Premature babies are at an increased risk of brain damage, but many are too fragile to make the journey to an MRI machine for a clearer diagnosis. Soon, thanks to the world’s first mini scanner, they may not need to
There’s a picture of our first daughter that my wife can’t bear to see. It was taken on Easter Sunday, 2008, the day she was born. Although it was the start of spring, it was snowing in London. Meanwhile, our daughter, just a few hours old, lay on a white blanket in an incubator in a neonatal intensive care unit (NICU), tubes and wires sprouting out of her.
We’d done everything right – or so we thought. Sophie had gone into labour naturally a week or two before her due date. When we got to the hospital the following morning, a doctor was soon listening to the heartbeats of mother and baby. Something was wrong. The baby’s heartbeat was too slow.
Suddenly I was being told to change into scrubs while nurses streamed into the room and started preparing Sophie for an emergency C-section. I was still pulling on the thin blue trousers when they wheeled her bed out of the room and down the hall. A nurse pointed me towards the double doors of the operating theatre. The knot in my stomach got tighter.
Minutes later, Edith was born. She didn’t cry, as babies are supposed to when their first breath fills their lungs. In silence, she was placed on a table under a warming lamp, medical staff around her, blocking our view. At last, she managed a squawk. Someone held her up for us to see her cross little face and then she was whisked away. By the time I went home that evening, Sophie was in the maternity ward recovering from surgery and Edith was in the NICU. Our first night as a family and the three of us all sleeping in different places.
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At just 2.1 kg, Edith was significantly underweight for a baby who wasn’t particularly premature, so she went to the NICU for observation and to make sure her brain hadn’t suffered from lack of oxygen when her heart was beating slowly. With no evident issues, she was there for only four days. It was long enough to adjust to the dim lighting, the continual bleeping of monitors, the collective anxiety and the stab of fear that accompanied anything out of the ordinary. But four days is nothing compared with the weeks and months that some babies and their parents spend in the NICU.
Scanning the opportunity
Most babies in a NICU are seriously ill, having had very premature or traumatic births. Around 70 per cent are at risk of brain damage. Predicting how they will fare is notoriously hard, and despite the best available specialist care, often it’s still a matter of waiting to see whether they will survive and with what, if any, impairments. Although an adult patient would go for an MRI scan as soon as brain damage was on the cards, many of these babies don’t ever get to have that basic test.
I’ve been in a number of neonatal intensive care units (NICUs) in the UK and the US now, each with dimly lit rooms full of incubators and the sounds of babies crying, monitors beeping, machines whirring and ventilators pumping. Doctors in charge of newborn intensive care departments have told me many things they think could become possible with a baby MRI machine.
If the baby can’t come to the MRI, can the MRI come to the baby?
Very premature babies are not just smaller versions of full-term newborns: they have a different physiology and that can make life in the NICU deeply uncertain. You can’t just try to recreate conditions inside their mother’s womb, either, because their needs aren’t the same as a fetus’s: they need to stay warm, breathe for themselves and do other things that a fetus doesn’t. No one really knows what the optimum nutrition is for a very premature baby, for instance, so being able to assess nutrition based on regular brain imaging rather than simply measuring the size of the baby’s head could make a big difference.
Other ideas range from general monitoring of brain activity, sedation and pain relief, to uses for specific conditions I’ve never heard of: paraoesophageal atresia, meaning a piece of the gullet that leads from the mouth to the stomach is missing. Post-haemorrhagic hydrocephalus, a buildup of pressure in the brain following internal bleeding. Necrotising enterocolitis, when an infection punches a hole in the gut wall. It’s also common for babies who suffered trauma during birth to have their bodies deliberately cooled to reduce the risk of brain injury – they get rewarmed after three days but there’s currently no way to measure whether one of them might need more or less time at low temperature.
In all these cases, doctors can see a role for MRI – if it were on the unit, that is, where decisions are being made, and not in another part of the hospital. And the benefits of developing better treatment and care in the NICU would be enormous. In every case a whole lifetime is at stake.
There is something seductive about the images an MRI scanner can produce. But, like photos of my daughters, an MRI picture is not the real thing. It’s a multitude of data points, taken apart, processed and put back together to look like a brain. That it manages to be so lifelike – to create an image of an organ most of us will never actually see alive – is miraculous. However, it might be misleading if the doctors or parents who are making decisions are tempted to give MRI results too much weight compared with ultrasound or other tests.
Scaling it down
Jessop Wing is getting ready to receive one of the first prototype NICU scanners in the world. Responsible for it coming is Paul Griffiths, professor of radiology at the University of Sheffield. He’s been trying to give more babies access to MRI for over a decade. He and his colleagues even built a low-strength baby scanner, although the images it produced were not good enough for clinical use so it could only be used for research.
After years of development and delays, setbacks and solutions, the first baby was scanned in the prototype system in Sheffield on 22 March 2016. Now, in January 2017, I’ve come back to the Jessop Wing NICU in the city to see a baby being scanned myself.
Alice-Rose Westbrook was born in early November at just 24 weeks’ gestation. Things are touch and go for babies born so prematurely. But after nearly two and a half months on the NICU she is now stable enough to move to a ward in the nearby Children’s Hospital. This is despite there remaining a few weeks before she would have reached full term, and when she still weighs less than 1.4 kg. Before she leaves the wing, her parents, Rachael and Shaun, have agreed to let her be scanned in the prototype MRI machine.
Lying in her incubator in the NICU’s high dependency unit, she is settled into the custom-made swaddle and sling. The Velcro is fastened and ear defenders put on, but before she moves to the scanner, she’s given a feed to help her relax, maybe even make her a little sleepy while the scan is taking place.
When she’s quite finished sucking milk from her narrow feeding tube, Alice-Rose is lifted out, placed securely on a specially adapted trolley and wheeled out of the room. Two nurses push the trolley between them, walking slowly down the corridor. They leave the NICU, and the MRI is just across the hall.
The benefits of developing better treatment and care in the NICU would be enormous
The trolley fits snugly against the scanner, and the top slides with Alice-Rose into the machine. It is a close fit but she seems happy enough. Her mum is with her, as well as one of the NICU nurses, who gently pats her through her clothes. It’s a little cold in the scan room, so they raise the temperature by a couple of degrees. Then the rasping buzz of the machine begins, taking scans in 22 seconds each time. Grey-scale images appear on the operator’s screen and we are looking at Alice-Rose’s tiny brain.
From many scans such as this, the prototypes can be evaluated for safety, accuracy and clinical relevance. If the results are positive, it could spur a company like GE Healthcare [US pharmaceutical company and medical equipment manufacturer] to develop a new product: a scanner that transforms the way premature and sick newborns are cared for and treated.
Until the evidence starts coming through, however, it’s still baby steps for the baby MRI.
The is a condensed version of an article first published on Mosaic. Read the full feature here
Featured image: Aaron Tilley and Kerry Hughes
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