Children undergoing anaesthesia: what are the rights of the child?

2.1 Right to enjoy the highest attainable standard of health

Children are not just small adults. They are different in respect to anatomy, physiology, and neurocognitive behavior. Hence this mandates special knowledge and a different approach to a child compared to the adult patient. The “APRICOT” study on adverse events in pediatric anesthesia found a higher incidence of airway and cardiovascular events when pediatric anesthesia was undertaken by less experienced staff [4]. A fact that has long been recognized in the pediatric anesthesia community, and hence there have long been strong arguments recommending special education and experience, especially in the undertaking of neonatal and infant anesthesia [5]. More European countries today offer fellowships in pediatric anesthesia of 1-2 years duration. An example hereof is the Scandinavian Society of Anesthesia and Intensive Care (SSAI) 2 years fellowship, consisting of clinical, academic courses and an abroad exchange program [6]. SAFETOTS recommend that anesthesia for children less than 3 years, ASA (American Society of Anesthesiologist) physical status class 3 or above, or anesthesia for major surgery is undertaken by an anesthesiologist with special training and that pediatric anesthesia is only carried out in dedicated children’s hospitals or larger hospital with pediatric wards.

The Royal College of Anesthetists (RCoA) have in their latest edition on “Guidelines for the provision of pediatric anesthetic services 2020” a detailed description of the competencies required and the facilities needed for conducting safe pediatric anesthesia and is an example of how a national scientific society makes recommendations in line with the recommendations above [7].

In the future, we will hopefully see more educational programs in pediatric anesthesia around the globe, including developing countries as a means of reducing perioperative child mortality and morbidity [8].

2.2 Rights to non-discrimination

Children have the right not to be discriminated against on basis of race, religion, sex, ability, whatever they think or say, or whatever family they come from. Healthcare workers should not be influenced by differences of the above standing. Cultural differences, language problems, and religious beliefs can undoubtedly pose a challenge to the clinician in his/her approach to the patients. A recent survey from the U.S. showed that children of African American ethnicity were 3.5 times more likely to die 30 days after surgery, 18% relative greater odds of developing postoperative complications, and 7% relative greater odds of developing serious adverse events compared to white Americans [9]. The apparent racial disparity could not be explained by differences in preoperative physical status, and although the authors do not conclude that racial discrimination is a direct cause, one can speculate about how low social status, different educational level, and religious belief as contributing factors in how healthcare workers interact in the caring of this group of patients. Other studies have likewise shown racial disparities in the outcome between patients of a different races [10].

It is therefore important that clinicians prepare for these probable challenges beforehand. Knowledge of cultures, religions, and regional habits, together with the help from persons with resources and knowledge could help the clinician.

2.3 Right to be protected from economic exploitation

Anesthesia for children shouldalways be of “the highestattainable standard” and hospitalsand/or private practices should notspeculate economically, for instance,by saving money on staff,equipment and/or physical facilitiesthat may result in a lowerstandard of care as generallyaccepted. A French survey hasshown that, although practices ingeneral are homogenous, anesthesiologistin private practices were lesslikely to insert an intravenousline during general anesthesia andless likely to use anairway device during adenoidectomy[11]. A highly educated staff,special equipment and interiordesign of a clinic can becostly for smaller privatepractices. This should, however, notprompt a lower standard, butrather letting a more suitableclinic do pediatric cases.

2.4 Right to be protected from unnecessary and investigations and treatment

There should always be a purpose for investigation and treatment, and it should always be in the best interest of the child. Unnecessary surgical procedures that risk leaving the child permanently disabled should always be carefully considered and at best discussed in multidisciplinary teams. Radiological procedures that risk exposure to radiation should be outweighed in favor of less risky procedures that could yield the same information. Surgical procedures where anesthesia bears a high degree of risk (neonates, critically ill, cardiac patients) should always be carefully considered in terms of outcome, timing, and competencies. Just as well as clinicians need to contemplate the necessity of specific procedures and outweigh the risk, they should avoid pressure from parents/guardians demanding various procedures, which from a professional viewpoint is not indicated or bears a higher risk than the possible outcome.

2.5 Right to avoid pain, fear, and stress

A cornerstone of pediatric anesthesia is the treatment of pain, fear, and stress and seems so inherent in the competencies of the pediatric anesthesiologist. However, pain and fear are often inadequately treated. Assessing pain, fear, and stress in children can be challenging for the anesthesiologist and requires pain management tools that are age-specific and postoperative care facilities staffed with nurses educated in pediatric pain management. Preoperative fear in children undergoing anesthesia is a common problem and is sometimes impossible to avoid. However, there are various methods to reduce anxiety and stress preoperatively. Among these tools are a variety of pharmacological and non-pharmacological approaches [12, 13]. Restraining children physically should as such be avoided, although the ambiguity of clinicians’ perception of the term exists [14].

2.6 Right to have their parents with them

Children should be allowed tobe accompanied by a parent/parentsin the operating room (OR).Although studies are conflicting, in regard to reducing anxiety of the child, the satisfaction of parents and of doctors after implementation of parents in the OR are of great significance [15, 16, 17]. Separating the child from its parents before induction of anesthesia can be of great stress to both parties and should be avoided, although the stress of induction of anesthesia may not be altered. We believe that parental presence is of great significance not only for the child, but also the parents and should always be allowed. Besides reducing the stress of separation, it could also build trust between parents and the anesthesia team, when the parents themselves can witness that their child are cared for with respect and competence. Concerns that parental presence should increase OR times is ungrounded [18].

2.7 Right to privacy

The privacy of the child should be respected during, under, and after surgery/anesthesia. A child should not be unnecessarily exposed during surgery/examination.

2.8 Right to be informed

Children and their parents have the right to be informed about their condition and their treatment. The information should be age-appropriate and in a language they understand. Information should not be damaging. There are many levels where information can be provided to the child. This can either be conveyed orally at the preoperative evaluation or in written form, or both. Video material or comic book are other measures to provide the child and parents information about the upcoming procedure [19].

Besides of giving information about procedures, information also serves to reduce unnecessary anxiety and to explain things that are common and normal to the anesthesiology staff, but uncommon/unknown to the child and its parents. The information also serves as the basis for the parent/guardian to give his/her informed consent on behalf of the child.

2.9 Right to be heard

Just as children have the right to be informed about anesthetic procedures, they also have the right to speak out their opinion. That could be a child having an opinion on induction either with inhalation or intravenously. No matter the child’s opinion can be fulfilled or not he/she has the right to be heard and respected. An example could be a child having an opinion on how induction of anesthesia should be. Should it be inhalational induction or intravenous? The child might only base his/her preference on an emotional conception but have an opinion. Children who have tried it several times might be clearer about what he/she wants. The anesthesiologist should be open-minded towards the opinions of the child but should also be wary of promising things he/she cannot keep.

2.10 Right to be cared for together with children who have the same developmental needs

Children have the right to be cared for in an environment together with children of the same developmental level. For instance, neonates are cared in a neonatal care unit, adolescents in another, and so forth. Surgical units organized for children and not mixed with adult surgical patients. Recovery rooms must be furnished in a child-friendly manner and a child should not be placed together with adult patients. Being in an environment with children of the same age and development stage makes the child feel it is a part of a group that it can relate to. Parents have opportunity to talk with parents who also have a sick child and create a small community.