CXR Chest Radiographs (x-ray) We usually obtain two views of the chest while the child is sitting or standing. If the child is too young or ill to stand, we lie the child down on the table. The arms are held out of the way of the chest and the image is taken when the baby or child has taken a deep breath. The parent or caregiver, wearing a lead apron, may need to hold the child in position while the images are acquired. Preparation No preparation is needed prior to this examination. AXR or KUB Abdominal Radiograph(s) (x-ray) This may consist of one view of the abdomen while the child is lying supine on the x-ray table, or two views, depending on the clinical situation. The second view is taken while the child is lying on his or her left side or while the child is standing. Rarely a third view, with the child lying prone, is necessary. KUB refers to kidneys, ureters and bladder and is a term left over from the early days of radiology. Preparation No preparation is needed prior to this examination. SXR Skull Radiographs (x-ray) Three films of the skull are taken while the child is lying on the x-ray table. Depending on the child's problem, special views may be needed. The skull is a sphere with lots of complex bony anatomy so getting the right angle for the diagnosis is often a challenging task for the radiographer. Preparation No preparation is needed prior to this examination. Extremities: Arms and Legs (x-ray) When there is concern about a fractured (broken) bone, or other problem of bone, the bone or joint or area is noted on the requisition. The radiographer will check to make sure that the requisition has been written correctly and confirm which part of the leg or arm has been injured or causing symptoms. Preparation No preparation is needed prior to this examination.

MCU Micturating Cystourethrography In order to be able to assess the structure and function of a child’s bladder, and to determine if urine goes backwards from the bladder up to the kidneys (vesico-ureteric reflux), we have to catheterise the bladder by passing a small plastic tube through the child’s urethra. This tube is taped to the child’s inner thigh so that it doesn’t fall out and then used to fill the bladder with clear fluid that contains iodine molecules. This fluid is commonly called contrast or dye; that is because the iodine allows us to see the fluid with x-rays. When the child micturates (urinates), the bladder contracts and the fluid comes to the outside, around the catheter, and onto the x-ray table where it is soaked up by towels. If there is reflux, we can see the dye go backwards into the ureter(s) which are the tubes that connect the kidneys to the bladder. If the reflux is severe, it will distend the collecting system of the kidney(s). For children older than 14 months, we can use premedication prior to the procedure. This usually is midazolam which relaxes the children and which also results in their not remembering the procedure at all, or nitrous oxide. Preparation Nothing to eat and drink for 4 hours, if the child is older than 14 months, so that sedation can be given on an empty stomach. Infants under 14 months of age should be given their usual feedings and encouraged to drink fluids. For children younger than 12 months of age who are not already on antibiotics, the referring clinician arranges 3 days of antibiotic coverage prior to the procedure. Children with certain cardiac conditions may require specific antibiotic coverage; if there is any question, the paediatric cardiologist should be consulted. IVU Intravenous Urography In order to see how the kidneys function and the structure of the kidneys, ureters, and bladder, a clear fluid which contains iodine is injected into a vein and radiographs are taken in the x-ray room at specific times thereafter. The fluid (also called contrast or dye because it shows up with x-rays) is filtered out of the blood by the kidneys. It shows up in the collecting systems of the kidneys, mixed with the urine that is being excreted. It then passes down the ureters into the bladder. Preparation 0-2 years, nothing to eat or drink for 3 hours prior to the examination. 2 years and older, nothing to eat or drink for 4 hours prior to the examination. RUG Retrograde Urethrography This examination is performed if the child has had trauma to the urethral region or if there is concern regarding narrowing or other abnormality of the urethra, the tube in which urine passes from the bladder to the outside. A small plastic catheter is inserted into the end of the urethra, and a clear fluid which contains iodine is injected into the urethra, through the catheter, so that the urethra can be seen with x-rays and any abnormality documented. Preparation No preparation is needed for this examination.

Ba Sw Barium Swallow and Videofluoroscopy The child swallows barium from a bottle or cup, depending on the child’s age. The radiologist can see how well the child swallows and if there is any problem with the oesophagus or junction of the oesophagus with the stomach. Usually, the child is lying on the table for this examination. It is the first part of an UGIS (see below). Depending on the clinical situation, the examination may be extended to include the stomach and first part of small bowel. Certain images are taken by the radiologist, using the x-ray camera, during the study. Preparation 0-2 years: nothing to eat or drink for 3 hours before the examination. 2-7 years: nothing to eat or drink for 4 hours before the examination. 7 years and older: nothing to eat or drink for 6 hours before the examination. When the child has feeding problems we use a study that is termed “videofluoroscopy.” It is performed in collaboration with the speech therapists. They prepare regular liquids, thickened liquids and solids (barium-coated food) in order to evaluate what foods the child can tolerate without problems. A parent or caregiver who usually feeds the child is asked to help with the barium feeding. The infant or child is positioned as for usual feeding, typically in a special chair, and the examination is recorded for later review. Preparation 0-2 years: nothing to eat or drink for 3 hours before the examination. 2-7 years: nothing to eat or drink for 4 hours before the examination. 7 years and older: nothing to eat or drink for 6 hours before the examination. UGIS Upper Gastrointestinal Series The child swallows barium or another type of liquid that can be seen on the x-ray screen. Because the images are fluoroscopic, the radiologist can see the child swallowing and look at the oesophagus, stomach and the first part of the small bowel as the barium moves through. The child will be lying on the table in different positions during the examination. Sometimes, the radiologist will begin the study with the child standing. Images are taken with the x-ray camera, by the radiologist, throughout the procedure. Sometimes a delayed view, after the barium has moved through the stomach, is obtained. Preparation 0-2 years: nothing to eat or drink for 3 hours before the examination. 2-7 years: nothing to eat or drink for 4 hours before the examination. 7 years and older: nothing to eat or drink for 6 hours before the examination. SBFT Small Bowel Follow Through If there is clinical concern about the small bowel, which is a long cylindrical tube extending from the stomach to the colon, there are several images taken after an UGIS - usually one every 30 minutes - so that the small bowel is outlined in its entirety. For these images, the child may lie on his back (supine) or prone (on his front) depending on the type of information that is needed. When the barium reaches the colon, the child may be taken back into the fluoroscopic room for special pictures of the junction of the small bowel with the colon because this area may be abnormal in certain diseases of childhood. Occasionally, if there has been a recent UGIS, we will omit repeating that part of the study. Preparation 0-2 years: nothing to eat or drink for 3 hours before the examination. 2-7 years: nothing to eat or drink for 4 hours before the examination. 7 years and older: nothing to eat or drink for 6 hours before the examination. BE Barium or Contrast Enema This study requires coating the inside wall of the colon with barium or other type of contrast (usually clear liquid that contains iodine which can be seen on x-ray images). In neonates, where obstruction is usually the problem, there is no preparation needed. For children, in order that any irregularities of the colonic wall can be seen on imaging, the colon has to be very clean before the study can begin. A tube is coated with a lubricating jelly and inserted into the rectum. It is usually taped in place so that it doesn’t fall out. Barium usually flows through the tube, into the colon, by gravity, from a bag that is hung above the x-ray table. Sometimes, barium is used to coat the inside wall of the colon before air is injected to distend the colon. The child is placed in several different positions for the images so that the barium can coat and outline the entire colon. Preparation No preparation is needed for neonates. For air contrast barium enema, the preparation is the same as currently used for colonography. This study, therefore, is only scheduled when there has been involvement from the paediatric gastroenterologist or paediatric surgeon.

If there is a tract or connection from the skin into the body caused by infection, or created by surgery, it may be necessary to outline the tract with contrast - the same iodinated contrast medium that is used in vascular studies - before treatment or further surgery is performed. A small catheter is placed into the hole in the skin and a clear fluid, which is visible on x-ray images, is injected into the tract. This is done with fluoroscopy (screening) so that images can be taken, and the child moved into different positions to outline the tract and the organ(s) with which it communicates. Preparation Typically, no preparation is needed for this examination.

Ultrasonography is the creation and interpretation of images that are formed by high frequency sound (ultrasound), in combination with sophisticated computerisation. A beam of sound that is higher in frequency than can be heard by humans, is sent into the body from a small crystal in a hand-held scanner head (transducer). When the beam meets an interface between tissues of different density, echoes of the sound beam are sent back into the transducer and fed into a computer. The computer creates an image that is displayed on a television screen. The scans are usually done when the child is lying down on a padded table next to the ultrasound machine. The parent(s) or caregiver(s) can stay in the scanning room. The child is positioned for the specific examination by the ultrasonographer or doctor who is doing the study. The transducer is moved over the area of interest after water soluble gel is put on the child’s skin to prevent air getting between it and the transducer surface. Sound does not pass through air nearly as well as it does through soft tissues and fluid. Ultrasonography is a very safe type of imaging; this is why it is so widely used during pregnancy. It does not hurt; the only feeling the child has is of the transducer being moved over the skin. Ultrasonography is particularly useful in the neonatal nursery for the imaging of the neonatal brain through the anterior fontanelle (soft spot of the skull) for evaluating solid organs in the abdomen like the liver, kidneys, pancreas and spleen, for investigating certain problems of muscles and cartilage, and for identifying collections of fluid, diagnosing some tumours or masses, and providing a means of their localisation if a biopsy is needed. Preparation Preparation for abdominal scans is 4 hours of no food or milk before the study so that there is less air and food throughout the gastrointestinal tract. The gallbladder will be full of bile if the child is fasting; it is easier to evaluate when it is distended. For those less than 3 years of age, 3 hours fasting is adequate. Clear fluids can be given, but no fizzy drinks. Preparation for renal scans is lots of fluids given by mouth. If toilet trained, the child should have a full bladder for the beginning of the scans. After the scans of the bladder are obtained, the child is allowed to empty the bladder before the kidneys are imaged. Preparation for a pelvic scan includes lots of fluid by mouth or intravenous route. The child should have a full bladder so that structures in the pelvis, like uterus and ovaries in a girl, are visible. When the bladder is empty, loops of bowel fill the pelvis and the genital tract cannot be seen. Other scans with ultrasound require no preparation.

The CT scanner that we use was donated by the Starship Foundation with special help from Lucy Lawless. C- or C+ may be written on the requisition. C- means no intravenous contrast is given for the CT examination. C+ means that contrast - a clear fluid that contains iodine which is visible on the images - is given through a needle or small tube (catheter) that has been placed in a vein before the images are acquired. Often, for abdominal scanning, and before coming to the CT room, the child is given fluid to drink that contains iodine or a small amount of barium. This oral contrast fills the inside of loops of bowel, and allows us to identify where they are in the abdomen. For the CT examination, the child usually lies on his or her back on a special x-ray table. We make sure that there is no metal on the child, or in a pocket because it causes artifacts (unwanted effects on the image). The table moves through a large donut-shaped structure which is a sophisticated x-ray machine combined with a special computer. The images are called “scans” and sometimes, “CT cuts” but this refers to cross-sectional images that are obtained after the computer has analysed the data; the machine does not touch or cut the child. The radiographer puts the child into the correct position, on the examination table, for the area that is to be imaged. The first scan that is obtained is of the area of interest, for example the brain, or abdomen or chest, and this is used as a type of map so that the cross sections are taken of the appropriate structures. Sometimes, if the blood vessels need to be visible, or if the amount of blood flow to a structure needs to be shown, intravenous contrast is administered, usually through a vein in the arm or hand. This intravenous contrast looks like a clear liquid but it contains iodine which is visible on x-ray images. Depending on the child’s medical or surgical problem, we sometimes need a second set of scans as the contrast moves through the bloodstream and into the kidneys where it is excreted into urine. The child may have to hold his or her breath for some examinations; they should lie as still as possible. If the child is very little and we need to have the child very still, we may need to give the child medicine for sedation. In some cases, we work with the anaesthetists who can give a child general anaesthesia. Usually a parent or caregiver, who is given a lead apron to wear, can be in the CT room with the child. The technologist sits in a separate control room that has a glass window between it and the scanner. There is an intercom so that people can talk between the two rooms. The scan time will vary depending on the type of examination required, but as a rule it will take less than 30 minutes. Preparation The list below provides instructions appropriate to the child’s age and type of scan. The instructions are general. You will be given detailed instructions at the time you receive your appointment. If you do not think your child can keep still for their CT, or if there is any other problem, please let the booking co-ordinator know well before the scan date so we can make other arrangements. Babies under 3 months of age: keep awake and do not feed for 3 hours before the appointment. Bring a bottle feed, security toy & pacifier if the child uses one. With these measures babies often sleep through their scan. Children 3 months to 3 years or less than 20kg in weight: most children in this age group will need sedation (a medicine given by mouth to make them sleepy). This will be given in the Radiology Department. In case the child needs sedation, the child of 3 months to 3 years of age must fast (have no food or milk) for 4 hours before the scan. They can have water or clear fluids such as diluted Ribena, apple juice, up to 2 hours before the scan. Clear fluids are anything you can see through. Do not give fizzy drink or milk. Children over 3 years of age or more than 20kg in weight: with our new ultrafast scanner most of these children do not need any sedation. If they are having intravenous contrast, they must not have any food or drink for 4 hours before the scan. This instruction does not include the oral contrast that might be needed. Instructions for that are below. GENERAL ANAESTHESIA (GA) If sedation fails, or if an older child cannot keep still, your child may need a brief GA for the CT. This is performed by qualified paediatric anaesthetists in the CT room. Fasting times vary for a child having a general anaesthetic, depending on their age and medical condition. Specific instructions will be sent to the parent/caregiver with the appointment. Please follow them correctly. If you have any questions please phone the booking clerk well in advance. The booking clerk’s number will be on the appointment letter. E-Z-CAT For scans that require abdominal contrast, a packet of E-Z-CAT dry barium sulfate suspension will be given or sent to the parent/caregiver. Instructions: please read and follow the instructions below, NOT those on the E-Z Packet. Inside this envelope is a pack of E-Z-CAT DRY BARIUM SULPHATE SUSPENSION. Pour 900mls of water into a container. Pour contents of packet into the container and stir well. Let mixture stand for 5 minutes and stir again. Stir again before drinking. You may prepare the mixture ahead of time and store in the refrigerator. There will be excess fluid that can be discarded. A CHILD BETWEEN 0 AND 6 MONTHS WILL DRINK 60mls 4 hours prior to CT Scan 60mls 2 hours prior to CT Scan Nothing else to eat or drink in the 4 hours prior to scan. A CHILD BETWEEN 6 AND 18 MONTHS WILL DRINK 100mls at 4 hours prior to CT Scan 100mls at 2 hours prior to CT Scan Nothing else to eat or drink in the 4 hours prior to scan. A CHILD BETWEEN 18 MONTHS AND 3 YEARS WILL DRINK 200mls at 4 hours prior to CT Scan 200mls at 2 hours prior to CT Scan Nothing else to eat or drink in the 4 hours prior to CT Scan. A CHILD BETWEEN 3 AND 8 YEARS WILL DRINK 250mls at 4 hours prior to CT Scan 250mls at 2 hours prior to CT Scan Nothing else to eat or drink in the 4 hours prior to CT Scan. A CHILD BETWEEN 8 AND 16 YEARS WILL DRINK 400mls at 4 hours prior to CT Scan 400mls at 2 hours prior to CT Scan Nothing else to eat or drink in the 4 hours prior to CT Scan. Your child may be given another small drink of the same contrast when you arrive for the scan.

If a child has a big liver or abnormally functioning kidneys or a mass, and a sample of the tissue from an organ or mass is needed for microscopic evaluation, the Radiology Department may be involved in planning or performing the biopsy. Imaging is used to localise the area from which a sample of tissue will be taken with a special needle. This type of procedure is very specific to the child and to the child’s problem. Most children have general anaesthesia for these procedures, and there is close collaboration between the radiologist, the clinician and the pathologist who looks at the tissue samples after the biopsy. Preparation Preparation is related to the type of sedation or anaesthesia that is required for the procedure.

If the blood vessels of the body, the arteries or veins, are thought to be abnormal, they can be filled with a fluid that is visible to x-rays. For imaging veins, a catheter is placed directly into a vein near the area of concern, or into a vein that drains into the area of concern. This study is usually done at Starship in the Radiology Department. For studying arteries, a catheter is often placed into the large artery in the groin because it can be directed to many areas of the body, including the head, from this approach. This specialised radiographic procedure is done in coordination with radiologists from Auckland City Hospital. The child who has an angiogram is asleep under general anaesthesia for the procedure. Preparation Preparation will depend on the type of examination needed.

Starship Hospital's MRI scanner was donated by Sir Graeme and Lady Ngaire Douglas and since September 2010, a full service, including scans under general anaesthesia, has been operational. Some services will continue to be delivered at other scanning units depending on time and demand but requests, other than those for cardiac (heart) scans, are handled through the Paediatric Radiology Department. Cardiac MRI requests are reviewed by a cardiac radiologist and are booked in the Auckland Hospital Radiology Department, phone number (09) 307 2822, extension 24522. MRI scanners use powerful magnetic forces to produce cross-sectional images and provide different information from that available on CT scanning or ultrasonography. MRI is particularly helpful in diseases of the brain and the spinal cord, as well as in diagnosing infections and tumours of the muscles and bones. The MRI equipment is similar in structure to CT but the tunnel is much bigger and the space around the patient is slightly less but, due to the special “cameras” MRI utilises, claustrophobia can be a significant issue. The tunnel with the new scanner is 70cm wide and approx. 165cm long. The strong magnetic forces prevent the use or presence of any metals that are attracted to magnets or equipment that is affected by magnets. Therefore children with certain implants e.g. pacemakers or cochlear implants, are not allowed into the MRI room. You and your child will be thoroughly screened by the technician before being allowed to enter the MRI room. The MRI unit makes a lot of noise so headphones or earplugs will be used to minimise the noise for your child. In most cases, we can play music or stories while the scan is performed. The technologists are in a separate room from the scanner itself, but there is a glass window between the rooms and an intercom so that people in the two rooms can speak to each other. Your child will also be provided in most cases with a special mirror which will allow them to see the technician and out of the scanner into the room. A parent or caregiver can usually stay in the scanning room with a child (pending safety checks). Before a child has imaging with MR, there is a checklist that is filled out by the technologist and parent in order to prevent any problems. These include MRI safety checks, previous surgeries and possible allergies to medicines or foods. Small children will need general anaesthesia in order to lie still for the time needed for an examination. The scan time will vary depending on the type of examination required, but as a rule it will take around 30-45 minutes. Some may take longer. Please follow all fasting guidelines closely or your child's scan will be cancelled. MRI Contrast A Gadolinium-based contrast agent is used for MRI. It is administered intravenously and circulates through the bloodstream before it is excreted by the kidneys. Its properties allow identification of blood vessels and blood flow to structures in the area being scanned. Your child may require this contrast depending on the imaging question, and this will either be administered by the technologist or a nurse, under radiologist guidance, via a small needle into a vein in the elbow or the back of the hand. Preparation Because there are several MRI centres providing services for paediatric patients, the specific preparation and instructions for the child's study will be sent from each MRI centre. Please read or record all instructions carefully, and note the location of the MRI scanner. Appointments Please try to be on time for your appointments when visiting the MRI Department. We ask people to allow plenty of time to allow for parking and finding the department and also for going over any safety questionnaires and preparation. If, for some reason, your child cannot attend an appointment, please inform the secretary in charge of bookings as soon as possible so that another child can be booked into that time slot. (Reception phone number, Starship Radiology Department is (09) 307 2836. Phone number for Cardiac MRI is (09) 307 2822, extension 24522.)

Starship Hospital does not have its own department of Nuclear Medicine. Children who require this type of imaging are seen in the Department of Nuclear Medicine at Auckland City Hospital. This is a specialised scanning method using extremely low-level radioactive isotopes, injected into the bloodstream. The scanner is called a gamma camera and is used to measure the gamma rays that are emitted from the isotopes. The radiation disappears with time so does not stay in the child's body. The primary use of Nuclear Medicine in paediatric imaging is for studying the function of the kidneys and bladder, and investigating diseases of bone, thyroid gland, and liver. Preparation Preparation for these studies depends on the region being imaged.