Anesthesia Risk in Infants: An Unresolved Question

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In 2017, when the Food and Drug Administration issued a black box warning for the use of general anesthetics use in children, Shriners Hospitals for Children — Northern California anesthesiologist Sampaguita Tafoya, M.D., encountered apprehensive parents.

Here’s how she addressed their worry: Yes, the suggestion is concerning, she used to
say. (Still does, actually.)

The FDA black box warning suggests that when a patient less than 3 years old is put under with a general anesthetic, for more than three hours, it may be harmful to neurodevelopment and could be associated with long-term negative effects on behavior or learning.

The concern arose from animal studies reported in the late 1990s. The evidence from those studies is pretty clear: The NDMA-receptor anesthetics, like ketamine, and the GABA-receptor anesthetics, like propofol, cause apoptosis of neurons.

But, concerned and absolutely convinced are two different things. Dr. Tafoya, the assistant chair of the department of anesthesiology at Shriners Hospitals for Children — Northern California says, “It is very difficult to take a rat brain and apply the duration and the amount of anesthetic exposure to what will happen in a human brain. Right? Giving a rat an hour’s worth of anesthesia is like giving a human three weeks of anesthesia, which is not clinically equivalent at all.”

The human data, on the other hand, is more conflicting. Some studies suggest a risk but others do not.

A study from the Mayo Clinic explored whether general anesthetic was associated with learning disabilities, as diagnosed by the school district or a professional. (1)

Because the Mayo Clinic is such a prominent institution in Olmstead County, Minn., it has access to a database of the health records of just about everyone in the county, and school records were obtainable.

The study looked at 5,357 children born in the county between 1976-82. Of those, 593 had received general anesthesia before age 4 years. The study’s authors reported that the incidence of learning disability by age 19 years was not greater in those who had a single exposure to general anesthesia prior to age 4. It was about 20%, same as in those not exposed at all. But it rose to about 35% in those exposed multiple times.

And so, out of an abundance of caution, Dr. Tafoya says she takes the potential hazard
extremely seriously and recommends waiting, when a child’s surgery is completely elective and can be delayed without consequence.

Unfortunately, at Northern California Shriners Hospital and in the world of pediatric surgery, it is extremely rare that a child’s surgical need can wait. Often more harm would come to these patients in delaying their surgery, than would any potential issue with neurodevelopment.

“The scientific community is up and trying to investigate this and get some solid answers for parents,” Dr. Tafoya says. “But we still don’t have the clear answers. We still have conflicting human studies.”

In the meantime, one thing Dr. Tafoya can do is to use regional blocks as often as she can, which is easier at Shriners Hospitals for Children — Northern California where a lot of the surgeries are orthopedic surgeries, done on limbs.

When Dr. Tafoya absolutely must use some general anesthesia, she frequently puts kids under, then administers a regional block and is able to lessen the amount of general anesthesia being given.

“For anesthetics here, we have a very regional block-heavy practice,” she says. “That lets us decrease the amount of general anesthesia needed and thus expose their brains to a lot less.”

Dr. Tafoya asserts that situations like this are why it is important to have a board-certified pediatric anesthesiologist providing care, especially for the very youngest patients.

The Northern California Shriners Hospital has a team of eight board-certified, pediatric anesthesiologists. They value safety and excellence in clinical care while maintaining children’s comfort as the priority.

References
1) Anesthesiology 2009;110:796-804.

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