Regional Anesthesia for Infants and Children

  • Chris Johnson
  • Chris Gibson


Regional anesthesia in children differs in many respects from adults. Most pediatric regional blocks are placed after induction of anesthesia to provide post-operative analgesia. Complications associated with this approach are very low as shown by several large prospective surveys. Local anesthetic spread is generally more reliable than in adults, but higher volumes in relation to body weight are usually required for neuraxial single shot blocks and infusions. Single shot blocks and wound infiltration are commonly used to minimize opiate use in day case surgery and to reduce the distress frequently seen when small children emerge from anesthesia with inadequate analgesia. The pharmacokinetics of local anesthetic agents are different in neonates and young children compared with adults. There is a high risk of toxicity in neonates and infants because of reduced protein binding and metabolism. Local anesthetic additives are not as well studied and less frequently used in children compared with adults. Clonidine however, is frequently added during caudal block to prolong duration and provide sedation. Sedation is sometimes an important addition to regional techniques, because good analgesia alone does not guarantee lack of distress, particularly in pre-school children who may be distressed by their environment, restriction of movement or effects of surgery or equipment.


Local anesthetic pharmacology in children Pediatric epidural Caudal block Sacral hiatus Dorsal nerve block 

Further Reading

  1. Davidson A, et al. Apnea after awake regional and general anesthesia in infants. The general anesthesia compared to spinal anesthesia study—comparing apnea and neurodevelopmental outcomes, a RCT. Anesthesiology. 2015;123:38–54.CrossRefGoogle Scholar
  2. Frawley G, Ingelmo P. Spinal anaesthesia in the neonate. Best Pract Res Clin Anaesthesiol. 2010;24:337–51. A detailed description of anatomy and technique of spinal anesthesia from the Royal Children’s Hospital in Melbourne.CrossRefGoogle Scholar
  3. Ingelmo P, et al. The optimum initial pediatric epidural bolus: a comparison of four local anesthetic solutions. Pediatr Anesth. 2007;17:1166–75.CrossRefGoogle Scholar
  4. Ivani G, Mossetti V. Continuous central and perineural infusions for postoperative pain control in children. Curr Opin Anesthesiol. 2010;23:637–42.CrossRefGoogle Scholar
  5. Johr M. Regional anesthesia in neonates, infants and children. An educational review. Eur J Anesthesiol. 2015;32:1–9.CrossRefGoogle Scholar
  6. Wiegele M et al. Caudal epidural blocks in paediatric patients. BJA. 2019;122:509–17.Google Scholar
  7. Lees D, et al. A review of the surface and internal anatomy of the caudal canal in children. Pediatr Anesth. 2014;24:799–805.CrossRefGoogle Scholar
  8. Llewellyn N, Moriarty A. The national pediatric epidural audit. Pediatr Anesth. 2007;17:520–33.CrossRefGoogle Scholar
  9. Lonnqvist PA. Adjuncts should always be used in pediatric regional anesthesia. Pediatr Anesth. 2015;25:100–6.CrossRefGoogle Scholar
  10. Lundbald M, Lonnqvist P. Adjunct analgesic drugs to local anesthetics for neuraxial blocks in children. Curr Opin Anesthesiol. 2016;29:626–31.CrossRefGoogle Scholar
  11. Marhofer P. Regional blocks carried out during general anesthesia: myths and facts. Curr Opin Anesthesiol. 2017;30:621–6. A review article showing in adults and children, blocks performed under anesthesia are as safe or safer than awake.CrossRefGoogle Scholar
  12. Mossetti B, Ivani G. Controversial issues in pediatric regional anesthesia. Pediatr Anesth. 2012;22:109–14. Discussion of test doses.CrossRefGoogle Scholar
  13. Rochette A, et al. Cerebrospinal fluid volume in neonates undergoing spinal anaesthesia: a descriptive magnetic resonance imaging study. Br J Anaesth. 2016;117:214–9.CrossRefGoogle Scholar
  14. Sandeman DJ, et al. Ultrasound guided dorsal penile nerve block in children. Anesth Intens Care. 2007;35:266–9.CrossRefGoogle Scholar
  15. Suresh S, Sawardekar A, Shah R. Ultrasound for regional anesthesia in children. Anesthesiol Clin. 2014;32:263–9.CrossRefGoogle Scholar
  16. Teunkens A, Van de Velde M, et al. Dorsal penile nerve block for circumcision in pediatric patients: a prospective, observer-blinded, randomized controlled clinical trial for the comparison of ultrasound-guided vs landmark technique. Pediatr Anesth. 2018;28:703–9.CrossRefGoogle Scholar
  17. Tsui BCH, Suresh S. Ultrasound Imaging for regional anesthesia in infants, children and adolescents. Anesthesiology. 2010;112:473–92 and 719–28.CrossRefGoogle Scholar
  18. Walker BJ, et al. Complications in pediatric regional anesthesia; an analysis of more than 100,000 blocks from the pediatric regional anesthesia network. Anesthesiology. 2018;129:721–32. A large prospective study from the multicenter PRAN group.CrossRefGoogle Scholar
  19. Visoiu M. Paediatric regional anaesthesia: a current perspective. Curr Opin Anesthesiol. 2015;28:577–82.CrossRefGoogle Scholar
  20. Willschke H, et al. Current trends in paediatric regional anaesthesia. Anaesthesia. 2010;65(Suppl 1):97–104.CrossRefGoogle Scholar
  21. Zywicke HA, Rozzelle CJ. Sacral dimples. Pediatr Rev. 2011;32:109–13.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Chris Johnson
    • 1
  • Chris Gibson
    • 2
  1. 1.Formerly Department of Anaesthesia and Pain ManagementPrincess Margaret Hospital for ChildrenSubiacoAustralia
  2. 2.Department of Anaesthesia and Pain ManagementPerth Children’s HospitalNedlandsAustralia

Personalised recommendations