MR Insights

A. I think over the years, of course, we’ve recognized that although we do many good things in the NICU, there are many babies, especially those born sick and premature, who have a brain injury, or who are very much at risk for brain injury. Although we do amazing clinical assessments, it’s difficult sometimes to be able to fully identify those injuries.

We can do a great neuro exam. We can do ultrasounds. We can send the baby to a follow-up clinic. But what we don’t really know, and what we don’t really have, is a very clear picture in the moment of time when the baby is in the NICU or near discharge. We don’t know what the brain really looks like, and the extent to which it has already been injured, or is maybe deficient in some part of its development.

MRI gives us images of such high detail and 360 degrees around the baby’s brain in 3D, unlike a single plane of an ultrasound. It gives more detail, it’s more sophisticated, and it’s a better tool for making those hard decisions to manage the baby in real time. It also gives the family tools needed when they are going home.

A. Speaking about conventional MRI, there are many complications. Number one is… does the hospital even have access to an MRI machine?

Babies are born on many different floor levels in a hospital or in different parts of the world. Sometimes there’s just no access to equipment. They may even have to be taken by ambulance to another hospital completely, just to have access to an MRI scan.

Or maybe the hospitals are lucky enough to be connected by a tunnel, and you can push the baby in a transport incubator for 10, 15 minutes, 20 minutes, 30 minutes basically underground into another hospital and maybe utilize an MRI located in another building.

I think the number one challenge is limited or difficult access to MRI and for this reason, for many years, we have just accepted that ultrasounds are good enough and haven’t invested in having better access to MRI. I think access is number one.

I’ve already talked about the fact that even if you have MRI in your hospital, it’s not nearby for the NICU. It’s at least two or three floors away. Typically, MRI machines are located in the basement of a hospital. Leaving the NICU and transporting the baby is a challenge.

With the many challenges that come with caring for a very sick baby, sometimes we are only able to do scans close to discharge when babies are more stable. But a very critically ill baby is just that, critically ill, and not necessarily able to be transported out of the NICU for scanning.

Trying to take the NICU with you – whether that’s equipment, whether that’s personnel – is also challenging, because maybe you don’t have enough staff that day. Maybe you don’t really have the skillset or the resources deep enough to transport this baby, so the baby just doesn’t get the imaging, and information provided to make clinical decisions is limited.

I think that another really critical issue we see is just not being able to scan very sick babies. We defer, defer, defer until they’re more stable. We’re not able to use it in real time.

There are many other risks, safety risk, infection risk, temperature risk.

A. I think number one is belief. There are still clinicians, who don’t believe all the things I just said about the value of MRI. Some of it is medical practice and belief systems, cultures of units, where they don’t really put as much emphasis or value on information provided by MRI. If you’re not already using MRI  that’s hard to get to, you probably won’t use the one that’s easy to get to.

The other thing is space. We often hear that bed spaces are precious. We want to be able to take care of as many babies as possible. If you’re licensed for 60 beds, do you want to give up a bed to put your MRI in there? That’s an administrative choice.

Sometimes people are concerned about the physical weight of MRI systems. NICU’s tend to be on very high floors. In some states we’re seeing them on the 10th floor, 11th floor and 12th floor. Weight may be an issue. An older building might need to have floor reinforcements. These are things that are just architectural barriers that with enough motivation, people can overcome.

There’s of course the investment of time and training and buying the equipment itself. Being able to implement anything new in the unit requires time to train staff.

A. Currently, I think most people default to ultrasound as a bedside tool. It’s non-invasive, with no radiation exposure. It’s pretty easy to do, with a low risk to the baby. We can bring it right to the baby.

But, it’s only one plane and a different way of looking at the brain structures. It’s good for big things and blood. But very small things and certain parts of the baby’s brain are not very easily accessible by the windows that we have with ultrasound imaging.

For ultrasound to work, you have to go through an open hole. Luckily babies have open holes (fontanels) in their heads because their brains are still developing and growing, we can use the holes behind their ears and over their soft spot. Those windows allow us to see parts of the brain, but we can’t see the whole brain. That’s where we would like to get better, more detailed imaging.

If you don’t have MRI, the only thing you’re going to do is get a CT scan. Although that is used in many parts of the developing world, in the U.S., in Europe, and in other developed nations, we would not use that due to the risk of ionizing radiation of CT and the extent of that being harmful to a developing brain. Certainly, there are places that don’t have anything and CT is better than nothing.

A. Yes. It’s really just a big, giant magnet. The magnet itself is safe. The MRI is non-radiating, so there’s no radiation exposure – none of those risks that we try to minimize.

The biggest risks with MRI for neonatal patients are all associated with doing the scans outside the NICU, in the Radiology department.  Getting the baby from the NICU to the radiology department, doing that transport safely can be very challenging. Temperature management is always an issue when moving babies from bed to bed and scanning in a large magnet system. 

Infection risk increases with exposure to more of the hospital, where the baby is going to be in the mix with a very high-paced environment that’s catering to inpatients and outpatients and pediatrics and adults.   It’s not a very selective environment. It’s a very exposed environment. I think that’s a very big problem.

Being so far away from the unit is stressful, not only on the family of that baby, who is getting this procedure done, but also to the staff and to staffing. It’s a very stressful experience to take a baby out of that safety zone of the NICU and having to care for them sometimes all by yourself in a very distant place in the hospital.

A. What we know about stress is that increased heart rate and decreased saturations can result in another injury to the brain. It can just be emotionally stressful to the baby.

Also cold stress to the baby. Temperature is very much tied to mortality. Cold babies are more likely to die, so we don’t want babies to get cold.
We spend a lot of time with very sophisticated equipment, trying to keep babies in the normal temperature range. Cold stresses their whole body.

We prefer to not sedate them, because there are harmful side effects that may occur by giving a sedation. We prefer to use what’s known as a feed and wrap technique as a tool for calming the baby and hopefully keeping them still throughout the scan.

We may delay their feeding, causing them to be hungry, so that they’ll eat right before they go into the scanner and have that little bit of a food coma. We know that stress and pain are not good for the developing brain, that those can alter their neurons and their connections in their brain for a lifetime.

A. For the NICUs that have a neonatal MRI system in their hospital, what we’ve noticed is nursing satisfaction. We hear nurses sometimes say, “The baby should be scanned in the on-unit MRI today.”  As an easier and more patient-friendly process, MR scanning is more readily utilized to more fully understand what is happening in the developing brain.

So, I think nurse satisfaction is part of it.  But, it’s also nurse time. One thing we didn’t talk about is how to prepare a very sick baby to go to the MRI. Because the magnet downstairs is so big and so powerful, we can’t bring any metal medical equipment into the room itself.

If we have a baby who has even something as basic as an IV, we have to switch to a different type of pump, which requires the nursing team to set up all of the IV fluids specifically for the new pumps. Or, we may have to add extension tubing, as much as 10, 15, or 20 feet of extension tubing, to keep the IV pumps a safe distance from the traditional MR system.

We would have to push the fluid through those extraordinary lengths of extensions so that we could keep our IV pumps outside of the MR room and then connect it into the baby. That is also a lot of money, it’s a lot of nursing time to prep that. I think saving time and money and then the stress are significant benefits of having point-of-care MR in the NICU.

If you’re a parent and you know your baby is still in the NICU, just down the hallway, that is much less stressful,  compared to knowing your baby has left the environment of the NICU and is all the way downstairs and you can’t go with them, that’s distressing to you. Parents can experience separation anxiety from the baby. Knowing their baby is closer to where they are, I think, always gives families a better sense of security.

We can’t overlook the stress of neonatal MR scanning on the Radiology department when babies are scanned on the traditional MR systems. 

Having a dedicated neonatal MRI in the NICU, puts space on the schedule and allows us to be able to just get the baby in and out. The tech can come and go without having to disrupt the workflow downstairs in Radiology.

A. As a staff member, as a nurse caring for that baby, especially if the baby is very sick, that is going to give me security to know that I have my resources, my backups right behind me if I need them, for example, if the baby decompensates in any way.

I think there’s really advantages on all sides for families, for nurses, for the babies, for the techs to have a point-of-care MRI in their unit.

A. Some of it is access. Some of it is what I just talked about, scheduling. The scanner is under such high demand that a baby scan doesn’t feel like a very high priority to people outside the NICU. It might get pushed from day to day to day.

I think the biggest question people have is if I know about the injury, will it change my management? Will that management make a difference in outcome? And these are big research questions.

We could say the same thing about many other interventions that we do, many other tests that we do. The question for me is why wouldn’t you want more information?

It is just information. One diagnostic test doesn’t tell the whole story of a baby or give you that crystal ball to know exactly that baby’s trajectory of life. But it’s information.

This is on us to become more familiar with the technology. We need to understand the limitations of the tool and the benefits of the tool. We need to gain even greater comfort understanding the information being provided by the MR images and the interpretations provided by Radiologists.

Learning how to have good conversations with our radiology colleagues, so that we can glean as much information as possible is key. And then put that information together and present that to the family so that they can then make decisions about their life. And make decisions about their baby’s life.

A. Certainly if injury is detected, then we can refer babies for very targeted interventions. If you have a grandmother or an aunt or someone who has a stroke, a brain injury, you determine what happened to better inform the decisions on how to respond to the injury.

We very much want that same thing for babies because brain injuries to a neonate are very much like a stroke.

Would you want to wait two years before you started any kind of rehabilitation, if you knew the injury had happened in an adult? Of course not. We would never wait.

We would say, “Where is our occupational therapist? Where is our physical therapist? Why is that we’re not starting right away to rehabilitate?” That’s an adult with a brain that’s very mature.

What about this very developing brain? We want interventions to start early and to be targeted, not just general approach of every baby getting three days of therapy.  If a known injury is there, then we want to tailor that intervention and be more vigilant in our follow-up.

We want to tell the families how important these therapies and follow-up appointments are, and just what to be on the lookout for. Again, I think it goes to values and whether or not you really believe that having more information is good.

A. I think some of that is still yet to be known. We haven’t had point of care MRI until now. We are finally seeing on-unit MRI systems around the U.S.  Historically, we may have done a series of ultrasounds and then one MRI at the conclusion of a baby stay.

As the access and comfort level increases with using MRI on-unit, people will begin to use it in a more serial fashion. We’ll be able to look at timing of injury. We’ll be able to look at effective interventions. We’ll be able determine if the intervention is nutrition, maybe we would look at brain growth in a different way. Maybe it wouldn’t just be measuring head circumference anymore.

I think some of the potential is still yet to be discovered once access is no longer an issue. Certainly, one of the most difficult decisions that we have to make in the NICU is offering to the family to withdraw support and to transition to comfort care. We have to make these very hard decisions. MRI is one of the tools that can be very helpful in telling families about the extent of injury and what the long-term chances are of their baby’s outcome.

I think using the device in these very sensitive and critical situations, where you really need the most information, is another use for the device. We currently don’t get to use MRI because taking these very sick babies, who are at that critical moment of that decision, is just not possible. Well, it’s possible. But it’s just so difficult to do that we defer and we just go without.

The information captured from the point-of-care MRI system helps with making hard end of life decisions and being able to track changes over time in a more detailed way. I think the sky’s the limit, and we’re going to be really excited to see where greater access to MRI information will take neonatal care over time.

A. Yes. I think that’s always the goal of early intervention. I think really the tool is to help identify the injury that sets the baby up for the outcome that may be negative. But the test, and no test, really changes outcome. The test provides information. I think it’s what we can do with that information and what we study about interventions over time guided by MRI that will really tell us the value of how we can link early scanning and serial scanning to outcomes. It’s really what we do with the information.

A. I would say point-of-care MRI systems in the NICU are a tool that really can have an impact across many different domains of the hospital from the staff experience, to the administrators, to the families and the babies.

Whether or not you use the on-unit MRI scanner, I would just implore all clinicians to consider scanning more with whatever tool they have, and really beginning to understand the value of that information. It’s about becoming more skilled at having difficult conversations and sharing the good and the bad news with families about what we discover.

It’s becoming transparent about what we still don’t know, but to not be afraid to get more information and to share what it means with the families.