g. Chest X-rays do not require fasting, but one usually prefers a full inspiratory film unless you are suspecting a pneumothorax,” explains Dr Chugh. “Swallow studies , GER Scans and Barium meals require the patient to be fasting. CT Scan, MRI need sedation, hence patient has to fast for 4-6 hours prior to the procedure. In Barium follow-through scans and GER Scans , delayed images upto 6–24 hours may be required,” he adds.
“One of the aims of the imaging study is to ensure patient comfort and minimise pain,” says Dr Prabhu. “Paediatric imaging centres are now designed with child-friendly colours and designed to make the place look less intimidating for the young child. Having dedicated personnel including radiation technologists, nursing staff and radiologists trained and experienced in dealing with children and well-versed in the most effective and optimal use of the technologies tailored for the paediatric patients is extremely important to ensure an overall improved experience for the child and family,” he adds.
Efforts are being made to reduce unnecessary needle use in children. “Many centres now try and minimise the number of needles that children require during their stay in the hospital by educating providers and instituting system practices that encourages use of dual-purpose catheters that can be used for multiple imaging procedures and administering medications,” explains Dr Prabhu.
Pre-play to familiarise the child with a particular modality also helps reduce fear. “In young children, use of ‘mock MRI’ where a play therapist helps the child acclimatise to the noises and closed space of the scanner on a non-working scanner replica before the real scan is another innovative method used in some paediatric centres,” Dr Prabhu explains.
Assessing the need
Although imaging answers a lot of questions about the disease one should tread carefully while prescribing them. “Paediatric imaging should be done only when really required. We generally order an X-ray or other modality of imaging like CT or MRI when it is actually going to affect the course of treatment, or make a diagnosis, or affect the future outcome. It should be remembered that radiation exposure has its own hazards and the most dangerous one is the risk of cancer following exposure to radiation,” says Dr (Maj) Manish Mannan, Consultant and Coordinator, Paediatrics and Neonatology, Mother and Child Unit, Paras Hospitals, Delhi. Agreeing Dr Chugh says, “Children are more radio-sensitive than adults (i.e., the cancer risk per unit dose of ionising radiation is higher), have a longer expected lifetime for any effects of radiation exposure to manifest as cancer; and use of equipment and exposure settings designed for adults may result in excessive radiation exposure if used on smaller patients. Hence most definitely in ordering radiological investigations in children, one should be absolutely sure whether it is necessary and not just a part of a basic or routine work up.”
Risks involved
Dr Chugh says, “Risks from X-ray imaging are due to exposure to ionising radiation and possible reactions to the intravenous contrast agent, or ‘dye’ that is sometimes used to improve visualisation.” He further explains, “These risks include tissue effects such as cataracts, skin reddening, and hair loss, which occur at relatively high levels of radiation exposure; more importantly, ionising radiation has enough energy to cause damage to DNA and thus puts the patient at risk of developing cancer in later life.
Talking about the risk of exposure to children, Dr Kalyanpur says, “Radiation dose and safety are issues that while not unique to the paediatric population, nonetheless have their greatest impact on children. This is because their cells and tissues are actively growing and developing and are therefore most sensitive to cumulative radiation damage resulting in potential mutation and carcinogenesis. Paediatric imaging therefore requires a much greater sensitivity on the part of the radiologist to the issue of radiation dose and safety.” Echoing his concerns, Dr Chavhan says, “One important point I would like to emphasise is radiation risks in children from imaging. There is now some evidence that radiation exposure from imaging puts children at a very small but definite risk of cancer development later in life CT scan is the biggest culprit for the radiation exposure because of high radiation doses. Smaller the child when he/she is exposed to radiation more is the chance of cancer development because of immature tissues and more years they liver as compared to adults. Because of this, the current educational and research efforts in paediatric imaging are either directed towards reduction in radiation doses for CT scan or utilisation of radiation-free modalities. In our hospital, we have decreased the use of CT scan and are using more ultrasound and MRI.”
ALARA
The knowledge of risks of exposing children to ionising radiations has always been there and the current focus of paediatric radiologists around the world is to keep radiation dose as low as reasonably achievable (ALARA).
“One should follow the recommendation of ALARA. When a child is being exposed to X-ray of one part of the body, it is very important to shield other parts, particularly the genitalia. Similarly, if a child in the ward is being exposed to an X-ray by means of a portable X-ray machine, it is important that other children in the vicinity are shielded from unnecessary radiation,” recommends Dr Mannan.
Concerns over radiation risk to children led to the formation of the Alliance for Radiation Safety in Pediatric Image Imaging (Image Gently Alliance). Their aim is to improve safety and effectiveness of imaging care of children worldwide. This is achieved through increased awareness, education and advocacy on the need for appropriate examination and amount of radiation dose when imaging children.
Recently, Dr Stephen J Swensen, Radiologist, Mayo Clinic called for standardisation of safe imaging protocol for children. In a commentary published online in the Journal of Patient Safety, he called for the American College of Radiology, Joint Commission, Intersociety Accreditation Commission, and the Centers for Medicare & Medicaid Services to require three safety practices for accreditation of all American hospitals and advanced diagnostic imaging facilities. His mantra for imaging children is ‘The Right Exam, ordered The Right Way, with The Right Radiation Dose’. “We have the knowledge and the tools today that can substantially improve the safety and quality of care for our children (while also decreasing costs). We have a compelling opportunity to reduce harm for the most susceptible population: our children,” Dr Swensen said in a press release.
Advances in India
Paediatric radiology is yet to take off in India. There are very few dedicated children’s hospitals in India though most hospitals have a paediatric unit. Radiologists in these set-ups are therefore expected to multi- task. In fact, there are very few avenues for radiologists to train in paediatric radiology and even fewer financial incentives to practice it. “In India, the radiologists who practice pure paediatric radiology would be less than 10. Given that we have a population of 1.2 billion with one-third below the age of 15, this is woefully inadequate,” says Dr Bhavin Jhankaria, President- SRL Diagnostics – Jankharia Imaging and President, Indian Radiological and Imaging Association.
An editorial he wrote for the journal of IRIA in 2010 highlighted the plight of paediatric radiology in India. He wrote, “training in paediatric radiology in India is inadequate, the focus on training is all but absent and this translates into inadequate and perhaps poor care in the majority of radiology centres and departments across the country.”
The creation of Indian Society of Pediatric Radiology (ISPR) in 2003 has given some hope to radiologists who are passionate about paediatric imaging. The society conducts annual conferences and CMEs but has not been able to successfully advocate for separate paediatric radiology training. This leaves a lot to be desired in paediatric imaging in India, specially in the area of dose management.
“Having worked both in India and Canada, I find the radiation risk awareness amongst the medical community, leave alone the general public, in India negligible as compared to North America. Here, it is not uncommon for us when parents come and ask how much radiation dose my child is getting and is there any alternative test that can provide the answer,” says Dr Chavhan. “This kind of awareness needs to be created in India as well,” he adds.
India has the world’s largest child population at 400 million and it is expected to rise. Demand for dedicated paediatric imaging continues to rise, but the radiologists have not yet woken up to the unique opportunity.
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