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Children should be treated by experienced pediatric anesthesiologists.
Good pediatric anesthesia care also requires pediatric anesthesia nurses, post-anesthesia recovery facilities, established SOPs, continuous education and training.
Safetots.org initiative aims to alert parents & practio- ners on the importance of education and experience of the pediatric anesthesiologist in charge.
Pediatric anesthesia is principally safe in experienced hands and well-organized pediatric anesthesia departments.  However, peri-operative complications do occur more often in neonates, infants and children when compared to adults. These patients also have an increased risk of morbidity and mortality when compared to adults. (1-3) The incidence and severity of these peri-operative complications are dependent on the age (reduced physiological reserves), pre-operative morbidity, urgency of the procedure as well as the training and experience of the anesthesiologist and the anesthesia team. (4-6) As a consequence, neonates, infants and toddlers, sick children and children with complex needs must be treated in specialised pediatric centres by experienced pediatric anesthesiologists. Older, otherwise healthy children for common elective procedures who are treated in non-pediatric hospitals benefit from anesthesiologists trained and experienced in pediatric anesthesia. (7) A specialist pediatric anesthesiologist has been trained for a minimum of one year at a large pediatric centre and may also have a specialist pediatric anesthesia certification. They routinely provide anesthesia care for at least 200-300 children per annum. (4,5,8) Good pediatric anesthesia care also requires well trained pediatric nurses, pediatric post-anesthesia recovery facilities, established standard operating protocols (SOPs) as well as continuous education and training. (9, 10) These recommendations apply to all places where children are anesthetized including dental practices, day case (office based) surgery and specialised areas.

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There is no proven causal link between anesthetic agents and cerebral damage in neonates, infants and small children undergoing general anesthesia in early childhood. (11) Surgery and anesthesia in early childhood in some surgical procedures may have a minimal negative effect on academic performance but is also greatly beneficial in others. Other factors such as age at school entry, gender and maternal background have a much more profound impact on academic performance. (12) Repeat anesthetic procedures in young children do not result in an increased risk of developmental delay at school entry when compared to a single anesthetic procedure. (14) There is a definite causal relationship between preventable poor perioperative anesthetic care and adverse events with persistent poor neurological outcome and mortality in neonates, infants and small children. (1,15-17) 1. Morray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM, Cheney FW. A comparison of pediatric and adult anesthesia closed malpractice claims. Anesthesiology. 1993; 78: 461-7. 2. Whitlock EL, Feiner JR, Chen LL. Perioperative Mortality, 2010 to 2014: A Retrospective Cohort Study Using the National Anesthesia Clinical Outcomes Registry. Anesthesiology. 2015; 123: 1312-21. 3. Nunnally ME, O'Connor MF, Kordylewski H, Westlake B, Dutton RP. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth Analg. 2015; 120: 364-70. 4. Zgleszewski SE, Graham DA, Hickey PR, Brustowicz RM, Odegard KC, Koka R, Seefelder C, Navedo AT, Randolph AG. Anesthesiologist- and System-Related Risk Factors for Risk-Adjusted Pediatric Anesthesia-Related Cardiac Arrest. Anesth Analg. 2016; 122: 482-9. 5. Auroy Y, Ecoffey C, Messiah A, Rouvier B. Relationship between complications of pediatric anesthesia and volume of pediatric anesthetics. Anesth Analg. 1997; 84: 234-5. 6. Robert Fischer – Doctoral Thesis. University of Aachen; 2009. (urn:nbn:82-opus-15169. 7. Harrison TE, Engelhardt T, MacFarlane F, Flick RP. Regionalization of pediatric anesthesia care: has the time come? Paediatr Anaesth. 2014; 24: 897-8. 8. Lunn JN. Implications of the National Confidential Enquiry into Perioperative Deaths for pediatric anesthesia. Paediatr Anaesth. 1992; 2: 69–72. 9. Section on Anesthesiology and Pain Medicine., Polaner DM, Houck CS; American Academy of Pediatrics. Critical Elements for the Pediatric Perioperative Anesthesia Environment. Pediatrics. 2015; 136: 1200-5. 10. Weiss M, Vutskits L, Hansen TG, Engelhardt T.Safe Anesthesia For Every Tot – The SAFETOTS initiative. Curr Opin in Anaesthesiol. 2015; 28: 302-7. 11. Hansen TG, Engelhardt T, Weiss M. The Relevance of Anesthetic Drug-Induced Neurotoxicity. JAMA Pediatr. 2016 Nov 7: [Epub ahead of print]. 12. Glatz P, Sandin RH, Pedersen NL, Bonamy AK, Eriksson LI, Granath F. Association of Anesthesia and Surgery During Childhood With Long-term Academic Performance. JAMA Pediatr. 2016; Nov 7: [Epub ahead of print]. 13. Engelhardt T, Hansen TG, Weiss M. Re: Cognition and brain structure following early childhood surgery with anesthesia. Pediatrics. 2015 (e-letters). 14. Graham MR, Brownell M, Chateau DG, Dragan RD, Burchill C, Fransoo RR. Neurodevelopmental Assessment in Kindergarten in Children Exposed to General Anesthesia before the Age of 4 Years: A Retrospective Matched Cohort Study. Anesthesiology. 2016; 125: 667-7. 15. McCann ME, Schouten AN, Dobija N, Munoz C, Stephenson L, Poussaint T, Kalkman C, Hickey PR. de Vries L, Tasker R. Infantile postoperative encephalopathy: perioperative factors as a cause for concern. Pediatrics. 2014; 133: e751-7. 16. Arieff AI, Ayus, JC, Fraser CL. Hyponatremia and death or permanent brain damage in healthy children. BMJ. 1992; 304: 1218-22. 17. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX Jr, Litman RS, Kovatsis PG. Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med. 2016; 4: 37-48.