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Anaesthetics

MagazineApril 2009 (Vol. 20 Issue 1)Anaesthetics

Q) My four-year-old son has glue ear and is due for surgery to have grom-mets inserted

Q) My four-year-old son has glue ear and is due for surgery to have grom-mets inserted. However, I'm worried about the general anaesthetic he will need-par-ticularly as I've heard in the news that it might put him at risk of developmental problems. Should I be worried?-T.L., via e-mail

A) Anaesthetics are routinely given to children for both major and minor opera-tions, and complications are rare. However, as you rightly point out, new research suggests a link between childhood exposure to general anaesthesia and an increased risk of behavioural and develop-mental disorders-of course, a cause for alarm to many parents.

These findings, from Dr Lena Sun and colleagues at Columbia Univer-sity in New York City, were presented at the 2008 Annual Meeting of the American Society of Anesthesiol-ogists (www.asahq.org), and involved children born between 1999 and 2000. The researchers identified 625 children under three years of age who had been given general anaesthesia for hernia repair. When compared with a random sample of 5000 chil-dren with no history of anaesthesia, the anaesthesia-exposed children were twice as likely to be later diagnosed with a developmental or behavioural disorder.

Their results are also backed up by mounting evidence-at least in animals-that anaesthesia can be harmful to the developing brain (Anesth Analg, 2008; 106: 1681-707). In one study, a combination of three commonly used paediatric anaes-thetics given to seven-day-old rats resulted in brain-cell death, along with persistent memory and learning deficits (J Neurosci, 2003; 23: 876-82). Another rat-pup study found that exposure to general anaesthesia caused "permanent neuronal dele-tion" in the most vulnerable parts of the brain (Ann N Y Acad Sci, 2007; 1122: 69-82).

Although these findings may not apply to humans and more research is needed, what's a parent to do in the meantime?

According to Dr Sun, parents shouldn't keep their children away from necessary surgery because of fears over anaesthesia. However, in your son's case, it may be argued that grommets-tubes inserted into the ear to drain otitis media ('glue ear')-is not a necessary operation.

When left alone, 80 per cent of cases of glue ear resolve within a year (HNO, 1987; 35: 55-60). Yet, around half of those with grommets have needed a repeat operation within five years (J Laryngol Otol, 1991; 105: 614-7).

Moreover, grommet surgery comes with its own potential problems, including damage to the eardrum, displacement of the grommets and tympanosclerosis-hearing loss due to scars on the eardrum (see WDDTY vol 15 no 6). So, you need to ask yourself whether the risks are worth the limited treatment benefits.

According to one review, the initial improvements in hearing from grommets diminishes within a year. In otherwise healthy children with long-standing otitis media and loss of hearing, early grommet insertion did not help language development or cognition. These facts, coupled with the risk of adverse effects, have led researchers to conclude that "watchful waiting" is the most appro-priate strategy for most children with glue ear (Cochrane Database Syst Rev, 2005; 1: CD001801).

In addition, there are alternative ways to deal with the problem. First, investigate allergies. When seven children underwent a food-elimina-tion diet instead of having grommets fitted, the glue ear resolved with no hearing loss or recurrence in every case. The 13 others in the trial treated with allergy immunotherapy achieved a 65-per-cent success rate (Otolaryngol Head Neck Surg, 1990; 102: 664-9). Also, eliminate any foods that are associated with the formation of mucus such as milk and white sugar.

Another option is osteopathy. In one trial, children who had three or four episodes of otitis media in the previous year were assigned to either routine care (mainly antibiotics) or routine care plus osteopathy. The latter group required less medical care and suffered fewer attacks than those receiving the antibiotics (Arch Pediatr Adolesc Med, 2003; 157: 861-6).

Herbal ear drops may also help-especially those including Calendula (marigold), garlic (Allium sativum), mullein (Verbascum thapsus), St John's wort (Hypericum perforatum), vitamin E and lavender in a base of olive oil-and can ease the pain associated with glue ear (Pediatr Rev, 2008; 29: 193-9).

Other remedies worth trying include cod liver oil as supplements (taken alongside a multivitamin), homeopathy and Allergina, a tradi-tional Chinese herbal formulation (Am J Health-Syst Pharm, 2006; 63: 33-9).

Other risks of anaesthesia

Outcomes for children undergoing anaesthesia have improved over the years as a result of advances in monitoring and equipment along with safer anaesthetic agents. However, side-effects and complications still happen (Curr Opin Anaesthesiol, 2006; 19: 262-7). Postoperative nausea and vomiting is especially common, affecting around one-third of children (Anesth Analg, 1990; 70: 160-7). More serious adverse effects during surgery include heart and breathing problems that may be potentially life-threatening (Paediatr Anaesth, 2004; 14: 158-66). Allergic reactions may also put the patient in danger, although this generally only affects one patient in 10,000-20,000 (Br J Anaesth, 2005; 95: 468-71).


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