Pediatric anesthesia and neurodevelopmental impairments: a Bayesian meta-analysis

Neurodevelopmental Outcomes in Children With Liver Diseases: a Systematic Review

OBJECTIVE

The aim of the study was to determine the neurodevelopmental outcomes of children with liver diseases based on a systematical review of the literature.

METHOD

A literature search according to the PRISMA statement was conducted using predefined search terms in PubMed, Cochrane Library, and PsycINFO. The inclusion criterion was studies published from 2000 onwards that reported on the neurodevelopmental outcomes of term-born children with liver diseases. A narrative synthesis was done to appraise the studies.

RESULTS

Twenty-five studies were included (1913 children), 19 of which described children after liver transplantation (LTx; 1372 children). Sixty-seven percentage of the studies on children with liver diseases who survived with their native livers showed low-average or abnormal scores on specific subscales of cognitive and behavioral measures. In studies on children after LTx, this was 82%. After LTx, 83% of studies demonstrated impaired outcomes on behavior, whereas 42% of children received special education. Motor development was impaired in 82% of studies in children with native liver and after LTx.

LIMITATIONS

Studies were heterogenic because of sample sizes, etiology of liver disease and type of assessment tools used.

CONCLUSIONS

More than two-third of included studies showed neurodevelopmental deficits in children with liver diseases, affecting all neurodevelopmental areas. Knowledge on risk factors for impaired neurodevelopment is limited and lack of long-term follow-up is worrying, especially considering the increasing survival rates, resulting in more at-risk patients. Studying early predictors and risk factors of abnormal developmental trajectories of children with liver diseases is indicated to assess strategies to improve their long-term neurodevelopmental outcomes.

Risk of ADHD After Multiple Exposures to General Anesthesia: A Nationwide Retrospective Cohort Study

OBJECTIVE

To study the association between general anesthesia exposure before age 3 years and having a later ADHD diagnosis.

METHOD

In a birth cohort, data were collected from a nationwide population database for children born between 1997 and 1999 who were exposed to general anesthesia before their third birthday. Age- and gender-matched enrollees without general anesthesia exposure were taken as the comparison. Groups were compared to identify the incidence of ADHD after age 4 and anesthesia-related predictive factors.

RESULTS

Among the 1,146 exposed children, 74 ADHD cases were identified, and 158 ADHD cases were identified in 3,438 matched controls. After adjusting for comorbid conditions and possible confounding factors, if exposure on more than one occasion or ≥3 hr, an increased likelihood of having a later ADHD diagnosis was found (HR, 1.71 and 2.43, respectively).

CONCLUSION

Children with multiple or ≥3 hr general anesthesia exposures before age 3 years have an increased likelihood of a later ADHD diagnosis.

Mapping targetable inflammation and outcomes with cystic fibrosis biomarkers

Cystic fibrosis is characterized by an overly exuberant neutrophilic inflammatory response to pathogens and other stimuli that starts very early in disease. The overwhelming nature of this response is a primary cause of remodeling and destruction of the airways, suggesting that anti-inflammatory therapies could be beneficial in CF. However, finding therapies that can effectively reduce the inflammatory response without compromising host defenses remains elusive. New approaches towards mapping inflammatory targets promise to aid in developing novel therapeutic strategies and improve outcomes in individuals with CF.

Isoflurane exposure regulates the cell viability and BDNF expression of astrocytes via upregulation of TREK‑1

Neonatal isoflurane exposure in rodents disrupts hippocampal cognitive functions, including learning and memory, and astrocytes may have an important role in this process. However, the molecular mechanisms underlying this disruption are not fully understood. The present study investigated the role of TWIK-related K⁺ channel (TREK-1) in isoflurane-induced cognitive impairment. Lentiviruses were used to overexpress or knockdown TREK-1 in astrocytes exposed to increasing concentrations of isoflurane or O₂ for 2 h. Subsequently, the mRNA and protein expression of brain-derived neurotrophic factor (BDNF), caspase-3, Bcl-2-associated X (Bax) and TREK-1 was measured by reverse transcription-quantitative polymerase chain reaction and western blot analysis, respectively. In addition, cell viability was assessed by a 2-(4-Iodophenyl)-3-(4-nitrophenyl)-5-(2,4-disulfophenyl)-2H-tetrazolium monosodium salt assay. The results demonstrated that, prior to manipulating TREK-1, isoflurane significantly decreased the cell viability and BDNF expression, and increased Bax, caspase-3 and TREK-1 expression was observed. However, TREK-1 overexpression in astrocytes significantly downregulated BDNF expression, and upregulated Bax and caspase-3 expression. Furthermore, lentiviral-mediated short hairpin RNA knockdown of TREK-1 effectively inhibited the isoflurane-induced changes in BDNF, Bax and caspase-3 expression. Taken together, the results of the present study indicate that isoflurane-induced cell damage in astrocytes may be associated with TREK-1-mediated inhibition of BDNF and provide a reference for the safe use of isoflurane anesthesia in infants and children.

Behavioral regression in 2 patients with autism spectrum disorder and attention-deficit/hyperactivity disorder after oral surgery performed with a general anesthetic

BACKGROUND AND OVERVIEW

Routine dental care for people with autism spectrum disorders can be complex. There is little published on postoperative behavioral changes associated with use of general anesthetics in this population.

CASE DESCRIPTION

The authors describe postoperative behavioral changes in 2 patients with autism spectrum disorder and attention deficit hyperactivity disorder that the patients' caretakers described as regression. In both cases, behaviors representative of autism spectrum disorder and attention deficit hyperactivity disorder worsened after uncomplicated oral surgery after receipt of a general anesthetic in the operating room. In both cases, behavioral changes caused great difficulties for the patients and caretakers and were difficult to address.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

With little in the scientific literature, these 2 cases have a great importance for the dental care practitioner. Awareness must be raised so that further investigation can occur regarding this phenomenon.

Neonatal Surgery for Noncardiac Congenital Anomalies: Neonates at Risk of Brain Injury

OBJECTIVE

To evaluate the incidence of brain injury after neonatal surgery for noncardiac congenital anomalies using magnetic resonance imaging (MRI).

STUDY DESIGN

An MRI was obtained in 101 infants at 7 days [range: 1-115] after neonatal surgery for major noncardiac congenital anomalies. Brain injury was assessed using T1, T2, diffusion weighted imaging, and susceptibility-weighted imaging.

RESULTS

Thirty-two preterm infants (<37 weeks of gestation) and 69 full-term infants were included. MRI abnormalities were found in 24 (75%) preterm and 40 (58%) full-term infants. Parenchymal lesions were noted in 23 preterm (72%) and 29 full-term infants (42%). These consisted of punctate white matter lesions (n = 45), punctate cerebellar lesions (n = 17), thalamic infarction (n = 5), and periventricular hemorrhagic infarction (n = 4). Nonparenchymal abnormalities were found in 9 (28%) preterm and 26 (38%) full-term infants. These included supra- and infratentorial subdural hemorrhages (n = 30), intraventricular hemorrhage grade II (n = 7), and asymptomatic sinovenous thrombosis (n = 1). A combination of parenchymal lesions was present in 21 infants. Of infants who had an MRI within 10 days after surgery, punctate white matter lesions were visible on diffusion weighted imaging in 22 (61%), suggestive of recent ischemic origin. Type of congenital anomaly and prematurity were most predictive of brain injury.

CONCLUSIONS

Infants who have neonatal surgery for noncardiac congenital anomalies are at risk of brain injury, potentially accounting for the neurodevelopmental delay frequently observed in this population. Further research is warranted into potential mechanisms of brain injury and its timing of onset. Long-term neurodevelopmental follow-up is needed in this vulnerable population.

The effect of anaesthesia on the infant brain

Pre-clinical studies have consistently found that most general anaesthetics produce accelerated apoptosis in the developing brain. The effect has been seen in species ranging from the nematode to the non-human primate. A variety of other effects are also seen. There is also some evidence that animals exposed to anaesthesia are at increased risk of deficits in memory and learning. The effects are only seen with prolonged exposure. There are numerous problems in translating these findings to human clinical scenarios. Several human cohort studies have found an association between surgery in infancy and increased risk of poorer neurobehavioural outcome; however the possibility of confounding factors such as co-morbidity and surgery itself make it impossible to determine if these associations are due to anaesthesia toxicity. A recent trial and cohort studies suggest that an exposure of less than an hour does not increase the risk of poor outcome.

Neurogenesis and developmental anesthetic neurotoxicity

The mechanism by which anesthetics might act on the developing brain in order to cause long term deficits remains incompletely understood. The hippocampus has been identified as a structure that is likely to be involved, as rodent models show numerous deficits in behavioral tasks of learning that are hippocampal-dependent. The hippocampus is an unusual structure in that it is the site of large amounts of neurogenesis postnatally, particularly in the first year of life in humans, and these newly generated neurons are critical to the function of this structure. Intriguingly, neurogenesis is a major developmental event that occurs during postulated windows of vulnerability to developmental anesthetic neurotoxicity across the different species in which it has been studied. In this review, we examine the evidence for anesthetic effects on neurogenesis in the early postnatal period and ask whether neurogenesis should be studied further as a putative mechanism of injury. Multiple anesthetics are considered, and both in vivo and in vitro work is presented. While there is abundant evidence that anesthetics act to suppress neurogenesis at several different phases, evidence of a causal link between these effects and any change in learning behavior remains elusive.

From Drug-Induced Developmental Neuroapoptosis to Pediatric Anesthetic Neurotoxicity-Where Are We Now?

The fetal and neonatal periods are critical and sensitive periods for neurodevelopment, and involve rapid brain growth in addition to natural programmed cell death (i.e., apoptosis) and synaptic pruning. Apoptosis is an important process for neurodevelopment, preventing redundant, faulty, or unused neurons from cluttering the developing brain. However, animal studies have shown massive neuronal cell death by apoptosis can also be caused by exposure to several classes of drugs, namely gamma-aminobutyric acid (GABA) agonists and N-methyl-d-aspartate (NMDA) antagonists that are commonly used in pediatric anesthesia. This form of neurotoxic insult could cause a major disruption in brain development with the potential to permanently shape behavior and cognitive ability. Evidence does suggest that psychoactive drugs alter neurodevelopment and synaptic plasticity in the animal brain, which, in the human brain, may translate to permanent neurodevelopmental changes associated with long-term intellectual disability. This paper reviews the seminal animal research on drug-induced developmental apoptosis and the subsequent clinical studies that have been conducted thus far. In humans, there is growing evidence that suggests anesthetics have the potential to harm the developing brain, but the long-term outcome is not definitive and causality has not been determined. The consensus is that there is more work to be done using both animal models and human clinical studies.

A Population-based Study Evaluating the Association between Surgery in Early Life and Child Development at Primary School Entry

Background

It is unclear whether exposure to surgery in early life has long-term adverse effects on child development. The authors aimed to investigate whether surgery in early childhood is associated with adverse effects on child development measured at primary school entry.

Methods

The authors conducted a population-based cohort study in Ontario, Canada, by linking provincial health administrative databases to children’s developmental outcomes measured by the Early Development Instrument (EDI). From a cohort of 188,557 children, 28,366 children who underwent surgery before EDI completion (age 5 to 6 yr) were matched to 55,910 unexposed children. The primary outcome was early developmental vulnerability, defined as any domain of the EDI in the lowest tenth percentile of the population. Subgroup analyses were performed based on age at first surgery (less than 2 and greater than or equal to 2 yr) and frequency of surgery.

Results

Early developmental vulnerability was increased in the exposed group (7,259/28,366; 25.6%) compared with the unexposed group (13,957/55,910; 25.0%), adjusted odds ratio, 1.05; 95% CI, 1.01 to 1.08. Children aged greater than or equal to 2 yr at the time of first surgery had increased odds of early developmental vulnerability compared with unexposed children (odds ratio, 1.05; 95% CI, 1.01 to 1.10), but children aged less than 2 yr at the time of first exposure were not at increased risk (odds ratio, 1.04; 95% CI, 0.98 to 1.10). There was no increase in odds of early developmental vulnerability with increasing frequency of exposure.

Conclusions

Children who undergo surgery before primary school age are at increased risk of early developmental vulnerability, but the magnitude of the difference between exposed and unexposed children is small.

Shared Decision Making and Office Insertion of Tympanostomy Tubes

Office insertion of tympanostomy tubes in young children without anesthesia is facilitated through shared decision making with families, including a candid discussion about anticipated pain (which is usually brief and transient) and how their child might react to being restrained. This commentary elaborates on the rationale for office tube insertion as an alternative to general anesthesia, including a clinical decision aid and suggestions for optimizing outcomes.

Optical coherence tomography to monitor vigabatrin toxicity in children

PURPOSE

The antiepileptic drug vigabatrin is known to cause permanent loss of vision. Both visual field testing and electroretinogram are used to detect retinal damage. Adult data on optical coherence tomography (OCT) shows that retinal nerve fiber layer (RNFL) thinning may be an early indicator of vigabatrin-induced retinal toxicity. The purpose of this study was to investigate whether OCT can detect early vigabatrin-induced retinal toxicity in children.

METHODS

Pediatric patients (≤18 years of age) requiring vigabatrin for seizure control who were followed at our institution were invited to participate. Patients were examined according to manufacturer guidelines, with most examinations taking place under general anesthesia. RNFL thickness was measured by OCT (Stratus Model 3000, Zeiss) and compared to total cumulative dose of vigabatrin. In most cases, indirect ophthalmoscopy, fundus photography, and electroretinography were also performed.

RESULTS

OCT and complete dosing data was available for 19 patients. Patients with tuberous sclerosis (TS, n = 12) received higher cumulative doses (mean, 1463 g) than non-TS patients (mean, 351 g, P = 0.044). RNFL thinning was detected in the nasal (P < 0.01), superior (P < 0.01), and inferior (P < 0.05) quadrants in patients with TS, particularly once cumulative dose exceeded 1500 g.

CONCLUSIONS

In our study population of patients with TS, higher cumulative doses of vigabatrin were associated with RNFL thinning in the nasal, superior, and inferior quadrants. These findings were pronounced once cumulative dose exceeded 1500 g. This pattern of RNFL thinning is similar to what has been shown in adult patients taking vigabatrin.

Short-Term Changes in Postoperative Cognitive Function in Children Aged 5 to 12 Years Undergoing General Anesthesia: A Cohort Study

Due to the neurotoxicity effects of general anesthesia (GA) and sedatives found in animal studies, there is a general recommendation to avoid nonurgent surgical procedures requiring anesthesia in children younger than 3 years of age. The aim of this study was to determine the incidence of anesthesia-related postoperative cognitive dysfunction (POCD) on the first day (Day 1) and at 6 weeks after elective noncardiac surgery in school-age children.This was a prospective cohort study of 118 children undergoing GA and 126 age-matched controls of school children aged 5 to 12 years. All children were given a panel of 4 neuropsychological assessments (Hong Kong List Learning for verbal memory, Visual Matching for processing speed, Visual Memory, and General Comprehension Skill from the Hong Kong Wechsler Intelligence Scale for Children). The primary outcome was the incidence of POCD on Day 1 and at 6 weeks after surgery. POCD was defined as when at least 2 of the 4 cognitive function tests showed individual Z-scores ≤-1.96 or a combined Z-score ≤-1.96.Using the combined Z-score definition, the incidence of POCD in the GA group on Day 1 and at 6 weeks were 5.1% (95% confidence interval [CI]: 2.1-10.3) and 3.4% (95% CI: 1.1-8.0), respectively. No POCD was found using the other definition. The incidences of decline and improvement in neuropsychological tests were similar between groups over time except for a higher risk in visual matching impairment in the anesthesia group (11.9%) versus control group (1.6%) on Day 1 (P < 0.01). The adjusted relative risk ratio of postoperative cognitive decline to improvement between groups on Day 1 and at 6 weeks were 0.85 (95% CI: 0.10-7.05) and 0.45 (95% CI: 0.04-4.84), respectively. The observed risk of POCD is assumed to apply to current drugs and techniques used in GA.In conclusion, the incidence of POCD was low. GA was associated with a transient effect on visual matching. When using the widely accepted Z-score definitions and relative risk ratio methodology, we found no anesthesia-related POCD per se in school-age children.

Erythropoietin diminishes isoflurane-induced apoptosis in rat frontal cortex

BACKGROUND

During the brain growth spurt, anesthetic drugs can cause cellular and behavioral changes in the developing brain. The aim of this study was to determine the neuroprotective effect of erythropoietin after isoflurane anesthesia in rat pups.

METHODS

A total of 42, 7-day-old Wistar rats were divided into three groups. Control group (GC; n = 14): Rats breathed 100% oxygen for 6 h; Isoflurane group (GI; n = 14): Rats were exposed to 1.5% isoflurane in 100% oxygen for 6 h; Isoflurane + erythropoietin group (GIE; n = 14): 1000 IU·kg(-1) (intraperitoneal; IP) Erythropoietin was administered after isoflurane anesthesia. Each group was divided into two groups for pathology and learning and memory tests. Silver, caspase-3, and fluoro-jade C staining were used for detecting apoptotic cells in frontal cortex, striatum, hippocampus, thalamus, and amygdala. Morris water maze was used to evaluate learning and memory.

RESULTS

There was a significant increase in apoptotic cell count after isoflurane anesthesia in the frontal cortex when compared with control group (29.0 ± 9.27 vs 3.28 ± 0.75 [P = 0.002], 20.85 ± 10.94 vs 2.0 ± 0.81 [P = 0.002] and 24.57 ± 10.4 vs 5.14 ± 0.69 [P = 0.024] with silver, caspase-3, and fluoro-jade C staining, respectively). The apoptotic cell count in the frontal cortex was significantly higher in GIE than GC with caspase-3 staining (9.14 ± 3.13 vs 2.0 ± 0.81, P = 0.002). The apoptotic cell count in GIE was significantly reduced in the frontal cortex when compared with GI (4.0 ± 0.81 vs 29.0 ± 9.27 [P = 0.002], 9.14 ± 3.13 vs 20.85 ± 10.94 [P = 0.04] and 4.0 ± 1.63 vs 24.57 ± 10.4 [P = 0.012] with silver, caspase-3, and fluoro-jade C staining, respectively).

CONCLUSIONS

A total of 1000 IU·kg(-1) IP erythropoietin diminished isoflurane-induced neuroapoptosis. Further experimental studies have to be planned to reveal the optimal dose and timing of erythropoietin before adaptation to clinical practice.

Neurodevelopmental Outcomes After Neonatal Surgery for Major Noncardiac Anomalies

CONTEXT

Increasing concerns have been raised about the incidence of neurodevelopmental delay in children with noncardiac congenital anomalies (NCCA) requiring neonatal surgery.

OBJECTIVE

This study aimed to determine the incidence and potential risk factors for developmental delay after neonatal surgery for major NCCA.

DATA SOURCES

A systematic search in PubMed, Embase and the Cochrane Library was performed through March 2015.

STUDY SELECTION

Original research articles on standardized cognitive or motor skills tests.

DATA EXTRACTION

Data on neurodevelopmental outcome, the Bayley Scales of Infant Development, and risk factors for delay were extracted.

RESULTS

In total, 23 eligible studies were included, reporting on 895 children. Meta-analysis was performed with data of 511 children, assessed by the Bayley Scales of Infant Development at 12 and 24 months of age. Delay in cognitive development was reported in a median of 23% (3%-56%). Meta-analysis showed a cognitive score of 0.5 SD below the population average (Mental Development Index 92 ± 13, mean ± SD; P < .001). Motor development was delayed in 25% (0%-77%). Meta-analysis showed a motor score of 0.6 SD below average (Psychomotor Development Index 91 ± 14; P < .001). Several of these studies report risk factors for psychomotor delay, including low birth weight, a higher number of congenital anomalies, duration of hospital admission, and repeated surgery.

LIMITATIONS

All data were retrieved from studies with small sample sizes and various congenital anomalies using different neurodevelopmental assessment tools.

CONCLUSIONS

Cognitive and motor developmental delay was found in 23% of patients with NCCA. Meta-analysis showed that the mean neurodevelopmental outcome scores were 0.5 SD below the normative score of the healthy population.

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

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 awake-regional 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-per-protocol analysis, the cognitive composite score (mean [SD]) was 98.6 (14.2) in the awake-regional 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.

FUNDING

Australia National Health and Medical Research Council (NHMRC), Health Technologies Assessment-National Institute for Health Research UK, National Institutes of Health, Food and Drug Administration, Australian and New Zealand College of Anaesthetists, Murdoch Childrens Research Institute, Canadian Institute of Health Research, Canadian Anesthesiologists' Society, Pfizer Canada, Italian Ministry of Heath, Fonds NutsOhra, and UK Clinical Research Network (UKCRN).

Impact of propofol anaesthesia on cytokine expression profiles in the developing rat brain: a randomised placebo-controlled experimental in-vivo study

BACKGROUND

Recent experimental data indicate that volatile anaesthetics can induce a neuroinflammatory response in the central nervous system. The questions of to what extent this occurs in the developing brain and whether nonvolatile anaesthetics are also involved remain unanswered.

OBJECTIVES

The objective of this study is to investigate the impact of propofol anaesthesia on cytokine mRNA expression profiles in the neonatal brain at defined stages of the brain growth spurt.

DESIGN

A randomised placebo-controlled experimental in-vivo study.

SETTING

Translational research laboratories at the University of Geneva Medical School.

METHODS

Wistar rats received 6-h propofol anaesthesia at postnatal day 10 or 20. A quantitative real-time PCR was used to evaluate the impact of this treatment paradigm on mRNA expression profiles of selected members of the cytokine family in the prefrontal cortex and hippocampus.

RESULTS

Propofol anaesthesia induced a transient 1.8-fold (interquartile range, IQR 1.7 to 2.2) increase (P = 0.004) in prefrontal but not hippocampal tumour necrosis factor mRNA concentrations in 10-day-old animals. No such effect was detected in 20-day-old animals. No changes in mRNA concentrations of two other pro-inflammatory cytokines, interleukins IL-6 and IL-1β, were detected following drug exposure at any developmental stages or in any studied brain regions. In contrast, propofol anaesthesia at postnatal day 10 induced a transient increase in the mRNA expression patterns of two chemokines: Ccl2 and Ccl3 [for Ccl2 mRNA: 4.4-fold (3.8 to 5.6) increase in the prefrontal cortex, P = 0.0002 and a 3.5-fold (2.8 to 5.3) increase in the hippocampus, P = 0.0001; for Ccl3 mRNA: 2.9-fold (2.6 to 4.31) increase in the prefrontal cortex, P = 0.0001, and a 2.7-fold (2.2 to 3.6) increase in the hippocampus, P = 0.0003]. Propofol did not affect Ccl2 and Ccl3 mRNA concentrations in 20-day-old animals. In addition, it did not impact on two other members of the chemokine family, Cxcl1 and Cx3cl1, at any time points or in any brain regions investigated.

CONCLUSION

This study suggests that propofol anaesthesia does not have a major impact on pro-inflammatory cytokine expression profiles in the developing central nervous system during the brain growth spurt. These results raise arguments against the involvement of neuroinflammatory pathways in propofol-related neurotoxicity observed following the administration of this drug in the early postnatal period.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Imaging Pediatric Vascular Lesions

Vascular anomalies are commonly encountered in pediatric and dermatology practices. Most of these lesions are benign and easy to diagnose based on history and clinical exam alone. However, in some cases the diagnosis may not be clear. This may be of particular concern given that vascular anomalies may occasionally be associated with an underlying syndrome, congenital disease, or serious, life-threatening condition. Defining the type of vascular lesion early and correctly is particularly important to determine the optimal approach to management and treatment of each patient. The care of pediatric patients often requires collaboration from a multitude of specialties including pediatrics, dermatology, plastic surgery, radiology, ophthalmology, and neurology. Although early characterization of vascular lesions is important, consensus guidelines regarding the evaluation and imaging of vascular anomalies does not exist to date. Here, the authors provide an overview of pediatric vascular lesions, current classification systems for characterizing these lesions, the various imaging modalities available, and recommendations for appropriate imaging evaluation.

Computed tomography vs magnetic resonance imaging for identifying acute lesions in pediatric traumatic brain injury

BACKGROUND AND OBJECTIVE

Pediatric traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Computed tomography (CT) is the modality of choice to screen for brain injuries. MRI may provide more clinically relevant information. The purpose of this study was to compare lesion detection between CT and MRI after TBI.

METHODS

Retrospective cohort of children (0-21 years) with TBI between 2008 and 2010 at a Level 1 pediatric trauma center with a head CT scan on day of injury and a brain MRI scan within 2 weeks of injury. Agreement between CT and MRI was determined by κ statistic and stratified by injury mechanism.

RESULTS

One hundred five children were studied. Of these, 78% had mild TBI. The MRI scan was obtained a median of 1 day (interquartile range, 1-2) after CT. Overall, CT and MRI demonstrated poor agreement (κ=-0.083; P=.18). MRI detected a greater number of intraparenchymal lesions (n=36; 34%) compared with CT (n=16; 15%) (P<.001). Among patients with abusive head trauma, MRI detected intraparenchymal lesions in 16 (43%), compared with only 4 (11%) lesions with CT (P=.03). Of 8 subjects with a normal CT scan, 6 out of 8 had abnormal lesions on MRI.

CONCLUSIONS

Compared with CT, MRI identified significantly more intraparenchymal lesions in pediatric TBI, particularly in children with abusive head trauma. The prognostic value of identification of intraparenchymal lesions by MRI is unknown but warrants additional inquiry. Risks and benefits from early MRI (including sedation, time, and lack of radiation exposure) compared with CT should be weighed by clinicians.

Isoflurane impairs the capacity of astrocytes to support neuronal development in a mouse dissociated coculture model

BACKGROUND

There is growing concern that pediatric exposure to anesthetic agents may cause long-lasting deficits in learning by impairing brain development. Most studies to date on this topic have focused on the direct effects of anesthetics on developing neurons. Relatively little attention has been paid to possible effects of anesthetics on astrocytes, a glial cell type that plays an important supporting role in neuronal development.

METHODS

Astrocytes were exposed to isoflurane and then cocultured with unexposed neurons to test for astrocyte-specific toxic effects on neuronal growth. Axon length was measured in the cocultured neurons to assess neuronal growth.

RESULTS

We found that neurons cocultured with astrocytes exposed to isoflurane exhibited a 30% reduction in axon outgrowth. Further experimentation showed that this effect is likely due to reduced levels of brain-derived neurotrophic factor in the coculture media.

CONCLUSIONS

Isoflurane interferes with the ability of cultured astrocytes to support neuronal growth. This finding represents a potentially novel mechanism through which general anesthetics may interfere with brain development.

Postoperative cognitive function following general versus regional anesthesia: a systematic review

The effect of anesthetic technique on postoperative outcomes remains in question. This systematic review compares the role of regional versus general anesthesia, with a particular focus on postoperative cognitive function. Potentially relevant articles were identified by searching publicly available computerized databases for this systematic review. Any surgical procedure was accepted with the exception of cardiac, carotid, and neurosurgical procedures. Any regional anesthetic technique was accepted unless combined with a general anesthetic or in conjunction with propofol as a sedative. Any measure of postoperative cognitive function was accepted as long as it was performed no sooner than 7 days postoperatively. Sixteen studies met inclusion criteria and were included in the final analysis. Three studies showed some difference in cognitive function between regional and general anesthesia, whereas the remaining 13 showed no difference between regional and general anesthesia on postoperative cognitive function.

Anesthesia in children: perspectives from nonsurgical pediatric specialists

The Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) study investigates the potential neurotoxicity of anesthetics in the pediatric population. At a recent symposium, a panel of nonsurgical physicians from the disciplines of radiology, neurology, cardiology, and critical care discussed the role anesthesia plays in their respective practices. To execute diagnostic studies and/or therapeutic interventions in each of these disciplines, general anesthesia is oftentimes required for pediatric patients. Given recent publications in the literature suggesting the potential for neurotoxicity following anesthesia in pediatric patients, physicians, parents, and other stakeholders are now challenged to continue to balance safety with efficacy in caring for children. This paper summarizes the panelist presentations and the ensuing discussion at the 2014 PANDA symposium.

Review: effects of anesthetics on brain circuit formation

The results of several retrospective clinical studies suggest that exposure to anesthetic agents early in life is correlated with subsequent learning and behavioral disorders. Although ongoing prospective clinical trials may help to clarify this association, they remain confounded by numerous factors. Thus, some of the most compelling data supporting the hypothesis that a relatively short anesthetic exposure can lead to a long-lasting change in brain function are derived from animal models. The mechanism by which such changes could occur remains incompletely understood. Early studies identified anesthetic-induced neuronal apoptosis as a possible mechanism of injury, and more recent work suggests that anesthetics may interfere with several critical processes in brain development. The function of the mature brain requires the presence of circuits, established during development, which perform the computations underlying learning and cognition. In this review, we examine the mechanisms by which anesthetics could disrupt brain circuit formation, including effects on neuronal survival and neurogenesis, neurite growth and guidance, formation of synapses, and function of supporting cells. There is evidence that anesthetics can disrupt aspects of all of these processes, and further research is required to elucidate which are most relevant to pediatric anesthetic neurotoxicity.

Association between childhood exposure to single general anesthesia and neurodevelopment: a systematic review and meta-analysis of cohort study

OBJECTIVE

Many studies have been done to seek the relationship between general anesthesia and neurodevelopment in pediatrics. However, there is no unified conclusion, especially single anesthesia affecting a child before 3 and 4 years. The association between anesthesia and neurodevelopment is studied using a meta-analysis.

METHODS

We summarized the currently available evidence by searching PubMed, EMBASE, and the Cochrane library over the past 10 years. An evaluation of neurodevelopment including learning disability, behavioral disorders, and cognitive problems was conducted. We estimated the synthesized hazard ratios (HR) and 95 % confidence interval (CI) according to inter-study heterogeneity and analyzed the factors for this association using meta-regression method.

RESULTS

Thirteen eligible studies met the inclusion criteria. The neurodevelopment damage was associated with single general anesthesia before age of 4 (adjusted HR 1.28 95 % CI 1.10-1.45). The pooled adjusted HR was 1.17 (95 % CI 1.07-1.28, p = 0.001) before 4 years old after the influence analysis and the adjusted HR was 1.18 (95 % CI 1.07-1.30, p = 0.001) before 3 years old. There was no significant difference between 3 and 4 years exposed to single general anesthesia (HR3/HR4 = 1.008, p = 0.9). Due to limitations of retrospective studies, prospective investigations are needed to determine whether anesthesia is causative.

CONCLUSIONS

The current evidence suggests a modestly elevated risk of neurodevelopmental disorders exists in children near 3 years of age. A single general anesthesia is relatively safe after 3 years, as the outcome is very close before 3 and 4 years old.

Socioeconomic and psychological impact of treatment for unilateral intraocular retinoblastoma

PURPOSE

To identify the socioeconomic and psychosocial impacts of clinical treatment decisions for advanced unilateral intraocular retinoblastoma.

DESIGN

Retrospective observational case series.

METHODS

SETTING

institutional study at Alexandria Main University Hospital.

STUDY POPULATION

records of 66 unilateral retinoblastoma cases treated from May 2005 to May 2013 were retrospectively reviewed. Sixty cases were eligible (International Intraocular Retinoblastoma Classification [IIRC] group C, D or E).

PROCEDURES

two treatment groups were compared: enucleation vs. salvage treatment. Salvage treatment eyes were further subdivided based on IIRC group. Six socioeconomic parameters (financial burden, financial impact, psychological, social, medical and tumor impacts) were scored. Parameter scores ranged from 0 to 3, for overall score range 0 (no adverse impact) to 18 (severe adverse impact).

MAIN OUTCOME MEASURES

derived Socioeconomic scores were correlated with treatment and outcomes.

RESULTS

The enucleation group (28 eyes) had a median overall Socioeconomic score of 4/18, significantly lower than the salvage treatment group (32 eyes), median score 11/18 (P<0.01). Socioeconomic score varied with IIRC group. Attempted eye salvage failed in 25 children, due to uncontrolled tumor (44%) and socioeconomic impact of cumulative therapies (56%). Treatment duration and Socioeconomic score were higher for the 5 children in the salvage treatment group who developed metastatic disease compared to those without metastasis (P<0.01).

CONCLUSIONS

The socioeconomic and psychosocial impacts of attempted ocular salvage for unilateral intraocular retinoblastoma are severe, in comparison to primary enucleation. Primary enucleation is a good treatment for unilateral retinoblastoma.

Early and late operation of cleft lip and intelligence quotient and psychosocial development in 3-7 years

BACKGROUND

Early and late operations of the cleft lip represent exposure to general anesthesia during the first year of life. The early exposure to the anesthetics may influence long term neurological outcome. Timing of the operation may also influence the quality of life as babies with early repair might be accepted better by their families.

AIMS

The aim of the study was to compare outcomes between two groups of patients operated on for the cleft lip in the first year of life.

STUDY DESIGN

Observational cohort study.

SUBJECTS

Early repair group included patients operated on in the first eight days of life and late repair group those operated on between 3 and 10 months.

OUTCOME MEASURES

Intelligence quotient (IQ) and psychosocial development of children who were operated on for cleft lip were compared at the age of 3-7 years.

RESULTS

No differences were found between early (n=15) and late (n=17) repair group in terms of IQ. In both IQ was within the normal range: 100.00 (SD 13.867), 98.76 (SD 10.109), respectively. Significantly better results in physical functioning (P=0.042) and self-esteem (P=0.014) concepts in early repair group were found.

CONCLUSIONS

We compared outcomes of two groups of patients operated on for cleft lip in the first year of life. The earlier anesthesia did not show a negative impact on intelligence quotient in 3-7 years compared to later anesthesia. The earlier repair of the cleft lip showed a significant positive impact on psychosocial development in 2 out of 13 concepts tested.

A retrospective study to classify surgical indications for infantile hemangiomas

Infantile hemangiomas (IHs) spontaneously involute, but some leave contour deformities necessitating surgical correction. There is a paucity of data reviewing predictive risk factors associated with a need for surgery to guide clinicians when counseling parents. Patients undergoing IH resection by a single surgeon from August 2004 to August 2011 were reviewed to determine patient (age, gender, birth history) and IH characteristics (size, location) associated with surgical intervention. Data were compared to published data from the Hemangioma Investigator Group (HIG). Statistical analysis was performed using Student's t-test, odds ratio, and logistic regression analysis. Out of 196 referred patients, 112 underwent surgery. There was a female preponderance (3.5:1). Two-thirds of patients (64.9%) first presented to the surgeon at ≤2 years of age, but most underwent surgery between 2 and 3 years (52.7%; average lag time, 11 months). 18 patients underwent surgery at ≤1 year of age. IH patients with preterm birth history had increased risk for needing surgical intervention (odds ratio 2.124, CI 1.31-3.44; p < 0.0012). A majority (84.7%) of resected IHs were located on the head or neck, significantly higher than the distribution from the HIG data (62.2%; p < 0.0001). Resected head and neck IHs were smaller than those below the neck (average, 8.85 cm(2) vs. 22.35 cm(2), p = 0.017). Preterm birth is associated with higher risk for requiring surgical intervention. IHs on the head and neck are more likely to be removed when compared to those below the neck, and at a smaller size threshold.

Surgery and neurodevelopmental outcome of very low-birth-weight infants

IMPORTANCE

Reduced death and neurodevelopmental impairment among infants is a goal of perinatal medicine.

OBJECTIVE

To assess the association between surgery during the initial hospitalization and death or neurodevelopmental impairment of very low-birth-weight infants.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort analysis was conducted of patients enrolled in the National Institute of Child Health and Human Development Neonatal Research Network Generic Database from 1998 through 2009 and evaluated at 18 to 22 months' corrected age. Twenty-two academic neonatal intensive care units participated. Inclusion criteria were birth weight 401 to 1500 g, survival to 12 hours, and availability for follow-up. A total of 12 111 infants were included in analyses.

EXPOSURES

Surgical procedures; surgery also was classified by expected anesthesia type as major (general anesthesia) or minor (nongeneral anesthesia).

MAIN OUTCOMES AND MEASURES

Multivariable logistic regression analyses planned a priori were performed for the primary outcome of death or neurodevelopmental impairment and for the secondary outcome of neurodevelopmental impairment among survivors. Multivariable linear regression analyses were performed as planned for the adjusted mean scores of the Mental Developmental Index and Psychomotor Developmental Index of the Bayley Scales of Infant Development, Second Edition, for patients born before 2006.

RESULTS

A total of 2186 infants underwent major surgery, 784 had minor surgery, and 9141 infants did not undergo surgery. The risk-adjusted odds ratio of death or neurodevelopmental impairment for all surgery patients compared with those who had no surgery was 1.29 (95% CI, 1.08-1.55). For patients who had major surgery compared with those who had no surgery, the risk-adjusted odds ratio of death or neurodevelopmental impairment was 1.52 (95% CI, 1.24-1.87). Patients classified as having minor surgery had no increased adjusted risk. Among survivors who had major surgery compared with those who had no surgery, the adjusted risk of neurodevelopmental impairment was greater and the adjusted mean Bayley scores were lower.

CONCLUSIONS AND RELEVANCE

Major surgery in very low-birth-weight infants is independently associated with a greater than 50% increased risk of death or neurodevelopmental impairment and of neurodevelopmental impairment at 18 to 22 months' corrected age. The role of general anesthesia is implicated but remains unproven.

Short term morphine exposure in vitro alters proliferation and differentiation of neural progenitor cells and promotes apoptosis via mu receptors

BACKGROUND

Chronic morphine treatment inhibits neural progenitor cell (NPC) progression and negatively effects hippocampal neurogenesis. However, the effect of acute opioid treatment on cell development and its influence on NPC differentiation and proliferation in vitro is unknown. We aim to investigate the effect of a single, short term exposure of morphine on the proliferation, differentiation and apoptosis of NPCs and the mechanism involved.

METHODS

Cell cultures from 14-day mouse embryos were exposed to different concentrations of morphine and its antagonist naloxone for 24 hours and proliferation, differentiation and apoptosis were studied. Proliferating cells were labeled with bromodeoxyuridine (BrdU) and cell fate was studied with immunocytochemistry.

RESULTS

Cells treated with morphine demonstrated decreased BrdU expression with increased morphine concentrations. Analysis of double-labeled cells showed a decrease in cells co-stained for BrdU with nestin and an increase in cells co-stained with BrdU and neuron-specific class III β-tubuline (TUJ1) in a dose dependent manner. Furthermore, a significant increase in caspase-3 activity was observed in the nestin- positive cells. Addition of naloxone to morphine-treated NPCs reversed the anti-proliferative and pro-apoptotic effects of morphine.

CONCLUSIONS

Short term morphine exposure induced inhibition of NPC proliferation and increased active caspase-3 expression in a dose dependent manner. Morphine induces neuronal and glial differentiation and decreases the expression of nestin- positive cells. These effects were reversed with the addition of the opioid antagonist naloxone. Our results demonstrate the effects of short term morphine administration on the proliferation and differentiation of NPCs and imply a mu-receptor mechanism in the regulation of NPC survival.

Patent ductus arteriosus ligation and adverse outcomes: causality or bias?

Observational studies have associated patent ductus arteriosus (PDA) ligation in preterm infants with increased chronic lung disease (CLD), retinopathy of prematurity, and neurodevelopmental impairment at long-term follow-up. Although the biological rationale for this association is incompletely understood, there is an emerging secular trend toward a permissive approach to the PDA. However, insufficient adjustment for postnatal, pre-ligation confounders, such as intraventricular hemorrhage and the duration and intensity of mechanical ventilation, suggests the presence of residual bias due to confounding by indication, and obliges caution in interpreting the ligation-morbidity relationship. A period of conservative management after failure of medical PDA closure may be considered to reduce the number of infants treated with surgery. Increased mortality and CLD in infants with persistent symptomatic PDA suggests that surgical ligation remains an important treatment modality for preterm infants.

Growth and developmental outcomes of infants with hirschsprung disease presenting in the neonatal period: a retrospective study

OBJECTIVES

To describe the presentation and progress over the first year of life of neonates with Hirschsprung disease, to describe their physical and developmental outcomes at 12 months of age, and to compare the outcomes of infants with short- vs long-segment Hirschsprung disease.

STUDY DESIGN

A retrospective study of neonates born with Hirschsprung disease in Western Australia between January 1, 2001, and December 31, 2010, to review their presentation, progress, growth, and development at 12 months of age.

RESULTS

Fifty-four infants were identified (40 with short and 11 with long segment and 3 with total colonic aganglionosis); 9 infants had a recognized syndrome and 1 infant died, unrelated to Hirschsprung disease. A primary pull-through procedure was performed in 97% and 21% of neonates with short- and non-short-segment Hirschsprung disease, respectively; 17 (31%) infants developed anal stenosis requiring dilatations. Enterocolitis occurred in 14 (26%) infants. Griffiths Mental Development Scale scores (1 year) were available in 31 of 45 nonsyndromic survivors: mean general quotient (94.2, SD 8.89) was significantly less than the population mean (P = .007), but the number of infants with developmental delay was within the expected range. Physical growth, except length, appeared adequate in nonsyndromic infants. There were no significant differences in the outcomes of infants with short- vs non-short-segment Hirschsprung disease.

CONCLUSIONS

At 1 year of age, many infants with Hirschsprung disease have ongoing gastrointestinal problems. Their overall growth appears satisfactory, and most infants are developing normally; however, their mean general quotient appears shifted to the left. Longer-term studies will better define developmental outcomes.

Neonatal pain control and neurologic effects of anesthetics and sedatives in preterm infants

Preclinical and clinical studies have demonstrated the adverse consequences of untreated pain and stress on brain development in the preterm infant. Sucrose has widely been implemented as standard therapy for minor procedural pain. Anesthetics are commonly utilized in preterm infants during major surgery. Pharmacologic agents (benzodiazepines and opioids) have been examined in clinical trials of preterm infants requiring invasive mechanical ventilation. Controversy exists regarding the safety and long-term impact of these interventions. Ongoing multidisciplinary research will help define the impact of these agents and identify potential alternative therapies.

Double J or transrenal transanastomotic stent in laparoscopic pyeloplasty in infants and children: a comparative study and our technique

PURPOSE

We compared our experience with intra- and extracorporeal stenting in laparoscopic transabdominal pyeloplasty in children and adolescents. As the placement of transanastomotic stents during laparoscopy can be difficult, we developed a technique for laparoscopic transrenal stent placement.

SUBJECTS AND METHODS

Eighty-six consecutive patients who underwent laparoscopic transabdominal pyeloplasty in our institution from December 2003 to November 2012 were retrospectively analyzed. Initially we antegradely placed the double J catheter (n=48), whereas in later patients transrenal/transcutaneous stents were inserted (n=38), either via a cannula from the flank (n=33) or from the inside-out by transrenal puncture using a specially constructed spear (n=5). End points of the analysis were stent-related technical problems and complications and the need for reoperation.

RESULTS

Sixty-two boys and 24 girls with a mean age of 5.6 years (range, 78 days-17.3 years) and mean weight of 22.1 kg (range, 5.5-71 kg) underwent laparoscopic transabdominal pyeloplasty. The most common technical problem in the double J group was inability to place the double J catheter in 9 of the 48 patients. In combination with other complications such as dislocations, urinary tract infections, or catheter occlusions, this led to an overall complication rate of 35% in the group that underwent double J catheter insertion versus 13% in the group with transrenal stenting (P<.05). In the whole series, 4 patients required a redo pyeloplasty, all of them in the double J group.

CONCLUSIONS

We recommend transrenal stents to facilitate stent removal without general anesthesia and to minimize complications such as stent dislocation. The initial experience with our simple device for transrenal puncture and stent placement is promising.

Current clinical evidence on the effect of general anesthesia on neurodevelopment in children: an updated systematic review with meta-regression

BACKGROUND

Several epidemiological studies have been conducted to address the later effect of anesthesia on neurodevelopment in children. However, the results are still inconclusive.

METHODS

We here conducted a systematic review and meta-analysis to summarize the currently available clinical and epidemiologic evidence on the association of anesthesia/surgery with neurodevelopmental outcomes in children by searching PubMed, EMBASE, and Web of Science database (from January-1 2000 to February-1, 2013). The evaluation of neurodevelopment includes language and learning disabilities, cognition, behavioral development, and academic performance. Both retrospective and prospective studies were included. Data were abstracted from seven eligible studies. We estimated the synthesized hazard ratios (HR) and 95% confidence interval (CI) according to inter-study heterogeneity.

RESULTS

The pooled HR for the association of anesthesia/surgery with an adverse behavioral or developmental outcome was 1.25 (95% CI, 1.13-1.38, P<0.001; random-effects model) in children undergoing the first anesthesia before the age of 4-year. Then we analyzed the factors for this association using meta-regression method. It showed that it was the number of times of exposure (HR = 1.75, 95% CI 1.31-2.33; P<0.001) rather than the time at exposure before 4-year (HR = 1.08, 95% CI 0.87-1.34 for the effect of per 1-year early exposure; P = 0.47) is a risk factor for neurodevelopmental impairment.

CONCLUSION

The current clinical evidence suggests modestly elevated risk of adverse neurodevelopmental outcomes in children who were exposed to anesthesia/surgery during early childhood, especially for those with multiple times of exposure. Due to limitation of retrospective studies, prospective investigations are needed to determine whether anesthesia/surgery is causative.

Anesthesia considerations in pediatric glaucoma management

PURPOSE OF REVIEW

This article reviews the potentially adverse neurodevelopmental effects of early exposure to general anesthesia and examines a changing paradigm in the management of pediatric glaucoma.

RECENT FINDINGS

Literature across multiple subspecialties has examined the potentially neurotoxic effects of general anesthesia on the developing child's brain. Associations between general anesthesia exposure early in life and attention deficit hyperactivity disorder, language processing, and cognition have been suggested but not confirmed. Several population studies support the conclusion that early anesthetic exposure may increase the risk of neurodevelopmental deficits, although this is unsupported in sibling cohorts. Newer technology such as rebound tonometry may decrease the frequency of examination under anesthesia in the long-term management of patients with pediatric glaucoma and may decrease the risk of these potentially adverse neurodevelopmental outcomes.

SUMMARY

As the potential long-term adverse neurodevelopmental effects of general anesthesia become better understood, pediatric glaucoma specialists should be cognizant of the relative lifelong risks and benefits of repeat examinations under anesthesia in young patients.

Cerebral blood flow in the neonate

Ensuring adequate oxygenation of the developing brain is the cornerstone of neonatal critical care. Despite decades of clinical research dedicated to this issue of paramount importance, our knowledge and understanding regarding the physiology and pathophysiology of neonatal cerebral blood flow are still rudimentary. This review primarily focuses on currently available human clinical and experimental data on cerebral blood flow and autoregulation in the preterm and term infant. Limitations of systemic blood pressure values as surrogates for monitoring adequate cerebral oxygen delivery are discussed. Particular emphasis is placed on the high interindividual variability in cerebral blood flow values, vasoreactivity, and autoregulatory thresholds making the applications of normative values highly questionable. Technical and ethical difficulties to conduct such trials leave us with a near complete lack of knowledge on how pharmacological and surgical interventions impact on cerebral autoregulation. The ensemble of these works argues for the necessity of highly individualized care by taking advantage of continuous bedside monitoring of cerebral circulation. They also point to the urgent need for further studies addressing the exciting but difficult issue of cerebral blood flow autoregulation in the neonate.

A systematic review and quantitative analysis of neurocognitive outcomes in children with four chronic illnesses

BACKGROUND

Concern has been expressed that infants and children exposed to uneventful surgery and anesthesia may incur neurological injury that becomes manifest in poor scholastic performance or future learning difficulties. A recent meta-analysis of seven clinical studies examined the relationship between learning or behavior difficulties and pediatric exposure to anesthesia/surgery and reported an odds ratio of 1.4; however, the level of association and causal factors remain unclear. The purpose of our study is to provide context to the pediatric anesthesia neurotoxicity question by reviewing the evidence linking four childhood illnesses with neurocognitive development. In the present review, we have sought to quantify the magnitude of the impact of chronic illness on neurocognitive development through a systematic review of publications that report the developmental trajectory of patients with four childhood diseases: cystic fibrosis (CF), hemophilia A, end-stage renal disease (ESRD) and end-stage liver disease (ESLD).

METHODS

Studies were identified by searching the electronic databases OVID MEDLINE and Pubmed and scanning reference lists of articles by two authors. Limits were applied to the English language and to humans. We used the following search terms: CF, hemophilia A, ESRD, ESLD in combination with academic performance, educational status, educational measurement, learning, achievement, developmental delay, learning disabilities, intellectual disabilities, behavioral disorders, intelligence quotient (IQ), cognition, school problems, absenteeism, school attendance, anxiety, learning regression, or developmental regression. The search strategy was reviewed independently by all four authors. Eligibility assessment was performed independently in an unblinded standardized manner by two authors who chose relevant articles from the overall search results by scanning the titles and abstracts of articles and from the references within citations. The full-text publications were reviewed by all four authors. All pertinent data related to the objectives were collected and independently reviewed by two authors. The data were summarized in the form reported in the studies. When possible, reported data were submitted to analysis with the Mantel-Haenszel method using a random effects model. Analyses were performed using the Review Manager computer program.

RESULTS

In the studies retrieved, the main outcomes were measures of intellectual or cognitive characteristics, as exemplified by the Wechsler battery of tests. Reporting of measures of achievement (for example, GPA) was rare. Children with CF and hemophilia A did not appear disadvantaged by their disease as general intelligence levels were comparable with the general population norms. In children with ESRD, mean IQ reported during dialysis improved after transplantation. Although they improved relative to their pretransplantation cognitive functioning, children with ESLD who received transplants are approximately eight IQ points below the population norm.

CONCLUSIONS

Overall, the results suggest that the burden of chronic childhood illness, by itself, does not impair cognitive development in children with hemophilia A and CF. Children with ESRD and ESLD, despite optimal management, show a mild cognitive deficit compared with the population norm. Given the impact of these four specific chronic illnesses on neurocognitive outcome in children and the improvement in IQ post-transplant in both ESRD and ESLD, the results suggest that the effect of an uncontrolled confounding illness on neurocognitive development is small.

[Neonatal exposure to anesthesia and adverse cognitive outcome in childhood. Insight from epidemiology]

Adverse effects of general anesthesia have been observed repeatedly, mainly in animal model studies and in rodents. Already in 2005, the Food and Drug Administration recommended proceeding to similar studies in human infants, highlighting that there were several methodological issues to solve before being able to appreciate the risk of anesthetic agents on the developing brain. Most studies conducted in humans were observational studies, showing a very mild adverse effect on cognitive functions, an effect that disappeared when properly adjusted analysis was performed (with various modalities for analysis and protocols for these adjusted results). Due to numerous biases in these observational studies - bias related to selection of the population and the control subjects and their comparability as well as outcome measure assessment, it has become extremely important to conduct prospective studies. Two international studies are currently under way, but their results will not be available for a few years. How animal model results can be relevant to human babies remains controversial. Until today, and according to the current state of the art, no changes in practices are indicated, and it is important for infants and their families to avoid sensationalist messages.