Pediatricians should play a central, proactive role in preparing children and adolescents for anesthesia and surgery, according to a new clinical report from the American Academy of Pediatrics (AAP).
In the revised report, experts from the AAP Section on Anesthesiology and Pain Medicine and the Committee on Practice and Ambulatory Medicine outline how primary care clinicians can optimize medical readiness, address psychosocial needs, and coordinate perioperative care for these patients.
With nearly 4 million pediatric operative procedures performed annually in the United States, children frequently present with complex comorbidities or developmental considerations that can influence perioperative risk. The study authors emphasize that the pediatrician’s role is not simply to “clear” a child for surgery, but to “help optimize the patient’s health prior to undergoing anesthesia/surgery and confirm that there are no contraindications to the planned procedures at the time.”
The report underscores the importance of a detailed preoperative history and physical examination. Information that may be particularly relevant to anesthesiologists includes prior anesthesia complications, difficult airway history, malignant hyperthermia, obstructive sleep apnea (OSA), prematurity, congenital heart disease, seizure disorders, and medication use — information to which pediatricians often have longitudinal access.
Recent respiratory infections also warrant special attention. Upper respiratory tract infections can increase the risk of perioperative laryngospasm, bronchospasm, and oxygen desaturation, and elective procedures may require postponement. Similarly, children with asthma should continue controller medications through the day of surgery, and poorly controlled disease may necessitate rescheduling.
For children with obstructive sleep apnea, severity and comorbidities help determine perioperative planning. The report notes that children younger than three years with OSA, or those with severe OSA, may require postoperative inpatient monitoring. In certain contexts — such as tonsillectomy — children with OSA who are under three years old or who have high-risk conditions including Down syndrome, neuromuscular disorders, or sickle cell disease may not be candidates for freestanding ambulatory surgery centers and should instead be admitted for postoperative observation.
Similarly, chronic conditions — including diabetes, renal insufficiency, sickle cell disease, obesity, neurologic disorders, and congenital heart disease — require tailored coordination with subspecialists to minimize perioperative complications.
Beyond medical optimization, the authors highlight the pediatrician’s unique position in addressing developmental and emotional readiness. Separation anxiety, fear of bodily harm, and difficulty understanding procedures vary by age and neurodevelopmental status. Children with neurodevelopmental disorders such as autism spectrum disorder or ADHD may benefit from modified workflows, early child life involvement, or premedication to reduce distress. Adolescents, meanwhile, should be engaged in age-appropriate discussions and encouraged to provide assent when possible, even when legal consent is provided by a parent or guardian.
The perioperative period also provides an opportunity to address substance use in adolescents. The report notes that vaping, nicotine use, cannabis exposure, and other substance use are common among adolescents and can increase anesthetic risk and complicate recovery. It also highlights a sharp rise in opioid-related overdose deaths among youth in recent years, underscoring the importance of screening and counseling as part of perioperative care.
The guidance provides practical recommendations for perioperative medication management. Antiepileptic drugs, asthma controllers, most psychiatric and ADHD medications, and many cardiac medications should typically be continued on the day of surgery. Certain agents — such as angiotensin-converting enzyme inhibitors, GLP-1 receptor agonists, and metformin — may require temporary adjustment depending on the clinical context.
The report also addresses special contexts, including anesthesia for imaging studies and dental procedures. Children receiving deep sedation for MRI should follow the same preoperative evaluation standards as those undergoing surgery. For office-based dental anesthesia, the AAP and the American Academy of Pediatric Dentistry recommend that at least two individuals certified in Pediatric Advanced Life Support be present when deep sedation or general anesthesia is administered, with one individual responsible for administering medications and monitoring the patient.
Finally, the authors discuss broader issues such as anesthesia exposure in children younger than three years. While repeated or prolonged exposures have raised concerns — prompting the FDA to issue a warning in December 2016 — current evidence suggests that a single, brief anesthetic is unlikely to result in significant neurodevelopmental harm. However, the authors emphasize that balancing the risks and benefits of anesthesia remains especially important in younger children.
In summary, the AAP report positions pediatricians as essential partners in perioperative safety. Through comprehensive evaluation, anticipatory guidance, and close communication with anesthesia teams, pediatricians can help reduce complications, minimize delays, and support a smoother, less stressful experience for children and their families.
Source: American Academy of Pediatrics