Pediatric Anesthesia at a Crossroads: Access, Guidelines, and Measuring What Matters

Flora Liu, MD

The session, “Challenges in Pediatric Anesthesia,” co‑sponsored by the World Federation of Societies of Anesthesiologists (WFSA) and held on Saturday, May 2, 2026 of the 2026 Annual Meeting, presented by IARS and SOCCA, examined how pediatric anesthetic care can remain safe, equitable, and evidence based in the face of global workforce shortages. Faye Evans, MD, senior associate in perioperative anesthesia in the Department of Anesthesiology, Critical Care & Pain Medicine at Boston Children’s Hospital, associate professor in anaesthesia at Harvard Medical School, and current director of Programmes for the WFSA, moderated an insightful conversation on this timely and crucial topic. The discussion addressed the tension between specialization and access, the limits of guidelines, and the role of risk scores in improving outcomes for children worldwide.

Dr. Evans opened the session with “Pediatric Anesthesia Fellowships: Advancing Quality or Limiting Access?,” highlighting a worldwide shortage of pediatric anesthesiologists. Not only a challenge in the United States, there is also a shortage of anesthesia providers in low‑ and middle‑income countries, particularly in Africa and Southeast Asia. In these regions, 76 countries fall below the WFSA recommended minimum anesthesia provider density of 5 per 100,000 population. Regions with the greatest shortages experience three to four times higher postoperative complication rates and up to eleven times higher in‑hospital mortality. Children present late in their disease course, compounded by infrastructural limitations: unreliable electricity in 22% of facilities and limited oxygen access in nearly 20%. No amount of subspecialty training can outrun the lack of oxygen.

Pediatric anesthesia fellowships should be viewed not simply as subspecialty pipelines but as system‑building tools—creating durable care models, driving quality improvement, training generalists, and developing local leadership. The WFSA‑affiliated Paediatric Anaesthesia Training in Africa (PATA) program was founded in 2020 and is led by African pediatric anesthesiologists. With fellowship sites across Kenya, Uganda, Nigeria, Zambia, Ethiopia, and Ghana, PATA has trained 32 pediatric anesthesiologists between 2022-2025, achieving nearly 100% retention. The program is projected to directly benefit more than 1.2 million children. The goal is not that every child be anesthetized by a fellowship‑trained specialist, but that every child receive care from someone trained well enough to bring them safely home.

Next, the importance and limitations of clinical guidance were addressed by Thomas Engelhardt, MD, Queen Elizabeth Hospital of Montreal Foundation chair of paediatric anaesthesia and anaesthetist-in-chief, Montreal Children’s Hospital, in “Challenges in Implementing Guidelines in Pediatric Anesthesia.” Guidelines are most useful in time‑critical emergencies, rare clinical situations, and unfamiliar or cross‑disciplinary scenarios. Dr. Engelhardt shared that despite more than 250,000 clinical practice guidelines published since 1947, the average adherence across specialties hovers around 40%, and fewer than half are routinely implemented. The challenges in guideline development and adherence may include variable quality, insufficient evidence, stakeholder omission, conflicts of interest, and poor applicability. When evaluated using the AGREE II instrument, only 5% of published guidelines met high‑quality criteria.

Pediatric fasting guidelines served as a landmark example. A more liberalized approach allowing clear fluids up to one hour before anesthesia has demonstrated no increase in adverse respiratory events and has been endorsed by multiple global societies noting international discordance remains despite strong evidence. Dr. Engelhardt emphasized that implementation must be considered throughout guideline development, ideally with input from implementation scientists, transparent processes, and broad stakeholder engagement. Resources recommended include: Guidelines for Guidelines and implementation using GUIDE-M.

The session concluded with Walid Habre, MD, PhD, senior associate in pediatric anesthesia in the Department of Anesthesiology, Critical Care and Pain Medicine at Boston Children’s Hospital, who presented “Scores in Pediatric Anesthesia: Which Ones to Use and How to Integrate into Clinical Practice.” Dr. Habre reviewed how risk scores can help predict perioperative adverse events and guide decision-making. Importantly, he distinguished between scores that measure only incidence or severity (such as pain or emergence delirium scales) and those that estimate risk and inform management.

Useful, actionable scores that have been externally validated, such as STBUR, PONV, PRAm, and the ASA Physical Status adapted for children, should be embedded systematically into the electronic medical record. While no existing score has complete external validation, these tools remain valuable when used alongside clinical assessment. Looking ahead, Dr. Habre suggested that artificial intelligence and machine‑learning approaches may further enhance pediatric risk stratification by integrating scores into decision‑support algorithms.

Speakers addressed recent reports of severe neurologic complications following general anesthesia in previously healthy patients of Venezuelan ancestry who carry a maternally inherited MT‑ND4 mitochondrial variant affecting complex I. Check the ASA guidance for up-to-date guidance including ancestry screening, consideration of genetic consultation, avoidance of volatile anesthetics, use of regional techniques or total intravenous anesthesia, processed EEG monitoring to avoid burst suppression, extended postoperative neurologic and acid–base monitoring, and reporting suspected cases to the Anesthesia Incident Reporting System.