UPMC

Adam Christopher

Cardiac Imaging Leader

Pediatric medicine has always taken a back seat when it comes to healthcare innovation and the imaging field is no exception. Despite the great value we place in the next generation and the inevitable effects of childhood disease on adult health, grownups get all the attention. While some argue that drug discovery and device testing in children is unethical, the common pediatrics mantra of “children are not just little adults” emphasizes the importance of pediatric-specific research. We cannot simply extrapolate results of adult trials and expect children to respond as if they are half of a 60-year-old male; yet, day in and day out at children’s hospitals all over the country we practice medicine with “off-label use” due to limited data. By and large, ultrasound, CT, and MRI technologies have all trickled down from adult medicine and been applied to different diseases in smaller bodies, but without intentional design. Of course, limited attention is based on the perceived limited return on investment. We are fortunate that far fewer children suffer from chronic illness than adults, and I cannot blame vendors for using disease incidence to guide their development strategies, but I will argue that when it comes to imaging innovation, the future lies with children.

There has certainly been some buy in from the ultrasound world where vendors have optimized smaller transducers with higher frequencies to provide improved spatial resolution. However, advanced ultrasound capabilities like 3D imaging have continued to lag in the pediatric space. Further, automated post-processing tools that promise to improve workflow and preserve limited technologist bandwidth use AI trained on adult imaging data.

This provides limited applicability to pediatric disease and continues to drain our already short-staffed imaging workforce of valuable time. If processing software was optimized to include smaller patients with a broader disease spectrum, we would not only serve the pediatric community, but adult centers would also have more reliable systems for their increasingly heterogeneous populations.

Computed tomography has made many recent advances with more detectors and faster gantry speeds to accelerate imaging while supplying exquisite resolution. It can interrogate countless structures at lightning speed and has become a mainstay in modern emergency rooms. However, there are no pediatric-specific scanners. In fact, before the last decade, there was little discussion on how to adjust radiation doses in children to minimize longterm risks of malignancy while preserving imaging quality. Even with the most recent advances in CT technology that promise to freeze the motion of non-compliant patients and their rapidly beating hearts, the pediatric community is asked to crowd-source solutions to leverage the technology for their unique applications. I maintain that if innovation had been focused on meeting the specific needs of small, fast-moving patients from the outset, not only would our children receive better care with less need for sedation, but adults of all shapes and sizes would benefit from flexible, dynamic systems that can compensate for confused elders or distressed claustrophobes all while delivering beautiful images at low radiation doses.

“Even with the most recent advances in CT technology that promise to freeze the motion of non-compliant patients and their rapidly beating hearts, the pediatric community is asked to crowd-source solutions to leverage the technology for their unique applications.”

Magnetic resonance imaging is the most junior of the common imaging modalities and has become the gold standard for tissue characterization across many organs and diseases. A recent innovation has led to greater variety in field strength, faster gradients, and highly accelerated imaging. However, I routinely hit roadblocks to quality imaging in our youngest patients with fast heart rates and continue to require sedation and anesthesia to make MRI possible. Cardiac MRI is particularly appealing to pediatric patients who can benefit from non-invasive heart tissue characterization at no radiation cost. However, high-quality late gadolinium enhancement that is routinely performed in adults is extremely challenging in babies, who must often undergo more invasive testing. A dedicated community of pediatric and congenital imagers continues to push the boundaries of spatial and temporal resolution in the MRI realm with improved motion correction. However, progress could be dramatically accelerated if the global MR community focused on the needs of the pediatric population from the design phase rather than relying on back-end solutions.

My request to the healthcare imaging field including vendors, engineers, and physicists is to not forget the little guys. Optimizing all modalities to meet the needs of our smallest patients will ultimately make for the most robust infrastructure to provide the highest quality of care to most patients, whether they are 3 months or 97 years old. This will, in turn, make the resulting infrastructure the most marketable to health systems of all shapes and sizes. Not only do children represent our future, but their imaging challenges stand to frame the future of medical innovation.