A new way to see

The MRI machine at Yale New Haven Children’s Hospital was eight floors down from the neonatal intensive care unit, a long and problematic journey for a preemie. Everything from temperature regulation to bringing along life-sustaining equipment like ventilators and IV lines presented a challenge. A baby’s need for an MRI had to be carefully weighed against the risks of transporting them a relatively far distance, said Matthew Bizzarro, MD, vice chair of clinical affairs for the Department of Pediatrics and medical director of the Yale Neonatal Intensive Care Unit (NICU) Network.

“We are often dealing with a very fragile population that doesn’t handle transportation well,” Bizzarro said. “It can really be a difficult undertaking to try to move them with a lot of support devices to an MRI. Putting critically ill newborns in an elevator and moving them several floors increases risk.”

When the hospital decided to build a bigger and improved NICU, Yale New Haven Children’s Hospital leadership, Bizzarro, and other Yale neonatologists saw an opportunity. Why not put an MRI in the new unit, eliminating the potentially perilous trip to and from the imaging suite?

Adding to the case for an in-house MRI was a new machine developed in Israel specifically for preterm and term newborns. The Neonatal Embrace® MRI is about half the size of a regular machine, Bizzarro said. Another plus: Its magnetic field is internal, allowing equipment containing metal to remain in the room during the procedure, he said. That eliminated the need for complicated and time-consuming measures to keep babies connected to medical equipment during imaging. It also meant that smaller, more unstable babies could now get an MRI, Bizzarro said.

Yale New Haven Children’s Hospital needed little convincing, and the new device arrived in the expanded and upgraded NICU in November of 2020, going into service early the next year. Yale New Haven Children’s Hospital is one of just three in the United States with the device. The machine has made an MRI for a critically ill newborn much easier and safer.

“Taking a baby down to the MRI took a good 15 minutes,” said Yeisid Gozzo, MD, director of the Yale New Haven Children’s NICU. “Now we can do it in a third of that time. It allows us to get important information more quickly.”

The new device has not entirely eliminated the need for anxious trips to the larger MRI. The NICU MRI doesn’t provide as much resolution and detail as a standard MRI. That said, most of the time, the NICU MRI is sufficient, Bizzarro said.

Given an MRI’s confined space, the noise it makes, and the need for patients to hold still, you would think babies would do poorly in the machine. The opposite is true, Gozzo said. Babies appear to tolerate the procedure better than many adults.

“What we have found is that the vast majority of the time, if we just feed and swaddle them, they just go to sleep,” she said. “They do pretty well in the scanner. The noise doesn’t seem to bother them.”

Yale doctors are using the MRI to check for brain bleeds, hydrocephalus, malformations, white-matter injuries, damage caused by oxygen deprivation, and other maladies associated with preterm birth. The most common usage is taking a snapshot of a preemie’s brain at discharge, setting a baseline for care.

“All in all, it’s been a benefit to the NICU to have the scanner in there,” said Steve Peterec, MD, the unit’s associate director. “We can see if interventions work or not.”

One of the biggest benefits of having a readily accessible MRI in the NICU is its potential ability to obtain serial studies and track brain development over time. A series of images may allow doctors to diagnose problems, such as white-matter injury (often a precursor to cerebral palsy) earlier, Bizzarro said.

“We can identify things on an MRI that we wouldn’t be able to see on a bedside ultrasound that could key us into an increased risk for that infant to develop, for example, long-term problems with motor function, such as cerebral palsy. That could mean earlier interventions beginning within the hospital and immediately after discharge.”

Bizzarro said there has been a learning curve as doctors figure out the best uses for the machine. The device is especially promising as a research tool, enabling physicians to develop better treatments and interventions, he said.

“I think there’s a lot of untapped potential as we get more and more used to the device,” Bizzarro said. “As we get more familiar with it and as the technology advances, it opens up a lot more options, particularly for research.”

The MRI is a highlight of Yale’s upgraded NICU. The new unit, which opened in 2018, is large enough to accommodate 68 babies compared to 54 in the old one. Babies who were once kept 10 to 12 to a room are now in singles or doubles. A series of couplet care rooms allows for a post-partum mother and her neonate requiring intensive care to be cared for in the same space, enabling them to more immediately bond. The unit also has its own special procedure room so that babies needing surgery no longer need to be moved to another part of the hospital, Peterec said.

While the MRI’s use can vary—in some months, doctors order only a few scans; other months it’s in heavy use—the machine has proven a major plus for the NICU, Gozzo said. In addition to being easier on the babies, the on-site machine allows doctors to get vital information fast, she added.

“It’s an additional resource,” she said. “It’s a pretty big deal when you want to take a baby in an incubator with all these pumps and on a ventilator down all these floors (to the MRI). It has made [imaging] a lot safer for the baby.”

In the last decade, the average number of babies in Yale’s NICU at any given time has gone from the 40s to about 60, Peterec said. The reasons for the increase are not entirely clear, as the incidence of prematurity has decreased in recent years from 13% to 10%. One explanation may be that more babies are very premature. “Babies are spending a longer time in the unit,” Peterec said.

Christopher Hoffman is a frequent contributor to Yale Medicine Magazine.