Gadolinium-based contrast agents in pediatric MRI: renal safety, risk mitigation, and emerging alternatives

Gadolinium-based contrast agents (GBCAs) are integral to pediatric magnetic resonance imaging (MRI), yet their use requires thoughtful consideration due to developmental differences in renal function, concerns about gadolinium retention, and the rare but serious risk of nephrogenic systemic sclerosis (NSF). This review summarizes current knowledge on GBCA molecular structure, pediatric-specific pharmacokinetics, and the spectrum of known adverse effects. We discuss practical, evidence-based strategies for risk mitigation, including identifying children at increased risk, avoiding group I and III agents when eGFR is 2 or kidney injury is suspected, minimizing cumulative lifetime exposure, and managing special populations such as neonates and children with prior allergic-like reactions. The review also outlines the growing role of alternative contrast agents, particularly ferumoxytol. By synthesizing current evidence and guideline recommendations, this article provides a comprehensive framework to support safe, effective, and judicious contrast-enhanced MRI in children while emphasizing areas where further pediatric-specific research is needed.