08/16/18 05:30:am

Recently, I had the opportunity to care for a woman that was in her 26th week of gestation, and the subject of the anesthetic effects on her developing fetus cam up during the discussion on informed consent.  I had recently read a summary on the current state of the research on the clinical evidence for any effect of anesthesia on the developing brain, and I was able to relay that information to her, (Anesthesiology 4 2018, Vol 128, 840-853) from which I will summarize for this post.

Let’s start by stipulating that because of the potential for any effect on the neurodevelopment, we should all pause prior to agreeing to elective surgery in our children.  However, as suggested in the labeling change regarding the safe use of anesthetic and sedative drugs ( brief exposure is probably safe and encourages the healthcare professional to consider the risks of delaying the surgery.

We have known for some time that surgical exposure early in life increased the risk of neurodevelopmental problems.  However, it was originally thought that there was no connection to anesthetic toxicity.  Recent laboratory evidence has shown that anesthetic exposure can modulate various aspects of brain development.

The problem with these preclinical studies is that they are very difficult to translate into useful information to guide the anesthesiologist in safe anesthetic practice.  The reason for this is that when applied to humans, there are several confounding factors to consider:

  • What comorbidities exist that influence the developing brain?  Sicker children with more severe congenital issues are more likely to experience repeated surgical procedures and have multiple anesthetic exposures.
  • Children with lower socioeconomic status are more likely to have poor dentition and therefore a higher incidence of anesthetic exposure.
  • Uncooperative children yet to be diagnosed with a behavioral problem are more likely to need anesthesia for procedures than other children would tolerate awake.

What we do know is the following: (excerpted and paraphrased from Anesthesiology 4 2018, Vol 128, 840-853)

  • The results of human studies are mixed.
  • Some, but not all, large population-based studies have found evidence for small differences in academic achievement and school readiness (< 1%) on sophisticated neuropsychiatric testing.
  • The difference in grades is negligible and not likely to have a measurable impact on the child’s wellbeing.
  • Anesthetic exposure is a less important determinant than the child’s sex or maternal education with respect to educational achievement and behavioral disorders.  Male children and children of mothers with less education are at risk. 
  • Some studies, but not all, have found evidence for a small increased risk of a diagnosis of behavioral disorder or learning disability.
  • Two prospective studies have found that there is no evidence in neurodevelopmental outcome for children having less than 2 hours of anesthetic exposure in infancy.  Prospective studies are important because they can used to draw conclusions on casuation.
  • There is very little human data to support the FDA warning regarding long and repeated anesthetic exposure in children less than 3 years of age.  This warning is presumably derived from the laboratory data. 
  • When added risk is observed, it is very small and difficult to separate from the impact of childhood illness.
  • The human evidence that anesthetic exposure causes poor neurodevelopmental outcomes is very weak.

Any time your child has surgery, it is a very stressful period for the child and parent.  It is reasonable for the parent to be concerned about these issues.  Any surgical or anesthetic intervention in your child should prompt a through discussion of the anticipated benefits of that surgical procedure and should be weighed against the potential surgical and anesthetic risks of that procedure. 


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