Kitten Scanner reduces the use of sedation in pediatric MRI

Abstract

The use of sedation before a magnetic resonance imaging (MRI) scan is a common practice to overcome motion artifacts and anxiety in children. However, this technique has its drawbacks. We retrospectively compared the number of children undergoing a brain MRI scan with or without sedation before and after the introduction of an educational training protocol using a toy scanner (the Philips Kitten Scanner) and we investigated the effectiveness of this training in relation to children’s age and gender. We considered 1461 children between 4 years and 14 years. Of them, 158 had a diagnosis of autism spectrum disorder or attention-deficit hyperactivity disorder and were excluded from further analysis. After the introduction of the Kitten Scanner training protocol, the sedation need decreased by 30% in the total sample group and in children younger than 10 years in particular. Before the training, females were more likely to undergo the MRI examination without sedation as compared to males, while after its introduction this gender difference was no more visible.

Keywords

Children educational intervention magnetic resonance imaging sedation toy scanner

Introduction

Magnetic resonance imaging (MRI) is a diagnostic technique commonly used in pediatric radiology since it lacks ionizing radiation and allows high-quality images.

However, undergoing an MRI examination can be quite an unpleasant experience for children. Since the MRI is sensitive to motion, children are required to remain still for prolonged periods of time during image acquisition, which can result in discomfort and agitation. In addition, the unfamiliar environment, the dimension of the machine, and the noises associated with the scan can cause anxiety and fear.

A common practice to overcome these difficulties is the use of sedation (Arlachov and Ganatra, 2012; Boyer, 1992; Serafini et al., 2005). However, this procedure has some drawbacks.

First, sedation is not free of medical complications due to the drugs used to induce it. A major side effect is cardiorespiratory depression. Other adverse events that children can experience are post-sedation gastrointestinal symptoms (i.e. nausea, vomiting), motor imbalance, and agitation (Arlachov and Ganatra, 2012; Kaila et al., 2012; Malviya et al., 2000a, 2000b).

In addition to health risks, sedation has an impact on hospitals’ resources. Vanderby and colleagues (2010) reported that the visit duration of children who underwent MRI examination with sedation or anesthesia was longer compared to the visit duration of children who did the examination awake. In addition, the costs for the MRI examination with sedation and anesthesia (in terms of human resource and medication use) were 3.24 and 9.58 times higher, respectively, than the costs for the MRI examination without them (Vanderby et al., 2010).

Finally, sometimes sedation failures can occur. In these cases, the examination has to be rescheduled, leading to increased costs and increased patients’ anxiety.

For these reasons, noninvasive strategies have been developed to reduce the use of sedation in pediatric radiology (Edwards and Arthurs, 2011; Jaimes and Gee, 2016). Simulation of an MRI examination with the help of a mock scanner and play therapy before the real MRI examination are typically used in children older than three to four years of age (Edwards and Arthurs, 2011; Jaimes and Gee, 2016). These strategies have proven to be successful in obtaining high-quality MRI and fMRI images and in improving the compliance of different clinical populations of children (Barnea-Goraly et al., 2014; de Bie et al., 2010; Nordahl et al., 2016; Raschle et al., 2009; Shearrer et al., 2016; Törnqvist et al., 2015). In addition, the use of educational videos (Szeszak et al., 2016) and psychological interventions such as clown shows, pet, and music therapy (Viggiano et al., 2015) have been reported to be beneficial in reducing fear and anxiety before an MRI examination.

In 2011, Villa Serena Hospital in Pescara (Italy) developed its first educational intervention with the aim to familiarize children with the MRI procedure and to reduce sedation using a miniaturized version of a real scanner, the Philips Kitten Scanner. In this report, (1) we retrospectively compared the number of children undergoing a brain MRI scan with or without sedation before and after the introduction of the Kitten Scanner training protocol and (2) we specifically investigated its effectiveness in relation to children’s age and gender. To our knowledge, this is the first Italian retrospective study examining in a large cohort of pediatric patients aged between 4 years and 14 years the effects of a noninvasive strategy in reducing the use of sedation before the MRI examination.

Materials and methods

Participants

In this retrospective analysis, we considered all children aged between 4 years and 14 years (N = 1461) who underwent for the first time a brain MRI investigation in Villa Serena Hospital (Pescara, Italy) during a period of seven years (from January 2008 to December 2015). Considering the retrospective nature of the study, a formal consent from the local ethic committee was not required.

The population consisted almost exclusively of outpatients and in minimal part of hospitalized patients. Principal diagnoses for MRI investigation were epilepsy, head injuries, suspected cerebral malformation, neuropsychiatric disorders, developmental delay, brain tumors, and headache.

In order to study the number of children undergoing a brain MRI scan without sedation before and after the introduction of the Kitten Scanner training protocol, we divided our population into two groups. Group 1 includes all children (n = 570) who underwent the MRI examination before the Kitten Scanner introduction (January 2008–August 2011) and group 2 includes all children (n = 891) who underwent the MRI examination after its introduction (September 2011–December 2015). In both groups, we further divided children as follows:

those whose treating physician’s referral didn’t require sedation (Req−); and

those whose treating physician’s referral required sedation (Req+).

In Req+ group, there were 158 children with autism spectrum disorder (ASD) or with attention-deficit hyperactivity disorder (ADHD; 3 and 155 in groups 1 and 2, respectively) which were excluded from further analysis. This was necessary because a diagnosis of ASD or ADHD was an exclusion criterion of the Kitten Scanner training protocol, which required a level of attention and cooperation that is difficult to achieve in these children.

Children of Req+ group included in the analysis were then subdivided into those who underwent the MRI examination with sedation (Sed+) or without sedation (Sed−; see Figure 1).

Figure 1.

Flowchart of the study sample. MRI: magnetic resonance imaging.

Kitten Scanner training protocol

Written informed consent to take part in the training was obtained from the parents or the legal guardians of all children. The training was always scheduled the same day of the actual MRI investigation and was conducted by an experienced child life specialist. Upon arrival, the children together with their parents were admitted in the Kitten Scanner room where they were welcomed by the child life specialist in charge of the training. The room is designed to be child-friendly and to reduce stress and anxiety in both children and parents with comfortable couches, soft lights, and small tables and chairs (see Figure 2).

Figure 2.

Kitten Scanner room.

The training protocol consisted in a role-play session guided by the child life specialist in the presence of the parents. During this session, children were engaged in a simulation of the real MRI investigation with a toy-scanner called Kitten Scanner (Philips Ambient Experience). During this simulation, the children impersonated the MRI technologist who conducts the MRI scan. The children were invited to choose one among four toy-animal “patients” (Doris the Chicken, Robbie the Robot, Olly the Elephant, and Chris the Crocodile) and to place it in the Kitten Scanner to start the examination. At this point, the TV-screen close to the Kitten Scanner was activated by the tag inside the toy, showing a short animated video. The animation was different for each toy-animal patient. However, the storyline of each animation followed the same script: The animated videos always explained why the toy-animal “patient” needed the MRI examination, what is an MRI scan, and how the examination is performed, using a child-friendly language. The duration of the role-play session (including watching the short videos—see the Online Supplementary Material 1 for short videos duration) could last between 30 minutes and 40 minutes depending on both children and parents’ collaboration.

The training protocol was planned to familiarize the children with the MRI process before the actual scan, by reducing distress and agitation for the upcoming examination. This would help them understand what they are going to experience (i.e. the noises of the MRI scan) and what they have to do in order to have a successful scan (i.e. to lie still for a prolonged period).

At the end of the role-play session, depending on the level of collaboration reached, children underwent the MRI examination with (failure of the training) or without sedation (success of the training).

Scanning protocol with and without sedation

In the case of MRI scanning with sedation, the routinely administration procedure usually requires between 5 minutes and 30 minutes before the examination, depending on children collaboration. During the MRI acquisition, parents are not allowed to stay inside the MRI room. After the scan session, sedated children are brought into the “awakening room” in which parents are allowed to enter and wait the children to wake up. Usually, children recovery lasts between 30 minutes and 60 minutes.

In the case of an MRI examination without sedation, as a standard procedure to encourage the children and obtain their best cooperation, one of the parents is allowed to stay inside the MRI room during the whole MRI scan session. Also for children who after the Kitten Scanner training decided to undergo the scan without sedation, one of the parents was allowed to be inside the MRI room during the scan session.

MRI investigation

Structural images were acquired on Philips Ingenia 1.5T scanner (Amsterdam, the Netherlands). Total MRI scanning session varied between 20 minutes and 40 minutes. The quality of MRI images taken after the Kitten Scanner training was evaluated by an experienced radiologist and categorized either as of sufficient quality for diagnostic purposes (little or no motion artifact) or of not sufficient quality for diagnostic purposes (excessive motion artifacts and/or incomplete scan).

Statistical analysis

We present the results for the total sample group (children between 4 years and 14 years) as well as per age group (4–9 years and 10–14 years). Statistical analysis was performed with R statistical software package, version 3.4.2 (http://www.R-project.org). Descriptive statistics were reported as median (interquartile range) as well as frequencies (percentages). For the comparison of categorical data, the χ ² test was performed. The comparison of continuous data was performed with nonparametric tests because the assumptions for parametric testing were not satisfied. For the comparison between two independent groups, we used the Wilcoxon rank sum test, while for the comparison between more than two independent groups, we performed the Kruskal–Wallis test followed by the Dunn’s test with Bonferroni adjustment of p-value for post hoc comparisons. All tests were two-sided and the level of significance was set to p < .05.

Results

Total group (4–14 years) and children between 4 years and 9 years

In Table 1, demographic characteristics of the total group and for the four to nine years age group are reported. There weren’t any significant differences in terms of age between males and females (total group: p = .2; four–nine years age group: p = .3) and between group 1 and group 2 (total group: p =.3; four–nine years age group: p = .5); moreover, the proportion of males and females did not differ between groups 1 and 2 (total group: p = .5; four–nine years age group: p = .5). As we could expect, children who didn’t need sedation as stated in their treating physician’s referral (Req−) were significantly older compared to children whose treating physician’s referral required sedation (Req+; total group: p < .001, 95% confidence interval (CI): −5 to −4.9; four–nine years age group: p < .001, 95% CI: −3 to −2).

Table 1.

Demographic characteristics of the total group (4–14 years) and of children between 4 years and 9 years.

	Total (N)	Age in years, median (IQR)	Females, n (%)
Total group (4–14 years)	1461	9 (6–12)	658 (45)
Group 1	570	9 (6–12)	263 (46)
Group 2	891	9 (6–12)	395 (44)
Children between 4 years and 9 years	763	6 (5–8)	339 (44)
Group 1	286	6 (5–8)	122 (46)
Group 2	477	7 (5–8)	217 (45)

Note: IQR: interquartile range.

Considering only Req+ children (except those with ASD or ADHD, as stated in the “Participants” section), after the introduction of the Kitten Scanner training, there was a significant increase in the number of children undergoing the brain MRI scan without sedation (group 2/Sed−), both for the total group (χ ² (1, N = 361) = 157.79, p < .001, odds ratio = 24.8, 95% CI: 14.4–44.2) as well as for the four to nine years age group (χ ² (1, N = 335) = 138.29, p < .001, odds ratio = 21.8, 95% CI: 12.6–39.2; see Table 2).

Table 2.

Demographic characteristics of subgroups Sed+ and Sed− in relation to group 1 and group 2 for the total group and for children between four years and nine years.

	Group 1		Group 2		p-Value
	Sed+	Sed−	Sed+	Sed−	p-Value
Total group (4–14 years)
n (%)	139 (84)	27 (16)	33 (17)	162 (83)	<.001^a
Age in years, median, (IQR)	5 (4–6)	7 (6–7)	6 (5–7)	7 (5–8.75)	<.001^b
Females, n (%)	52 (37)	18 (67)	13 (39)	70 (43)	.009^c
Children between 4 years and 9 years
n (%)	139 (84)	26 (16)	33 (19)	137 (81)	<.001^d
Age in years, median, (IQR)	5 (4–6)	7 (6–7)	6 (5–7)	6 (5–8)	<.001^e
Females, n (%)	52 (37)	17 (65)	13 (39)	60 (44)	.01^f

Note: IQR: interquartile range; CI: confidence interval.

^a Odds ratio = 24.8, 95% CI: 14.4–44.2.

^b Group 2/Sed+ > group 1/Sed+ (p = .003, 95% CI: 16–121); group 1/Sed− > group 1/Sed+ (p < .001, 95% CI: 56–169).

^c Group 1: odds ratio = 3.3, 95% CI: 1.4–8.3; group 2: p = .8.

^d Odds ratio = 21.8, 95% CI: 12.6–39.2.

^e Group 2/Sed+ > group 1/Sed+ (p = .001, 95% CI: 20–117), group 1/Sed− > group 1/Sed+ (p < .001, 95% CI: 55–162).

^f Group 1: odds ratio = 3.1, 95% CI: 1.3–7.9; group 2: p = .8.

In the total sample, before the Kitten Scanner training introduction, more females underwent the MRI scan without sedation (67%) than did males (33%), χ ² (1, N = 166) = 6.8, p = .009, odds ratio = 3.3, 95% CI: 1.4–8.3. After, there was no difference between male and female sedation need (p = .8). This same pattern of results was observed in the four to nine years age group (see Table 2).

In group 1, both in the total sample as well as in the four to nine years age group, Sed− children were older than Sed+ children (total sample: p < .001, 95% CI: 56–169; four to nine years age group: p < .001, 95% CI: 55–162). This difference was not present in group 2. In addition, we found that group 1/Sed+ children were younger than those of group 2/Sed+. In order to control whether older age could have boosted the number of scans without sedation after the Kitten Scanner training, we performed a further analysis only on four to six years aged children which is reported in Online Supplementary Material 2.

According to adopted criteria (see the “MRI investigation” section), all brain MRI examinations performed without sedation after the Kitten Scanner training were of sufficient quality to be used for diagnostic purposes.

Children between 10 years and 14 years

Ninety-seven percent (97%) of children in this age group did not need sedation. In 10–14 years/group 1 (n = 284), all children had the MRI examination without sedation. In 10–14 years/group 2 (n = 414), 396 children did not need sedation; of them, 371 as required by their treating physician’s referral and 25 thanks to the Kitten Scanner training protocol.

Discussion

Despite the frequent use of sedation in pediatric MRI, this procedure can put at risk children’s health (Arlachov and Ganatra, 2012; Boyer, 1992; Serafini et al., 2005) and can be quite expensive (Vanderby et al., 2010). For these reasons, in the last few years, several noninvasive psychological interventions have been developed in order to reduce the use of sedation in pediatric patients (Edwards and Arthurs, 2011). These strategies are preferable because they can minimize the negative emotions that can be associated with the upcoming examination (Szeszak et al., 2016; Viggiano et al., 2015) and can help children to understand that the procedure is not dangerous (Szeszak et al., 2016).

The aim of this retrospective study was to examine the number of children (aged between 4 years and 14 years) undergoing a brain MRI scan with or without sedation before and after the introduction of a noninvasive strategy—the Kitten Scanner educational training protocol—to reduce the use of sedation in pediatric MRI. In addition, we wanted to investigate whether the Kitten Scanner training protocol was effective in all children or whether some demographic characteristics (age and sex) could have modulated its efficacy.

Considering the period before the introduction of the Kitten Scanner training (January 2008–August 2011), 30% of all children aged between 4 years and 14 years were admitted to our hospital for a brain MRI investigation with sedation (as requested by the treating physician’s referral). Of them, only 16% underwent the MRI examination without the need to be sedated. After the introduction of the Kitten Scanner training (period taken into consideration: September 2011–December 2015), the number of children undergoing the scanning without sedation, even if they were admitted for an MRI scan with sedation, increased up to 46% (83% when children with ASD or ADHD are excluded). Children who received most benefit from this training were in the four to nine years age group. Precisely, before the Kitten Scanner introduction, in the four to nine years age group, there were 59% of children requiring sedation; of them, 83% underwent MRI scan with sedation. After the Kitten Scanner introduction, of the 64% of children requiring sedation, those who needed to be sedated decreased to 55% (11% when children with ASD or ADHD are excluded).

As for the Kitten Scanner training, rates of success were high. In children aged between 4 years and 14 years who took part in the training, 83% of them after the training did not need to be sedated. When we subdivided children into two age groups, we found that in the small group of children aged between 10 years and 14 years who took part to the training, this was 100% successful. In the larger group of children younger than 10 years old, the Kitten Scanner training was successful in 81% of cases. de Bie and colleagues (2010) reported similar rates of success in children aged less than seven years with a mock scanner training protocol. Similarly, Barnea-Golany et al. (2014) reported that of their cohort of children aged 4–10 years, just 4 out of 226 children did not pass the mock scanner training.

Older age can account for less sedation need: in our total sample, 97% of children between 10 years and 14 years were scanned without sedation. In addition, before the introduction of the Kitten Scanner training, the small number of children who underwent the examination without sedation despite a specific request was older. However, this age difference was not present after the introduction of the training. As expected, the training helped younger children to overcome their difficulties and was successful in the reduction of sedation. On the other hand, we should point out that the age spread of the 195 children of group 2 admitted to the training was broader (between five years and eight years) than of the 166 children of group 1 (four–six years), but also considering only children between four years and six years, the reduction in sedation use remains highly significant between groups 1 and 2, excluding the potential influence of older age on our results (see Online Supplementary Material 2).

As for gender differences, we noticed that before the introduction of the Kitten Scanner training, females were more likely to undergo the examination without sedation than males. This wasn’t the case after the introduction of the training protocol. Since the proportion of males and females was the same between groups 1 and 2, we can infer that the training was more helpful in males.

We are aware that ruling out children with ADHD or ASD is a possible limitation for the training protocol, also considering the increase in the requests of sedation for MRI in these children in the last years (group 1: 3 children; group 2: 155 children). However, specific protocols (Nordahl et al., 2016) are needed for this particular population of patients and we do not exclude to implement a training tailored for them in the future.

Conclusion

To our knowledge, this is the first Italian study in which the rates of sedation use and the efficacy of a noninvasive strategy to reduce the use of sedation were investigated. After the introduction of this educational training protocol, we assisted to an overall decrease in the use of sedation of 30%. Moreover, considering that a large proportion of children needing sedation were in the four to nine years age group, we can conclude that this training was highly effective in these children.

Supplemental Material

Supplementary_material_1 - Kitten Scanner reduces the use of sedation in pediatric MRI

Supplementary_material_1 for Kitten Scanner reduces the use of sedation in pediatric MRI by Eleonora Cavarocchi, Ilde Pieroni, Antonio Serio, Lucio Velluto, Biancamaria Guarnieri and Sandro Sorbi in Journal of Child Health Care

Supplemental Material

Supplementary_material_2 - Kitten Scanner reduces the use of sedation in pediatric MRI

Supplementary_material_2 for Kitten Scanner reduces the use of sedation in pediatric MRI by Eleonora Cavarocchi, Ilde Pieroni, Antonio Serio, Lucio Velluto, Biancamaria Guarnieri and Sandro Sorbi in Journal of Child Health Care

Footnotes

Authors’ note

The Kitten Scanner was not provided free of charge but it has been regularly acquired by Villa Serena Hospital according to Philips official price list.

Acknowledgement

The authors would like to thank Dr Concetta Petruzzi, Chairman Board of Directors of Villa Serena Hospital, for her particular attention and contribution in the development of this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

References

Arlachov

Ganatra

(2012) Sedation/anaesthesia in paediatric radiology. The British Journal of Radiology 85: e1018–e1031. DOI: 10.1259/bjr/28871143.

Barnea-Goraly

Weinzimer

Ruedy

. (2014) High success rates of sedation-free brain MRI scanning in young children using simple subject preparation protocols with and without a commercial mock scanner–the Diabetes Research in Children Network (DirecNet) experience. Pediatric Radiology 44(2): 181–186. DOI: 10.1007/s00247-013-2798-7.

Boyer

(1992) Sedation in pediatric neuroimaging: the science and the art. AJNR 13(2): 777–783.

de Bie

HMA

Boersma

Wattjes

. (2010) Preparing children with a mock scanner training protocol results in high quality structural and functional MRI scans. European Journal of Pediatrics 169(9): 1079–1085.

Edwards

Arthurs

(2011) Paedriatic MRI under sedation: Is it necessary? What is the evidence for the alternatives? Pediatric Radiology 41(11): 1353–1364.

Jaimes

Gee

(2016) Strategies to minimize sedation in pediatric body magnetic resonance imaging. Pediatric Radiology 46(6): 916–927. DOI: 10.1007/s00247-016-3613-z.

Kaila

Chen

Kannikeswaran

(2012) Postdischarge adverse events related to sedation for diagnostic imaging in children. Pediatric Emergency Care 28(8): 796–801. DOI: 10.1097/PEC.0b013e3182628829.

Malviya

Voepel-Lewis

Eldevik

. (2000a) Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. British Journal of Anaesthesia 84(6): 743–748. DOI: 10.1093/bja/aer407.

Malviya

Voepel-Lewis

Prochaska

. (2000b) Prolonged recovery and delayed side effects of sedation for diagnostic imaging studies in children. Pediatrics 105(3): e42–e42. DOI: 10.1542/peds.105.3.e42.

10.

Nordahl

Mello

Shen

. (2016) Methods for acquiring MRI data in children with autism spectrum disorder and intellectual impairment without the use of sedation. Journal of Neurodevelopmental Disorders 8(20): 1–10. DOI: 10.1186/s11689-016-9154-9.

11.

Raschle

Lee

Buechler

. (2009) Making MR imaging child’s play-pediatric neuroimaging protocol, guidelines and procedure. Journal of Visualized Experiments: JoVE 1–5. DOI: 10.3791/1309.

12.

Serafini

Ongaro

Mori

. (2005) Anesthesia for MRI in the pediatric patient. Minerva Anestesiologica 71(6): 361–366.

13.

Shearrer

House

Gallas

. (2016) Fat imaging via magnetic resonance imaging (MRI) in young children (ages 1–4 years) without sedation. PLoS One 11(2): e0149744. DOI: 10.1371/journal.pone.0149744.

14.

Szeszak

Man

Love

. (2016) Animated educational video to prepare children for MRI without sedation: evaluation of the appeal and value. Pediatric Radiology 46(12): 1744–1750. DOI: 10.1007/s00247-016-3661-4.

15.

Törnqvist

Månsson

Hallström

(2015) Children having magnetic resonance imaging: a preparatory storybook and audio/visual media are preferable to anesthesia or deep sedation. Journal of Child Health Care 19(3): 359–369.

16.

Vanderby

Babyn

Carter

. (2010) Effect of anesthesia and sedation on pediatric MR imaging patient flow. Radiology 256(1): 229–237. DOI: 10.1148/radiol.10091124/-/DC1.

17.

Viggiano

Giganti

Rossi

. (2015) Impact of psychological interventions on reducing anxiety, fear and the need for sedation in children undergoing magnetic resonance imaging. Pediatric Reports 7(1): 13–15. DOI: 10.4081/pr.2015.5682.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.22 MB

0.02 MB