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In 1990, a British Epidemiologist, David Barker proposed the hypothesis that low birth weight infants with intrauterine growth retardation developed pathophysiological changes that were associated with an increased risk of developing diseases such as coronary heart disease, hypertension, and type 2 diabetes in middle age. The ‘Barker Hypothesis’ is now well accepted, and there is now a better mechanistic understanding of how early events in early development can have far reaching consequences that are not always evident until later in life [1]. This concept that early events may have profound long-term consequences has been embraced by neonatologists who have for many years undertaken long-term outcome studies in an attempt to determine how to optimize management of the very preterm infant. Data from these studies have demonstrated a steady improvement not only in mortality but morbidity which can in part be ascribed to ‘fine tuning’ in management of these fragile neonates and is described by Neil Marlow in this special edition of Pediatric anesthesia [2].

Early pioneers of anesthesia concentrated on the fundamental understanding of physical principles of equipment, drugs, and physiology to allow surgery to take place with a relative degree of safety. Later came the recognition that anesthesia required more than a ‘one size fits all’ approach and the need for subspecializations that included pediatrics. This has developed further into an integrated speciality that can deliver successful acute outcomes for complex conditions in the neonate that were inconceivable until quite recently [3].

While headline survival for sick or very low birth weight neonates has become excellent, it is time to examine what happens beyond the simple horizons of the operating room. The consequences of our pediatric management of the fragile child in the operating room may not be immediately obvious and can be easily lost in wider pediatric management. The preterm infant undergoing ligation of a patent ductus arteriosus is expected to survive this ‘simple procedure’ but the consequences long after the surgical and anesthetic teams have left may be significant [4]. Studies in neonatal anesthesia continue to focus on drugs, equipment, and techniques that look at short-term outcomes. While this remains important particularly where resources are limited [5], we need to evaluate the more subtle longer term outcomes that have reference to our anesthetic practice. The current highly successful study comparing general anesthesia to awake regional anesthesia in preterm infants (the GAS collaboration) is a good example of where we should be heading in learning how we can optimize long-term outcomes in neonates.

There is so much to do in this area. Neonatal organs particularly the brain and lungs have long-term vulnerabilities to even brief periods of exposure outside tightly controlled physiological limits and blood pressure variation may be poorly tolerated by organ beds that have limited autoregulation. As a specialized group, we still have divergent and nonevidence-based opinions on what constitutes hypotension [6] and indeed, current devices that measurement of blood pressure noninvasively may not be reliable [7].

This special edition on the neonate is divided into three sections. The first part examines the scientific basis of vulnerabilities of the neonate with particular interest in areas where our interactions may have greatest impact: organ perfusion, ventilation, pain management, and fluid therapy. In the second section, key clinical areas of concern are reviewed, with individual opinions on how to deal with the challenge. The procon debate in the last section then pulls the theory and clinical opinion into the practical issue of where to best anesthetize the very low birth weight infant. While the arguments are strong on both sides, it is my opinion that neither has yet been optimized. Pediatric anesthetic teams need to get away from simply using and coping with what is available and deliver perioperative care with the same physiological control that is now increasingly being demanded in the NICU.

Conflict of interest

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No conflicts of interest declared.

References

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  2. Conflict of interest
  3. References