Postoperative Cognitive Function in Children Undergoing General Anesthesia

December 31, 2019

Postoperative cognitive dysfunction (POCD) is a persistent minor impairment of cognitive functions such as memory, attention, and language comprehension following surgery [1, 2]. Incidence rates depend on a variety of factors including surgery type, age of patient, and number of operations requiring general anesthesia [1]. Aun et al. (2014) found that around 5.1% of children experienced POCD one day after surgery and 3.4% of children experienced POCD 6 weeks after surgery [2]. Furthermore, this study found that POCD in their sample did not affect one specific domain of cognitive functioning, but instead slightly impaired many cognitive functions [2]. While this study suggests that the incidence of POCD in children is low, there is some research to suggest that the type of general anesthesia may affect this rate.

For instance, Millar et al (2014) found that 5 to 14-year-old children given intravenous general anesthesia (propofol) had greater impairment of verbal recall immediately after and a day after surgery compared to children given inhalation general anesthesia (isoflurane) [3]. Another study compared 7 to 13-year-old children given intravenous anesthesia (propofol) and those given inhalant anesthesia (sevoflurane) during an elective hernia surgery [4]. Seven days after surgery, children given propofol had greater impaired short-term memory compared to those given sevoflurane [4]. Three months after surgery, there was no impairment in either anesthesia group in short-term memory [4]. A third study replicated this effect – using an inhalant general anesthesia (halothane-N2O) in 5 to 8-year-old children resulted in impairments in reasoning and memory functions two hours after an ear surgery but no impairments compared to a control group 24 hours post-surgery [5]. These studies suggest some cognitive functioning may be impaired in children following surgery but that these effects are typically short-lived. However, two other factors, age and the length of time under general anesthesia, are also widely studied in related to the development of POCD in children, particularly long-term effects.

In this vein, the FDA does not recommend anesthesia in children under three years old, except during emergencies, to avoid the neurotoxicity and adverse effects to neuroplasticity present in animal studies [2, 6]. However, a recent study found that infants (<1-year-old) who received general anesthesia did not show any long-term cognitive dysfunction at five years old [7]. Another study found that if children received general anesthesia before the age of two, there was no association between anesthesia exposure and cognitive functioning in kindergarten [8]. However, children who received general anesthesia between the ages of 2-4 years old were reported to have greater language and cognition deficits compared to those who did not [8]. Furthermore, one study of over 5,000 children who underwent surgery with general anesthesia before the age of four found that children who underwent more than one surgery with general anesthesia and those who had “longer culminative duration” under general anesthesia had an elevated risk of developing a learning disability later in childhood [9]. These studies elucidate some of the factors that may be related to the development of long-term POCD in children.

In conclusion, the evidence suggests that when POCD is present, it is present in the short-term, and it is likely to affect multiple domains of cognitive functioning. However, POCD is unlikely to have permanent long-term effects on cognitive functioning in children. Additionally, more work should be done to investigate the incidence rates of POCD in children.

References:

  1. Wang, W. et al. (2014). Postoperative Cognitive Dysfunction: Current Developments in Mechanism and Prevention. Medical Science Monitor, 20, 1908-1912. doi: 10.12659/MSM.892485
  2. Aun, C. et al. (2016). Short-Term Changes in Postoperative Cognitive Function in Children Aged 5 to 12 Years Undergoing General Anesthesia: A Cohort Study. Medicine (Baltimore), 95(14). doi: 10.1097/MD.0000000000003250
  3. Millar et al. (2013). Children’s cognitive recovery after day‐case general anesthesia: a randomized trial of propofol or isoflurane for dental procedures. Pediatric Anesthesia, 24(2), 201-207. doi: 10.1111/pan.12316
  4. Yin, J., Wang, S.L., and Liu, X.B. (2014). The effects of general anaesthesia on memory in children: a comparison between propofol and sevoflurane. Anaesthesia: Peri-operative medicine, critical care and pain, 69(2), 118-123. doi: 10.1111/anae.12504
  5. Morgan, S., Furman, E., and Dikmen, S. (1981). Psychological Effects of General Anesthesia on Five- to Eight-year-old Children. Anesthesiology, 55, 386-391. doi: 10.1097/00000542-198110000-00009
  6. Sinner, B., Becke, K., and Engelhard, K. (2014). General anaesthetics and the developing brain: an overview. Anaesthesia: Peri-operative medicine, critical care and pain, 69(9). doi: 10.1111/anae.12637
  7. McCann, M.E. et al. (2019). Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. The Lancet, 393(10172), 664-677. doi: 10.1016/S0140-6736(18)32485-1
  8. Graham, M.R., Brownell, M., Chateau, D.G., Burchill, C., and Fransoo, R.R. (2016). Neurodevelopmental Assessment in Kindergarten in Children Exposed to General Anesthesia before the Age of 4 Years: A Retrospective Matched Cohort Study. Anesthesiology, 125(4), 667-677. doi: 10.1097/ALN.0000000000001245
  9. Wilder RT, Flick RP, Sprung J, et al. (2009). Early exposure to anesthesia and learning disabilities in a population‐based birth cohort. Anesthesiology, 110, 796–804. doi: 10.1097/01.anes.0000344728.34332.5d
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