Is general anesthesia safe for children?

The Pediatric Insider

© 2015 Roy Benaroch, MD

Meghan wrote in:

My 10 month old son (a twin) has a mild hypospadias and chordee. The recommendation from our pediatric urologist was surgery at 6 months. Another specialist said that we could wait a few months, which may even lead to better outcomes (due to difference in size) but that we would absolutely need to operate before he was walking and reached ‘genital awareness.’

This surgery requires general anesthesia, and there have been a number of studies published recently (i.e. NEJM and Pediatrics) that suggest that this poses serious risks (learning disabilities, etc.) Of course for life threatening conditions, you would need to operate, but for a non-life threatening condition (mild hypospadias) I wonder if the pros outweigh the potential cons?

I would greatly appreciate your thoughts. The specialists whom I have tried to engage (urologists and anesthesiologists) have been unfortunately, very dismissive to entering into discussions around this issue. Even guidance on who to approach for their thoughts would be so appreciated!

First: hypospadias, if mild, probably doesn’t have to be repaired at all. But that chordee—if that’s present, Junior would appreciate it if you’d get that fixed for him before he has painful erections that don’t (for lack of a better term) work.

What Meghan really wanted to know about was the potential risks of anesthesia, especially in light of recent publications that have brought up questions about anesthesia’s long term affect on children’s brains. Some of these studies have been on animals (both rodents and primates), showing “anesthetic neurotoxicity”—the death of brain cells with exposure to anesthetic agents. But rats and monkeys aren’t people, and we know that brain cells (especially cells in brains of children in intellectually stimulating environments) can regrow and regain function. In fact, it may well be that younger children could conceivably recover from this kind of damage better than adults.

Other studies have been observational, retrospective studies—looking at groups of children who did and did not have exposure to anesthesia. One from a few months ago did show that kids who had anesthesia before age four did have slightly lower IQ scores (tho IQ remained in the normal range for both groups, it was 5-6 points higher in the children who had not had anesthesia.) But these kinds of studies aren’t very reliable. It’s difficult to know, for instance, if the difference is from the anesthesia itself, or from the health condition that necessitated the surgery. That is, kids who require surgery and kids who don’t require surgery aren’t equal in many ways. The ones who need surgery are more likely to have health problems, and maybe that’s why their measured IQ at age four could be lower. Besides, does the IQ at four even matter? What if it’s recovered to the same by school age?

Meghan might think that for what’s going on with her son, which is a genital concern, there wouldn’t be any expected difference in brain strength. But statistically, that’s not true. We know babies born prematurely are more likely to have hypospadias; and we know that babies born prematurely are more likely to have intellectual deficits, ADHD, autism, and cerebral palsy. Statistically speaking, having a hypospadias means you’re more likely to have these other things, too. We also know that the most effect on development and IQ is seen in children who’ve had multiple surgeries (who are also the children most likely to have the most complicated medical histories, like heart disease or brain malformations.) So was is it the anesthesia that’s the risk?

Chicken, meet egg.

The best studies to tease this out haven’t been completed yet, but they’re underway. Children with the same health conditions (for example, a group of boys with hypospadias) need to be randomized so some have surgery now, and some wait a few years. Then they can be followed with periodic neuropsychiatric testing to see how they do. This kind of randomized, prospective study is the best way to isolate a variable (in this case, anesthesia) and establish whether that’s really a risk.

Since those studies haven’t been done yet, for now I’d say: if general anesthesia isn’t required – if the procedure is entirely cosmetic, or can safely be put off until a child is older – it makes sense to wait. But in some cases, there’s a medical benefit to doing surgery earlier. Cleft lip repair early allows for better language development and feeding; a shunt to treat hydrocephalus prevents brain damage when done young; eye muscle surgery allows the development of sharp vision. The potential risk of general anesthesia has to be balanced against the risk of waiting, and there’s no “general rule” that you can apply that could account for all circumstances.

The most troubling part of Meghan’s question was her last comment—that the surgeons and anesthesiologists were dismissive of her concerns. Those are the people she ought to be able to depend on to follow the literature closely and be able to discuss this. If they’re unwilling to take these questions seriously, it’s probably best to Meghan to find some new doctors.

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6 Comments on “Is general anesthesia safe for children?”

  1. E Canfield Says:

    They didn’t explain much when they knocked out my 1 year old to put a spica cast on him. (His femur is healing nicely). Mostly, the doc just said it was so he wouldn’t feel it and wouldn’t be frightened. I figure part of it is also so he would lay still. Granted, they could have been brief because we were pretty clearly on autopilot.

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  2. Meghan Says:

    This is late – but I wanted to say thank you so much! This was a really helpful for me in framing the issue for myself – but also in communicating it to others. I am planning to see two other urologists in the hopes that they will be more open to discussion and to decide how to proceed. Thanks again! I really enjoy al of your thoughtful posts and guidance!

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  3. Steve Auer,M.D. Says:

    I am a recently retired anesthesiologist. Over the last 10 years I became more and more concerned that general anesthesia can cause long term decreased cognitive function postoperatively. There are group studies suggesting harmful effects in the pediatric and geriatric patient groups. This is in addition to Laboratory studies showing damage to nerve cells after anesthetic exposure.
    So what can you do if you need surgery?
    1. if possible, have the surgery awake under local or regional anesthesia
    2 if general anesthesia or heavy sedation are required, it gets complicated. General anesthesia is achieved by using a mixture of drugs given intravenously and through the lungs. Almost all of these drugs act on the brain by stimulating GABA receptors and these are the routinely used(harmful) anesthetic agents (propofol,barbiturates, versed, inhalation agents.)
    The trick is to have a general anesthesia drug combination that has a minimum of these GABA type drugs and instead uses mostly narcotics(Fentanyl,Morphine, etc.) and another newer class drug called Precedex.

    So that’s one anesthesiologist’s opinion:
    The good: Local & Regional anesthesia, Narcotics, Precedex

    The bad: Everything else.

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  4. Dr. Roy Says:

    Thanks Dr. Auer. The point “1. if possible, have the surgery awake under local or regional anesthesia” is excellent advice, though unfortunately often less useful for children, especially young children, who may panic and squirm. There is an in-between option, sometimes, called conscious sedation (or “twilight sedation”) where the patient is sleepy tho awake enough to breathe, tho this uses similar anesthetics at lower doses and has its own risks.

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  5. Steve Auer,M.D. Says:

    Thanks, Dr. Roy. As you correctly point out, children need to be sedated when having surgery under local or regional techniques and also need sedation for diagnostic procedures like MRIs. Unfortunately, Propofol is the main drug used for this purpose and is one of the GABA class drugs implicated in neurotoxic side effects.
    Many pediatric centers are instead doing sedation with a drug called Dexmedetomidine (Precedex.)
    [cf. Keira P. Mason,MD, Children’s Hospital Boston, Harvard,
    Anesthesia and Analgesia, Nov 2011, vol.213]

    Dex” is not only a non-neurotoxic sedative but can also be used in general anesthesia in combination with a GABA inhalation drug (e.g. Sevoflurane) This allows about a 75% dose reduction of the Sevoflurane.
    In addition, there have been numerous neonatal animal studies showing that Dex actually protects young neurons from the toxic effects of the GABA anesthetic agents.
    Unfortunately, the routine, outpatient, clinical use of Dex is hampered by it’s high cost and it’s slow elimination from the body. Patients are sometimes sleepy for a couple of hours after surgery and can’t reliably be quickly discharged to go home.
    Ironically, this should not be an issue because there exists a safe, effective reversal agent for Dex. However, it is currently only approved for use in veterinary practice. The company that manufactures Dex has no desire to navigate the long, costly FDA process for approval of this reversal agent for humans.

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  6. Meghan Says:

    In follow up to my earlier post –

    We sought out the opinion of another highly recommended pediatric urologist at another well-known hospital and he did not recommend surgery. We hardly touched on the issue of anesthesia — he said that the hypospadias was extremely mild and that there was no chordee. He said that functionally, my son would be fine, and that any surgery done now would be purely for aesthetic reasons.

    He also said that as surgeons have become better and better at the procedure, they have become more inclined to operate.

    I wanted to share this information in case any other parent is in a similar situation.

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