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Putting Babies To Sleep

February 27, 2015

OK, nobody panic.  Remain calm and call anesthesia.  Or maybe, if you’re 2, don’t call anesthesia.  The New England Journal of Medicine on Feb. 25 published an article that warns of an increasing body of evidence suggesting that anesthesia is bad for babies.  Denise Grady, a New York Times reporter, said this in her piece yesterday: (http://www.nytimes.com/2015/02/26/health/researchers-call-for-more-study-of-anesthesia-risks-to-young-children.html?ref=health&_r=0)”

“… five experts described a ‘heightened level of concern’ about the potential risks, called the data from animal studies ‘compelling’ and said ‘parents and care providers should be made aware of the potential risks that anesthetics pose to the developing brain.'”

Evidence of this possible risk as been growing since the 1990’s, when the first animal studies came out.  In 2009, the F.D.A. and the International Anesthesia Research Society formed Strategies for Mitigating Anesthesia-Related Neurotoxicity in Tots or SmartTots, to futher research this potential problem.  In 2012, SmartTots recommended that elective surgery under general anesthesia be avoided in children younger than 3.  Here is what SmartTots is saying this year (http://www.smarttots.org):

Infants and very young children who are exposed to anesthesia may experience higher rates of learning disabilities and cognitive difficulties than children who are not exposed to anesthesia, according to research and emerging data presented during the SmartTots: Pediatric Anesthesia Neurotoxicity panel at the International Anesthesia Research Society annual meeting in Vancouver, B.C.  “We want to impress upon people that there is a very reliable link between the animal and human data that is rapidly emerging,” said panel moderator Dr. Vesna Jevtovic-Todorovic, M.D., Ph.D., M.B.A., Professor of Anesthesiology and Neuroscience at the University of Virginia Health System and SmartTots Scientific Advisory Board member.

SmartTots warns that “Children younger than 4 years who were exposed to anesthesia for 120 min and longer for at least two times are at high risk.”

So what is this emerging data?  Well, it’s mostly primate and rat data at this point.  Researchers found, for example, that a single 24-hour episode of ketamine anesthesia results in very long-lasting deficits in brain function in nonhuman primates.  Another found that multiple exposures to anesthesia before a monkey is two years old are a risk factor for the development of Attention Deficit Hyperactivity Disorder.  Yet a third paper has demonstrated that common anesthetics, alone and in combination, caused damage in the brain of baby rodents, with widespread death of nerve cells. These rats suffered long-lasting problems with learning and memory, which got worse as they aged.

Yikes.  Now, as I said before, don’t panic.  There are a few things to consider when reading about this stuff.

1. Your toddler getting her tonsils out or ear tube put in is not at risk.  Those are 10 minute procedures in otherwise healthy children.  Please do not let your kid suffer years of unnecessary infections and possible hearing loss because of concerns over the anesthesia.  I know people are going to.  Don’t.

2. Very young children exposed to surgeries lasting two or more hours on multiple occasions generally have either severe birth defects or severe injuries of some kind.  I’m not sure you can isolate anesthesia as a cause of brain damage in these situations, in which cognitive development is at risk in multiple other ways.

3. I’m not sure what study Dr. Jevtovic-Todorovic is referring to when she talks about a “very reliable link” between nonhuman and human data.  There is an ongoing multicenter study sponsored by Boston Children’s Hospital which is studying 650 infants getting inguinal hernia repairs, looking for neurodevelopmental outcomes in kids getting regional anesthesia (a spinal) vs. general anesthesia.  Such a study will involve mostly healthy children with anesthetic exposures significantly lower than those SmartTots says are most concerning, but it might help.

4. General anesthesia is not just the drugs we use.  It’s also the type of surgery being done, how much blood loss there is, how much oxygen gets to the patient, how much carbon dioxide builds up, how well blood pressure is maintained, and multiple other factors that anesthesiologists monitor very carefully.  Many of these things are under our control, but all anesthesia and surgery interferes with these systems to some extent.

And since personal anecdote has been shown to be more effective than statistics, I will tell you that my second child had major thoracic surgery at age 3 days.  She was under anesthesia for about 4 hours.  She is now a healthy 4 1/2 year old with no signs of any mental problems except persistent four-ishness. Hope this helps.

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4 Comments
  1. Tom West permalink

    I’ve been following this story as an interested observer for a few years now, and my guess is that this is to raise funds for Smarttots (even the name is revealing). Smarttots consistently underplays studies that fail to show an association between anesthesia and development in humans, while hyping studies that do.

    Even the animal studies seem calculated to cause maximum effect. The “reliable link” in rodents seems to only manifest after 6 hours of anesthesia..it is curious that few animals studies examine shorter durations-why is this?

    I don’t think this is malicious-they have a goal-to raise funds for research- and they need to do this by raising the alarm level. There is a risk (for researchers in this area) that a failure to show single exposures are harmful, will push this issue even further off the agenda and possibly block further necessary research into multiple exposures and longer durations.

    • I agree. I don’t think SmartTots is fear-mongering on purpose. But I do think that things like this, especially when they get reported in widely-read publications like the New York Times, have a tendency to scare people in a way that can be harmful.

  2. jane permalink

    The animal studies are not “calculated to cause maximum effect” because researchers wish to fearmonger in order to raise more money, just as that is not why climatologists do research. Animal studies of all kinds of drugs and toxins regularly use higher doses than are given to humans, for several reasons: (1) if there is an effect, you need to be able to see it, and to achieve statistical significance, without using a financially impossible number of animals; (2) rodents have somewhat different metabolisms and may require higher doses than humans to show the same effects; and (3) animals can only be evaluated for biomarkers or for outcomes that are relatively large and obvious. Studies that have shown a correlation between infant anesthesia and later reduced cognitive function in humans can evaluate things like tests of reading ability; if you want to see brain damage in a monkey, you have to do enough damage to noticeably impair performance in ordinary tasks. The fact that anesthesia in older adults is correlated with increased risk of subsequent dementia is a third line of evidence.

    Certainly some children really need early surgery, meaning that they’ll die or be disabled without it and live with an acceptable quality of life with it. In those cases, it’s rational to go ahead. Some kids won’t be harmed by the anesthesia, and if others lose a few IQ points, it doesn’t mean their lives are ruined; indeed they may still end up being above-average if they were starting with a good enough baseline and environment. But there are cases where surgery is questionably necessary or might be delayed, and depending upon the family’s values, it is reasonable to consider the tradeoffs that might be involved. There are too many fields of medicine that feel that interventions with benefits should be assumed, or pretended, not to have risks as well.

    • Good point. I think in the area of imaging tests for children your point about waiting is especially true, since young children are usually given general anesthesia for CT scans, MRIs, and invasive radiologic procedures.

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