Gadolinium-Based Intravascular Contrast Agents in Children

There are only a few published studies that address adverse reactions to IV gadolinium-based contrast media in children. The guidelines for IV use of gadolinium-based contrast agents are generally similar in both the pediatric and adult populations. There are currently six gadolinium-based contrast agents approved for IV use in the United States. These agents are commonly used “off-label” in children as several of these agents are not approved for use in pediatric patients and no agent is approved for administration to individuals less than two years of age. A few pediatric-specific issues regarding these contrast agents are discussed below.
Osmolality and Viscosity

--> As with iodinated contrast media, there is a significant range in osmolality and viscosity of gadolinium-based MR contrast agents. Osmolality of gadolinium-based contrast media ranges from approximately 630 mosm/kg H2O for gadoteridol (Prohance) to 1,970 mOsm/kg H2O for gadobenate dimeglumine (Multihance). Viscosities (at 37 degrees Celsius) range from 1.3 cps for gadoteridol (Prohance) to 5.3 cps for gadobenate dimeglumine (Multihance). These physical properties, however, are less important when using gadolinium-based contrast agents in children compared to iodinated contrast agents. The much smaller volumes of gadolinium-based contrast agents that are typically administered to pediatric patients’ likely result in only minimal fluid shifts. The slower injection flow rates generally used for gadolinium-based contrast agents result in lower injection-related pressures and decreased risk for vessel injury and extravasation.
Allergic-Like Reactions and Other Adverse Events
While rare, allergic-like reactions to intravascular gadolinium-based contrast media in children do occur. A study by Dillman et al  documented a 0.04% allergic-like reaction rate to these contrast agents in children. While mild reactions are most common, more significant reactions that require urgent medical management may occur . Pediatric allergic-like reactions to gadolinium-based contrast media are treated similarly to those reactions to iodinated contrast agents. A variety of physiologic side effects may also occur following administration of gadolinium-based contrast media, including coldness at the injection site, nausea, headache, and dizziness (see package inserts). There is no evidence for pediatric renal toxicity from gadolinium-based contrast media at approved doses. Extravasation of gadolinium-based contrast media is usually of minimal clinical significance because of the small volumes injected.
Nephrogenic Systemic Fibrosis (NSF) and Gadolinium-Based Contrast Media
There are only a small number of reported case of NSF in children (fewer than 10 as of 2008), the majority of which were described prior to this condition’s known apparent association with gadolinium-based contrast agents . The youngest reported affected pediatric patient is 8 years of age, and all reported pediatric patients had significant renal dysfunction. As there are no evidence-based guidelines for the prevention of NSF in children, we recommend that adult guidelines for identifying at-risk patients and administering gadolinium-based contrast media in the presence of impaired renal function be followed. While there has been no reported case of NSF in a very young child, caution should be used when administering these contrast agents to preterm neonates and infants  due to renal immaturity and potential glomerular filtration rates under 30 ml/min/1.73 m2