Anesthesia in any patient is a highly complex medical service that requires careful attention and assessment to avoid complications that can be severe and even fatal. For particularly complex pediatric patients who require these services very early in life for medical procedures, the stakes are particularly high but are ultimately well-managed by pediatric anesthesiologists and guidelines that ensure safe practice. A lingering question remains, however, around how exposure to anesthesia could impact brain development in the early stages of life—in particular, infants and toddlers.
This concern has been a relevant topic of research for many years, with increased attention in recent years. In 2015, a broad statement was issued from about 20 medical and patient organizations calling for expanded research into the use of sedatives and anesthetics in children under the age of 4. This call to action was led by an organization called SmarTots, formed through a collaboration between the FDA and International Anesthesia Research Society. The statement noted the important implications of such research, directing high-risk decisions around whether to delay certain surgeries or avoid surgical interventions in particular patients. This interest was spurred by a study released by Dr. Andrew J. Davidson finding that exposure to one hour of general anesthesia in infants under 2 did not correspond to different cognitive outcomes than those who only had regional anesthesia.
In 2017, the FDA released a warning to health care providers stating that there could be development issues in children who had repeated or prolonged exposure to anesthesia before the age of 3. This statement, while grounded in reasonable concerns and evidence, caused a response from the American Academy of Pediatrics who were concerned that such public warnings may lead families to decline necessary interventions for their children out of fear of cognitive risks. This recent conversation has only reaffirmed the importance of further investigating this area.
Recently, a groundbreaking study released from Mayo clinic researchers shows results that should be encouraging for patients, their families, and the anesthesiologists who care for them. Dr. David Warner led a team of researchers in evaluating Minnesotan children via the Mayo Anesthesia Safety in Kids (MASK) study. The basic question this study aimed to answer was: do children who require multiple procedures facilitated by general anesthesia have a higher risk of adverse neurodevelopmental outcomes?
Much to the relief of researchers and clinicians alike, this rigorous cohort study suggests that the answer is no. The main objective of the study was to track the children’s differences in IQ, a useful barometer for adverse neurological impact. However, it also utilized screening and parental reporting to identify any behavioral or learning-related issues. This provided a holistic picture of many possible risks in the mental well-being of children who receive anesthesia before the age of 3. Results indicated that children with any exposure to anesthesia were not associated with lower IQs compared to children who had no anesthesia before the age of 3. With regard to the behavioral and learning issues, children with a single anesthesia experience also had no increased risk. However, children with multiple anesthesia experiences had slightly more reported learning and reading difficulties from parent accounts.
This study is a promising and important update in a long trajectory of research on this issue. However, it is not without potential limitations. On a basic level, children who require medical interventions multiple times at a very young age likely have other differences from children who do not beyond their anesthesia exposure. It is nearly impossible to say whether the anesthesia drugs are the determinant of a slight delay in reading, for example, or whether it is on account of an early childhood disrupted by medical challenges.
The results from this paper are a useful addition to the field of research and may help direct the questions asked in future studies. Just as medical societies and patient organization have been advocating for over the years, further attention and research into pediatric anesthesiology is crucial as the medical field progresses to treat and intervene in medically complex infants and toddlers. Alongside the exciting medical innovations that ensure the survival and health of these children are the pediatric anesthesiologists that ensure these procedures are done safely and that pain is well-managed and addressed. Now, we may also rest assured that these patients have an uncompromised chance for healthy mental development.
Warner, Zaccariello, Katusic, Schroeder, Hanson, Schulte, . . . Flick. (2018). Neuropsychological and Behavioral Outcomes after Exposure of Young Children to Procedures Requiring General Anesthesia: The Mayo Anesthesia Safety in Kids (MASK) Study. Anesthesiology, -.