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LETTER TO THE EDITOR J Oral Maxillofac Surg -:1, 2015
PEDIATRIC ANESTHESIA—CONCERNS ABOUT NEUROTOXICITY
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cific deficits associated with pediatric anesthesia, which is practically impossible in animal model studies. As a fellowship-trained craniofacial and pediatric oral and maxillofacial surgeon, I administer sedation anesthesia in some form to my pediatric patients on a daily basis. As with any procedure, the benefits must outweigh the risks of not only surgery but also anesthesia. It is imperative that parents be informed of these risks, which should include a frank discussion that even successful anesthesia in the pediatric population is not without the risk of effects later in life. After having this discussion, I find that parents will generally elect to delay routine procedures, such as frenectomies, unless the child is having pain or feeding issues, until after 3 years of age. For larger hospital procedures, such as cleft repair, the benefits would more clearly outweigh the risks. Moving forward, cohorts and retrospective reviews like the one by Ing et al will likely contribute to the bulk of our knowledge base regarding pediatric anesthesia and neurotoxicity, because clinical trials are not likely to happen. Each of us who sedates children in the office has the duty to stay on top of current anesthesia literature in this regard. We owe that to our pediatric patients and their families.
To the Editor:—Thank you for raising awareness within our specialty on what I consider one of the most important issues facing the oral and maxillofacial surgeon each day with your editorial, ‘‘Pediatric Anesthesia—Concerns About Neurotoxicity.’’1 Pediatric anesthesia is core to oral and maxillofacial surgical training, and every oral and maxillofacial surgeon in the country should have the knowledge to appropriately manage pediatric patients when called upon. Sedations are one of the most serious procedures we perform in our specialty, particularly in our pediatric population, in whom we have the potential to do serious harm. Patients and families place their lives in our hands and expect us to have the knowledge of the pharmacodynamics and pharmacokinetics of the drugs we administer. Pediatric patients are not merely ‘‘small adults.’’ Their physiology is inherently different. Compared with adults, children have increased extracellular fluid, decreased adipose tissue, and decreased skeletal muscle. Younger children have a decreased glomerular filtration rate, variable plasma protein concentration, and decreased cardiopulmonary reserve. These variations in physiology often necessitate higher concentrations of hydrophilic drugs in younger children, putting them at risk for overdose and cardiopulmonary complications. As you eloquently pointed out in your editorial, we are now learning that children also are at risk for late neurotoxic effects. In the eye-opening study by Ing et al2 published in Pediatrics in 2012, a retrospective review of 2,868 children, with 321 exposed to anesthesia for a surgical or diagnostic procedure before 3 years of age, was performed. Based on neuropsychological testing, they found that children exposed to anesthesia before 3 years of age were associated with a higher risk of deficits in language and abstract reasoning at 10 years. This is the first study to identify spe-
REYNALDO RIVERA, DDS, MD Clinical Instructor, Grand Rapids, MI
References 1. Hupp JR: Pediatric anesthesia—Concerns about neurotoxicity. J Oral Maxillofac Surg 73:1021, 2015 2. Ing C, DiMaggio C, Whitehouse A, et al: Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 130:e476, 2012
http://dx.doi.org/10.1016/j.joms.2015.05.040
1 COR 5.2.0 DTD YJOMS56851_proof 30 June 2015 6:13 pm CE AH
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LETTER TO THE EDITOR J Oral Maxillofac Surg -:1, 2015
PEDIATRIC ANESTHESIA—CONCERNS ABOUT NEUROTOXICITY
Q1
Q2
cific deficits associated with pediatric anesthesia, which is practically impossible in animal model studies. As a fellowship-trained craniofacial and pediatric oral and maxillofacial surgeon, I administer sedation anesthesia in some form to my pediatric patients on a daily basis. As with any procedure, the benefits must outweigh the risks of not only surgery but also anesthesia. It is imperative that parents be informed of these risks, which should include a frank discussion that even successful anesthesia in the pediatric population is not without the risk of effects later in life. After having this discussion, I find that parents will generally elect to delay routine procedures, such as frenectomies, unless the child is having pain or feeding issues, until after 3 years of age. For larger hospital procedures, such as cleft repair, the benefits would more clearly outweigh the risks. Moving forward, cohorts and retrospective reviews like the one by Ing et al will likely contribute to the bulk of our knowledge base regarding pediatric anesthesia and neurotoxicity, because clinical trials are not likely to happen. Each of us who sedates children in the office has the duty to stay on top of current anesthesia literature in this regard. We owe that to our pediatric patients and their families.
To the Editor:—Thank you for raising awareness within our specialty on what I consider one of the most important issues facing the oral and maxillofacial surgeon each day with your editorial, ‘‘Pediatric Anesthesia—Concerns About Neurotoxicity.’’1 Pediatric anesthesia is core to oral and maxillofacial surgical training, and every oral and maxillofacial surgeon in the country should have the knowledge to appropriately manage pediatric patients when called upon. Sedations are one of the most serious procedures we perform in our specialty, particularly in our pediatric population, in whom we have the potential to do serious harm. Patients and families place their lives in our hands and expect us to have the knowledge of the pharmacodynamics and pharmacokinetics of the drugs we administer. Pediatric patients are not merely ‘‘small adults.’’ Their physiology is inherently different. Compared with adults, children have increased extracellular fluid, decreased adipose tissue, and decreased skeletal muscle. Younger children have a decreased glomerular filtration rate, variable plasma protein concentration, and decreased cardiopulmonary reserve. These variations in physiology often necessitate higher concentrations of hydrophilic drugs in younger children, putting them at risk for overdose and cardiopulmonary complications. As you eloquently pointed out in your editorial, we are now learning that children also are at risk for late neurotoxic effects. In the eye-opening study by Ing et al2 published in Pediatrics in 2012, a retrospective review of 2,868 children, with 321 exposed to anesthesia for a surgical or diagnostic procedure before 3 years of age, was performed. Based on neuropsychological testing, they found that children exposed to anesthesia before 3 years of age were associated with a higher risk of deficits in language and abstract reasoning at 10 years. This is the first study to identify spe-
REYNALDO RIVERA, DDS, MD Clinical Instructor, Grand Rapids, MI
References 1. Hupp JR: Pediatric anesthesia—Concerns about neurotoxicity. J Oral Maxillofac Surg 73:1021, 2015 2. Ing C, DiMaggio C, Whitehouse A, et al: Long-term differences in language and cognitive function after childhood exposure to anesthesia. Pediatrics 130:e476, 2012
http://dx.doi.org/10.1016/j.joms.2015.05.040
1 COR 5.2.0 DTD YJOMS56851_proof 30 June 2015 6:13 pm CE AH
Q3
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