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Introduction

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Dating back to ancient Egypt of 2500 bc, regional anesthesia was emphasized for circumcision. Traditional Chinese medicine has touted the use of needles and acupuncture for pain management for centuries. August Bier reported in 1899 the first study on regional anesthesia in children. This was followed by a report by Bainbridge on the use of spinal anesthesia in children.1 The use of caudal analgesia in children was described in the urology literature in the early 1930s.2 In the past two decades, numerous studies have demonstrated the need for analgesia in newborn children and infants.3 This has resulted in significant changes and advances in clinical anesthesia care for infants, children, and adolescents. In particular, the decrease in stress has resulted in better outcomes in infants and children. Infants exposed to significant pain in the neonatal period may experience biobehavioral changes with advancing age.4 This and other related research have led the medical community to improve analgesia in infants. Although research in regional anesthesia in adults continues to be performed and is written about prolifically in literature, there seems to be a relative lack of publications in regional anesthesia in children. Most work in regional anesthesia has been carried out by a few researchers with a firm commitment to the use of regional techniques in children. Although the usual dictum that children are just small adults may apply to regional analgesia in the adolescent population, it is much less applicable to infants and toddlers. The goal of this chapter is to provide general principles of practice of regional anesthesia in children.

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Anatomic Differences between Children & Adults

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Significant anatomic variations exist between infants and older adolescents and adults. Differences in anatomy between children and adults are described in greater detail elsewhere in this chapter. CT-guided mechanisms and the use of other imaging techniques including ultrasound have led to a better understanding of the anatomy of infants and children.5 This has facilitated a more accurate placement of needles in children with less risk of complications. The epidural space is superficial compared with that in adults, and this requires greater skill and care while placing a needle.6 Numerous formulas are available for estimating the distance of the epidural space from the skin.6 However, this should not alter the judgment of the skilled anesthesiologist placing a needle in the spinal or epidural space.

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Assessment & Consent

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Parents typically provide consent for a procedure for their child. However, if the child has the cognitive ability to discern right from wrong, it is suggested that the child's consent for performance of a regional technique be obtained as well.7 There is growing debate as to when or what this age may be. We routinely obtain consent for children over the age of 12 years. If a child refuses to have a regional procedure despite the parents' insistence, ...

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