Quality assessment of fluoroscopic imaging obtained during neonatal contrast enema exams

The American College of Radiology (ACR) and Society for Pediatric Radiology (SPR) have published practice parameters for pediatric fluoroscopic contrast enema (CE) exams. The purpose of our quality assurance (QA) study was to assess adherence to neonatal (< 2 days of age) CE practice parameters at a large tertiary care pediatric hospital.

Image database review identified all CE exams performed on children ≤ 2 days old at our institution between February 2019 and August 2022. Two pediatric radiologists conducted independent review of CE imaging and reports for six subjective quality criteria. One radiologist assessed six objective quality metrics. Data were summarized as counts and percentages and inter-reviewer agreement p_o was calculated for the subjective metrics.

70 neonatal CEs met inclusion criteria and were reviewed. For subjective criteria: A small-caliber rectal catheter was used in 93% (R1) to 94% (R2) of cases. 96-97% of exams included a true lateral rectal view; this view was obtained at early filling in 83-86% of cases. The rectosigmoid index was readily assessed in nearly all studies (100% R1; 97% R2). The entirety of the colon was visualized through to the cecum in 87% of studies. In 74-76% of cases, the appendix and/or terminal ileum were visualized. Observed inter-reader agreement was substantial for all metrics, ranging from 83% to 97%. For the objective quality metrics: 83% of CEs included a scout image. Lateral rectal imaging included visualization of the sacrum in 91% of cases. Radiation dose and fluoroscopy time were documented in 90% of cases. 63% of cases were performed without direct exposures. All 70 CEs were performed without documented complications.

Although the majority of studies included a scout image, radiation dose and fluoroscopy time, operators should be reminded to collect and store these basic components for every exam. Similarly, while most cases used an appropriately small rectal catheter, staff should be aware to do so in every exam. Approximately one-fourth of studies did not include visualization of the appendix and/or terminal ileum, which may reflect the difficulty of obtaining these views for certain pathologic entities in neonatal practice. Our study demonstrates the importance of continuous quality assessment even in expert centers and we recommend that a Quality Standards checklist be used for all neonatal CE studies, possibly incorporated as part of a template report.