In December 2012, SmartTots released its first Consensus Statement on the Use of Anesthetics and Sedatives in Children. Its purpose was to provide guidance to health care providers and parents with regard to research findings that suggest anesthetics may be harmful to the developing brain.
SmartTots has now updated the statement in light of recent research. The results of these research studies demonstrate that exposure to some anesthetics and sedatives can cause memory and learning difficulties and other harmful changes in the central nervous systems of some laboratory animals.
Studies in humans have been less clear, but some studies have suggested that there may also be adverse effects on behavior, learning and memory when children under 4 years of age have prolonged or repeated exposures to anesthesia and surgery.
To date, there is no direct evidence that anesthetics are unsafe for children but more research is needed.
Listen as Julie Drobish, MD discusses Anesthetic Neurotoxicity in Infants and Children.
The Risks of Anesthetic Neurotoxicity in Infants and Children
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Learn more about Julie Drobish, MD
Julie Drobish, MD
Julie Drobish, MD, is a Washington University pediatric anesthesiologist at St. Louis Children’s Hospital.Learn more about Julie Drobish, MD
Transcription:
The Risks of Anesthetic Neurotoxicity in Infants and Children
Melanie Cole (Host): Development of neurotoxicity in infants and children who have been exposed to general anesthetics has garnered attention in recent times and sparked various debates. The effects range from learning disability, cognitive defects to development of neurodegenerative diseases like Alzheimer’s disease in later life. My guest today is Dr. Julie Drobish. She's a Washington University pediatric anesthesiologist at St. Louis Children’s Hospital. Welcome to the show. What are some of the concerns about anesthetics in children?
Dr. Julie Drobish (Guest): Thank you for having me. There are some concerns about anesthetics in children and that mainly has come to be in our concern because of some animal studies that have been done over the last 15 years or so. The concern primarily is that exposure to these anesthesia drugs can possibly by harmful to the brain cells, or neurons, meaning that there could be altered function even after their anesthesia has stop.
Melanie: Are pediatric patients not miniature versions of adult physiology?
Dr. Drobish: Actually, they aren’t. One thing we commonly say is that kids are not just small adults. They are developing very rapidly, in particular brain development is going on in very important ways until approximately age three is when the majority of the rapid brain development goes on. During this period, the neurons in the brains are thought to be more vulnerable to the exposure of anesthesia than in an older child or young adult.
Melanie: How did physicians become aware of this problem?
Dr. Drobish: We became aware of this problem because initially there were several animal studies that were done using exposure to anesthetics, and maybe different anesthetics were tested, and in most cases, the exposure to anesthetics caused some cell death in the brain of the animals that were studied. In many cases, in addition to the cell death, the animals developed problems with learning and memory later on in life.
Melanie: If anesthetics caused problems in animals, does it necessarily follow that they’ll cause similar problems in people?
Dr. Drobish: It does not necessarily follow, but it is a potential concern, which is why there are is so much discussion regarding this topic and research going on. There are some differences in the way the studies are done in animals. The animals are not capable of being monitored all the time the way a child would be having anesthesia, and so children are monitored very carefully and the amount of anesthesia drugs that are given is changed over time according to the needs of the child during surgery as opposed to a set amount just being given in the majority of these studies. We really need to continue to study the effects of anesthesia as we practice it clinically in children and how they develop and any issues they may have later on down the road.
Melanie: Are all anesthetics created equal? Are some sedatives or anesthetics better or worse than another?
Dr. Drobish: We really don’t know for sure. As of right now, nearly all of the commonly used anesthetics have been shown to have potential anesthetic toxicity in the animals. We’re still doing ongoing studies to determine whether certain ones may be better than others – perhaps there's certain combinations may be better or worse than others – and so at this point, we really can't recommend a single anesthetic is better than another one.
Melanie: In December of 2012, SmartTots released its first consensus statement on the use of anesthetics and sedatives in children. Tell us a little bit about this consensus statement and why it was developed.
Dr. Drobish: The reason for the consensus statement was to provide some guidance to healthcare providers and parents with regard to these research findings that have suggested that anesthetics could be harmful. SmartTots is an organization that was developed with the goal of promoting research and making anesthetics safely for all the children who undergo it, so it’s important for them to put out statements such as this for the public to understand.
Melanie: Who developed and reviewed the consensus statement?
Dr. Drobish: The consensus statement was developed and reviewed by a group of experts in multiple disciplines of medicine, including anesthesia, pediatrics, and the neurosciences. They considered all of the evidence and studies that have been done in order to make a statement regarding the anesthetic toxicity.
Melanie: Who’s the audience?
Dr. Drobish: The audience is meant for multiple groups, so healthcare providers and the public – parents and caregivers are all included.
Melanie: Tell us about some of the ongoing research and give us a little blueprint for the future research of what's going on.
Dr. Drobish: There are several studies that have either recently completed or ongoing. There are two recent studies that have compared children who receive one episode of general anesthesia that was relatively short with children who received either no anesthesia or regional anesthesia – meaning a numbing medication – and both of those have recently shown that there were no differences in the testing of those children. There are still some ongoing studies regarding children who have had multiple exposures to anesthesia compared to children who have had zero or one exposure, and those are still in progress. There are many mechanistic aspects that we don’t understand how exactly are the anesthetics affecting the neurons, and so studies are ongoing in animals as well in order to continue to understand that interactions.
Melanie: What should physicians tell parents if their child needs surgery or a procedure that requires anesthesia? Are there some contraindications for institution of it?
Dr. Drobish: In general, today anesthesia is safer than it has ever been for children primarily because we have improved monitoring and new anesthetic drugs of many choices. However, we do have some concerns sometimes. The important thing would be to tell parents what are the benefits versus risks to the surgery, and the surgeon in particular as an important role here in order to advise the family on whether a surgery is really necessary at a given time or whether it can be postponed. Many surgeries are necessary in the first few years of life and it’s actually detrimental to brain development to not anesthetize a child and not provide proper pain control. All of these factors have to be considered and that the entire healthcare team make an appropriate decision along with the family as to whether a procedure needs to be done and what anesthetic is required for it.
Melanie: Are there some treatments or research that you're doing at St. Louis Children’s that other physicians may not be aware of?
Dr. Drobish: There is not specific study going on at St. Louis Children’s regarding anesthetic neurotoxicity. There are many centers participating in some of these ongoing studies that I mentioned, but we do not have our own separate studies.
Melanie: In summary, tell other physicians what you'd like them to know about the risk of anesthetic neurotoxicity in infants and children and when to refer to a specialist.
Dr. Drobish: The main issue to think about is that we’re not really sure whether anesthetics cause neurotoxicity, but there's a significant concern. Anesthesia should not be treated lightly. Any procedure that might be elective or could be postponed should be potentially postponed in light of knowing that anesthesia could cause problems and we don’t want to do anything that’s not necessary. However, it is safe to do anesthesia particularly if only one anesthetic is required in young children and it’s very important for necessary surgeries to be carried out in order for the overall health of the child and development to go as best as possible.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
The Risks of Anesthetic Neurotoxicity in Infants and Children
Melanie Cole (Host): Development of neurotoxicity in infants and children who have been exposed to general anesthetics has garnered attention in recent times and sparked various debates. The effects range from learning disability, cognitive defects to development of neurodegenerative diseases like Alzheimer’s disease in later life. My guest today is Dr. Julie Drobish. She's a Washington University pediatric anesthesiologist at St. Louis Children’s Hospital. Welcome to the show. What are some of the concerns about anesthetics in children?
Dr. Julie Drobish (Guest): Thank you for having me. There are some concerns about anesthetics in children and that mainly has come to be in our concern because of some animal studies that have been done over the last 15 years or so. The concern primarily is that exposure to these anesthesia drugs can possibly by harmful to the brain cells, or neurons, meaning that there could be altered function even after their anesthesia has stop.
Melanie: Are pediatric patients not miniature versions of adult physiology?
Dr. Drobish: Actually, they aren’t. One thing we commonly say is that kids are not just small adults. They are developing very rapidly, in particular brain development is going on in very important ways until approximately age three is when the majority of the rapid brain development goes on. During this period, the neurons in the brains are thought to be more vulnerable to the exposure of anesthesia than in an older child or young adult.
Melanie: How did physicians become aware of this problem?
Dr. Drobish: We became aware of this problem because initially there were several animal studies that were done using exposure to anesthetics, and maybe different anesthetics were tested, and in most cases, the exposure to anesthetics caused some cell death in the brain of the animals that were studied. In many cases, in addition to the cell death, the animals developed problems with learning and memory later on in life.
Melanie: If anesthetics caused problems in animals, does it necessarily follow that they’ll cause similar problems in people?
Dr. Drobish: It does not necessarily follow, but it is a potential concern, which is why there are is so much discussion regarding this topic and research going on. There are some differences in the way the studies are done in animals. The animals are not capable of being monitored all the time the way a child would be having anesthesia, and so children are monitored very carefully and the amount of anesthesia drugs that are given is changed over time according to the needs of the child during surgery as opposed to a set amount just being given in the majority of these studies. We really need to continue to study the effects of anesthesia as we practice it clinically in children and how they develop and any issues they may have later on down the road.
Melanie: Are all anesthetics created equal? Are some sedatives or anesthetics better or worse than another?
Dr. Drobish: We really don’t know for sure. As of right now, nearly all of the commonly used anesthetics have been shown to have potential anesthetic toxicity in the animals. We’re still doing ongoing studies to determine whether certain ones may be better than others – perhaps there's certain combinations may be better or worse than others – and so at this point, we really can't recommend a single anesthetic is better than another one.
Melanie: In December of 2012, SmartTots released its first consensus statement on the use of anesthetics and sedatives in children. Tell us a little bit about this consensus statement and why it was developed.
Dr. Drobish: The reason for the consensus statement was to provide some guidance to healthcare providers and parents with regard to these research findings that have suggested that anesthetics could be harmful. SmartTots is an organization that was developed with the goal of promoting research and making anesthetics safely for all the children who undergo it, so it’s important for them to put out statements such as this for the public to understand.
Melanie: Who developed and reviewed the consensus statement?
Dr. Drobish: The consensus statement was developed and reviewed by a group of experts in multiple disciplines of medicine, including anesthesia, pediatrics, and the neurosciences. They considered all of the evidence and studies that have been done in order to make a statement regarding the anesthetic toxicity.
Melanie: Who’s the audience?
Dr. Drobish: The audience is meant for multiple groups, so healthcare providers and the public – parents and caregivers are all included.
Melanie: Tell us about some of the ongoing research and give us a little blueprint for the future research of what's going on.
Dr. Drobish: There are several studies that have either recently completed or ongoing. There are two recent studies that have compared children who receive one episode of general anesthesia that was relatively short with children who received either no anesthesia or regional anesthesia – meaning a numbing medication – and both of those have recently shown that there were no differences in the testing of those children. There are still some ongoing studies regarding children who have had multiple exposures to anesthesia compared to children who have had zero or one exposure, and those are still in progress. There are many mechanistic aspects that we don’t understand how exactly are the anesthetics affecting the neurons, and so studies are ongoing in animals as well in order to continue to understand that interactions.
Melanie: What should physicians tell parents if their child needs surgery or a procedure that requires anesthesia? Are there some contraindications for institution of it?
Dr. Drobish: In general, today anesthesia is safer than it has ever been for children primarily because we have improved monitoring and new anesthetic drugs of many choices. However, we do have some concerns sometimes. The important thing would be to tell parents what are the benefits versus risks to the surgery, and the surgeon in particular as an important role here in order to advise the family on whether a surgery is really necessary at a given time or whether it can be postponed. Many surgeries are necessary in the first few years of life and it’s actually detrimental to brain development to not anesthetize a child and not provide proper pain control. All of these factors have to be considered and that the entire healthcare team make an appropriate decision along with the family as to whether a procedure needs to be done and what anesthetic is required for it.
Melanie: Are there some treatments or research that you're doing at St. Louis Children’s that other physicians may not be aware of?
Dr. Drobish: There is not specific study going on at St. Louis Children’s regarding anesthetic neurotoxicity. There are many centers participating in some of these ongoing studies that I mentioned, but we do not have our own separate studies.
Melanie: In summary, tell other physicians what you'd like them to know about the risk of anesthetic neurotoxicity in infants and children and when to refer to a specialist.
Dr. Drobish: The main issue to think about is that we’re not really sure whether anesthetics cause neurotoxicity, but there's a significant concern. Anesthesia should not be treated lightly. Any procedure that might be elective or could be postponed should be potentially postponed in light of knowing that anesthesia could cause problems and we don’t want to do anything that’s not necessary. However, it is safe to do anesthesia particularly if only one anesthetic is required in young children and it’s very important for necessary surgeries to be carried out in order for the overall health of the child and development to go as best as possible.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP. That’s 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to stlouischildrens.org. That’s stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.