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Figure.  Prevalence and Trends in Surgical Intervention by Age
Prevalence and Trends in Surgical Intervention by Age

A, Sample weight-adjusted period prevalence of surgery by age. B, Adjusted odds ratio of surgery across time eras separated by age. Error bars indicate 95% CIs.

Table.  Multivariable Adjusted Odds and Absolute Period Prevalence of Surgical Intervention Stratified by Age Between 1998 and 2017a
Multivariable Adjusted Odds and Absolute Period Prevalence of Surgical Intervention Stratified by Age Between 1998 and 2017a
1.
Wilder  RT, Flick  RP, Sprung  J,  et al.  Early exposure to anesthesia and learning disabilities in a population-based birth cohort.  Anesthesiology. 2009;110(4):796-804. doi:10.1097/01.anes.0000344728.34332.5dPubMedGoogle ScholarCrossref
2.
US Federal and Drug Administration. 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. Published December 14, 2016. https://www.fda.gov/news-events/press-announcements/fda-statement-dr-janet-woodcock-director-fdas-center-drug-evaluation-and-research-new-safety. Accessed August 29, 2019.
3.
McCann  ME, de Graaff  JC, Dorris  L,  et al; GAS Consortium.  Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial.  Lancet. 2019;393(10172):664-677. doi:10.1016/S0140-6736(18)32485-1PubMedGoogle ScholarCrossref
4.
Bartels  DD, McCann  ME, Davidson  AJ, Polaner  DM, Whitlock  EL, Bateman  BT.  Estimating pediatric general anesthesia exposure: Quantifying duration and risk.  Paediatr Anaesth. 2018;28(6):520-527. doi:10.1111/pan.13391PubMedGoogle ScholarCrossref
5.
Centers for Disease Control and Prevention. National Health Interview Survey. https://www.cdc.gov/nchs/nhis/index.htm. Accessed September 3, 2019.
6.
IPUMS. National Health Interview Series (NHIS): version 6.3. https://ipums.org/projects/ipums-health-surveys/d070.v6.3. Accessed September 3, 2019.
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    Research Letter
    October 7, 2019

    Trends in Surgery for Children Younger Than 3 Years From 1998 to 2017

    Author Affiliations
    • 1UT Southwestern Medical Center, Dallas, Texas
    • 2Children’s Medical Center Dallas, Department of Anesthesiology and Pain Management, Dallas, Texas
    • 3Children’s Medical Center Dallas, Department of Pediatric Critical Care, Dallas, Texas
    • 4UT Southwestern Medical Center, Department of Radiation Oncology, Dallas, Texas
    • 5Children’s Medical Center, Dallas, Department of Pediatric Surgery, Dallas, Texas
    • 6Outcomes Research Consortium, Cleveland, Ohio
    JAMA Pediatr. 2019;173(12):1199-1201. doi:10.1001/jamapediatrics.2019.3372

    Preclinical data demonstrating neuroapoptosis in animals exposed to anesthetics and human data identifying an association between anesthesia and learning deficits1 led to the 2016 US Food and Drug Administration warning that repeated or lengthy anesthetic exposure in children younger than 3 years may affect brain development.2 Recent prospective studies demonstrate no harm from short anesthetic exposure in infants.3 Most anesthetic exposures in young children are under 2 hours.4 Despite these reassuring findings, concerns regarding neurocognitive impairment may lead parents and physicians to defer anesthetic exposure and, thus, surgery. Pediatric surgical epidemiology has been geographically limited without assessment of trends over time. We assessed trends in surgical exposure among children younger than 3 years using a comprehensive national database.

    Methods

    The National Health Interview Survey, an annual cross-sectional survey, collects health indicator data for noninstitutionalized US civilians.5 Harmonized National Health Interview Survey data from 1998 to 2017 were obtained through the Integrated Health Interview Series.6 Survey participants were asked, “During the past 12 months, has sample child had surgery or other surgical procedures either as an inpatient or outpatient?”6

    The University of Texas Southwestern institutional review board deemed the study exempt. The 12-month period prevalence of surgery, stratified by age, was calculated. Multivariable logistic regression defined the adjusted odds ratio (AOR) and 95% confidence intervals of undergoing surgery within 5-year eras. The model was adjusted for sex (male vs female), birth weight (<2500 g), trisomy 21 (yes vs no), congenital heart disease (yes vs no), race (white vs black, Asian American, Native American, multiple), Hispanic ethnicity (yes vs no), region (Northeast vs North Central/Midwest, South, Northwest), maternal education (no high school degree, high school, college, advanced/professional degree), insurance status (yes vs no), and health care visit in the preceding 12 months (yes vs no). Sample weighting stratified by year was used to limit year-to-year sampling variance. Analysis began in August 2018. Statistical analyses, performed with Stata/SE version 15.1 (StataCorp), was 2-sided with the significance threshold for P values set at .05.

    Results

    Among 41 938 children younger than 3 years with responses to the query about surgery, 2883 (6.9%) underwent surgical procedures in the prior 12 months. The weight-adjusted period prevalence for children younger than 3 years was 72 per 1000 and was highest among infants younger than 1 year (90 per 1000 children) (Figure, A).

    Compared with 1998 to 2002, more recent eras were associated with decreased odds of surgery, which was most significant for 2008 to 2012 (AOR, 0.87; 95% CI, 0.76-0.99) and 2013 to 2017 (AOR, 0.78; 95% CI, 0.68-0.91) (Table). Infants younger than 1 year accounted for the largest decrease in odds of surgery for 2008 to 2012 (AOR, 0.69; 95% CI, 0.55-0.86; P = .001) and 2013 to 2017 (AOR, 0.61; 95% CI, 0.49-0.78; P < .001) (Table and Figure, B). The weight-adjusted period prevalence of surgery for infants younger than 1 year declined in progressive eras (1998-2002: 108 per 1000 children; 2003-2007: 94 per 1000 children; 2008-2012: 81 per 1000 children; 2013-2017: 75 per 1000 children) (Table). Variables associated with decreased odds of surgery included black race (AOR, 0.68; 95% CI, 0.59-0.79; P < .001), Asian American race (AOR, 0.46; 95% CI, 0.35-0.61; P <  .001), Hispanic ethnicity (AOR, 0.56; 95% CI, 0.48-0.65; P < .001), no insurance (AOR, 0.61; 95% CI, 0.47-0.80; P < .001), and no health care visit (AOR, 0.65; 95% CI, 0.53-0.81; P < .001). Variables associated with increased odds of surgery included maternal education beyond high school (AOR, 1.25; 95% CI, 1.04-1.50; P = .02), North Central/Midwest region (AOR, 1.34; 95% CI, 1.14-1.58; P < 001), Southern region (AOR, 1.33; 95% CI, 1.14-1.55; P < .001), low birth weight (AOR, 1.59; 95% CI, 1.35-1.88; P < .001), trisomy 21 (AOR, 3.02; 95% CI, 1.58-8.65; P = .003), and congenital heart disease (AOR, 4.37; 95% CI, 2.37-8.06; P < .001).

    Discussion

    Using a large, nationally representative cross-sectional survey, we observed a decline in odds of surgery from 1998 to 2017 that was most significant in children younger than 1 year. We controlled for demographic variables and clinical factors expected to impact surgical exposure. While surgical techniques have continually evolved, we are unaware of drastic changes in surgical management for infants during this period. Our findings support the hypothesis that alternative factors including parental and practitioner concerns about anesthetic exposure may have affected surgical decision-making in infants. Interestingly, while maternal education may improve awareness of anesthesia risk, this was associated with increased odds of surgery. This study was limited by lack of data on procedure type, anesthetic details, associated outcomes, and inability to control for all confounders. We therefore recommend further prospective studies assessing these trends and associated health outcomes.

    Conclusions

    The period prevalence and adjusted odds of surgery declined significantly from 1997 through 2017 for children younger than 1 year. The clinical and nonclinical factors affecting the use of surgical intervention in infants merit further investigation.

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    Article Information

    Corresponding Author: Ethan L. Sanford, MD, UT Southwestern Medical Center, Pediatric Anesthesiology and Pediatric Critical Care, 1935 Medical District Dr, Dallas, TX 75235 (ethan.sanford@utsouthwestern.edu).

    Accepted for Publication: May 6, 2019.

    Published Online: October 7, 2019. doi:10.1001/jamapediatrics.2019.3372

    Author Contributions: Dr E. L. Sanford had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: E. L. Sanford, N. N. Sanford, Alder.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: E. L. Sanford, N. N. Sanford, Alder.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: E. L. Sanford, N. N. Sanford.

    Administrative, technical, or material support: E. L. Sanford, Alder.

    Supervision: N. N. Sanford, Alder, Szmuk.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Wilder  RT, Flick  RP, Sprung  J,  et al.  Early exposure to anesthesia and learning disabilities in a population-based birth cohort.  Anesthesiology. 2009;110(4):796-804. doi:10.1097/01.anes.0000344728.34332.5dPubMedGoogle ScholarCrossref
    2.
    US Federal and Drug Administration. 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. Published December 14, 2016. https://www.fda.gov/news-events/press-announcements/fda-statement-dr-janet-woodcock-director-fdas-center-drug-evaluation-and-research-new-safety. Accessed August 29, 2019.
    3.
    McCann  ME, de Graaff  JC, Dorris  L,  et al; GAS Consortium.  Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial.  Lancet. 2019;393(10172):664-677. doi:10.1016/S0140-6736(18)32485-1PubMedGoogle ScholarCrossref
    4.
    Bartels  DD, McCann  ME, Davidson  AJ, Polaner  DM, Whitlock  EL, Bateman  BT.  Estimating pediatric general anesthesia exposure: Quantifying duration and risk.  Paediatr Anaesth. 2018;28(6):520-527. doi:10.1111/pan.13391PubMedGoogle ScholarCrossref
    5.
    Centers for Disease Control and Prevention. National Health Interview Survey. https://www.cdc.gov/nchs/nhis/index.htm. Accessed September 3, 2019.
    6.
    IPUMS. National Health Interview Series (NHIS): version 6.3. https://ipums.org/projects/ipums-health-surveys/d070.v6.3. Accessed September 3, 2019.
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