What are the effects of sedation and anesthesia in children?

The long-term effects of repeated sedation in children cover three main domains: neurocognitive development, behavioral changes and psychological sensitization. The key finding of current data: a single short sedation or anesthetic does not cause significant neurocognitive impairment. ^[1]

Risk modifiers

• Age — vulnerability is greatest during the period of active synaptogenesis (under 3 years). The AAP (2026) recommends considering postponing elective procedures until an older age when clinically acceptable ^[1]
• Number of exposures — a dose-dependent effect — multiple exposures are associated with a higher risk than a single one ^[5][8]
• Duration — animal models show that exposure of 3 hours or more, or 3 or more repeated sessions, causes a considerably greater neurotoxic effect than a single short exposure ^[9]
• Intraoperative hypotension — may be an additional factor that worsens neurocognitive outcomes in children with multiple exposures (a causal link has not been proven) ^[10]

The study by Silber et al. (Anesthesiology, 2024, n=134,388 appendectomies versus 154,887 hospitalizations without anesthesia), a “natural experiment”, showed that children hospitalized without anesthesia (pneumonia, cellulitis, gastroenteritis) had a higher risk of later neurobehavioral diagnoses than children after appendectomy under anesthesia. This suggests that the observed associations between anesthesia and neurobehavioral problems are not specific to anesthesia and may reflect the effect of the illness itself, hospitalization and stress. ^[22]

Practical recommendations

The AAP guideline (2026) and the consensus of professional societies recommend: [1-2]

• A single short sedation or anesthetic is not a reason to refuse a medically necessary procedure at any age
• If multiple exposures are needed in children under 3, consider combining procedures under one anesthetic whenever possible
• For elective procedures, consider postponing until after the age of 3 if clinically acceptable
• Prefer dexmedetomidine to benzodiazepines for prolonged sedation, especially in children under 1 year ^[11]
• Minimize intraoperative hypotension — keep mean arterial pressure above age-specific minimums ^[10]
• Use non-pharmacological methods (VR, child life, preparation) to reduce pre-operative anxiety and the risk of emergence delirium ^[15][18]
• Inform parents about transient behavioral changes (sleep disturbances, separation anxiety) — in most cases they resolve within 2–4 weeks ^[17]