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Association of Paediatric Anaesthetists of Great Britain and Ireland 21 Portland Place London W1B 1PY tel: 020 7631 8887 fax: 020 7631 4352 email: [email protected] July 2015 Anaesthesia in Babies Infants and Young Children For over 10 years the scientific community has been aware that exposing infant animals to general anaesthesia produces identifiable structural changes in the brain. Effects are specific to the developing brain and have been identified in a number of species, but depend on the type and dose of drug administered. Some experimental studies do not mirror clinical use as no surgery was performed and general anaesthesia was continued for several hours or at higher doses than used for routine surgery in children. Associations between exposure to anaesthetic agents in young animals and longer-term changes in behavioural development, particularly deficits in learning and memory tasks, have raised concern regarding the potential for general anaesthetics to produce detrimental effects in young babies and infants. However, it is difficult to compare doses of anaesthetic across different species of experimental animals or to match the ages at which the developing brain of animals or humans are vulnerable to these effects. Nevertheless, this information has driven many studies to evaluate potential learning and behavioural changes in children and adolescents who have required anaesthesia and surgery as babies or in the first 4 years of life. The paediatric anaesthesia community both in the UK and abroad have taken this issue very seriously and are actively involved in individual and collaborative efforts to try to determine what risk, if any, exposure to anaesthetic drugs has in the young infant and child. Anaesthesia and surgery is only undertaken when absolutely necessary in children. This is particularly so in babies and infants when the nature of their disease mandates that surgical treatment cannot wait until later in life or because it is of an urgent or emergency nature. Surgery cannot be performed without adequate anaesthesia and analgesia: inadequate anaesthesia impairs recovery and carries a life threatening risk in itself. Serious complications related to anaesthesia are rare nowadays with modern day anaesthesia, even in the very young and the very sick. New technologies in the operating room are used by anaesthetists to continuously monitor the circulation, oxygen levels and function of other organs to control wellbeing during surgery. Therefore, while the beneficial effects of anaesthetic agents in ensuring unconsciousness and minimising the stress of surgery are clear, it is also now important to determine if the anaesthetic agents themselves have any longer term effects, so that we can balance the benefits against any potential risks of anaesthesia. If risks are identified, current and future research will determine the safest ways for minimising or preventing adverse effects. Resolving this issue with relevant and high quality ethical, research to improve the quality of current evidence is necessarily difficult. Several approaches are being used simultaneously. Firstly, there are studies which look back at medical records to identify children who have 21 Portland Place, London, W1B 1PY The Association of Paediatric Anaesthetists of Great Britain and Ireland, is a UK Registered Charity Number - 1128113 undergone surgery compared with those who have not. These have examined the link between anaesthesia exposure and subsequent behavioural development or disorders reported by parents, teachers or from medical records, School performance, or other measures that assess learning abilities such as IQ. These studies are useful, but can only identify associations with prior anaesthetic exposure, rather than confirming that the anaesthetic drug has caused the reported changes. Interpretation is difficult as surgery itself may have an effect, and children who need prolonged or repeated anaesthetics in early life often have underlying conditions or illnesses that may also significantly affect their behaviour or may disrupt their school attendance or family life. To date, these studies have varied greatly in the numbers of children included, the type of anaesthesia and surgery they required, and the outcomes used to measure potential adverse effects. It is reassuring that many of the studies to date have not identified an association between anaesthesia in early life and adverse effects. This includes comparisons of twins, in whom only one had anaesthesia before 3 years of age. The data from these children, who have similar genetic and environmental backgrounds, but do not show an identifiable effect of anaesthetic exposure on intelligence and behaviour, is important, but the numbers involved are small. Given that anaesthetic exposure in early life has not been consistently linked to adverse changes from clinical studies to date, no changes in anaesthetic clinical practice are recommended currently. Nevertheless, all these studies looking backwards and relating early anaesthesia to outcome (retrospective studies) have limitations: their sensitivity to identify small differences or small increases in risk is limited. Therefore, it cannot be said that collectively these studies have proven conclusively that there is no problem. The definitive way to determine if anaesthesia in early life can affect neurodevelopmental outcome would be through carefully controlled planned (prospective) clinical trials, with detailed assessment of infants for many years after exposure to anaesthetic drugs. The international “GAS” (general anaesthesia compared to spinal anaesthesia) study is currently following a large group of children who had surgery and anaesthesia as infants. It is hoped that this and other ongoing initiatives will give professionals and parents a definitive answer to this concerning question. In the meanwhile, the Association of Paediatric Anaesthetists of Great Britain and Ireland have made this, and other documents available on the APAGBI website with articles and guidance for both professionals and parents (http://www.apagbi.org.uk/safety/safety-statements). As the evidence unfolds we will update the articles on this site and we will continue to be available to help interpret the current concerns. Professor Andrew Wolf On Behalf of the Association of Paediatric Anaesthetists of Great Britain and Ireland