WAGS: Wonderful Alternatives to General Anesthesia & Sedation

Who is eligible?

Infants under six months of age are eligible.

Who is not eligible?

Infants over the age of six months or infants with feeding problems (e.g. severe gastroesophageal reflux) are not eligible.

Instructions for parents before MRI scan:

• Arrive one hour prior to MRI scan time
• Withhold one feed from baby before coming to MRI department (arrive hungry)
• Keep baby awake for three to four hours before the MRI (arrive tired)

On arrival for MRI:

• Fill out the MRI screening form
• Tell the nurse or technologist how long it typically takes to feed your baby
• Change your baby into non-metallic hospital clothing
• Change diaper if needed
• Your baby’s height and weight will be measured
• Your baby may require an IV to be inserted for contrast enhanced images

Getting ready for MRI scan:

• Small cushions or cloths are placed between baby's legs and between their arms and body so they don't touch
• ​Baby is swaddled in a baby blanket and placed in an MRI-compatible immobilizer

​To encourage sleeping during MRI scan:

• Room lights are kept dim
• Baby is given a large feed immediately before the scan
• Ear plugs and earmuffs are used to reduce noise
• Baby pacifier and/or sucrose may be used if baby wakes up

The feed and sleep technique does not always work. If that happens, sometimes the patient is rebooked to try this technique again on another day, or instead the patient is booked for MRI using general anesthesia.

How do I request feed and sleep for my baby when they need to have an MRI?

There are a few ways to do this:

1. Your referring doctor can contact our MRI scheduling team or write this on the MRI request.
2. Parents/caregivers can ask our MRI scheduling team when they contact you about the date and time of the scan or you can contact them at any time during business hours.
3. Our MRI scheduling team and radiologists may decide it might be a good option for your child when they review the request.

What happens next?

Our MRI nurse or Child Life Specialist will review the request to see if your baby is eligible for the feed and sleep technique, which may then be scheduled for the daytime or evening. This is based on your infant's age and development, the type and length of the MRI scan requested, and other information that might mean a general anesthetic is still needed.

"My son was born with a very serious heart condition and at a young age required numerous medical interventions. One of these interventions required him to have more than one MRI throughout the course of his hospital stay. There were times when a feed and sleep method was used, and although it may have taken a longer time (as my son was at a young age), the desire not to give him sedation medication was a preferred option for me. Especially given the fact that my son was already on quite a few medications, I found that the feed and sleep method was less invasive and allowed my child's body to naturally adjust to the upcoming procedure. My experience with the feed and sleep method was a positive one and I was glad that the staff showed patience and care before, during and after the MRI scan.”

Who is eligible?

Patients over the age of three and a half are eligible.

Who is not eligible?

Patients under the age of three and a half are not eligible. Patients with the following conditions or circumstances are also not eligible:

• Cerebral palsy
• Immediate post-operative (especially if neurosurgery)
• More than two body parts are being scanned or the scan will last longer than 90 minutes
• MRSA, VRE and/or CPE carrier or infection

Upon arriving in the MRI department and after completing the standard registration and screening process, the patient and their parents/caregivers meet the therapy dog team – the dog and their handler - in the waiting room.

The interaction with the therapy dog includes the patient sitting near the dog, petting it and engaging in low-level play under the supervision of the handler. The handler keeps the dog on a loose leash at all times, attends to the dog's needs and can answer any questions. They use the dog to reassure the child about the upcoming scan – such as placing a pair of "mutt muffs" (headphones used to protect a dog's hearing in small aircraft) on the dog as a way of explaining to the patient that they will also be wearing ear plugs.

The dog accompanies the patient into the MRI preparation area (including IV placement if necessary), and then the MRI scan room during patient positioning on the MRI table. The dog gets up on the table first and then the child follows.

Once the patient is positioned in the MRI scanner, the therapy dog waits in the MRI control room during the scan, occasionally re-entering the scan room during the MRI (between sequences) if the medical imaging technologist feels it may help calm the patient. At all times during the interaction the handler encourages the child to hold the dog's leash with them.

The patient spends between 20 and 60 minutes with the therapy dog before the scan, with interaction time during and after the scan more variable. They always get a chance to have one more interaction with the therapy dog after completing their MRI outside the scan room, with time for photos and one last snuggle.

How do I request a therapy dog for my child when they need to have an MRI?

There are a few ways to do this: 

1. Your referring doctor can contact our MRI scheduling team or write this on the MRI request.
2. Parents/caregivers can ask our MRI scheduling team when they contact you about the date and time of the scan or you can contact them at any time during business hours.
3. Our MRI scheduling team and radiologists may decide it might be a good option for your child when they review the request.

What happens next?

Our MRI nurse or Child Life Specialist will review the request to see if your child is likely to benefit from a therapy dog. This is based on your child's age and development, the type and length of the MRI scan requested, and other information that might mean a general anesthetic is still needed. 

If it's determined a therapy dog may help with your child's MRI scan - the MRI scheduling team will find a time during business hours to book your child's scan, coordinating this with one of our therapy dog teams (a dog and their handler). Timing depends on you, on how quickly the scan is needed, and on the availability of our therapy dog teams!

"Thank you for organizing the therapy dog for the MRE... It was incredible to see R's interaction and response to the dog. I firmly believe she is the reason R was able to complete the test. My older three boys have now decided they will do some fundraising for more therapy dogs.”

Who is eligible?

Patients over the age of three and a half are eligible.

Who is not eligible?

Patients under the age of three and a half are not eligible. Patients with the following conditions or circumstances are also not eligible:

• Cerebral palsy
• Immediate post-operative (especially if neurosurgery)
• More than two body parts are being scanned or the scan will last longer than 90 minutes

MRI simulation can be done using full scale "mock" or real MRI scanners (just without the magnet!), toy MRI scanners and virtual reality (VR) MRI scanners using special headsets.

Play therapy usually takes the form of practicing lying on a table, then sliding the table-top in and out of a tunnel while practicing staying still, usually for a few minutes at a time. Practicing breath-holding for 10-20 second intervals can also be useful in older children. Sometimes patients also wear headphones and listen to recordings of the sound of real MRI scanner with loud clicks and buzzing. 

These steps are helpful in alleviating anxiety and improving patient co-operation, assisting patients with staying still for the short periods of an MRI sequence, e.g. 5 minutes, with several sequences performed during a whole MRI scan. Together with breath-holding, these are important factors in minimizing motion. MRI Simulation with a full-scale "Mock MRI" Unit has been found to be most effective in reducing need for general anesthesia in children aged three to eight years old.

Other types of MRI Simulation are becoming available such as the use of virtual reality. Currently at SickKids we are using disposable VR headsets in the hospital as part of preparing patients for MRI by providing a distraction when having an IV (intravenous) cannula inserted. Advanced VR devices to further aid patient preparation through patient education and training, e.g. learning to lie still and breath-hold for short periods by practice, and familiarising the patient with the MRI environment, are coming soon.

How do I request MRI simulation?

There are a few ways to do this:

1. Your referring doctor can contact our MRI scheduling team or write this on the MRI request.
2. Parents/caregivers can ask our MRI scheduling team when they contact you about the date and time of the scan or you can contact them at any time during business hours.
3. Our MRI scheduling team and radiologists may decide it might be a good option for your child when they review the request.

What happens next?

Our MRI nurse or Child Life Specialist will review the request to see if your child is likely to benefit from MRI simulation. This is based on your child's age and development, the type and length of the MRI scan requested, and other information that might mean a general anesthetic is still needed.

If it's determined simulation may help with your child's MRI scan - the MRI scheduling team will find a time during business hours to book your child's scan, coordinating this with one of our Child Life Specialists. Timing depends on you, on how quickly the scan is needed, and on the availability of our Child Life team.

All patients at SickKids are eligible for support from a child life specialist.

With an innovative and fun approach, a child life specialist aims to improve patient and family care, satisfaction, wait times and overall hospital experience. This program is designed to familiarize patients with the sights and sounds of an MRI and to explain the step-by-step process of what they can expect to do during their appointment.

This profession believes that by giving clear, honest and developmentally appropriate explanations to our patients that their ability to cope increases and their experience overall is more positive. Children respond to medical encounters in unique ways which is why child life specialists will assess each patient’s needs in order to create an individualized coping plan. Child life specialists, alone or in conjunction with other non-sedate strategies, can provide an alternate approach to general anesthesia for some children. 

Child life specialists can provide:

• Education and preparation: Through an interactive and visual approach, child life educates patients by using a tablet, virtual reality or a mock MRI table with a cloth doll to help patients gain a better understanding of their MRI. Developmentally appropriate explanations are used.  
• Distraction techniques: For some cases, a patient may need contrast (a liquid dye) that helps to highlight a certain part of the body to get a clearer picture, which means an IV is needed. Child life offers coping techniques to make this process quicker and more positive such as guided imagery, breathing techniques, playing fun games like "I-spy" and listening to music. Additionally, non-pharmacological techniques to reduce pain can be offered such as numbing cream or freezing spray applied to the skin before an IV is inserted.  
• Coping skills discussion and practice: Child life can provide a coping plan and coach your child through their MRI scan to help keep them calm and still. This might entail practicing staying still beforehand, practicing positive-self talk, guided imagery and deep breathing.  
• Emotional and family support: Child life will spend the time to build rapport, understand the patient and parents' needs and advocate their concerns to the rest of the healthcare team to ensure that the child or adolescent is comfortable throughout their appointment.

How do I request a Child Life Specialist for my infant/child when they need to have an MRI?

There are a few ways to do this:

1. Your referring doctor can contact our MRI scheduling team or write this on the MRI request.
2. Parents/caregivers can ask our MRI scheduling team when they contact you about the date and time of the scan or you can contact them at any time during business hours.
3. Our MRI scheduling team and radiologists may decide it might be a good option for your child when they review the request.

What happens next?

Our MRI nurse or Child Life Specialist will review the request to see if your child is likely to benefit from Child Life support. This is based on your child's age and development, the type and length of the MRI scan requested, and other information that might mean a general anesthetic is still needed.

If it's determined Child Life support may help with your child's MRI scan - the MRI scheduling team will find a time during business hours to book your child's scan, coordinating this with one of our Child Life Specialists. Timing depends on you, on how quickly the scan is needed, and on the availability of our Child Life team.

"To be able to see and talk to a Child Life Specialist every visit, every blood test, finger poke and especially for each and every MRI is truly support like no other. From personal experience, one of the hardest things to go through was an MRI. Having to stay still and try to block out the noise and focus on a distraction, sometimes I was lucky to have child life there as my distraction. That is the magic of Child Life, you can be having a conversation and a 45-minute scan is over in an instant. ...not only do they bring support when patients need it, they put a smile on the face of kids and the families that have to bear witness to the difficulties patients face on a daily basis. I wish I could thank all Child Life Specialists individually.”

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• The impact of preparation and support procedures for children with sickle cell disease undergoing MRI Cejda KR et al. (2012) Pediatric Radiology doi:10.1007/s00247-012-2422-2
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• MRI techniques to decrease imaging times in children Kozak BM et al. (2020) Radiographics doi: 10.1148/rg.2020190112