Immobilization in paediatric radiography

Marjo Puolakanaho, radiographer

Oulu University Hospital

15.5.2019

Oulu University HospitalChildren’s radiology departement

• Oulu University Hospital (OYS) is the northernmost of five university central hospitals in Finland.

• There are over 6000 employees

• In the department of radiology we have 150 radiographers and 55 radiologists.

• In the children’s radiology department there are 15 radiographers, 3 radiologists.

X-rays taken of children in Oulu University hospital

• There were 14 500 x-ray examinations taken of children in Oulu university hospital in the year 2018.

Interaction with children in the radiology department

• Radiographic imaging of infants and young children requires the special attention of radiographers.

• When the patient is a child, the radiographer faces number of challenges in carrying out the examination successfully.

Interaction with children in the radiologydepartment• Childrens behaviour is often difficult to

predict

• One approach will not suit all children

• It’s all about radiographers interactionskills

• It’s challenging to create trust in the shortmoment that we have with our patients.

Children's fears in hospital

As a radiographer we work in a challenging environment whatcomes to childrens fears.

According to studies children fearthe most when being in hospital:• Medical operations

• Being seperated from parents

• Pain

• Darkness

• Noises

Environment

• Pay attention what your enviroment looks like and make it more childfriendly if possible.

Immobilization

• For infants and children whocannot co-operate, followdirections or control theirbody movement during x-ray, immobilization techniques arenecessary.

Immobilization

Immobilization is needeed to get diagnostic images and to keep the dose as low as possible.

Infants and young children are at risk for injuri from adverse effects of radiation.

With a appropriate use of immobilization equipment:

• We manage to prevent repeated x-rays

• We can pay attention to a proper collimation

• We reduce motion artefacts

• It’s easier to shield non-examined parts of the body

Immobilization

• Children reach different levels of cognitive thinking at different ages

• The ability varies from child to child at what age they can understanddirection.

• Usually children can be talked through an examination at the age of 3-4 but there are huge variances from child to child.

• The most important part is building trust to the child and making thechild feel comfortable

Referral

• Well written referral is an important tool for a radiographer

as we have to build trust in such a short time

• Anamnesis should be exact.

• Radiographer must have enough information and knowledge of the child’s illness or injury to procede the examination and guide both parents and child professionally.

• A little extra words in referral like ”a shy boy” or ”swedishspeeking girl” can help a radiographer to build trust withpatient better starting from the first impression.

Knowledge of children's disease

• As a radiographer we have to be aware of the typical features of child's development or typical features of child’s disease

• If patient has a disease that you don’t recognize, find it out.

• Knowledge of children's diseases helps you to face parents and to understand family's and child's situation.

• There are also rare diseases (for example osteogenesis imperfecta) that needs to be taken consider when planning a safe immobilization.

First impression

• How radiographers approch and communicates with child and

parents, can either "make it or brake it".

• Talk to both parents and child

• The first impression is very important and when it’s done properly it helps building trust to the parents and child.

• From the first imperssion try to reach child's confidence. Besupportive and praise immediately when possible.

Parental presence and assistance duringradiographic examination• With infants and young children, parents (or other accompanying

person) can stay with child during radiographic examination.

• The presence of the familiar parent is comforting to a child and canlessen anxiety and protest.

• With radiographers good quidance, parent can assist restraining thechild.

If assistance person is required for immobilization

Primaly a family member

Generally not to be done by radiological or hospital staff

If hospital staff assist, needs to ensure that thesame staff members are not repeatedly exposed

Those who are pregnant are not allowed to act as assistace

Neither person younger than 18 years

Guide and explain to parents

First tell tell the parent what is about to happen

• how many x-rays should be taken

• in which position the x-rays are taken

What should the parent do

• give exact instructions for the parent

• where should the parent stand or sit

• what should the parent do with her/his hands when assisting in the examination

• encourage the parent, remember that examinations in a hospital may be frightening also for parents

Explain to parents...

• Why is immobilizationequipment needeen?

• Is it painful?

"We use this sadbags to preventbaby moving when taking x-ray..."

"...These sadbags are replaced sothat it's not painfull for baby."

"If baby cries, it's ok."

Guiding a parent and a child

• Give positive and spesific instuctions to the child

"You're doing great, keep your hand still, just like that... ”

• If parent is assisting, give instructions to the parent as well.

”With your left hand, hold here. Try to keep this area from notmoving.."

Chest x-ray (0-6 months)

• Usually parent stays assisting if there's any risks for baby turning on the bed.

• For a newborn it's not usually necessery to have parent assisting if we use sadbags properly and the baby is calm.

• Fine tools for chest x-ray are swaddling clothes and sadbads. Photo:Pixabay

Chest x-ray (0-6 months): AP

Use a swaddling clothe to immobilize arms. Put a sadbag over the hips and around arms and head.

Chest x-ray (0-6 months): AP Just before exposure

Chest x-ray (0-6 months)

How to use swaddling clothes to immobilize hands.

• Head mains straght as we lifthands up

• It’s important that hands aresymmetrically to get a straightview of the lungs.

Chest x-ray lateral

Lateral view can be more challenging . If baby resists this position much, it's useful to have parent holding hands and head if baby is older than a newborn. Sometimes AP is taken without anyone assisting, and lateral is taken with parent assisting.

Chest x-ray (6 months – 3 years)

• After baby has started to practice sitting (usuallyafter 6-7 months) chest x-ray can be taken seated. (You can ask parents if baby has sitted in a high chair for babies at home)

• As a tool we use in Oulu a custom made chair and sometimes a sadbag is needed over hips.

• Usually parent stays assisting by lifting child'shands up.

Chest x-ray (6 months - 3 years)

Chest x-ray (3 years - 4 years)

• When parent is not needed to assist, child is guided to take from the handle above.

• When lifting hans up we usually get also moreair to the lungs.

• If child is lively, seated x-ray is easier for many 3-4 years old.

• When giving breathing instructions for smaller

children, notice that collimation is not too strictas they might move when taking a deep breath.

Chest x-ray (3 years - 4 years)

This is the time to be really supportive andpraise the child!

With little things youcan make the

experience great. Member to give a sticker or two to

reward child after theexamination.

Chest x-ray (over 3 years)

• It's in radiographers concideration, when to take chest x-rayseated/standing, AP/PA, wheather to give breathing instructions

• When taking the x-ray AP instead of PA child is feelingmore confortable, but as soon as child is co-operative enough we take chest x-rays PA becouse of the effects of radiation

Chest x-ray of a newborn in theintensivecare unit• Radiographer usually goes to

intensivecare unit independentlyat my workplace. Alsoradiographer student is participating and guided as well.

• We cherish good co-operation and teamwork withnurses in the intensive care unit

Chest x-ray of a newborn in theintensivecare unit1. Collect tools: sadbags and swaddling clothes

2. Set exposure settings

3. Prepare ”camera” nearby

4. Straighten bed

5. Take of blanket, clothes, everything extra so it’s easier to work

6. Tell the nurse when it’s okey for her/him to lift the baby and putdetector under the baby

7. Put a sandbag over the hips. When doing this, the nurse holdshead and hands of the newborn

Chest x-ray of a newborn in theintensivecare unit7. Then immobilize arms. Experienced nurses mayhelp with the other arm if you can’t reach to theother side. Be careful with tubings whenimmobilization.

8. Straighten head carefully.

9. Make sure hands are symmetrically and estimatethat you get a straight radiograph in this position

10. Collimate and make yourself proud with perfectcollimation! :)

Chest x-ray of a newborn in theintensivecare unit

Chest x-ray of a newborn in theintensivecare unit• Almost never is assistance person needeed.

• Usually a newborn doesn’t like to be put in this position, but after youget the final position and sadbags are used properly, babies oftenseem to calm down and feel safe in this thight position.

• Notice that if you’re taking the lateral view also, and baby is calm, start by setting exposure values, turning the ”camera” ready for thelateral view and then release the sandbags and take off detectorunder the baby.

Upper libs (0-6 months)

• With babies use swaddlingclothes and sadbags to immobilize body. Tape is useful for immobilize the hand.

• Usually parent stays assisting ifthere's any risks for baby turning on the bed or baby moves hand

Upper limbs (6 months - 3 years)

• With smaller children upperlimbs x-rays are often takenso that the child is sitting on parent's laps.

• Parent can assist by heldingchild's hand

• Sometimes tape can be a useful tool. For examplewhen taking a x-ray of a finger.

Skull x-ray

• Skull x-ray is usually taken so that baby or child is lying.

• With a co-operative child examination can be done child seated.

• Usually parents stay assisting with babies and smaller children.

Skull x-ray: AP

• As a tool we use custom made paddings and swaddling clothesas well. Also a thin pillow can beused under the head.

Skull x-ray: AP

• If you think that baby or childresist much, start with swaddlingthe baby or child, to get hers/hishands away from the head.

• Put a sandbag over body/hands.

Skull x-ray: AP

• Paddings are used to support headstraight. With paddingswe manage to keep parents handsaway from head and exposuredarea.

• Remember to tell that paddings areneeded to immobilize head and this way parents hands don't cover anything we like to see in the x-ray.

• Highlight that paddings are notpainful for the child

Skull x-ray: lateral

• Lateral view of skull is often challenging.

• You can use a sheet/swaddling clothe as tool. We use these ribbons cut from swaddling clothes

• Assistance person takes a tight grip of the ribbon

• You can either turn the head, but for smaller babies you might need to turn the baby on the left side.

Skeletal survey

• In this examination radiographer gets to use all immobilizationtechniques

• Usually child is under 1,5 years old and needs always immobilizationwhen taking so many x-rays.

• For a parent it can be a stressful situation, because of the clinicalconcerns that have occured.

Skeletal survey

• Guide parent/accompanying person well. Tell the plan: how manyradiographs are supposed to be taken (15 or more) and it can taketime about 45 minutes to get the examination done.

• Highlight the importance of immobilization, when taking somany radiographs.

• Create a calm athmosphere. If baby/child cries, it makes parentseasily unfocused. When you're giving advice for immobilization take a eye contant with the parent and give specific instruction.

Skeletal survey

• To our experience 3 radiographers are needed to make examinationreally succesful.

• One radiographer is guiding the child and parent/accompanyingperson and is "in lead" of the examination.

• Other radiographer is assisting withimmobilization.(giving sand bags, tape, putting leadshields on…)

• Third radiographer is checking the exposure settings

Strong-willed unco-operative child is a challenge• At times we need to do procede the examination without co-

operation with the child. Child may resist hard and cry a lot.

• Sometimes two assistants are needeed to keep child still during x-ray.

• When child resist hard, it’s radiographer who stays calm and professional all the way

• Usually children stop resisting and crying soon after they are notimmobilized anymore.

• It's important to tell parents that they managed well, and thatsometimes the examination is this challenging.

TAKE HOME

For the child and parent it may be a uniqueexperience.

With babies and smaller children it’s aboutguiding the whole family well and creating a calmatmosphere even we need to use immobilization.

With bigger children create trust, be supportiveand remember to praise the child during theexciting situation.

Use immobilization techniques to get diagnosticimages at first the exposure

Thank you!