The second most frequently asked question to me…
Not so short, since 1996 I’ve been dealing with pediatric surgery. And, the second most frequently asked question to me: “Does anesthesia harm my child?”
In the Journal of the Pediatric Surgeon, I’ll try to provide you with the answer to this question. The first question? At the end of the blog…
First, I’ll give you some statistical information. Unfortunately, this data is from abroad. I wish we had such detailed data as well…
In the United States, approximately 1.3 million children undergo surgery each year. The total number of children who have received anesthesia is 1.5 million, with an average anesthesia duration of 57 minutes, and about 6% of them have received anesthesia for more than 3 hours. When the anesthesia received by children under 1 year of age was examined, the rate of anesthesia for more than three hours was found to be 13.7%. So, younger babies are exposed to surgeries requiring longer anesthesia. 21,000 born children were examined, and it was observed that 26% of them were exposed to anesthesia before the age of 3.
The importance of what I’ve said is this: The assumption that anesthetic agents may cause damage to the developing brain with neurotoxic effects, resulting in cognitive and behavioral problems, occupies the minds of patients, parents, and us clinicians a lot.
There are dozens of animal studies available. In studies conducted on rodents, it was found that commonly used anesthetic agents cause nerve damage, disruption of interneuronal communication in the hippocampus, and behavioral problems in young ones. But they couldn’t translate these findings to humans because the human brain is more complex and advanced in structure, hence more resistant to assaults. Because the developmental timing of the human race is different. Because the drug doses used in animal studies are many times higher than those used in humans. And because it is very difficult for rodents to be monitored during anesthesia, i.e., to be monitored against oxygen deficiency or carbon dioxide elevation that could harm the brain.
This time, scientists have conducted experimental studies on monkeys. After administering anesthetic agents to baby monkeys at certain times, increases in separation anxiety from mothers, decreases in motor reflexes, and findings such as increased apoptotic cell death, called conscious cell death, and decreased white matter in the brain were observed in histopathological studies. There are some difficulties in extrapolating these findings to humans. It is impossible to prove that the histopathological changes found also occur in humans because microscopic sampling cannot be done in humans. And the behavioral findings caused by these findings in animals cannot be adapted to humans because our brains are much more developed. Our behaviors are much more complex and advanced.
Once again, scientists have not given up and started conducting studies on humans. They compared children who received anesthesia with those who did not. They grouped them into subgroups according to the drugs received, the age of the child at the time of anesthesia, the frequency, duration, and number of anesthesia received, and compared them with children who did not receive anesthesia at all. Of course, many factors that could affect the results have emerged. Because for an observational study to be conducted, the same subjects are needed. However, each child’s environment in which they grow up, their communication with their parents and surroundings, the reason for receiving anesthesia, and where they live are different, so there are too many variables.
Now let me elaborate a little.
There is a prospective study. General anesthesia was given to 363 children under 1 year of age who underwent hernia surgery lasting an average of 54 minutes, and awake regional anesthesia was given to 354 children. It was found that there was no behavioral or cognitive difference based on the results of the FSIQ tests of these children. Of course, it was said that this study could yield different results in long and repeated anesthesia applications.
There are dozens of studies. Learning disabilities, developmental and psychiatric disorders, IQ results, parental evaluations, and academic achievements have all been compared. For example, there are studies comparing the future achievements of children who received anesthesia for simple dental treatment with those who did not. In Canada, they examined the IQ test results of young people when they were enlisted in the army and compared them as children who received anesthesia and those who did not. While some studies reported problems in children who received anesthesia, others reported no difference. Meta-analyses have been published by combining the results of dozens of studies. Evaluating them is difficult due to the many variables involved.
In December 2016, the U.S. Food and Drug Administration (FDA) issued a warning regarding possible negative effects of anesthetic drugs in pregnant women in the last three months of pregnancy and children under 3 years of age who undergo repeated anesthesia lasting more than 3 hours. However, it was said that the degree of risk is unknown. When sufficient clinical and experimental data were not available, it updated its warning in 2017. It said that in cases of medical necessity, treatment should not be delayed in pregnant women and children under 3 years of age, clinicians should follow their general practices and traditional actions, and continue the practice.
In conclusion, there are some neurological/developmental/behavioral differences between children who have undergone surgery and anesthesia and those who have not, but this difference cannot be directly attributed to exposure to anesthesia and the long-term effects of anesthesia. This last sentence is the summary of what I have told you so far. And I compiled this important and bold statement from the UptoDate website.
All of what I have told you, articles I have read on the subject, and my personal observation and opinion as a clinician dealing with pediatric surgery for nearly 30 years, what is it? I think it’s not a problem for outpatient surgeries such as hernia, undescended testicle, circumcision, which require short-term, relatively superficial anesthesia. However, if surgery requiring more than 3 hours is needed, if repeated anesthesia sessions are necessary, if we are not forced, it seems more appropriate to pass the age of 3. Actually, no surgeon would take a 6-month-old baby for a 3-hour surgery unless forced. I think the most important thing is to have a good anesthesia team.
I’ve tried to share as much as I can about a topic that is very complicated, debated, and has many variables.
I hope we have been able to complete this journey without boring you or blowing up your head. You know, the important thing is to be able to dock at the port. Please click if you want to watch the shorter youtube video version.
You wonder what is the most frequently asked question to me? The question “Is circumcision necessary or not?” I have detailed it in our previous journeys. You can also find it in my book “The Story of Male Circumcision.”
Stay happy,
Prof. Dr. Egemen Eroğlu
February 2023