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Rundell MR, Bailey RA, Wagner AJ, Warner BB, Miller LE. Long-Term Neurodevelopmental Outcomes in Children with Gastroschisis: A Review of the Literature. Am J Perinatol 2024. [PMID: 38810899 DOI: 10.1055/s-0044-1787173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
This study aimed to investigate and present a review of the literature on long-term neurodevelopmental outcomes in children with gastroschisis. Gastroschisis is the most common abdominal wall defect. Children with gastroschisis are at high risk for premature birth, intestinal failure, sepsis, and repeated anesthesia exposure, which collectively increase the risk for adverse long-term neurodevelopmental outcomes. The existing literature on neurodevelopmental outcomes is limited in number, quality, and generalizability, creating a gap in clinical knowledge and care. Five internet databases were searched by a professional research librarian: Ovid MEDLINE, Scopus, Web of Science, PsycINFO, and Cochrane Library. Included articles were (1) published in English, (2) included postneonatal hospital discharge neurodevelopmental outcomes of children with gastroschisis, and (3) included patients under the age of 18 years. No date parameters were applied. The paucity of literature on long-term neurodevelopmental outcomes in gastroschisis children has left large gaps in the body of knowledge on post-hospital care of such children. In this review, 37 articles were found evaluating neurodevelopmental outcomes in gastroschisis and, while conclusions were contradictory, the literature broadly indicated the potential for neurodevelopmental deficits in the gastroschisis pediatric population. A significant limitation of this review was the heterogeneous samples included in available literature, which confounded the ability to determine cognitive risk of gastroschisis independent of other abdominal wall defects. Findings of this review demonstrate potential risk for neurodevelopmental deficits in the pediatric gastroschisis population exist, yet additional research is needed to definitively predict the significance, type, onset, and trajectory of neurodevelopmental impairment in this population. The significant gaps in long-term outcomes data have elucidated the need for prospective, longitudinal investigation of various cognitive domains in homogenous gastroschisis populations to properly evaluate prevalence of neurodevelopmental deficits and guide recommendations for long-term clinical care. KEY POINTS: · Limited literature exists regarding long-term neurodevelopmental outcomes in gastroschisis.. · There is some evidence to suggest worse cognitive behavioral outcomes in gastroschisis over time.. · Developmental surveillance, screening, and evaluation may be beneficial for gastroschisis patients..
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Affiliation(s)
- Maddie R Rundell
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel A Bailey
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Amy J Wagner
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Barbara B Warner
- Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Lauren E Miller
- Division of Neuropsychology, Department of Neurology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Turedi B, Gollu G, Ates U, Kose K, Oner O, Bingol-Kologlu M, Yagmurlu A, Aktug T, Dindar H, Cakmak M. Neurodevelopmental evaluation of children who were operated due to congenital anomaly with the 'Ages and Stages Questionnaire (ASQ)' and 'ASQ: Social-Emotional'. Pediatr Surg Int 2024; 40:47. [PMID: 38300305 PMCID: PMC10834557 DOI: 10.1007/s00383-023-05625-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/26/2023] [Indexed: 02/02/2024]
Abstract
BACKGROUND The purpose of surgeries performed for congenital anomalies in children is to increase the survival rates and provide a developmental comparison to that of their peers. AIM The objective of this study was to investigate the development of children following surgery for congenital anomalies and the risk factors affecting their development. METHODS Our study included 33 children who underwent surgery for gastrointestinal anomalies in our clinic between 2011 and 2016, and did not have any syndrome, chromosomal abnormality, or additional abnormality. Developmental levels were evaluated using the Ages and Stages Questionnaire (ASQ) and the ASQ: Social-Emotional (ASQ: SE) scales adapted for the use on Turkish children. Data on patient history were obtained retrospectively from patient files. RESULTS The study included 33 patients, including 11 with esophageal atresia, 6 with intestinal atresia, 11 with anorectal malformation, and 5 with Hirschsprung's disease. Developmental delay was found in the ASQ of 72.7% of the patients and the ASQ: SE tool was 27% of the patients. The rate of patients with scores below the threshold from each parameter of ASQ was higher than that of the normal population (p < 0.05). Development delay was detected using the ASQ scale in 100% of those with microcephaly at birth, in 91% of premature infants born between 1500 and 2500 g, and in 83.3% of those with low birth weight to gestational age. CONCLUSIONS In children who underwent surgery due to congenital anomalies, an evaluation through developmental tests, a post-surgical follow-up process, and a referral to the relevant disciplines when necessary may increase the success of surgery as well as increase the life quality of the patient.
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Xiao A, Feng Y, Yu S, Xu C, Chen J, Wang T, Xiao W. General anesthesia in children and long-term neurodevelopmental deficits: A systematic review. Front Mol Neurosci 2022; 15:972025. [PMID: 36238262 PMCID: PMC9551616 DOI: 10.3389/fnmol.2022.972025] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/30/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundMillions of children experienced surgery procedures requiring general anesthesia (GA). Any potential neurodevelopmental risks of pediatric anesthesia can be a serious public health issue. Various animal studies have provided evidence that commonly used GA induced a variety of morphofunctional alterations in the developing brain of juvenile animals.MethodsWe conducted a systematic review to provide a brief overview of preclinical studies and summarize the existing clinical studies. Comprehensive literature searches of PubMed, EMBASE, CINAHL, OVID Medline, Web of Science, and the Cochrane Library were conducted using the relevant search terms “general anesthesia,” “neurocognitive outcome,” and “children.” We included studies investigating children who were exposed to single or multiple GA before 18, with long-term neurodevelopment outcomes evaluated after the exposure(s).ResultsSeventy-two clinical studies originating from 18 different countries published from 2000 to 2022 are included in this review, most of which are retrospective studies (n = 58). Two-thirds of studies (n = 48) provide evidence of negative neurocognitive effects after GA exposure in children. Neurodevelopmental outcomes are categorized into six domains: academics/achievement, cognition, development/behavior, diagnosis, brain studies, and others. Most studies focusing on children <7 years detected adverse neurocognitive effects following GA exposure, but not all studies consistently supported the prevailing view that younger children were at greater risk than senior ones. More times and longer duration of exposures to GA, and major surgeries may indicate a higher risk of negative outcomes.ConclusionBased on current studies, it is necessary to endeavor to limit the duration and numbers of anesthesia and the dose of anesthetic agents. For future studies, we require cohort studies with rich sources of data and appropriate outcome measures, and carefully designed and adequately powered clinical trials testing plausible interventions in relevant patient populations.
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Affiliation(s)
- Aoyi Xiao
- Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yingying Feng
- Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Shan Yu
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Chunli Xu
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jianghai Chen
- Department of Hand Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Wang
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
- Tingting Wang
| | - Weimin Xiao
- Department of Anesthesiology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Weimin Xiao
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Reighard C, Junaid S, Jackson WM, Arif A, Waddington H, Whitehouse AJO, Ing C. Anesthetic Exposure During Childhood and Neurodevelopmental Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5:e2217427. [PMID: 35708687 PMCID: PMC9204549 DOI: 10.1001/jamanetworkopen.2022.17427] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023] Open
Abstract
Importance Clinical studies of neurodevelopmental outcomes after anesthetic exposure have evaluated a range of outcomes with mixed results. Objective To examine via meta-analyses the associations between exposure to general anesthesia and domain-specific neurodevelopmental outcomes in children. Data Sources PubMed/MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from inception to August 31, 2021. Study Selection Inclusion criteria were exposures to procedures requiring general anesthesia at younger than 18 years and evaluation of long-term neurodevelopmental function after exposure. Studies lacking unexposed controls or focused on children with major underlying comorbidities were excluded. Data Extraction and Synthesis Extracted variables included effect size; hazard, risk, or odds ratio; number of exposures; procedure type; major comorbidities; age of exposure and assessment; presence of unexposed controls; and study design. Studies were independently reviewed by 2 coders, and review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were pooled using a random-effects model. Main Outcomes and Measures The main outcomes were standardized mean differences (SMD) for scores in the neurodevelopmental domains of academics, behavioral problems, cognition, executive function, general development, language, motor function, nonverbal reasoning, social cognition, and hazard and risk of neurodevelopmental disorder diagnoses. Results A total of 31 studies contributed data for meta-analysis. For each of the assessed neurodevelopmental domains, the numbers of children evaluated ranged from 571 to 63 315 exposed and 802 to 311 610 unexposed. Children with any exposure (single or multiple) had significantly worse behavioral problems scores, indicating more behavioral problems (SMD, -0.10; 95% CI, -0.18 to -0.02; P = .02), and worse scores in academics (SMD, -0.07; 95% CI -0.12 to -0.01; P = .02), cognition (SMD, -0.03; 95% CI, -0.05 to 0.00; P = .03), executive function (SMD, -0.20; 95% CI, -0.32 to -0.09; P < .001), general development (SMD, -0.08; 95% CI, -0.13 to -0.02; P = .01), language (SMD, -0.08; 95% CI, -0.14 to -0.02; P = .01), motor function (SMD, -0.11; 95% CI, -0.21 to -0.02; P = .02), and nonverbal reasoning (SMD, -0.15; 95% CI, -0.27 to -0.02; P = .02). Higher incidences of neurodevelopmental disorder diagnoses were also reported (hazard ratio, 1.19; 95% CI, 1.09 to 1.30; P < .001; risk ratio, 1.81; 95% CI, 1.25 to 2.61; P = .002). Conclusions and Relevance These findings support the hypothesis that associations between anesthetic exposure during childhood and subsequent neurodevelopmental deficits differ based on neurodevelopmental domain.
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Affiliation(s)
- Charles Reighard
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Shaqif Junaid
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - William M. Jackson
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Ayesha Arif
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Hannah Waddington
- Faculty of Education, Victoria University of Wellington, Wellington, New Zealand
| | | | - Caleb Ing
- Department of Anesthesiology and Epidemiology, Columbia University Vagelos College of Physicians and Surgeons and Mailman School of Public Health, New York, New York
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Roorda D, Königs M, Eeftinck Schattenkerk L, van der Steeg L, van Heurn E, Oosterlaan J. Neurodevelopmental outcome of patients with congenital gastrointestinal malformations: a systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2021; 106:635-642. [PMID: 34112720 PMCID: PMC8543204 DOI: 10.1136/archdischild-2021-322158] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 12/29/2022]
Abstract
AIM Children with congenital gastrointestinal malformations may be at risk of neurodevelopmental impairment due to challenges to the developing brain, including perioperative haemodynamic changes, exposure to anaesthetics and postoperative inflammatory influences. This study aggregates existing evidence on neurodevelopmental outcome in these patients using meta-analysis. METHOD PubMed, Embase and Web of Science were searched for peer-reviewed articles published until October 2019. Out of the 5316 unique articles that were identified, 47 studies met the inclusion criteria and were included. Standardised mean differences (Cohen's d) between cognitive, motor and language outcome of patients with congenital gastrointestinal malformations and normative data (39 studies) or the studies' control group (8 studies) were aggregated across studies using random-effects meta-analysis. The value of (clinical) moderators was studied using meta-regression and diagnostic subgroups were compared. RESULTS The 47 included studies encompassed 62 cohorts, representing 2312 patients. Children with congenital gastrointestinal malformations had small-sized cognitive impairment (d=-0.435, p<0.001; 95% CI -0.567 to -0.302), medium-sized motor impairment (d=-0.610, p<0.001; 95% CI -0.769 to -0.451) and medium-sized language impairment (d=-0.670, p<0.001; 95% CI -0.914 to -0.425). Patients with short bowel syndrome had worse motor outcome. Neurodevelopmental outcome was related to the number of surgeries and length of total hospital stay, while no relations were observed with gestational age, birth weight, age and sex. INTERPRETATION This study shows that children with congenital gastrointestinal malformations exhibit impairments in neurodevelopmental outcome, highlighting the need for routine screening of neurodevelopment during follow-up.
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Affiliation(s)
- Daniëlle Roorda
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
- Department of Pediatrics, Emma Neuroscience Group, Amsterdam Reproduction & Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marsh Königs
- Department of Pediatrics, Emma Neuroscience Group, Amsterdam Reproduction & Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Laurens Eeftinck Schattenkerk
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
| | - Lideke van der Steeg
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
- Pediatric Surgery, Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Ernest van Heurn
- Department of Pediatric Surgery, Amsterdam Reproduction and Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam and Free University Amsterdam, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Neuroscience Group, Amsterdam Reproduction & Development Research Institute, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Uchitel J, Wallace K, Tran L, Abrahamsen T, Hunanyan A, Prange L, Jasien J, Caligiuri L, Pratt M, Rikard B, Fons C, De Grandis E, Vezyroglou A, Heinzen EL, Goldstein DB, Vavassori R, Papadopoulou MT, Cocco I, Moré R, Arzimanoglou A, Panagiotakaki E, Mikati MA. Alternating hemiplegia of childhood: evolution over time and mouse model corroboration. Brain Commun 2021; 3:fcab128. [PMID: 34396101 PMCID: PMC8361420 DOI: 10.1093/braincomms/fcab128] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 03/05/2021] [Accepted: 06/03/2021] [Indexed: 11/30/2022] Open
Abstract
Alternating hemiplegia of childhood is a rare neurodevelopmental disorder caused by ATP1A3 mutations. Some evidence for disease progression exists, but there are few systematic analyses. Here, we evaluate alternating hemiplegia of childhood progression in humans and in the D801N knock-in alternating hemiplegia of childhood mouse, Mashlool, model. This study performed an ambidirectional (prospective and retrospective data) analysis of an alternating hemiplegia of childhood patient cohort (n = 42, age 10.24 ± 1.48 years) seen at one US centre. To investigate potential disease progression, we used linear mixed effects models incorporating early and subsequent visits, and Wilcoxon Signed Rank test comparing first and last visits. Potential early-life clinical predictors were determined via multivariable regression. We also compared EEG background at first encounter and at last follow-up. We then performed a retrospective confirmation study on a multicentre cohort of alternating hemiplegia of childhood patients from France (n = 52). To investigate disease progression in the Mashlool mouse, we performed behavioural testing on a cohort of Mashlool- mice at prepubescent and adult ages (n = 11). Results: US patients, over time, demonstrated mild worsening of non-paroxysmal disability index scores, but not of paroxysmal disability index scores. Increasing age was a predictor of worse scores: P < 0.0001 for the non-paroxysmal disability index, intellectual disability scale and gross motor scores. Earliest non-paroxysmal disability index score was a predictor of last visit non-paroxysmal disability index score (P = 0.022), and earliest intellectual disability score was a predictor of last intellectual disability score (P = 0.035). More patients with EEG background slowing were noted at last follow-up as compared to initial (P = 0.015). Similar worsening of disease with age was also noted in the French cohort: age was a significant predictor of non-paroxysmal disability index score (P = 0.001) and first and last non-paroxysmal disability index score scores significantly differed (P = 0.002). In animal studies, adult Mashlool mice had, as compared to younger Mashlool mice, (i) worse balance beam performance; (ii) wider base of support; (iii) higher severity of seizures and resultant mortality; and (iv) no increased predisposition to hemiplegic or dystonic spells. In conclusion, (i) non-paroxysmal alternating hemiplegia of childhood manifestations show, on average over time, progression associated with severity of early-life non-paroxysmal disability and age. (ii) Progression also occurs in Mashlool mice, confirming that ATP1A3 disease can lead to age-related worsening. (iii) Clinical findings provide a basis for counselling patients and for designing therapeutic trials. Animal findings confirm a mouse model for investigation of underlying mechanisms of disease progression, and are also consistent with known mechanisms of ATP1A3-related neurodegeneration.
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Affiliation(s)
- Julie Uchitel
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Keri Wallace
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Linh Tran
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Tavis Abrahamsen
- Department of Statistical Science, Duke University, Durham, NC 27708, USA
| | - Arsen Hunanyan
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Lyndsey Prange
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Joan Jasien
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Laura Caligiuri
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Milton Pratt
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Blaire Rikard
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Carmen Fons
- Department of Child Neurology, Sant Joan de Déu Children’s Hospital, Member of the ERN EpiCARE, Barcelona 08950, Spain
| | - Elisa De Grandis
- Child Neuropsychiatry Unit, IRCCS Istituto Giannina Gaslini, Genoa 16147, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa 16147, Italy
| | - Aikaterini Vezyroglou
- Department of Developmental Neurosciences, UCL NIHR BRC Great Ormond Street Institute of Child Health, London WC1N 3JH, UK
| | - Erin L Heinzen
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - David B Goldstein
- Institute of Genomic Medicine, Columbia University, New York, NY 10032, USA
| | - Rosaria Vavassori
- Euro Mediterranean Institute of Science and Technology I.E.ME.ST, Palermo 90139, Italy
| | - Maria T Papadopoulou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon 69500, France
| | - Isabella Cocco
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon 69500, France
| | - Rebecca Moré
- Department of Paediatric Neurology Outpatient Clinic/Neonatal Paediatrics and Intensive Care, University Hospital of Rouen, Rouen 76000, France
| | | | | | - Alexis Arzimanoglou
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon 69500, France
| | - Eleni Panagiotakaki
- Department of Pediatric Clinical Epileptology, Sleep Disorders and Functional Neurology, Member of the ERN EpiCARE, University Hospitals of Lyon (HCL), Lyon 69500, France
| | - Mohamad A Mikati
- Division of Pediatric Neurology and Developmental Medicine, Department of Pediatrics, Duke University, Durham, NC 27710, USA
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Grabowski J, Goldin A, Arthur LG, Beres AL, Guner YS, Hu YY, Kawaguchi AL, Kelley-Quon LI, McAteer JP, Miniati D, Renaud EJ, Ricca R, Slidell MB, Smith CA, Sola JE, Sømme S, Downard CD, Gosain A, Valusek P, St Peter SD, Jagannathan N'S, Dasgupta R. The effects of early anesthesia on neurodevelopment: A systematic review. J Pediatr Surg 2021; 56:851-861. [PMID: 33509654 DOI: 10.1016/j.jpedsurg.2021.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity. METHODS Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms "general anesthesia and neurodevelopment" as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence. RESULTS In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures. CONCLUSION There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist. TYPE OF STUDY Systematic review of level 1-4 studies. LEVEL OF EVIDENCE Level 1-4 (mainly level 3-4).
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Affiliation(s)
- Julia Grabowski
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University, 225 E. Chicago, Box 63, Chicago, IL 60611, United States.
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - L Grier Arthur
- Division of Minimally Invasive, Thoracic and General Surgery, St. Christopher's Hospital for Children, Philadelphia, PA, United States
| | - Alana L Beres
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California, Davis. Sacramento, CA, United States
| | - Yigit S Guner
- Department of Surgery, Children's Hospital of Orange County Division of Pediatric Surgery, University of California, Irvine, United States
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital, Northwestern University, 225 E. Chicago, Box 63, Chicago, IL 60611, United States
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, Mc Govern Medical School at the University of Texas HSC, Houston, TX, United States
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States; Department of Preventive Medicine, University of Southern California Los Angeles, CA, United States
| | | | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children's Center, Roseville, CA, United States
| | - Elizabeth J Renaud
- Division of Pediatric Surgery, Hasbro Children's Hospital, Alpert Medical School at Brown University, Providence, RI, United States
| | - Robert Ricca
- Division of Pediatric Surgery, Naval Medical Center Portsmouth, VA, United States
| | - Mark B Slidell
- Section of Pediatric Surgery, Comer Children's Hospital, The University of Chicago Medicine, Chicago, IL, United States
| | - Caitlin A Smith
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA, United States
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Stig Sømme
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, United States
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY, United States
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN, United States; Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States
| | - Patricia Valusek
- Pediatric Surgical Associates, Ltd., Children's Minnesota, United States
| | | | - Narasimhan 'Sim' Jagannathan
- Department of Pediatric Anesthesiology, Ann and Robert H. Lurie Children's Hospital, Northwestern University, Chicago, IL, United States
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, United States
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8
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Foubert R, Devroe S, Foubert L, Van de Velde M, Rex S. Anesthetic neurotoxicity in the pediatric population: a systematic review of the clinical evidence. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.2.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Background: Exposure to general anesthesia (GA) in early life is known to be neurotoxic to animals.
Objectives: To evaluate the risk of GA inducing long-term neurodevelopmental deficits in human children.
Design: Systematic review.
Methods: We included observational and randomized studies that compared the long-term neurodevelopment of postnatal children exposed to GA to the long-term neurodevelopment of children not exposed to GA. We searched MEDLINE, Embase and Web of Science for relevant studies published in the year 2000 or later. We screened all the identified studies on predetermined inclusion and exclusion criteria. A risk of bias assessment was made for each included study. We identified 9 neurodevelopmental domains for which a sub-analysis was made: intelligence; memory; learning; language/speech; motor function; visuospatial skills; development/emotions/behavior; ADHD/attention; autistic disorder.
Results: We included 26 studies involving 605.391 participants. Based on AHRQ-standards 11 studies were of poor quality, 7 studies were of fair quality and 8 studies were of good quality. The major causes of potential bias were selection and comparability bias. On 2 neurodevelopmental domains (visuospatial skills and autistic disorder), the available evidence showed no association with exposure to GA. On 7 other neurodevelopmental domains, the available evidence showed mixed results. The 4 studies that used a randomized or sibling-controlled design showed no association between GA and neurodevelopmental deficits in their primary endpoints.
Limitations: The absence of a meta-analysis and funnel plot.
Conclusions: Based on observational studies, we found an association between GA in childhood and neuro-developmental deficits in later life. Randomized and sibling-matched observational studies failed to show the same association and therefore no evidence of a causal relationship exists at present. Since GA seems to be a marker, but not a cause of worse neurodevelopment, we argue against delaying or avoiding interventional or diagnostic procedures requiring GA in childhood based on the argument of GA-induced neurotoxicity.
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Walkden GJ, Pickering AE, Gill H. Assessing Long-term Neurodevelopmental Outcome Following General Anesthesia in Early Childhood: Challenges and Opportunities. Anesth Analg 2019; 128:681-694. [PMID: 30883414 PMCID: PMC6436726 DOI: 10.1213/ane.0000000000004052] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neurodegeneration has been reported in young animals after exposure to all commonly used general anesthetic agents. The brain may be particularly vulnerable to anesthetic toxicity during peak synaptogenesis (in gestation and infancy). Human studies of long-term neurodevelopmental outcome following general anesthesia in early childhood report contradictory findings. This review assesses the strengths and deficiencies in human research methodologies to inform future studies. We identified 76 studies, published between 1990 and 2017, of long-term neurodevelopmental outcome following early childhood or in utero general anesthesia exposure: 49 retrospective, 9 ambidirectional, 17 prospective cohort studies, and 1 randomized controlled trial. Forty-nine studies were explicitly concerned with anesthetic-induced neurotoxicity. Full texts were appraised for methodological challenges and possible solutions. Major challenges identified included delineating effects of anesthesia from surgery, defining the timing and duration of exposure, selection of a surgical cohort and intervention, addressing multiple confounding life course factors, detecting modest neurotoxic effects with small sample sizes (median, 131 children; interquartile range, 50–372), selection of sensitive neurodevelopmental outcomes at appropriate ages for different developmental domains, insufficient length of follow-up (median age, 6 years; interquartile range, 2–12 years), and sample attrition. We discuss potential solutions to these challenges. Further adequately powered, multicenter, prospective randomized controlled trials of anesthetic-induced neurotoxicity in children are required. However, we believe that the inherent methodological challenges of studying anesthetic-induced neurotoxicity necessitate the parallel use of well-designed observational cohort studies.
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Affiliation(s)
- Graham J Walkden
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Anthony E Pickering
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Hannah Gill
- From the School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, United Kingdom.,Bristol Anaesthesia, Pain and Critical Care Sciences, Translational Health Sciences, Bristol Medical School, Bristol Royal Infirmary, Bristol, United Kingdom.,Department of Paediatric Anaesthesia, Bristol Royal Hospital for Children, Bristol, United Kingdom
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Allendorf A, Dewitz R, Weber J, Bakthiar S, Schloesser R, Rolle U. Necrotizing enterocolitis as a prognostic factor for the neurodevelopmental outcome of preterm infants - match control study after 2years. J Pediatr Surg 2018; 53:1573-1577. [PMID: 29409620 DOI: 10.1016/j.jpedsurg.2018.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE Necrotizing enterocolitis (NEC) in very low birth weight infants is a risk factor for developmental delay. To our knowledge, there are no studies published investigating the neurodevelopmental outcome of patients with NEC comparing surgically treated and conservatively treated patients versus match paired controls. The aim of this retrospective case control study was to measure the neurodevelopmental outcome of patients with NEC who were treated surgically or conservatively METHODS: All patients were identified, who have been diagnosed with NEC (ICD-10 code, P77) born between 2006 and 2013. Patients with NEC received antibiotic therapy, nasogastric decompression and fasting. Surgical treatment was indicated for patients with Bell stages IIIb. We excluded patients suffering from other relevant diseases with a possible impact on their neurodevelopmental outcome (e.g., intraventricular hemorrhage, associated malformations, asphyxia, focal intestinal perforation, short bowel syndrome). Patients were tested at the corrected gestational age of 24months according to the Bayley Scales of Infant Development II. Each participant was compared to a child of the same sex, gestational age at birth (+/-two days), birth weight (+/-10%), and age at neurodevelopmental testing (IRB approval, No. 14/2014). The outcome measures were the psychomotor index (PDI) and the mental developmental index (MDI). RESULTS We included 13 conservatively and 24 surgically treated patients. The patients in group A (without surgery) achieved a mean PDI of 106, and those in group B (with surgery) a mean PDI of 90. These values were significantly higher in the conservative group A. The mean MDIs were 99 in the patient group A and 85 in patient group B. This difference was also significant. CONCLUSION We found significantly lower MDIs and PDIs in children with surgical treatment of NEC. Further systematic prospective research on the prevention of NEC and systematic follow-ups at later stages in the patients' development are necessary in order to implement early intervention. TYPE OF STUDY case control study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Antje Allendorf
- Department of Neonatology, University Hospital of the Goethe-University Frankfurt/M, Germany
| | - Ruth Dewitz
- Department of Neuropediatrics, University Hospital of the Goethe-University Frankfurt/M, Germany
| | - Joy Weber
- Department of Neuropediatrics, University Hospital of the Goethe-University Frankfurt/M, Germany
| | - Shahrzad Bakthiar
- Department of Neonatology, University Hospital of the Goethe-University Frankfurt/M, Germany
| | - Rolf Schloesser
- Department of Neonatology, University Hospital of the Goethe-University Frankfurt/M, Germany
| | - Udo Rolle
- Department of Pediatric Surgery and Pediatric Urology, University Hospital of the Goethe-University Frankfurt/M, Germany.
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11
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Lee JR, Loepke AW. Does pediatric anesthesia cause brain damage? - Addressing parental and provider concerns in light of compelling animal studies and seemingly ambivalent human data. Korean J Anesthesiol 2018; 71:255-273. [PMID: 29969889 PMCID: PMC6078876 DOI: 10.4097/kja.d.18.00165] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/04/2018] [Indexed: 02/07/2023] Open
Abstract
Anesthesia facilitates surgery in millions of young children every year. Structural brain abnormalities and functional impairment observed in animals have created substantial concerns among clinicians, parents, and government regulators. Clinical studies seemed ambivalent; it remains unclear whether differential species effects exist towards anesthetic exposure. The current literature search and analysis attempts to unify the available clinical and animal studies, which currently comprise of > 530 in vivo animal studies and > 30 clinical studies. The prevalence of abnormalities was lowest for exposures < 1 hour, in both animals and humans, while studies with injurious findings increased in frequency with exposure time. Importantly, no exposure time, anesthetic technique, or age during exposure was clearly identifiable to be entirely devoid of any adverse outcomes. Moreover, the age dependence of maximum injury clearly identified in animal studies, combined with the heterogeneity in age in most human studies, may impede the discovery of a specific human neurological phenotype. In summary, animal and human research studies identify a growing prevalence of injurious findings with increasing exposure times. However, the existing lack of definitive data regarding safe exposure durations, unaffected ages, and non-injurious anesthetic techniques precludes any evidence-based recommendations for drastically changing current clinical anesthesia management. Animal studies focusing on brain maturational states more applicable to clinical practice, as well as clinical studies focusing on prolonged exposures during distinct developmental windows of vulnerability, are urgently needed to improve the safety of perioperative care for thousands of young children requiring life-saving and quality of life-improving procedures daily.
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Affiliation(s)
- Jeong-Rim Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Andreas W Loepke
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Clausen N, Kähler S, Hansen T. Systematic review of the neurocognitive outcomes used in studies of paediatric anaesthesia neurotoxicity. Br J Anaesth 2018; 120:1255-1273. [DOI: 10.1016/j.bja.2017.11.107] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 10/22/2017] [Accepted: 11/21/2017] [Indexed: 01/08/2023] Open
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