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General Anesthesia for Young Children: Should Parents Worry?
by Pediatric Perspectives on 08/17/2011 at 9:21 AM

John Huntington, MD, Anesthesiologist

Ever since news articles appeared last spring about an FDA federal panel meeting to evaluate concerns John Huntington, MDabout cognitive problems or learning disabilities from general anesthesia in young children, I, like other anesthesiologists, have been fielding questions from concerned parents about the safety of anesthesia for their children. I'm sure you, as primary care physicians, are receiving similar questions. 

The concern about the possible effects of anesthesia on children's cognitive development began with animal studies published several years ago that demonstrated brain neuron death and long-term cognitive issues in 7-day-old rats given a combination of anesthesia drugs early in life. The FDA held a meeting in 2007 to discuss that research, concluding that anesthesia did not appear to cause similar issues in children but urging continued research. 

Much of the research since then has also been done in animals. However, several retrospective studies do suggest that children who receive repeated exposure to anesthesia before age 4 are more likely to have cognitive problems.1,2,3,4

The study from Wilder et al, I think, is the one that has raised the current concerns. The authors looked at a cohort of 5,347children, approximately 600 of who had received general anesthesia before age 4 between 1976 and 1982. After 15 years, the authors found a correlation between two or more early anesthesia exposures and learning disabilities (hazard ratio [HR] =1.59, 95% CI 1.06-2.37 for two exposures; and HR 2.60, 95% CI 1.60-4.24, for three or more).4

Keep in mind that this is a correlation; we do not know if the anesthesia itself caused the learning deficits. Also consider, as we all know, that children who require two or more surgeries with general anesthesia before age 4 likely have other medical problems that could have contributed to those cognitive deficits. 

Still, if you combine retrospective studies like the one from Wilder et al with the animal studies, you can see how the current firestorm began. Thus, it's not surprising that the FDA felt it had act. 

The bottom line is that, at present, there is no alternative to general anesthesia for young children who require invasive procedures and such treatment is a must; we know even neonates feel pain. However, we always err on the side of caution, such as reserving elective procedures until children are older and limiting the number of anesthetics we give. If a child needs several procedures, we try to combine them into a single surgical session if possible. 

Also, if a child under 4 needs surgery it is likely related to a serious medical condition. So while I'm seeing more questions from parents in the past few months, none have cancelled surgeries. My advice is to take the time to counsel parents about the reality of the studies and our knowledge, and help them, as we do in so many things related to pediatric medicine, weigh the potential risks and benefits of the procedure.  

What are your thoughts about general anesthesia for young children? What are you hearing from parents?

John Huntington, MD, is an anesthesiologist at Helen DeVos Children's Hospital 

References

1. DiMaggio C, Sun LS, Kakavouli A, Byrne MW, Li G. A retrospective cohort study of the association of anesthesia and hernia repair surgery with behavioral and developmental disorders in young children. J Neurosurg Anesthesiol. 2009;21:286-91. 

2. Kalkman CJ, Peelen L, Moons KG, et al. Behavior and development in children and age at the time of first anesthetic exposure. Anesthesiology. 2009;110:805-12.

3. Backman ME, Kopf AW. Iatrogenic effects of general anesthesia in children: considerations in treating large congenital nevocytic nevi. J Dermatol Surg Oncol. 1986;12:363-7. 

4. Wilder RT, Flick RP, Sprung J, et al. Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology. 2009;110:796-804.

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