Skip to main content
SpringerLink
Log in

Non-sedation of the neonate for radiologic procedures

  • Minisymposium: Fetal/neonatal imaging
  • Published:
Pediatric Radiology Aims and scope Submit manuscript

Abstract

On Dec. 16, 2016, the U.S. Food and Drug Administration (FDA) released a warning regarding the potential neurotoxicity of anesthesia and sedation agents on the developing brain in children younger than 3 years and in women during their 3rd trimester of pregnancy. These concerns have relevance to the pediatric radiologist who must take into consideration how the child’s state might impact image quality. In this review the author provides background on the special concerns in the potentially highest-risk group, pre-term and term neonates, and provides guidance and rationale for the avoidance of sedation in procedural imaging of the newborn.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Goske MJ, Applegate KE, Boylan J et al (2008) The 'Image Gently' campaign: increasing CT radiation dose awareness through a national education and awareness program. Pediatr Radiol 38:265–269

    Article  PubMed  Google Scholar 

  2. Walters JL, Paule MG (2017) Review of preclinical studies on pediatric general anesthesia-induced developmental neurotoxicity. Neurotoxicol Teratol 60:2–23

    Article  CAS  PubMed  Google Scholar 

  3. Montana M, Evers A (2017) Anesthetic neurotoxicity: new findings and future directions. J Pediatr 181:279–285

    Article  PubMed  Google Scholar 

  4. Rappaport B, Suresh S, Hertz S et al (2015) Anesthetic neurotoxicity — clinical implications of animal models. New Engl J Med 372:796–797

    Article  CAS  PubMed  Google Scholar 

  5. Sall J (2016) Anesthesia kills brain cells, but what does it mean? Anesthesiology 125:1090–1091

    Article  PubMed  PubMed Central  Google Scholar 

  6. Shih J, May L, Gonzalez H et al (2012) Delayed environmental enrichment reverses sevoflurane-induced memory impairment in rats. Anesthesiology 116:586–602

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Slikker W, Zou X, Hotchkiss C et al (2007) Ketamine-induced neuronal cell death in the perinatal Rhesus monkey. Toxicol Sci 98:145–158

    Article  CAS  PubMed  Google Scholar 

  8. Hoffman G, Nowakowski R, Troshynski T et al (2002) Risk reduction in pediatric procedural sedation by application of an American Academy of Pediatrics/American Society of Anesthesiologists process model. Pediatrics 109:236–243

    Article  PubMed  Google Scholar 

  9. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists (2002) Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 96:1004–1017

    Article  Google Scholar 

  10. Committee on Pediatric Anesthesia, American Society of Anesthesiologists (2016) Statement on practice recommendations for pediatric anesthesia http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/statement-on-practice-recommendations-for-pediatric-anesthesia.pdf. Accessed 22 Sept 2017

  11. Mason K (2008) The pediatric sedation service: who is appropriate to sedate, which medications should I use, who should prescribe the drugs, how do I bill? Pediatr Radiol 38:218–224

    Article  Google Scholar 

  12. Monroe K, Beach M, Reindel R et al (2013) Analysis of procedural sedation provided by pediatricians. Pediatr Int 55:17–23

    Article  PubMed  Google Scholar 

  13. Allegaert K, van den Anker J (2015) Neonatal drug therapy: the first frontier of therapeutics for children. Clin Pharmacol Ther 98:288–297

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Anderson B, Allegaert K (2010) The pharmacology of anaesthetics in the neonate. Best Pract Res Clin Anaesthesiol 24:419–431

    Article  CAS  PubMed  Google Scholar 

  15. Kuehn B (2011) FDA considers data on potential risks of anesthesia use in infants, children. JAMA 305:1749

    Article  CAS  PubMed  Google Scholar 

  16. Martin L (2017) The basic principles of anesthesia for the neonate. Colombian J Anesthesiol 45:54–61

    Article  Google Scholar 

  17. Houck CS, Vinson AE (2017) Anaesthetic considerations for surgery in newborns. Arch Dis Child Fetal Neonatal Ed 102:F359–F363

    Article  PubMed  Google Scholar 

  18. Havidich J, Beach M, Dierdorf S et al (2016) Preterm versus term children: analysis of sedation/anesthesia adverse events and longitudinal risk. Pediatrics 137:e20150463

    Article  PubMed  Google Scholar 

  19. Krauss B, Green SM (2006) Procedural sedation and analgesia in children. Lancet 367:766–780

    Article  CAS  PubMed  Google Scholar 

  20. Kaila R, Chen X, Kannikeswaran N (2012) Postdischarge adverse events related to sedation for diagnostic imaging in children. Pediatr Emerg Care 28:796–801

    Article  PubMed  Google Scholar 

  21. Mellon R, Simone A, Rappaport B (2007) Use of anesthetic agents in neonates and young children. Anesth Analg 104:509–520

    Article  CAS  PubMed  Google Scholar 

  22. McCann M, Soriano S (2012) General anesthetics in pediatric anesthesia: influences on the developing brain. Curr Drug Targets 13:944–951

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Arlachov Y, Ganatra R (2012) Sedation/anaesthesia in paediatric radiology. Br J Radiol 85:e1018–e1031

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Slovis T (2011) Sedation and anesthesia issues in pediatric imaging. Pediatr Radiol 41:514–516

    Article  PubMed  Google Scholar 

  25. Anand KJS, Hickey PR (1987) Pain and its effects in the human neonate and fetus. N Engl J Med 317:1321–1329

    Article  CAS  PubMed  Google Scholar 

  26. Delgado J, Toro R, Rascovsky S et al (2014) Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists. Pediatr Radiol 45:108–114

    Article  PubMed  Google Scholar 

  27. Litman R, Soin K, Salam A (2010) Chloral hydrate sedation in term and preterm infants: an analysis of efficacy and complications. Anesth Analg 110:739–746

    Article  CAS  PubMed  Google Scholar 

  28. Ikonomidou C, Bosch F, Miksa M et al (1999) Blockade of NMDA receptors and apoptotic neurodegeneration in the developing brain. Science 283:70–74

    Article  CAS  PubMed  Google Scholar 

  29. Jiang Y, Tong D, Hofacer RD et al (2016) Long-term fate mapping to assess the impact of postnatal isoflurane exposure on hippocampal progenitor cell productivity. Anesthesiology 125:1159–1170

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Rappaport B, Mellon R, Simone A et al (2011) Defining safe use of anesthesia in children. New Engl J Med 364:1387–1390

    Article  CAS  PubMed  Google Scholar 

  31. Davidson AJ, Disma N, de Graaff JC et al (2016) Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 387:239–250

    Article  PubMed  Google Scholar 

  32. Sun L, Li G, Miller T et al (2016) Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. JAMA 315:2312–2320

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Pinyavat T, Warner DO, Flick RP et al (2016) Summary of the update session on clinical neurotoxicity studies. J Neurosurg Anesthesiol 28:356–360

    Article  PubMed  PubMed Central  Google Scholar 

  34. Gleich SJ, Flick R, Hu D et al (2015) Neurodevelopment of children exposed to anesthesia: design of the mayo anesthesia safety in kids (MASK) Study. Contemp Clin Trials 41:45–54

    Article  PubMed  Google Scholar 

  35. Chinn G, Russell J, Sall J (2016) Is a short anesthetic exposure in children safe? Time will tell: a focused commentary of the GAS and PANDA trials. Ann Transl Med 4:408

    Article  PubMed  PubMed Central  Google Scholar 

  36. Filan P, Hunt R, Anderson P et al (2012) Neurologic outcomes in very preterm infants undergoing surgery. J Pediatr 160:409–414

    Article  PubMed  Google Scholar 

  37. Flick R, Katusic S, Colligan R et al (2011) Cognitive and behavioral outcomes after early exposure to anesthesia and surgery. Pediatrics 128:e1053–e1061

    Article  PubMed  PubMed Central  Google Scholar 

  38. Glatz P, Sandin R, Pedersen N et al (2017) Association of anesthesia and surgery during childhood with long-term academic performance. JAMA Pediatr 171:e163470

    Article  PubMed  Google Scholar 

  39. Graham M, Brownell M, Chateau D et al (2016) Neurodevelopmental assessment in kindergarten in children exposed to general anesthesia before the age of 4 years. Anesthesiology 125:667–677

    Article  CAS  PubMed  Google Scholar 

  40. Hansen T, Pedersen J, Henneberg S et al (2011) Academic performance in adolescence after inguinal hernia repair in infancy. Anesthesiology 114:1076–1085

    Article  PubMed  Google Scholar 

  41. Istaphanous G, Loepke A (2009) General anesthetics and the developing brain. Curr Opin Anaesthesiol 22:368–373

    Article  PubMed  Google Scholar 

  42. Lee B, Hazarika O, Quitoriano G et al (2014) Effect of combining anesthetics in neonates on long-term cognitive function. Int J Dev Neurosci 37:87–93

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  43. Williams R, Black I, Howard D et al (2014) Cognitive outcome after spinal anesthesia and surgery during infancy. Anesth Analg 119:651–660

    Article  CAS  PubMed  Google Scholar 

  44. Zhang H, Du L, Du Z et al (2015) Association between childhood exposure to single general anesthesia and neurodevelopment: a systematic review and meta-analysis of cohort study. J Anesth 29:749–757

    Article  PubMed  Google Scholar 

  45. Psaty BM, Platt R, Altman RB (2015) Neurotoxicity of generic anesthesia agents in infants and children: an orphan research question in search of a sponsor. JAMA 313:1515–1516

    Article  CAS  PubMed  Google Scholar 

  46. Card E, Wells N (2016) An introduction to the Smart Tots consensus statement on the use of anesthetic and sedative drugs in infants and toddlers. J Perianesth Nurs 31:3–10

    Article  PubMed  Google Scholar 

  47. U.S. Food & Drug Administration (2016) FDA drug safety communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women https://www.fda.gov/Drugs/DrugSafety/ucm532356.htm. Accessed 22 Sept 2017

  48. U.S. Food & Drug Administration (2016) FDA statement from Dr. Janet Woodcock, director of FDA’s Center for Drug Evaluation and Research, on new safety information on anesthesia use in young children and pregnant women https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm533346.htm. Accessed 22 Sept 2017

  49. Brown RE Jr, Agarwal R (2017) AAP responds to FDA warning on anesthesia use in children. AAP News. http://www.aappublications.org/news/2017/01/10/Anesthesia011017. Accessed 2 Oct 2017

  50. Andropoulos D, Greene M (2017) Anesthesia and developing brains — implications of the FDA warning. New Engl J Med 376:905–907

    Article  PubMed  Google Scholar 

  51. Shimony JS, Smyser CD, Wideman G et al (2016) Comparison of cortical folding measures for evaluation of developing human brain. NeuroImage 125:780–790

    Article  PubMed  Google Scholar 

  52. Caperell K, Pitetti R (2009) Is higher ASA class associated with an increased incidence of adverse events during procedural sedation in a pediatric emergency department? Pediatr Emerg Care 25:661–664

    Article  PubMed  Google Scholar 

  53. Green S, Mason K (2011) Stratification of sedation risk — a challenge to the sedation continuum. Pediatr Anesth 21:924–931

    Article  Google Scholar 

  54. Shariat M, Mertens L, Seed M et al (2014) Utility of feed-and-sleep cardiovascular magnetic resonance in young infants with complex cardiovascular disease. Pediatr Cardiol 36:809–812

    Article  PubMed  Google Scholar 

  55. Edwards A, Arthurs O (2011) Paediatric MRI under sedation: is it necessary? What is the evidence for the alternatives? Pediatr Radiol 41:1353–1364

    Article  PubMed  Google Scholar 

  56. Windram J, Grosse-Wortmann L, Shariat M et al (2011) Cardiovascular MRI without sedation or general anesthesia using a feed-and-sleep technique in neonates and infants. Pediatr Radiol 42:183–187

    Article  PubMed  Google Scholar 

  57. Gale C, Jeffries S, Logan K et al (2012) Avoiding sedation in research MRI and spectroscopy in infants: our approach, success rate and prevalence of incidental findings. Arch Dis Child Fetal Neonatal Ed 98:F267–F268

    Article  PubMed  Google Scholar 

  58. Ureta-Velasco N, Martínez-de Aragón A, Moral-Pumarega M et al (2015) Magnetic resonance imaging without sedation in neonates. An Pediatr 82:354–359

    Article  CAS  Google Scholar 

  59. Neubauer V, Griesmaier E, Baumgartner K et al (2011) Feasibility of cerebral MRI in non-sedated preterm-born infants at term-equivalent age: report of a single centre. Acta Paediatr 100:1544–1547

    Article  CAS  PubMed  Google Scholar 

  60. Mathur A, Neil J, McKinstry R et al (2007) Transport, monitoring, and successful brain MR imaging in unsedated neonates. Pediatr Radiol 38:260–264

    Article  PubMed  Google Scholar 

  61. Mason K (2010) Sedation trends in the 21st century: the transition to dexmedetomidine for radiological imaging studies. Pediatr Anesth 20:265–272

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Pediatric Newborn Medicine, Brigham and Women’s Hospital, 75 Francis St., Rm. CWN418, Boston, MA, 02115, USA

    Richard B. Parad

  2. Department of Pediatrics, Harvard Medical School, Boston, MA, 02115, USA

    Richard B. Parad

Authors
  1. Richard B. Parad
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Richard B. Parad.

Ethics declarations

Conflicts of interest

None

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Parad, R.B. Non-sedation of the neonate for radiologic procedures. Pediatr Radiol 48, 524–530 (2018). https://doi.org/10.1007/s00247-017-4002-y

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00247-017-4002-y

Keywords

Search

Navigation