Recent headlines from The New York Times and other sources have increased parental anxiety surrounding the already-stressful experience of young children having surgery. Anesthesiologists at the Hospital for Special Surgery (HSS) are using this public awareness to help families of children undergoing surgery make the best decision regarding anesthesia.
“Anesthesiologists previously thought there were one or two anesthetic agents that could be used without worrying about neurotoxicity, but now it seems that almost every single anesthetic agent we use has some kind of effect on the developing brain,” said Kathryn (Kate) DelPizzo, MD, attending anesthesiologist at the Hospital for Special Surgery in New York.
General anesthesia is associated with a low-level amount of risk for patients at any age, but its potential neurotoxicity -- a term used to describe a destructive effect on nerve development -- is especially troubling for patients aged three years and younger. At this age, according to neuroscientists, children’s brains are at their most impressionable, leaving these patients more susceptible to the potential long-term effects of general anesthesia.
An article published in The New England Journal of Medicine (NEJM) reported that growing evidence from animal trials suggests there may be a link between learning disabilities and general anesthesia exposure in children aged three years and younger. The results of recent trials have made a panel of pediatric anesthesiologist experts “heighten the level of concern” regarding general anesthesia in pediatric patients, stating that more research is urgently needed to investigate these potential adverse outcomes.
“One of the issues that the authors presented was the fact that dose probably matters,” explained Dr. DelPizzo, regarding the February NEJM article. “It’s not just a question of did your child receive anesthesia, it’s also for how long and how much?”
“For the most part, we think that a single exposure to general anesthesia in a healthy child, aged three years or under, is safe. But for those children who have to go under anesthesia for multiple procedures, we have to be honest and let parents know that there may be some long-term effect, and that we still have a lot to learn about this topic” said Dr. DelPizzo.
One way to mitigate concerns surrounding anesthesia is to use regional anesthesia when possible. General anesthesia renders patients entirely unconscious and unaware of any feeling in the body. Regional anesthesia is a targeted anesthetic approach that numbs only certain areas of the body. Regional anesthesia is associated with less postoperative bleeding, lower hospital infection rates, and fewer days spent in the hospital, and can be used in conjunction with general anesthesia.
Anesthesiologists at the Hospital for Special Surgery are expert practitioners in the field of pediatric regional anesthesia.
“We can use regional anesthesia to decrease the amount of general anesthesia a patient needs,” explained Dr. DelPizzo. “Sometimes, we don’t even do general anesthesia, even on children as young as three years of age.”
Surgeons help parents of young children by limiting operative procedures to only those that are absolutely necessary. If surgery can be delayed until after the age of three, parents should choose that option. However, some children may not be able to avoid surgery. In those situations, Dr. DelPizzo urges parents to consider the full picture.
“I have had conversations with concerned parents who are afraid of the anesthesia, so they will not let their children have their tonsils out, or get ear tubes placed, but the child is not breathing well at night, or their speech is delayed because of hearing problems. In cases like these, parents and their doctors should weigh the risks of anesthesia against the benefits of a healthier toddler,” said Dr. DelPizzo. “Anesthesiologists keep the patient under general anesthesia for as little time as possible.”
To limit general anesthesia exposure where regional anesthesia is not an option, Dr. DelPizzo offered this example: a young patient diagnosed with scoliosis may present for her first “Risser” (body) cast around the age of two years, and they may have anesthesia as often as every two to three months.
Although the procedure isn’t painful and there’s no surgical incision, the casting procedure requires patients to stay completely still and asleep. So, anesthesiologists put the patients under general anesthesia -- but there’s an approach to limit this time, said Dr. DelPizzo, and it involves the pro-active coordination of the entire surgical team.
“You can turn off general anesthesia about 30 minutes before you leave the operating room instead of five minutes before,” explained Dr. DelPizzo. “The practitioners who do the casting can touch it up and make adjustments while the patient is drowsy and unaware, but not completely under anesthesia.”
Dr. DelPizzo noted that while many parents are terrified of the idea of anesthesia for their child, at HSS, the focus on regional anesthesia can help ease parental concerns. “That’s another great thing about being at HSS, we can honestly tell them that we will decrease the amount of anesthesia their child’s brain is exposed to, because we use regional anesthesia.”
In this article
Kathryn DelPizzo, MD
Attending Anesthesiologist, Hospital for Special Surgery
Clinical Professor of Anesthesiology, Weill Cornell Medical College
More from Kathryn DelPizzo, MD
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