To Sleep, Perchance, To Get Brain Damage?

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When I was in training, people would talk about “brutane” being their preferred agent for keep a child still during a procedure: hold them down by brute force. We didn’t have a lot of great options for sedation for relatively short procedures, so the choice might be knocking the child out for hours, or just getting it over with. We often went with the latter.

In hindsight, it sounds primitive and inhumane. (You are probably wondering if I studied with Hippocrates, and carried leeches around in my kit. No, and no.) But in the last 25 years, newer short-acting analgesic and sedative agents have been developed and approved. During that same time, there has been an increased understanding of the long-term effects of inadequately treated neonatal and early childhood pain, including changes in the brain’s structure and responsiveness and the immune response. Among pediatric specialists and subspecialists, use of analgesics and sedation for even minor procedures is now exceptionally common, and is in many cases an important quality differentiator.

OK, the sound you hear is that of the pendulum swinging back and getting ready to hit you in the head. In the past 5 years, there has been a growing body of literature demonstrating that the anesthetic and sedative agents we use to treat and prevent procedural pain in infants and children may themselves cause adverse effects in the developing brain. Most of the evidence comes from effects in baby animals, though there is some (albeit still incomplete) data on effects in humans as well. Some professional organizations and the FDA have begun to raise a red flag and suggest that at least some elective procedures should be deferred until after age 3.

There is evidence that pain is bad, and that preventing pain is bad. Now what? Do we go back to brutane? And more importantly, how can we help parents make sense of the options and make the best possible choice for their child.

First, this is a great illustration of the principle that children are not just small adults. Providers with the extra expertise that comes with subspecialty training are in the best position to understand the data and interpret it for families. The evidence for some agents being harmful is stronger than for others, and some have not been linked to these side effects. Pediatric subspecialists are also more likely to be familiar with and have access to the full range of alternatives. For example, sucrose solution (i.e., sugar water) has been shown to provide adequate analgesia and sedation for many minor procedures in infants, but is unlikely to have the kind of adverse effects seen with other agents. My anecdotal experience is that non-pediatric physicians are not as familiar with this option. Non-pharmacologic measures, including swaddling, or distraction and other techniques provided by child life specialists, may also be effective for babies and young children.

While the experts try to sort out the data, I may think twice before automatically giving a strong sedative. I’ll think carefully about the alternatives. And I’ll certainly try to keep up on the literature and emerging guidelines.   But I don’t want to go back to the brutane era. I still have images of children struggling mightily to break free of the 2 or 3 large adults holding them down while I tried to put stitches in or remove a bead from the ear; I have to imagine those kids have even worse memories of it than I do. They deserve better than that. They deserve the best.



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