Neonatal Anesthesia

Pediatrics, Volume 80, Issue 3: Page 446, September 1987.

Committee on Fetus and Newborn
Committee on Drugs
Section on Anesthesiology
Section on Surgery

In the past, some practicing physicians have advocated withholding anesthetic or analgesic agents from neonates undergoing surgical procedures. The rationale expressed for such practice is that some neonates undergoing surgery are often so unstable that the risk of an anesthetic agent is too great to justify the possible benefit of pain relief. An analogy may be drawn to the adult patient with major trauma who must undergo life-saving surgery in whom anesthesia is reduced or withheld because of the fear of worsening an already compromised physiologic homeostasis.¹ Also cited in support of this practice is the impression that nerve pathways are not sufficiently myelinated to transmit painful stimuli or that neonates do not have sufficiently integrated cortical function to recall painful experiences.

There is an increasing body of evidence that neonates, including those born preterm, demonstrate physiologic responses to surgical procedures that are similar to those demonstrated by adults and that these responses can be lessened with anesthetic agents.^2-6 Other studies have suggested that stability of variables such as blood pressure, heart rate, and oxygenation is important in reducing complications such as intraventricular hemorrhage or pulmonary hypertension.^7-8 There is also increasing evidence that neonatal cortical function is far greater than previously thought^9,10 and some suggestion that short-term behavior may be affected by prior painful stimuli.^11,12

The Committee on Fetus and Newborn, the Committee on Drugs, the Section on Anesthesiology, and the Section on Surgery believe that local or systemic pharmacologic agents now available permit relatively safe administration of anesthesia or analgesia to neonates undergoing surgical procedures and that such administration is indicated according to the usual guidelines for the administration of anesthesia to high-risk, potentially unstable patients. In occasional situations, physiologic instability will be so great that the anesthetic agents must be reduced or discontinued. However the decision to withhold such medication should be based on the same medical criteria used for older patients. The decision should not be based solely on the infant's age or perceived degree of cortical maturity.

COMMITTEE ON FETUS AND NEWBORN
Ronald L. Poland, MD, Chairman

COMMITTEE ON DRUGS
Ronald J. Roberts, MD, PhD, Chairman

SECTION ON ANESTHESIOLOGY
Juan F. Gutierrez-Mazorra, MD, Chairman

SECTION ON SURGERY
Eric W. Fonkalsrud, MD, Chairman

REFERENCES

1. Bogetz MS, Katz JA; Recall of Surgery for major trauma. Anesthesiology 1984;61:6-9
2. Owens ME: Pain in infancy: Conceptual and methodological issues. Pain 1984;20:213-230
3. Robinson S, Gregory GA: Fentanyl-air-oxygen anesthesia for ligation of patent ductus arteriosus in preterm infants. Anesth Analg 1981;60:331-334
4. Gregory GA: Anesthesia for premature infants, in Gregory GA (ed): Pediatric Anesthesia, New York, Churchill Livingstone, 1983, vol 2., pp 587-606
5. Williamson, PS, Williamson ML: Physiologic Stress Reduction by a local anesthetic during newborn circumcision. Pediatrics 1983; 71:36-40
6. Volpe JJ: Intracranial hemorrhage: Periventricular-intraventriclar hemorrhage of the premature infant, in Neurology of the Newborn, ed 2. Philadelphia, WB Saunders Co. 1987, pp 311-361
7. Vacanti JP, Crone RK, Murphy JD. et al: The pulmonary hemodynamic response to perioperative anesthesia in the treatment of high-risk infants with congenital diaphramatic hernia. J Pediatr Surg 1984;19:672-679
8. Brazelton, TB: Behavioral competence of the newborn infant. Semin Perinatol 1979;3:35-44
9. Dixon S, Synder J Holve R, et al: Behavioral effects of circumcision with and without anesthesia. J Dev Behav Pediatr 1984;5:246-250
10. Richards MPM, Bernal J, Brackbill Y: Early Behavior differences: gender or circumcision? Dev Psychobiol 1975;9:89-95
11. Schecter NL: Pain and pain control in children. Current Problems in Pediatrics 1985, 1515
12. Anand KJS, et al: Randomized trial of fentanyl anesthesia in preterm babies undergoing surgery: Effects on the stress response. Lancet 1987;1:243-247

[* Policy Reference Guide of The AAP, 9th Edition.]

• Neonatal anesthesia. Pediatrics 1987;80(3):446.

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