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President’s Message on Children and Immigration

SPA Members:

As you are no doubt aware there is an ongoing, very vigorous and often acrimonious debate around the issue of immigration and most importantly the separation of children from their parents.

The Society, as a professional organization devoted to the health and welfare of children in the perioperative setting, takes no position on the federal policies or legislation addressing legal or illegal immigration.

Regardless of the diversity of opinion regarding immigration, as professionals devoted to the care of children, we understand the lasting emotional harm that may result when children and parents are forcibly separated regardless of the reason.

The Society joins the American Academy of Pediatrics, American Medical Association and many other professional societies in strongly condemning the policy of forcibly separating children from their parents. The Society further urges that those children who were previously separated be rapidly reunified with their parents in a setting that ensures their emotional and physical safety.

The Society and its members cannot support policies that jeopardize the health and welfare of the children about whom we care so passionately.

Randall Flick, MD, MPH, FAAP
President, Society for Pediatric Anesthesia

Open Letter on Gun Violence

Dear Colleagues,

Over the past several days I have received multiple e-mails expressing shock and outrage regarding what has now become known as the Valentine’s Day massacre. The most recent in a seemingly endless string of mass shootings occurred last week in a Parkland, Florida High School leaving 17 students and teachers dead and many more injured. The authors of those e-mails ask whether the Society should take an individual position or join other groups such as the American Academy of Pediatrics or American Pediatric Surgical Association supporting legislation and should the Society in some way recognize the march scheduled to occur during the winter meeting. Included are links to position statements by the AAP and APSA.

Each of our more than 3,000 members has a personal position and strong feelings about the issue of gun violence that flows from their experience and background. The Society for Pediatric Anesthesia is a professional organization that represents each of those members and seeks to be the voice of the specialty. Central to our mission is the health and well – being of children. As a Society we are committed not only to the perioperative care of children but also to the advancement of the science that improves the lives of the children and families about whom we care so deeply.

In 1996 congress passed the Dickey amendment, severely limiting the ability of the Center for Disease Control to study gun violence. Regardless of one’s political views or position on the restriction of firearm availability, as scientists and advocates for children, we must come together to seek a more robust understanding of the impact of gun violence on children and families. The deaths of the children of Sandy Hook Elementary, of Columbine High School, of Marjory Stoneman Douglas High School and the countless other school shootings that occur on an almost weekly basis are first and foremost issues of public health no different than the opioid crisis, smoking, automobile crashes or epidemic infectious disease. Knowledge is fundamental to understanding and understanding is essential to positive change. As physicians and members of a society devoted to the pursuit of knowledge we cannot remain silent in the face of a policy that is contrary to our obligations as physicians, scientists and advocates for children.

To do less represents intellectual dishonesty and a moral failure.

Randall Flick, MD, MPH, FAAP
President, Society for Pediatric Anesthesia

Joint IARS SPA Press Release on Study of Anesthesia Safety

San Francisco – April 18, 2018 – A Mayo Clinic study of children who received one or more exposures to anesthesia before the age of 3 has provided valuable information about the potential neurological and behavioral impact of general anesthesia on very young children, according to the International Anesthesia Research Society and the Society for Pediatric Anesthesia.

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Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial

Summary
Background
Preclinical data suggest that general anaesthetics affect brain development. There is mixed evidence from cohort studies that young children exposed to anaesthesia can have an increased risk of poor neurodevelopmental outcome. We aimed to establish whether general anaesthesia in infancy has any effect on neurodevelopmental outcome. Here we report the secondary outcome of neurodevelopmental outcome at 2 years of age in the General Anaesthesia compared to Spinal anaesthesia (GAS) trial.

Methods
In this international assessor-masked randomised controlled equivalence trial, we recruited infants younger than 60 weeks postmenstrual age, born at greater than 26 weeks’ gestation, and who had inguinal herniorrhaphy, from 28 hospitals in Australia, Italy, the USA, the UK, Canada, the Netherlands, and New Zealand. Infants were randomly assigned (1:1) to receive either awake-regional anaesthesia or sevoflurane-based general anaesthesia. Web-based randomisation was done in blocks of two or four and stratified by site and gestational age at birth. Infants were excluded if they had existing risk factors for neurological injury. The primary outcome of the trial will be the Wechsler Preschool and Primary Scale of Intelligence Third Edition (WPPSI-III) Full Scale Intelligence Quotient score at age 5 years. The secondary outcome, reported here, is the composite cognitive score of the Bayley Scales of Infant and Toddler Development III, assessed at 2 years. The analysis was as per protocol adjusted for gestational age at birth. A difference in means of five points (1/3 SD) was predefined as the clinical equivalence margin. This trial is registered with ANZCTR, number ACTRN12606000441516 and ClinicalTrials.gov, number NCT00756600.

Findings
Between Feb 9, 2007, and Jan 31, 2013, 363 infants were randomly assigned to receive awakeregional anaesthesia and 359 to general anaesthesia. Outcome data were available for 238 children in the awake-regional group and 294 in the general anaesthesia group. In the as-perprotocol analysis, the cognitive composite score (mean [SD]) was 98·6 (14·2) in the awakeregional group and 98·2 (14·7) in the general anaesthesia group. There was equivalence in mean between groups (awake-regional minus general anaesthesia 0·169, 95% CI −2·30 to 2·64). The median duration of anaesthesia in the general anaesthesia group was 54 min.

Interpretation
For this secondary outcome, we found no evidence that just less than 1 h of sevoflurane anaesthesia in infancy increases the risk of adverse neurodevelopmental outcome at 2 years of age compared with awake-regional anaesthesia.

Anesthesia and Brain Development in Your Child

On Dec. 14, 2016 the U.S. Food and Drug Administration (FDA) issued a safety announcement regarding the potential effect of anesthetics on children younger than 3 years of age. Recent studies suggest that a single, relatively short exposure to general anesthetic and sedation drugs in infants or toddlers is unlikely to have negative effects on behavior or learning. However, further research is needed to fully characterize how early life anesthetic exposure affects children’s brain development. To better inform the public about this potential risk, we have taken points from the FDA’s communication and are sharing those with families to help them make educated decisions about the care of their young child.

Facts About General Anesthetic and Sedation Drugs

General anesthetic and sedation drugs are used to put infants and children into a deep sleep so they do not feel pain during surgery or procedures.
These drugs are usually injected into a vein or inhaled through a mask or breathing tube.
General anesthetic drugs are used in millions of children every year to ensure their health, safety and comfort during surgery and other procedures.

Additional Information for Parents and Caregivers

Anesthetic and sedation drugs are necessary for infants and children who require surgery or other painful or stressful procedures. Additionally, untreated pain can be harmful to children and their developing nervous systems.
Research suggests that repeated or prolonged use of general anesthetic or sedative drugs may be associated with negative effects on the developing brain.
These effects are subtle and may include learning, memory, or behavior problems.
The FDA has issued a warning that this may affect children younger than 3 years who are undergoing anesthesia for more than three hours, or are exposed to repeated anesthetics.
Recent studies in children suggest that a single, short duration exposure to general anesthetic and sedation drugs under age 3 years is unlikely to have negative effects on behavior or learning.
No specific anesthetic or sedative medications have been shown to be safer than any other.
Parents and caregivers should ask for information about the planned surgery or procedure, including duration of anesthesia and need for any repeated procedures.
Parents should discuss with their anesthesiologist and surgeon the potential adverse effects of anesthesia and brain development and appropriate timing of procedures that could be delayed without jeopardizing their child’s health.
Examples of life-threatening conditions in newborns and other children younger than 3 years that require surgery or other procedures that should not be delayed include, but are not limited to:
- Congenital heart defects
- Esophageal atresia, a disorder in which the esophagus does not develop properly
- Intestinal blockage or twisting of the intestines
- Gastroschisis and omphalocele, which are birth defects of the abdominal wall
- Diaphragmatic hernia, which is a birth defect in which there is an abnormal opening in the diaphragm
- Congenital lung lesions
- Pyloric stenosis, which is a narrowing of the opening from the stomach into the small intestine
- Craniofacial reconstruction
- Complex urological reconstruction
Examples of other common procedures for non-life-threatening conditions in children younger than 3 years that are necessary and should not be delayed are cleft lip or palate repair and surgery to repair undescended testicles in boys.
If you have further questions about your child’s care, talk to your anesthesiologist and surgeon.
Other useful resources:
- SmartTots website: www.smarttots.org
- Society for Pediatric Anesthesia website: pedsanesthesia.org
- U.S. FDA Website: www.fda.gov

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