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Smith’s
Anesthesia for
Infants and Children
Volume1
Smith’s
Anesthesia for
Infants and Children

Tenth Edition
Peter J. Davis, MD
Professor
Department of Anesthesiology and Perioperative Medicine
Department of Pediatrics
Dr. Joseph H. Marcy Endowed Chair in Pediatric Anesthesia
University of Pittsburgh School of Medicine
Anesthesiologist-in-Chief
UPMC Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Franklyn P. Cladis, MD, FAAP

Professor
Department of Anesthesiology and Perioperative Medicine
UPMC Children’s Hospital of Pittsburgh
Pittsburgh, Pennsylvania
Elsevier
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SMITH’S ANESTHESIA FOR INFANTS AND CHILDREN, ISBN: 978-0-323-69825-2

TENTH EDITION

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DEDICATION
To our patients, who have allowed us the privilege of caring for them
and providing the opportunity of learning from them, and to our mentors, who
have shaped the way we care for patients and who have profoundly impacted the
specialty of pediatric anesthesiology.
CONTRIBUTORS
Phillip S. Adams, DO, FASA Benjamin B. Bruins, MD Ira Todd Cohen, MD, MEd, FAAP
Assistant Professor Assistant Professor Professor of Anesthesiology and Pediatrics
Department of Anesthesiology and Anesthesia and Critical Care Medicine Department of Anesthesiology and Pain
Perioperative Medicine Children’s Hospital of Philadelphia Medicine
Residency Program Director Philadelphia, PA Children’s National Medical Center
UPMC Children's Hospital of Pittsburgh Thomas M. Chalifoux, MD Ashley A. Colletti, MD
Pittsburgh, PA Assistant Professor Assistant Professor
Department of Anesthesiology and Department of Anesthesiology and Pain
Devon O. Aganga, MD Perioperative Medicine Medicine
Consultant University of Pittsburgh School of Medicine University of Washington
Department of Anesthesiology and UPMC Children's Hospital of Pittsburgh Seattle Children’s Hospital
Perioperative Medicine, Mayo Clinic UPMC Magee-Women's Hospital Seattle, WA
Assistant Professor in Anesthesiology Pittsburgh, PA
College of Medicine, Mayo Clinic Erin Conner, MD
Rochester, MN Mary Chapman Assistant Professor of Anesthesiology and
Pediatric Dentist Pediatrics
Sean S. Barnes, MD, MBA UPMC Children’s Hospital of Pittsburgh Oregon Health and Science University
Assistant Professor Pittsburgh, PA Portland, OR
Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Debnath Chatterjee, MD, FAAP Edward B. Cooper, MD
Medicine Associate Professor of Anesthesiology, Associate Professor
Baltimore, MD Children’s Hospital Colorado Departments of Anesthesiology and
Director of Fetal Anesthesia, Colorado Fetal Pediatrics
Bruno Bissonette, MD, FRCPC Care Center University of Cincinnati School of Medicine
Professor Emeritus of Anesthesia University of Colorado School of Medicine Cincinnati Children’s Hospital Medical
University of Toronto Aurora, CO Center
Founder and President Cincinnati, OH
Children of the World Anesthesia Rajeev Chaudhry, MD
Foundation Assistant Professor Joseph P. Cravero, MD
Rimouski, Quebec, Canada Department of Urology Anesthesiologist-in-Chief
University of Pittsburgh School of Medicine Boston Children’s Hospital
Brian Blasiole, MD, PhD UPMC Children’s Hospital of Pittsburgh Professor of Anaesthesia
Assistant Professor Pittsburgh, PA Harvard Medical School
Department of Anesthesiology and Boston, MA
Perioperative Medicine Sylvia Choi, MD, FAAP
University of Pittsburgh School of Medicine Associate Professor Jessica Cronin, MD, MBA
UPMC Children’s Hospital of Pittsburgh Department of Pediatrics Assistant Professor
Pittsburgh, PA University of Pittsburgh School of Medicine Division of Anesthesiology, Pain and
UPMC Children’s Hospital of Pittsburgh Perioperative Medicine
Adrian Bosenberg, MBChB FFA(SA) Pittsburgh, PA Children’s National Hospital
Professor Washington, DC
Department Anesthesiology and Pain Franklyn P. Cladis, MD
Management Professor Nicholas M. Dalesio, MD
University of Washington Department of Anesthesiology and Associate Professor
Pediatric Anesthesiologist Perioperative Medicine Anesthesiology and Critical Care Medicine
Seattle Children’s Hospital University of Pittsburgh School of Medicine Johns Hopkins School of Medicine
Seattle, WA UPMC Children's Hospital of Pittsburgh Baltimore, MD
Pittsburgh, PA
Claire M. Brett, MD, FAAP Jessica Davis, BA, JD, LLM
Emeritus Professor of Anesthesia and David E. Cohen, MD Troutman Pepper Hamilton Sanders, LLP
Perioperative Care and Pediatrics Associate Professor of Anesthesiology at Philadelphia, PA
Division of Pediatric Anesthesia The Children’s Hospital of Philadelphia
University of California Emeritus, Perelman School of Medicine
San Francisco, CA University of Pennsylvania
Anesthesiology and Critical Care Medicine
Children’s Hospital of Philadelphia
Philadelphia, PA
vi
CONTRIBUTORS vii
Peter J. Davis, MD Branden M. Engorn, MD Jessica A. George, MD, MEd

Professor Pediatric Anesthesiologist and Intensivist Assistant Professor
Department of Anesthesiology and Anesthesia Service Medical Group Medical Director for Pediatric Enhanced
Perioperative Medicine Rady Children’s Hospital San Diego Recovery After Surgery (ERAS) program
Dr. Joseph H. Marcy Endowed Chair in San Diego, CA Division of Pediatric Anesthesiology and
Pediatric Anesthesia Critical Care Medicine
University of Pittsburgh School of Medicine James J. Fehr, MD Johns Hopkins University School of
Anesthesiologist-in-chief Clinical Professor Medicine
UPMC Children’s Hospital of Pittsburgh Service Chief Anesthesia Baltimore, MD
Pittsburgh, PA Anesthesiology and Perioperative Pain
Stanford University School of Medicine Thierry Girard, MD
Karen A. Dean, MD Lucile Packard Children's Hospital Professor of Anesthesiology
Associate Professor of Anesthesiology, Palo Alto, CA Department of Anesthesiologie
Children’s Hospital Colorado University Hospital Basel
University of Colorado School of Medicine Jeffrey M. Feldman, MD, MSE University of Basel
Aurora, CO Attending Anesthesiologist Switzerland
Children’s Hospital of Philadelphia
Nina Deutsch, MD Professor of Clinical Anesthesiology Nancy L. Glass, MD, MBA, FAAP
Associate Professor Perelman School of Medicine Professor of Pediatrics and of Anesthesiology
Division of Anesthesiology, Pain and University of Pennsylvania Baylor College of Medicine and Texas
Perioperative Medicine Philadelphia, PA Children’s Hospital (Voluntary)
Children’s National Hospital Butterfly Team Physician, Houston Hospice
Washington, DC Marla B. Ferschl, MD Houston, TX
Professor of Anesthesia and Perioperative
James A. DiNardo, MD, FAAP Care Christine D. Greco, MD
Professor of Anaesthesia Division of Pediatric Anesthesia Section 2.01 Interim Chief, Division of Pain
Harvard Medical School University of California Medicine
Boston, MA San Francisco, CA Boston Children’s Hospital
Chief, Division of Cardiac Anesthesia Department of Anesthesiology, Critical Care
Francis X. McGowan Jr. MD Chair in Jonathan D. Finder, MD and Pain Medicine
Cardiac Anesthesia Director, Program for Technology Boston, MA
Boston Children’s Hospital Dependent Children
Boston, MA Professor, University of Tennessee Health Eliot Grigg, MD
Science Center Associate Professor
Laura A. Downey, MD Le Bonheur Children’s Hospital Department of Anesthesiology and Pain
Assistant Professor of Anesthesiology and Memphis, TN Medicine
Pediatrics University of Washington
Emory University School of Medicine Sean Flack, MBChB, DA, FCA Seattle Children’s Hospital
Children’s Healthcare of Atlanta Associate Professor, Anesthesiology and Pain Seattle, WA
Atlanta, GA Medicine
Director, Clinical Anesthesia Services Lorelei Grunwaldt, MD
John B. Eck, MD University of Washington Associate Professor of Plastic Surgery,
Associate Professor of Anesthesiology and Seattle Children’s Hospital Division of Pediatric Plastic Surgery
Pediatrics Seattle, WA Plastic Surgery
Duke University UPMC Children’s Hospital of Pittsburgh
Durham, NC Randall P. Flick, MD Pittsburgh, PA
Consultant
Peter Ehrlich, MD, MSC Department of Anesthesiology and Nina A. Guzzetta, MD, FAAP
Professor of Pediatric Surgery Perioperative Medicine, Mayo Clinic Professor of Anesthesiology and Pediatrics
Department of Surgery Assistant Professor in Anesthesiology Emory University School of Medicine
University of Michigan CS Mott Children’s College of Medicine, Mayo Clinic Children’s Healthcare of Atlanta
Hospital Rochester, MN Atlanta, GA
Ann Arbor, MI
Jeffrey L. Galinkin, MD Dawit T. Haile, MD
Demetrius Ellis, MD Anesthesiologist Consultant
Pediatrics US Anesthesia Partners Department of Anesthesiology and
University of Pittsburgh School of Medicine Greenwood Village, CO Perioperative Medicine, Mayo Clinic
UPMC Children's Hospital of Pittsburgh Assistant Professor in Anesthesiology
Pittsburgh, PA College of Medicine, Mayo Clinic
Rochester, MN
viii CONTRIBUTORS
Denise M. Hall-Burton, MD, FAAP Robert S. Holzman, MD, MA (Hon), FAAP Todd J. Kilbaugh
Assistant Professor Senior Associate in Perioperative Anesthesia Associate Professor of Anesthesiology,
Department of Anesthesiology and Boston Children’s Hospital Critical Care, and Pediatrics
Perioperative Medicine Professor of Anaesthesia Department of Anesthesiology and Critical
University of Pittsburgh School of Medicine Harvard Medical School Care Medicine
UPMC Children’s Hospital of Pittsburgh Department of Anesthesiology, Critical Perelman School of Medicine at the
Pittsburgh, PA Care and Pain Medicine University of Pennsylvania
Boston Children’s Hospital Children’s Hospital of Philadelphia
Gregory B. Hammer, MD Boston, MA Philadelphia, PA
Professor
Anesthesiology, Perioperative and Vincent C. Hsieh, MD, MS Anjali Koka, MD
Pain Medicine, and Pediatrics Associate Professor Department of Anesthesia
Stanford University School of Medicine Department of Anesthesiology and Pain Critical Care and Pain Medicine
Stanford, CA Medicine Boston Children’s Hospital
University of Washington Harvard Medical School
Jennifer L. Hamrick, MD Seattle Children’s Hospital Boston, MA
Senior Partner Seattle, WA
Anesthesia Service Medical Group Rahul Koka, MD, MPH
Pediatric Anesthesia Elizabeth A. Hunt, MPH, PhD, MD Section Chief, Pediatric General Anesthesia
Rady Children’s Hospital Drs. David S. and Marilyn M. Zamierowski Medical Director, Pediatric Operating
San Diego, CA Director Rooms
Johns Hopkins Medicine Simulation Center Assistant Professor
Justin T. Hamrick, MD Professor Anesthesia and Critical Care Medicine
Senior Partner Departments of Anesthesiology and Critical Johns Hopkins University School of
Anesthesia Service Medical Group Care Medicine, Pediatrics Medicine
Pediatric Anesthesia Health Informatics and Health Policy and Baltimore, MD
Pediatric Critical Care Medicine Management
Rady Children’s Hospital Johns Hopkins University School of Pete G. Kovatsis, MD, FAAP
San Diego, CA Medicine Senior Associate in Perioperative Anesthesia
Baltimore, MD Director of Anesthesia for Transplantation
Helen Harvey Co-Director, Anesthesia Advanced Airway
UCSD Pediatric Critical Care Fellowship James W. Ibinson, MD, PhD Management Service
Director Assistant Professor Department of Anesthesiology, Critical Care
Pediatric Critical Care Department of Anesthesiology and and Pain Medicine
University of California, San Diego, Rady Perioperative Medicine Boston Children’s Hospital
Children’s Hospital University of Pittsburgh School of Medicine Assistant Professor of Anaesthesia
San Diego, CA Chief of Anesthesiology Harvard Medical School
VA Pittsburgh Healthcare System Boston, MA
Andrew Herlich, DMD, MD, FAAP, FASA, Pittsburgh, PA
FAAOMS(H) Tatiana Kubacki, MD
Professor Emeritus Caleb Ing Assistant Professor
Department of Anesthesiology and Associate Professor Department of Anesthesiology
Perioperative Medicine Anesthesiology College of Physicians and Surgeons
University of Pittsburgh School of Medicine Columbia University Medical Center Columbia University
Clinical Professor, Department of Dental New York, NY New York, NY
Anesthesiology
University of Pittsburgh School of Dental Amanpreet Kalsi Barry D. Kussman, MBBCh, FFA (SA), FAAP
Medicine Clinical Assistant Professor Associate Professor of Anaesthesia
Pittsburgh, PA Division of Pediatric Anesthesiology Harvard Medical School
University of Michigan Boston, MA
Monica A. Hoagland, MD Ann Arbor, MI Senior Associate in Cardiac Anesthesia
Associate Professor of Anesthesiology, Boston Children’s Hospital
Children’s Hospital Colorado Evan Kharasch, MD, PhD Boston, MA
Associate Director of Obstetric and Fetal Merel H. Harmel Professor of Anesthesiology
Anesthesia, Colorado Fetal Care Center Vice-Chair for Innovation Kirk Lalwani, MD, FRCA, MCR, FASA
University of Colorado School of Medicine Department of Anesthesiology Professor of Anesthesiology and Pediatrics
Aurora, CO Duke University School of Medicine Vice Chair for Faculty Development
Durham, NC Department of Anesthesiology and
Perioperative Medicine
Oregon Health and Science University
Portland, OR
CONTRIBUTORS ix
Mary Landrigan-Ossar Ronald S. Litman, DO, ML* Lynn Martin, MD

Senior Associate in Perioperative Anesthesia Department of Anesthesiology and Critical Professor
Anesthesiology, Perioperative and Pain Medicine Care Department of Anesthesiology and Pain
Boston Children’s Hospital The Children’s Hospital of Philadelphia Medicine
Boston, MA Professor of Anesthesiology and Pediatrics University of Washington
Perelman School of Medicine at the Seattle Children’s Hospital
Robert Scott Lang, MD University of Pennsylvania Seattle, WA
Assistant Professor of Anesthesiology and Philadelphia, PA
Pediatrics, Director of Pain Management Francis X. McGowan Jr., MD, FAAP
Anesthesiology Justin L. Lockman, MD, MSEd, FAAP William J. Greeley Endowed Chair and Director,
Division of Surgical Anesthesiology, Associate Chair, Education Pediatric Anesthesiology Research
Department of Anesthesiology and Department of Anesthesiology and Critical Professor of Anesthesiology and Critical
Perioperative Medicine Care Medicine Care Medicine
A. I. duPont Hospital for Children/Sidney Children’s Hospital of Philadelphia Attending Cardiac Anesthesiologist
Kimmel Medical College at Thomas Associate Professor of Clinical Anesthesiology Children’s Hospital of Philadelphia
Jefferson University and Critical Care University of Pennsylvania Perelman School
Wilmington, DE Perelman School of Medicine of Medicine
University of Pennsylvania
Helen Victoria Lauro, MD, MPH, MSEd, Philadelphia, PA Gregory McHugh, MD
FAAP Clinical Assistant Professor
Clinical Associate Professor of Anesthesiology Joseph Losee, MD Department of Anesthesiology and
Department of Anesthesiology Ross H. Musgrave Professor of Pediatric Perioperative Medicine
State University of New York Downstate Plastic Surgery University of Pittsburgh School of Medicine
Health Sciences University Department of Plastic Surgery UPMC Children’s Hospital of Pittsburgh
Brooklyn, NY; University of Pittsburgh Medical Center Pittsburgh, PA
Site Director of Education Pittsburgh, PA
Department of Anesthesiology Carrie C. Menser, MD
State University of New York Downstate Igor Luginbuehl, MD Associate Professor of Anesthesiology
Health Sciences University Associate Professor Division of Pediatric Anesthesiology
University Hospital of Brooklyn Pediatric Anesthesiologist Monroe Carell Jr. Children’s Hospital at
Brooklyn, NY Department of Anesthesia and Pain Vanderbilt University Medical Center/
Medicine/Division of Cardiovascular Vanderbilt University School of Medicine
Elizabeth K. Laverriere, MD, MPH, FAAP Anesthesia Nashville, TN
Assistant Professor The Hospital for Sick Children
Department of Anesthesiology and Critical Toronto, Ontario, Canada Bruce E. Miller, MD
Care Medicine Associate Professor of Anesthesiology and
Children’s Hospital of Philadelphia Jennifer R. Marin, MD, MSc Pediatrics
Perelman School of Medicine at The Associate Professor of Pediatrics and Emory University School of Medicine
University of Pennsylvania Pediatric Emergency Medicine, Medical Children’s Healthcare of Atlanta
Philadelphia, PA Director Atlanta, GA
Point-of-Care Ultrasound
Susan Lei, MD UPMC Children’s Hospital of Pittsburgh Constance L. Monitto, MD
Assistant Professor and University of Pittsburgh School of Assistant Professor
Department of Anesthesiology Medicine Director, Pediatric Acute Pain Service
College of Physicians and Surgeons UPMC Children’s Hospital of Pittsburgh Division of Pediatric Anesthesiology and
Columbia University Pittsburgh, PA Critical Care Medicine
New York, NY Johns Hopkins University School of
Brian Martin, DMD, MHCDS Medicine
David Levin, MD, FRCPC, MSc, BESc (Mech) Vice President of Medical Affairs Baltimore, MD
Pediatric Anesthesiologist UPMC Children’s Hospital of Pittsburgh
Department of Anesthesia and Pain Medicine Clinical Assistant Professor Philip G. Morgan, MD
The Hospital for Sick Children (SickKids) University of Pittsburgh School of Dental Professor
Assistant Professor Medicine Anesthesiology and Pain Medicine
Department of Anesthesia Pittsburgh, PA University of Washington
The University of Toronto Seattle, WA
Toronto, Ontario Lizabeth Martin, MD
Assistant Professor Michael L. Moritz, MD
Richard Levy Department of Anesthesiology and Pain Professor
Professor Medicine Pediatrics
Anesthesiology University of Washington University of Pittsburgh Medical Center
Columbia University Medical Center Seattle Children’s Hospital UPMC Children’s Hospital of Pittsburgh
New York, NY Seattle, WA Pittsburgh, PA
x CONTRIBUTORS
Etsuro K. Motoyama, MD, FAAP Andrew Nowalk, MD, PhD Teeda Pinyavat, MD
Professor Emeritus Associate Professor and Clinical Director Assistant Professor of Anesthesiology
Anesthesiology and Pediatrics Division of Infectious Disease Department of Anesthesiology
University of Pittsburgh School of Medicine Department of Pediatrics Columbia University Medical Center
Pittsburgh, PA UPMC Children’s Hospital of Pittsburgh New York, NY
Advisory Dean
Rebecca Nause-Osthoff University of Pittsburgh School of Medicine George Demetrios Politis, MD, MPH
Clinical Assistant Professor Pediatric Residency Program Co-Director Associate Professor of Anesthesiology and
Division of Pediatric Anesthesiology Pediatric Scientist Development Program Pediatrics
University of Michigan (PedSDP) Co-Director University of Virginia Health System
Ann Arbor, MI UPMC Graduate Medical Education Charlottesville, VA
Pittsburgh, PA
Michael E. Nemergut, MD, PhD Andrew J. Powell, MD
Consultant Julie Nyquist, PhD Chief of the Division of Cardiac Imaging
Department of Anesthesiology and Director, Master of Academic Medicine Department of Cardiology
Perioperative Medicine, Mayo Clinic Program Boston Children’s Hospital
Assistant Professor in Anesthesiology Professor, Department of Medical Education Professor of Pediatrics
College of Medicine, Mayo Clinic Chair, 2021 Innovations in Medical Harvard Medical School
Rochester, MN Education Conference Boston, MA
Keck School of Medicine of the University of
Desiree Noel Wagner Neville, MD Southern California Alexander Praslick, MD
Assistant Professor of Pediatrics and Los Angeles, CA Clinical Assistant Professor
Pediatric Emergency Medicine Department of Anesthesiology and
Associate Director of Emergency Point-of- Shelley Ohliger, MD Perioperative Medicine
Care Ultrasound Assistant Professor University of Pittsburgh School of Medicine
UPMC Children’s Hospital of Pittsburgh Department of Anesthesiology UPMC Children's Hospital of Pittsburgh
and University of Pittsburgh School of Rainbow Babies and Children’s Hospital Pittsburgh, PA
Medicine Cleveland, OH
UPMC Children’s Hospital of Pittsburgh Srijaya K. Reddy, MD, MBA
Pittsburgh, PA Michale Sung-jin Ok, MD Associate Professor of Anesthesiology
Assistant Professor of Clinical Anesthesia Division of Pediatric Anesthesiology
Thanh Nguyen, MD and Pediatrics Monroe Carell Jr. Children’s Hospital at
Department of Anesthesiology University of Cincinnati College of Medicine Vanderbilt University Medical Center/
University of Colorado Anschutz Campus Cincinnati Children’s Hospital Medical Vanderbilt University School of Medicine
Children’s Hospital of Colorado Center Nashville, TN
Aurora, CO Cincinnati, OH
Paul Reynolds, MD, FAAP
Jonathan A. Niconchuk, MD Meghna D. Patel Professor
Assistant Professor of Anesthesiology Clinical Assistant Professor in Pediatric Chief of Pediatric Anesthesiology
Division of Pediatric Anesthesiology Cardiovascular ICU/Cardiology University of Michigan
Monroe Carell Jr. Children’s Hospital at Department of Pediatrics at Stanford Ann Arbor, MI
Vanderbilt University Medical Center/ University
Vanderbilt University School of Medicine Lucile Packard Children’s Hospital Karene Ricketts, MD
Nashville, TN Palo Alto, CA Associate Professor of Anesthesiology and
Pediatrics
Julie Niezgoda, MD James Peyton, MBChB MRCP FRCA Anesthesiology
Pediatric Anesthesiology Associate in Perioperative Anesthesia University of North Carolina
Cleveland Clinic Main Campus Department of Anesthesiology, Critical Care Chapel Hill, NC
Cleveland, OH and Pain Medicine
Boston Children’s Hospital Bobbie L. Riley, MD
Ken K. Nischal, MD, FAAP, FRCOphth Assistant Professor of Anaesthesia, Harvard Department of Anesthesia
Professor Medical School Critical Care and Pain Medicine
Department of Ophthalmology Boston, MA Boston Children's Hospital
University of Pittsburgh School of Medicine Harvard Medical School
Pediatric Ophthalmology Division Chief Phillip M.T. Pian, MD, PhD Boston, MA
UPMC Children’s Hospital of Pittsburgh Anesthesiologist
Pittsburgh, PA Anesthesiology Service
Veterans Affairs Eastern Colorado Health
Care System
Aurora, CO
CONTRIBUTORS xi
Mark A. Rockoff, MD Donald H. Shaffner, MD Deborah Studen-Pavlovich, DMD

Vice-Chairman Associate Professor Professor and Chair
Department of Anesthesiology, Perioperative Anesthesia and Critical Care Medicine Department of Pediatric Dentistry
and Pain Medicine Johns Hopkins University School of University of Pittsburgh School of Dental
Boston Children’s Hospital Medicine Medicine
Boston, MA Baltimore, MD Pittsburgh, PA
Thomas Romanelli, MD, FAAP Allan F. Simpao, MD, MBI Lena S. Sun, MD, FAAP, D.ABA
Assistant Professor of Anesthesiology Associate Professor of Anesthesiology and Emanuel M. Papper Professor of Pediatric
Division of Pediatric Anesthesiology Critical Care Anesthesiology
Monroe Carell Jr. Children’s Hospital at Children’s Hospital of Philadelphia Professor of Anesthesiology and Pediatrics
Vanderbilt University Medical Center/ University of Pennsylvania Perelman School Executive Vice Chairman, Department of
Vanderbilt University School of Medicine of Medicine Anesthesiology
Nashville, TN Philadelphia, PA Chief, Division of Pediatric Anesthesia
College of Physicians and Surgeons
Rachael S. Rzasa Lynn, MD Erica L. Sivak, MD Columbia University
Associate Professor Assistant Professor of Anesthesiology New York, NY
Department of Anesthesiology Department of Anesthesia and Pain Medicine
University of Colorado School of Medicine Nationwide Children’s Hospital Melissa Sutcliffe
University of Colorado Hospital Pain Columbus, OH Pediatric Neuropsychologist
Management Clinic Clinical Assistant Professor
Aurora, CO Sarah M. Smith, MD Division of Pediatric Rehabilitation
Assistant Professor Medicine
Nancy Bard Samol, MD Pediatric Cardiac Anesthesiology Children’s Hospital of Pittsburgh Inpatient
Associate Professor of Pediatric Center for Pediatric and Congenital Heart Rehabilitation Unit
Anesthesiology Disease Pittsburgh, PA
Cincinnati Children’s Hospital Medical Dell Children’s Medical Center
Center University of Texas at Austin Jonathan M. Tan, MD, MPH, MBI, FASA
Cincinnati, OH Austin, TX Assistant Professor of Anesthesiology and
Spatial Sciences
Paul J. Samuels, MD Jenna H. Sobey, MD Department of Anesthesiology Critical Care
Professor of Clinical Anesthesia and Pediatrics Assistant Professor of Anesthesiology Medicine
University of Cincinnati College of Medicine Division of Pediatric Anesthesiology Children’s Hospital Los Angeles
Cincinnati Children’s Hospital Medical Monroe Carell Jr. Children’s Hospital at Keck School of Medicine at the University of
Center Vanderbilt University Medical Center/ Southern California
Cincinnati, OH Vanderbilt University School of Medicine Spatial Sciences Institute at the University of
Nashville, TN Southern California
Jamie McElrath Schwartz, MD Los Angeles, CA
Division Chief, Pediatric Critical Care Kyle Soltys, MD
Medicine Associate Professor Jennifer M. Thomas, BSc, STD (Edu),
Co-Director, Blalock-Taussig-Thomas Thomas E. Starzl Transplant Institute MBChB, FFA
Pediatric and Congenital Heart Center University of Pittsburgh School of Medicine Emeritus Professor Paediatric Anaesthesia
Assistant Professor UPMC Children’s Hospital of Pittsburgh Red Cross War Memorial Children's Hospital
Anesthesia and Critical Care Medicine Pittsburgh, PA Department of Anaesthesia and Perioperative
Johns Hopkins University School of Medicine
Medicine Judy H. Squires, MD University of Cape Town
Baltimore, MD Associate Professor Rondebosch, Cape Town, South Africa
Chief of Ultrasound Imaging
Deborah A. Schwengel, MD Associate Program Director, Diagnostic Stevan P. Tofovic, MD, PhD, FAHA, FASN
Associate Professor Radiology Residency Associate Professor of Pharmacology and
Department of Anesthesiology and Critical Department of Radiology Chemical Biology and Medicine
Care Medicine University of Pittsburgh School of Medicine Department of Pharmacology and Chemical
Johns Hopkins University School of UPMC Children’s Hospital of Pittsburgh Biology
Medicine Pittsburgh, PA University of Pittsburgh School of Medicine
Baltimore, MD Pittsburgh, PA
Eric T. Stickles, MD
Victor L. Scott Assistant Professor of Anesthesiology and
Director Abdominal Transplant Pediatrics
Anesthesiology Alfred I. duPont Hospital for Children/
Avera Transplant Institute Sidney Kimmel Medical College at
Avera McKennan University Hospital Thomas Jefferson University
Sioux Falls, SD Wilmington, DE
xii CONTRIBUTORS
Lieu Tran, MD Keith M. Vogt, MD, PhD Eric P. Wittkugel, MD, FAAP
Assistant Professor Assisant Professor Associate Professor of Anesthesiology and
Department of Anesthesiology and Department of Anesthesiology and Pediatrics
Perioperative Medicine Perioperative Medicine Cincinnati Children’s Hospital Medical
University of Pittsburgh School of Medicine Bioengineering and Center for the Neural Center
UPMC Children’s Hospital of Pittsburgh Basis of Cognition Cincinnati, OH
Pittsburgh, PA University of Pittsburgh School of Medicine
Pittsburgh, PA Samuel Yanofsky, MD, MSEd
Premal M. Trivedi, MD Professor of Anesthesiology
Associate Professor of Anesthesiology Andrew Waberski, MD Vice Chair of Education
Department of Anesthesiology, Perioperative, Assistant Professor Department of Anesthesiology and Critical
and Pain Medicine, Division of Pediatric Division of Anesthesiology, Pain and Care Medicine
Cardiovascular Anesthesiology Perioperative Medicine Children’s Hospital Los Angeles
Texas Children’s Hospital, Baylor College of Children’s National Hospital
Medicine Washington, DC Myron Yaster, MD
Houston, TX Professor of Anesthesiology, Critical Care
Jeffrey R. Wahl, JD Medicine, and Pediatrics
Chinwe Unegbu, MD President and Co-Founder Johns Hopkins University School of Medicine
Assistant Professor MIDAS Healthcare Solutions, Inc. Retired
Division of Anesthesiology, Pain and Cleveland, OH Baltimore, MD
Perioperative Medicine
Children’s National Hospital Ari Y. Weintraub, MD Steven Zgleszewski, MD, FAAP
Washington, DC Assistant Professor of Clinical Anesthesiology Associate in Anesthesia
and Critical Care Anesthesiology, Perioperative and Pain
Samuel M. Vanderhoek Anesthesiology Medicine
Assistant Professor Perelman School of Medicine at the Boston Children’s Hospital
Department of Anesthesiology and Critical University of Pennsylvania Boston, MA
Care Medicine Children’s Hospital of Philadelphia
Johns Hopkins School of Medicine Philadelphia, PA Basil J. Zitelli, MD
Baltimore, MD Professor Emeritus
Timothy P. Welch, MD, MSPH Department of Pediatrics
Lisa Vecchione, DMD, MDS* Associate Professor of Anesthesiology and University of Pittsburgh School of Medicine
Director, Orthodontic Services Pediatrics UPMC Children’s Hospital of Pittsburgh
Cleft-Craniofacial Center Children’s Hospital and Medical Center Pittsburgh, PA
Children’s Hospital of Pittsburgh of UPMC University of Nebraska
Assistant Clinical Professor of Surgery College of Medicine Aaron L. Zuckerberg, MD
University of Pittsburgh School of Medicine Omaha, NE Children’s Diagnostic Center
Pittsburgh, PA North American Partners of Anesthesia
Emmett E. Whitaker, MD Sinai Hospital of Baltimore
Chido Vera, MD, MPH Associate Professor Baltimore, MD
Assistant Professor Departments of Anesthesiology, Neurological
Department of Radiology Sciences, & Pediatrics
VIDEO CONTRIBUTOR – SMITH
University of Vermont Larner College of
UPMC Children’s Hospital of Pittsburgh Medicine TALKS: A LECTURE-SEMINAR
Pittsburgh, PA Burlington, VT Peggy P. McNaull, MD
John Rowlingson Professor and Chair
Adriana M. Vieira, DDS, DMD, MS, PhD Robert K. Williams, MD Department of Anesthesiology
Professor and Chair University of Vermont Larner College of University of Virginia School of Medicine
Department of Pediatric Dentistry Medicine Charlottesville, VA, USA
University of Pittsburgh School of Dental Department of Anesthesiology
Medicine Burlington, VT
Pittsburgh, PA
*Deceased
P R E FA C E
Dr. Robert Smith, a distinguished pioneer in pediatric anesthesia and a great teacher and clinician, wrote the
first edition of this book in 1959, a book subsequently referred to as “the bible” of pediatric anesthesia. The
foreword to the first edition was written by the famous pediatric surgeon Robert E. Gross, the William E.
Ladd Professor of Children’s Surgery at the Harvard Medical School. Though his words in the foreword were
written over 60 years ago, at a time when the specialty of pediatric anesthesia and surgery was in its infant
stages, his words and ideas are still poignant and insightful today.
During the past decade surgery has made important strides in providing safer and improved methods for
handling various problems in infancy and childhood, indeed now making it possible to correct some condi-
tions that were previously thought to be entirely hopeless. Many factors have contributed to these dramatic
advances in pediatric surgery. Outstanding among them is the work of anesthesiologists who have focused
on the field and have provided well-standardized procedures for carrying small and critically ill patients
through operations on literally all portions and every system of the body. The surgeon realizes that the
chances for success or failure are determined in great measure by the capabilities of the person at the head
of the table who is administering the anesthetic.
In some medical circles, there seems to be an attitude that the surgical operator is managing the show; in
others, the anesthetist has an overly possessive feeling toward the patient. Neither approach is proper. It
is best for each to be cognizant of one’s own problems and also to know of the other’s difficulties; both must
work together for total care of the patient. Certainly, this is the most pleasant way to work, and surely it
is the most effective way to conduct a child through a surgical ordeal.
Since the initial printing of this textbook in 1959, the book has been markedly transformed in its content and
in its appearance. The book has gone from mainly a single- to a multi-author book and from a 400-page 70
by 100 book to a 1500-page 11.50 by 8.50 text with an online version. As learning styles have changed, so has
the format of this book. The book uses multimedia presentations to supplement, emphasize, and reinforce
concepts of pediatric anesthesia. However, even with the increases in page number, new information, and
media platforms, the basic tenets of anesthesia care and patient compassion, the legacy and tradition of the
nine previous editions have been retained.
The tenth edition has been prepared with the same considerations as the previous editions: to give anesthe-
siology care providers comprehensive coverage of physiology, pharmacology, and clinical anesthetic man-
agement of infants and children of all ages. The tenth edition has been reorganized into eight main sections.
Part I, Basic Principles and Physiology, contains updated chapters on behavioral development and respira-
tory, cardiovascular, renal, and thermal physiology.
Part II, Pharmacology, now has additional authors with specific chapters in developmental pharmacology,
intravenous anesthetic agents, inhaled anesthetic agents, opioids, local anesthetic agents, neuromuscular
blocking agents, and anesthetic adjuncts.
Part III, General Approach, addresses the basic concepts of caring for children and the principles involved in
the administration of anesthetics to children. The chapters have all been updated. Two new chapters have been
added to Part III: Normal and Difficult Airway Management and Point of Care Ultrasonography.
Part IV is a new section dedicated to Pain Management. It includes updated chapters on acute pain manage-
ment and regional anesthesia. The chapter on regional anesthesia has added some new authors with an
emphasis on ultrasound techniques. The reader will also be able to access video demonstrations of specific
regional anesthetic techniques in children. Part IV also has new chapters: Chronic Pain Management and
Palliative Pain Management.
Part V, Clinical Management of Specialized Surgical Problems, contains material written by new authors.
New authors for chapters on Anesthesia and Sedation for Out of OR Procedures, Pediatric Sedation, and
Medical Missions have been added. The chapter on Solid Organ Transplantation has been updated and also
contains new authors. The use of video has been maintained in a variety of chapters to further supplement
the clinical material. The chapter on Neonatology for Anesthesiologists has been revised into a comprehen-
sive work that updates the anesthesia provider with perinatal outcome data and serves as a primer for pedi-
atric anesthesiologists to better understand the pathophysiology of prematurity and the developmental
xiii
xiv PREFACE
physiology that occur with neonatal growth. This chapter also serves as a rich resource for the chapters on
Anesthesia for General Surgery in Neonates and Anesthesia for Fetal Surgery.
In view of the significant number of disorders that pediatric anesthesiologists are confronted with in the
everyday care of their patients, Part VI, Systemic Disorders and Associated Problems, was created to better
organize and provide information for both unusual patient diseases and to address everyday common peri-
operative anesthetic concerns. All of the chapters in this part have been updated. The chapter on Dermatol-
ogy for the Anesthesiologist has an extensive number of figures (both in the book and online) of lesions and
rashes that anesthesiologists frequently encounter. A new chapter on Infectious Diseases has been added to
this part.
Part VII, Critical Care in Pediatric Anesthesia, contains revised chapters on critical care medicine, cardiac
intensive care, and cardiopulmonary resuscitation. The Cardiopulmonary Resuscitation chapter contains
the latest (2020) recommendations from the American Heart Association.
Part VIII, Special Topics, includes updated chapters on Safety and Outcome in Pediatric Anesthesia, History
of Pediatric Anesthesia, Medicolegal and Ethical Aspects of Pediatric Anesthesia, and Statistics. A new chap-
ter on Education has been added. This chapter focuses on the role of education and provides guidance to
those who engage in teaching the specialty of pediatric anesthesiology as part of postgraduate training. The
education chapter is organized into six sections and uses “mind maps” (a graphic image of the key concepts)
to provide a quick overview of each of the chapter’s sections.
In keeping with advancements in technology, this edition is in color, and text material is further supple-
mented by a website. Videos of airway techniques, single-lung isolation, regional anesthesia, the use of
ultrasound, and anatomic dissections of congenital heart lesions are accessible with just a click of the mouse.
In addition, supplemental materials on organ transplantation, airway lesions, and pediatric syndromes
remain available.
The appendices, which can be found online at

ExpertConsult.com, include an updated list of
drugs and their dosages, normal growth curves,
normal values for pulmonary function tests in
children, and an expanded list of common and
uncommon syndromes of clinical importance for
pediatric anesthesiologists.
Finally, this edition, like the previous edition, also

includes online multiple-choice questions with an-
swers and explanations. As with any learning pro-
cess, it is important for the reader to have some
method to affirm that they understand the salient
features and to reinforce the learning process. Most
chapters have associated questions to aid the reader
in understanding the material.
In summary, considerable developments and prog-

ress in the practice of pediatric anesthesia are re-
flected in this new edition. The emphasis on the
safety and well-being of young patients during the
perianesthetic period remains unchanged—just as
Dr. Smith would have wanted.
Peter J. Davis, MD, FAAP

AC K N OW L E D G M E N T S
The project of revising a classic medical textbook presents many opportunities and challenges, and revising
this textbook during the SARS-CoV-2 (COVID-19) pandemic—when people were stressed, isolated, and
uncertain about their futures—proved to be particularly challenging. Nonetheless, the opportunity to review
and evaluate the new developments that have emerged in pediatric anesthesia since the publication of the last
edition of Smith’s Anesthesia for Infants and Children in 2017 has been rewarding. As always, we are deeply
indebted to the extraordinary work done and commitment made by Dr. Robert M. Smith in the first four
editions that made Anesthesia for Infants and Children a classic textbook in pediatric anesthesia.
Our ability to maintain this book’s standard of excellence is not just a reflection of the many gifted con-
tributors but also a result of the level of support that we have received at work and at home. We wish to thank
the staff members of the Department of Anesthesiology at UPMC Children’s Hospital of Pittsburgh for their
support and tolerance.
Our special thanks go to Joy Holden and Patty Klein, administrative assistants, of the Department of
Anesthesiology, UPMC Children’s Hospital of Pittsburgh, for their many hours of diligent work on the
book. We are also appreciative of Dr. Basil Zitelli, Professor Emeritus of Pediatrics, University of Pittsburgh
at UPMC Children’s Hospital of Pittsburgh, for his generosity in allowing us to use many of the photo-
graphs published in his own book, Atlas of Pediatric Physical Diagnosis.
Our special thanks also go to Elsevier’s Sarah Barth, Content Strategist; Kristen Helm, Content Develop-
ment Specialist; and Julie Taylor, Project Manager, for their editorial assistance.
As with the previous editions, we are deeply indebted to our family members Katie, Evan, Zara, Will,
Hunter, and Jake Davis; Julie, Andy, Elliott, Eila, and Mugsy Peet Potash; and Joseph Losee and Hudson
Cladis Losee for remaining loyal, for being understanding, and for providing moral support throughout the
lengthy and, at times, seemingly endless project. Finally, we are indebted to our patients, who grant us the
privilege to care and learn from them and who keep us humble.
Peter J. Davis, MD, FAAP

xv
CO
G NSTSEANRTYS
LO
Contributors, vi 22 Transfusion Medicine, 455

Preface, xii Michael E. Nemergut, Dawit T. Haile, Devon O. Aganga, and
Acknowledgments, xiv Randall P. Flick
PART I Basic Principles and Physiology PART IV Pain Management

1 Special Characteristics of Pediatric Anesthesia, 2 23 Acute Pain Management, 481
Peter J. Davis, Etsuro K. Motoyama, and Franklyn P. Cladis Constance L. Monitto, Jessica A. George, and Myron Yaster
2 Behavioral Development, 11 24 Regional Anesthesia, 519
Julie Niezgoda, Melissa Sutcliffe, Caleb H. Ing, and Richard J. Levy Robert Scott Lang, Denise Hall-Burton, Alexander Praslick,
3 Respiratory Physiology, 28 and Sean Flack
Etsuro K. Motoyama and Jonathan D. Finder 25 Chronic Pain Management, 578
4 Airway Physiology and Development, 78 Bobbie L. Riley, Anjali Koka, and Christine D. Greco
Robert S. Holzman 26 Pediatric Palliative Care and Hospice, 587
5 Cardiovascular Physiology, 90 Nancy L. Glass
Andrew Waberski, Chinwe Unegbu, and Nina Deutsch
6 Regulation of Fluids and Electrolytes, 119
Michael L. Moritz and Demetrius Ellis PART V C
linical Management of Specialized
7 Thermoregulation, 158 Surgical Problems
Branden Engorn, Helen Harvey, Peter J. Davis, Igor Luginbuehl,
and Bruno Bissonnette 27 Neonatology for Anesthesiologists, 596
Marla B. Ferschl and Claire M. Brett
28 Anesthesia for General Surgery in Neonates, 669
PART II Pharmacology Sean S. Barnes, Peter J. Davis, and Claire Brett
29 Anesthesia for Fetal Surgery, 709
8 Developmental Pharmacology, 179 Monica A. Hoagland, Karen A. Dean, and Debnath Chatterjee
Stevan P. Tofovic and Evan Kharasch 30 Anesthesia for Congenital Heart Disease, 732
9 Intravenous Anesthetics, 198 Barry D. Kussman, Francis X. McGowan Jr., Andrew J. Powell, and
Brian Blasiole and Peter J. Davis James A. DiNardo
10 Inhaled Anesthetics, 213 31 Anesthesia for Neurosurgery, 832
Susan Lei, Lena S. Sun and Tatiana Kubacki Jenna H. Sobey, Jonathan A. Niconchuk, Eric T. Stickles,
11 Local Anesthetics, 228 Carrie C. Menser, and Srijaya K. Reddy
Adrian T. Bösenberg 32 Anesthesia for Thoracic Surgery, 866
12 Opioids, 233 Gregory B. Hammer
Phillip M. T. Pian, Rachael S. Rzasa Lynn, Jeffrey L. Galinkin, and 33 Anesthesia for General Abdominal, Urologic Surgery, 885
Peter J. Davis Emmett E. Whitaker, Robert K. Williams, Helen Victoria Lauro, Rajeev
13 Neuromuscular Blocking Agents, 257 Chaudhry, and Peter J. Davis
John B. Eck 34 Anesthesia for Otorhinolaryngologic Surgery, 917
14 Anesthetic Adjuncts, 279 Samuel M. Vanderhoek, Nicholas M. Dalesio, and Deborah A. Schwengel
Erica L. Sivak and Denise M. Hall-Burton 35 Anesthesia for Plastic Surgery, 945
Franklyn P. Cladis, Lorelei Grunwaldt, and Joseph Losee
PART III General Approach 36 Anesthesia for Orthopedic Surgery, 969
Aaron L. Zuckerberg, Thanh Nguyen, and Myron Yaster
15 Psychological Aspects of Pediatric Anesthesia, 289 37 Anesthesia for Ophthalmic Surgery, 1001
Kirk Lalwani and Erin Conner Karene Ricketts and Ken Nischal
16 Preoperative Preparation, 302 38 Solid Organ Transplantation, 1024
Franklyn P. Cladis and Peter J. Davis Phillip S. Adams, Brian Blasiole, Peter J. Davis, Gregory McHugh,
17 Equipment, 328 Victor L. Scott, and Kyle Soltys
Allan Simpao, Jeffrey M. Feldman, and David E. Cohen 39 Anesthesia for Conjoined Twins, 1062
18 Monitoring, 358 Jennifer M. Thomas
Jonathan M. Tan and David E. Cohen 40 Anesthesia for Pediatric Trauma, 1083
19 Normal and Difficult Airway Management, 382 Rebecca Nause-Osthoff, Paul Reynolds, Aman Kalsi, Peter Ehrlich,
Pete G. Kovatsis, James Peyton, Edward B. Cooper, and Peter J. Davis Franklyn P. Cladis, and Peter J. Davis
20 Point-of-Care Ultrasonography, 405 41 Anesthesia for Burns, 1113
Desiree Noel Wagner Neville and Jennifer R. Marin Thomas Romanelli
21 Induction, Maintenance, and Recovery, 423
Shelley Ohliger, Jessica Cronin, and Nina Deutsch
xvi
CONTENTS xvii
42 Anesthesia for Dental Procedures, 1132 55 Dermatology for the Anesthesiologist, 1343
Andrew Herlich, Franklyn P. Cladis, Deborah Studen-Pavlovich, Thomas M. Chalifoux, Sylvia Choi, and Basil J. Zitelli
Adriana M. Vieira, Brian Martin, Mary Chapman, and Lisa Vecchione 56 Infectious Diseases, 1358
43 Anesthesia and Sedation for Out-of-Operating-Room Andrew Nowalk
Procedures, 1148
Lieu Tran, Judy Squires, Chido Vera, and Brian Blasiole
44 Pediatric Sedation, 1168 PART VII C
ritical Care in Pediatric
Mary Landrigan-Ossar and Joseph P. Cravero Anesthesia
45 Anesthesia for Surgical Missions, 1184
George Demetrios Politis 57 Cardiopulmonary Resuscitation, 1365
Jamie McElrath Schwartz, Rahul Koka, Justin T. Hamrick,
Jennifer L. Hamrick, Elizabeth A. Hunt, and Donald H. Shaffner
PART VI S
ystemic Disorders and Associated 58 Critical Care Medicine, 1413
Problems Elizabeth K. Laverriere, Benjamin Bruins, and Justin L. Lockman
59 Cardiac Critical Care Medicine, 1425
46 Endocrine Disorders, 1199 James Fehr, Meghna Patel, and Timothy Welch
Benjamin B. Bruins, Todd J. Kilbaugh, and Ari Y. Weintraub
47 Respiratory Disorders, 1214
Sarah M. Smith and Premal M. Trivedi
PART VIII Special Topics
48 Cardiovascular Disorders, 1238 60 Safety and Outcome in Pediatric Anesthesia, 1444
Phillip S. Adams Eliot Grigg, Lizabeth Martin, and Lynn Martin
49 Hematology and Coagulation Disorders, 1251 61 History of Pediatric Anesthesia, 1462
Nina A. Guzzetta, Laura A. Downey, and Bruce E. Miller David Levin and Mark A. Rockoff
50 Oncologic Disorders, 1282 62 Medicolegal and Ethical Aspects
Steven Zgleszewski, Franklyn P. Cladis, and Peter J. Davis of Pediatric Anesthesia, 1478
51 Genetic and Muscular Disorders, 1295 Jessica Davis and Jeffrey R. Wahl
Ashley A. Colletti, Philip G. Morgan, and Vincent C. Hsieh 63 Education, 1488
52 Malignant Hyperthermia, 1305 Samuel Yanofsky, Ira Todd Cohen, Franklyn P. Cladis, and Julie Nyquist
Teeda Pinyavat, Thierry Girard, and Ronald S. Litman 64 Statistics, 1499
53 Pediatric Obesity, 1319 James W. Ibinson and Keith M. Vogt
Paul J. Samuels and Michale Sung-jin Ok
54 Special Pediatric Disorders, 1330 Abbreviations, 1510
Eric P. Wittkugel and Nancy Bard Samol Index, 1516
*Deceased
PA R T I
Basic Principles and
Physiology
1. Special Characteristics of Pediatric 5. Cardiovascular Physiology, 90
Anesthesia, 2
6. Regulation of Fluids and Electrolytes, 119
2. Behavioral Development, 11
7. Thermoregulation, 158
3. Respiratory Physiology, 28
4. Airway Physiology and Development, 78
1
1
Special Characteristics of Pediatric Anesthesia
Peter J. Davis, Etsuro K. Motoyama, Franklyn P. Cladis
OUTLINE
Introduction, 2 Anatomic and Physiologic Differences, 7
Perioperative Monitoring, 2 Body Size, 7
Anesthetic Agents, 3 Relative Size or Proportion, 7
Airway Devices and Adjuncts, 4 Central and Autonomic Nervous Systems, 8
Intraoperative and Postoperative Analgesia in Neonates, 5 Respiratory System, 9
Point of Care Ultrasound, 5 Cardiovascular System, 9
Regional Analgesia in Infants and Children, 5 Fluid and Electrolyte Metabolism, 9
Fundamental Differences in Infants and Children, 6 Temperature Regulation, 9
Psychological Differences, 6 Summary, 10
Differences in Response to Pharmacologic Agents, 6
INTRODUCTION many anesthesiologists monitored only the heart rate in infants and
In the past few decades, new scientific knowledge of physiology and small children during anesthesia and surgery. Electrocardiographic
pharmacology in developing humans and technologic advancements and blood pressure measurements were either too difficult or too ex-
in equipment and monitoring have markedly changed the practice of travagant and were thought to provide little or no useful information.
pediatric anesthesia. In addition, further emphasis on patient safety Measurements of central venous pressure were thought to be inaccu-
(e.g., correct side-site surgery, correct patient identification, correct rate and too invasive, even in major surgical procedures. The insertion
procedure, appropriate prophylactic antibiotics) coupled with ad- of an indwelling urinary (Foley) catheter in infants was considered
vances in minimally invasive pediatric surgery have created a need invasive, and surgeons resisted its use.
for better pharmacologic approaches to infants and children and Smith also added an additional physiologic monitoring: soft, latex
improved skills in pediatric anesthetic management. blood pressure cuffs suitable for newborn and older infants, which
As a result of the advancements and emphasis on pediatric subspe- encouraged the use of blood pressure monitoring in children (Smith
cialty training and practice, the American Board of Anesthesiology has 1968). The Smith cuff (see Chapter 61: History of Pediatric Anesthesia;
now come to recognize the subspecialty of pediatric anesthesiology in Fig. 61.7) remained the standard monitoring device for infants and
its certification process, and the first subspecialty board examination children until the late 1970s, when automated blood pressure devices
was administered in 2013. began to replace them.
The introduction of pulse oximetry for routine clinical use in the early
1990s has been the single most important development in monitoring and
PERIOPERATIVE MONITORING patient safety, especially related to pediatric anesthesia, since the advent of
In the 1940s and 1950s, the techniques of pediatric anesthesia, and the the precordial stethoscope in the 1950s (Smith 1956) (see Chapter 17:
skills of those using and teaching them, evolved more as an art than Equipment; Chapter 18: Monitoring). Pulse oximetry is superior to clini-
as a science, as Dr. Robert Smith (now deceased) vividly and elo- cal observation and other means of monitoring, such as capnography,
quently recollected through his firsthand experiences in his chapter for the detection of intraoperative hypoxemia (Coté et al. 1988, 1991). In
on the history of pediatric anesthesia (see Chapter 61: History of Pe- addition, Spears and colleagues (1991) have indicated that experienced
diatric Anesthesia, updated by Mark A. Rockoff and David Neville pediatric anesthesiologists may not have an “educated hand” or a “feel”
Levine). The anesthetic agents and methods available were limited, as adequate to detect changes in pulmonary compliance in infants. Pulse
was the scientific knowledge of developmental differences in organ oximetry has revealed that postoperative hypoxemia occurs commonly
system function and anesthetic effect in infants and children. Moni- among otherwise healthy infants and children undergoing simple surgical
toring pediatric patients was limited to inspection of chest movement procedures, presumably as a result of significant reductions in functional
and occasional palpation of the pulse until the late 1940s, when Smith residual capacity (FRC) and resultant airway closure and atelectasis
introduced the first physiologic monitoring to pediatric anesthesia by (Motoyama and Glazener 1986). Consequently, the use of supplemental
using the precordial stethoscope for continuous auscultation of heart- oxygen in the postanesthesia care unit (PACU) has become a part of
beat and breath sounds (Smith 1953, 1968). Until the mid-1960s, routine postanesthetic care (see Chapter 3: Respiratory Physiology).
2
CHAPTER 1 Special Characteristics of Pediatric Anesthesia 3
Although pulse oximetry greatly improved patient monitoring,

there were some limitations, namely, motion artifact and inaccuracy in
ANESTHETIC AGENTS
low-flow states and in children with levels of low oxygen saturation More than a decade after the release of isoflurane for clinical use, two
(e.g., cyanotic congenital heart disease). Advances have been made in volatile anesthetics, desflurane and sevoflurane, became available in
the new generation of pulse oximetry, most notably through the use of the 1990s in most industrialized countries. Although these two agents
Masimo Signal Extraction Technology (SET). This device minimizes are dissimilar in many ways, they share common physiochemical and
the effect of motion artifact, improves accuracy, and has been shown pharmacologic characteristics: very low blood gas partition coeffi-
to have advantages over the existing system in low-flow states, mild cients (0.4 and 0.6, respectively), which are close to those of nitrous
hypothermia, and moving patients (Malviya et al. 2000; Hay et al. oxide and are only fractions of those of halothane and isoflurane; rapid
2002; Irita et al. 2003). induction of and emergence from surgical anesthesia; and hemody-
Trending of hemoglobin (Hgb) can also be performed with oxim- namic stability (See Chapter 10: Inhaled Anesthetic Agents; Chapter 21:
etry. Noninvasive pulse cooximetry (SpHb) has been used in both Induction, Maintenance, and Recovery). In animal models, the use of
children and neonates to measure SpHb. Pulse cooximetry uses pulse inhaled anesthetic agents has been shown to attenuate the adverse ef-
oximeter technology that involves sensors with light emitting diodes fects of ischemia in the brain, heart, and kidneys, whereas other studies
of many wavelengths. Patino and colleagues (2014) demonstrated in have raised concerns regarding the anesthetic agents causing neurotox-
children undergoing major surgical procedures with anticipated sub- icity in infants and children. (See Chapter 2: Behavioral Development.)
stantial blood loss that SpHb followed the trend in invasively measured Although these newer, less soluble inhaled agents allow for faster
Hgb with respect to bias and precision and that the trend accuracy was emergence from anesthesia, emergence excitation or delirium associ-
better than the absolute accuracy. In both term and preterm neonates ated with their use has become a major concern to pediatric anesthe-
who weighed less than 3000 g at birth, Nicholas and colleagues (2015) siologists (Davis et al. 1994; Sarner et al. 1995; Lerman et al. 1996;
noted a good agreement between the noninvasive SpHb and the inva- Welborn et al. 1996; Cravero et al. 2000; Kuratani and Oi 2008).
sive Hgb. In a study of adults and children, Park and colleagues (2018) Adjuncts, such as opioids, analgesics, serotonin antagonists, and
noted that the difference between lab-measured Hgb and SpHb was a1-adrenergic agonists, have been found to decrease the incidence of
less in children than in adults. emergence agitation (Aono et al. 1999; Davis et al. 1999a; Galinkin
Monitoring of cerebral function and blood flow, as well as infrared et al. 2000; Cohen et al. 2001; Ko et al. 2001; Kulka et al. 2001; Voepel-
brain oximetry, has advanced the anesthetic care and perioperative Lewis et al. 2003; Lankinen et al. 2006; Aouad et al. 2007; Tazeroualti
management of infants and children with congenital heart disease and et al. 2007; Bryan et al. 2009; Erdil et al. 2009; Kim et al. 2009; Hauber
traumatic brain injuries. Depth of anesthesia can be difficult to assess et al. 2015).
in children, and anesthetic overdose was a major cause of anesthesia- Propofol has increasingly been used in pediatric anesthesia as an
associated cardiac arrest and mortality. Depth-of-anesthesia monitors induction agent, for intravenous sedation, or as the primary agent of a
(bisectral index monitor [BIS], Patient State Index, Narcotrend) have total intravenous anesthetic technique (Martin et al. 1992). Propofol
been used in children and have been associated with the administra- has the advantage of aiding rapid emergence and causes less nausea
tion of less anesthetic agent and faster recovery from anesthesia. How- and vomiting during the postoperative period, particularly in children
ever, because these monitors use electroencephalography and a sophis- with a high risk for vomiting. When administered as a single dose
ticated algorithm to predict consciousness, the reliability of these (1 mg/kg) at the end of surgery, propofol has also been shown to de-
monitors in children younger than 1 year of age is limited. crease the incidence of sevoflurane-associated emergence agitation
More recently, interest has developed in the use of noninvasive (Aouad et al. 2007).
monitors to assess fluid responsiveness. Static variables (central venous Dexmedetomidine is an a1-adrenergic agonist approved for use as
pressure, pulmonary artery wedge pressure, and left ventricle area) are a sedation agent for adult ICU patients (Mason and Lerman 2011). In
not reliable predictors of fluid responsiveness. Dynamic indicators that pediatrics, off-label use of dexmedetomidine is common and has been
are based on cardiopulmonary interactions in mechanically ventilated used in the settings of procedural sedation and ICU sedation. It also
patients, such as aortic peak velocity, systolic blood pressure variation has been administered as an adjunct to general anesthesia in order to
(SPV), pulse pressure variation (PPV), and pleth variability index decrease both opioid and inhalational anesthetic requirements. It has
(PVI), have been shown to be predictive in adults. In children, the re- been used to treat supraventricular tachycardia and junctional ectopic
sults of studies involving dynamic variables have been mixed, but it tachycardia in pediatric cardiac patients and has been used successfully
appears that aortic peak velocity is a reliable indicator of fluid respon- for both prophylaxis and treatment of emergence agitation in postop-
siveness (Marik et al. 2009; Feldman et al. 2012; Byon et al. 2013; erative surgical patients (Erdil et al. 2009; Jooste et al. 2010; Gupta
Gan et al. 2013; Pinsky 2014; Nicholas et al. 2015). et al. 2013; Sun et al. 2014). In order to attenuate the biphasic hemo-
In addition to advances in monitors for individual patients, hospi- dynamic response of dexmedetomidine, the package insert recom-
tal, patient, and outside agency initiatives have focused on more global mends infusing the drug over 10 minutes. However, studies involving
issues. Issues of patient safety, side-site markings, time-outs, and rapid bolus administration (less than 3 seconds) of dexmedetomidine
proper patient identification, together with appropriate administra- in both healthy children and children who had received a heart trans-
tion of prophylactic antibiotics, have now become major priorities for plant demonstrated minimal clinical significance (Jooste et al. 2010;
healthcare systems. World Health Organization (WHO) checklists are Dawes et al. 2014; Hauber et al. 2015).
positive initiatives that have ensured that the correct procedure is per- Remifentanil, a µ-receptor agonist, is metabolized by nonspecific
formed on the correct patient and have fostered better communication plasma and tissue esterases. The organ-independent elimination of
among healthcare workers. In anesthesia, patient safety continues to be remifentanil, coupled with its clearance rate (highest in neonates and
a mantra for the specialty. Improved monitoring, better use of anes- infants compared with older children), makes its kinetic profile differ-
thetic agents, and the development of improved airway devices, cou- ent from that of any other opioid (Davis et al. 1999b; Ross et al. 2001).
pled with advancements in minimally invasive surgery, continue to In addition, its ability to provide hemodynamic stability, coupled with
advance the frontiers of pediatric anesthesia as a specialty medicine its kinetic profile of rapid elimination and nonaccumulation, makes
and improve patient outcomes and patient safety. it an attractive anesthetic option for infants and children. Numerous
4 PART 1 Basic Principles and Physiology
clinical studies have described its use for pediatric anesthesia (Wee Equipment; Chapter 19: Normal and Difficult Airway Management).
et al. 1999; Chiaretti et al. 2000; Davis et al. 2000, 2001; German et al. The importance of these advanced airway devices cannot be over-
2000; Dönmez et al. 2001; Galinkin et al. 2001; Keidan et al. 2001b; stated, as evidenced by their use in the algorithms for the difficult
Chambers et al. 2002; Friesen et al. 2003). When combined, intrave- pediatric airway (Park et al. 2017; Garcia-Marcinkiewicz et al. 2019;
nous hypnotic agents (remifentanil and propofol) have been shown to Fiadjoe and Nishisaki 2020).
be as effective and of similar duration as propofol and succinylcholine The variety of pediatric endotracheal tubes (ETTs) has focused on
for tracheal intubation. improved materials and designs. ETTs are sized according to the inter-
The development of more predictable, shorter-acting anesthetic nal diameter; however, the outer diameter (the parameter most likely
agents (see Part II: Pharmacology) has increased the opportunities for involved with airway complications) varies according to the manufac-
pediatric anesthesiologists to provide safe and stable anesthesia with turer (Table 1.1). Tube tips are both flat and beveled, and a Murphy eye
less dependence on the use of neuromuscular blocking agents. may or may not be present. The position of the cuff varies with the
Remimazolam is a new benzodiazepine that is metabolized by tissue manufacturer. The use of cuffed endotracheal tubes in pediatrics con-
carboxylesterases to an inactive metabolite. In adult volunteers it tinues to be controversial. In a multicenter, randomized prospective
is rapidly metabolized with fast onset and recovery times and has study of 2246 children from birth to 5 years of age undergoing general
moderate hemodynamic effect (Masui 2020; Schüttler et al. 2020). anesthesia, Weiss and colleagues (2009) noted that cuffed ETTs com-
pared with uncuffed ETTs did not increase the risk for postextubation
stridor (4.4% vs. 4.7%) but did reduce the need for ETT exchanges
AIRWAY DEVICES AND ADJUNCTS (2.1% vs. 30.8%), thereby reducing the possibility of additional trauma
Significant changes in pediatric airway management that have patient from multiple intubation attempts.
safety implications have emerged over the past few years. The laryngeal There has been a recent gradual but steady trend toward the routine
mask airway (LMA), in addition to other supraglottic airway devices and exclusive use of cuffed ETTs in pediatric anesthesia, including in
(e.g., the King LT-D, the Cobra pharyngeal airway), has become an infants (Dullenkopf et al. 2005; Weiss et al. 2009; Litman and Maxwell
integral part of pediatric airway management. Although the LMA is 2013; Tobias 2015). Murat (2001) was the first to propose the use of
not a substitute for the endotracheal tube, it can be safely used for cuffed ETTs exclusively for children of all ages with the record of no
routine anesthesia in both spontaneously ventilated patients and pa- complications without using uncuffed ETTs for a 3-year span in a
tients requiring pressure-controlled support (Keidan et al. 2001a). The major children’s hospital in Paris. The change in practice of not using
LMA can also be used in the patient with a difficult airway to aid in uncuffed ETT is due to the recognition that the shape of the glottic
ventilation and to act as a conduit to endotracheal intubation both opening at the cricoid ring, the narrowest fixed diameter in the upper
with and without a fiber optic bronchoscope. airways, is more elliptic in shape than circular, with a larger anteropos-
In addition to supraglottic devices, advances in technology for vi- terior (AP) diameter and a narrower transverse diameter (Dalal et al.
sualizing the airway have improved patient safety. Since the larynx 2009; Litman and Maxwell 2013). These findings mean that the most
could be visualized, at least 50 devices intended for laryngoscopy have appropriately sized uncuffed ETT (,20 cm H2O leak pressure) would
been invented. The newer airway visualization devices have combined compress the lateral wall mucosa of the cricoid, causing ischemia
better visualizations, video capabilities, and high resolution. even when there are enough anteroposterior spaces left for air leaks
The development and refinement of airway visualization equip- (Motoyama 2009). A recently developed thin-walled (with smaller
ment such as the McGrath, C-MAC, and Glidescope have added more outer diameter), cuffed endotracheal tube specifically designed for
options to the management of the pediatric airway and literally give pediatric anesthesia (Microcuff by Kimberly-Clark) has two major
the laryngoscopist the ability to see around corners (see Chapter 17: modifications: the cuff is made of ultrathin polyurethane, allowing a
TABLE 1.1 Measured Outer Diameters of Pediatric Cuffed Tracheal Tubes According
to the Internal Diameter of Tracheal Tubes Supplied by Different Manufacturers
ID Tracheal Tube Brand 2.5 3 3.5 4 4.5 5 5.5
OD (mm) Sheridan Tracheal Tube Cuffed Murphy NA 4.2 4.9 5.5 6.2 6.8 7.5
Sheridan Tracheal Tube Cuffed Magill NA 4.3 NA 5.5 NA 6.9 NA
Mallinckrodt TT High-Contour Murphy NA 4.4 4.9 5.7 6.3 7 7.6
Mallinckrodt TT High-Contour Murphy P-Series NA 4.3 5 5.7 6.4 6.7 7.7
Mallinckrodt TT Lo-Contour Magill NA 4.5 4.9 5.7 6.2 6.9 7.5
Mallinckrodt TT Lo-Contour Murphy NA 4.4 5 5.6 6.2 7 7.5
Mallinckrodt TT Hi-Lo Murphy NA NA NA NA NA 6.9 7.5
Mallinckrodt TT Safety Flex NA 5.2 5.5 6.2 6.7 7.2 7.9
Portex TT-Profile Soft Seal Cuff, Murphy NA NA NA NA NA 7 7.6
Rüsch Ruschelit Super Safety Clear Magill 4 5.1 5.3 5.9 6.2 6.7 7.2
Rüsch Ruschelit Super Safety Clear Murphy NA NA NA NA NA 6.7 7.3
Halyard Microcuff (formerly Kimberly-Clark Healthcare) NA 4.3 5.0 5.6 6.3 6.7 7.3
ID, Inner diameter; OD, outer diameter.

Modified from Weiss, M., Dullenkopf, A., Gysini, C., et al. (2004). Shortcomings of cuffed pediatric tracheal tubes. British Journal of Anaesthesia,
92, 78–88.
more effective tracheal seal at a much lower pressure than the pressure therapeutic applications in pediatric patients of all ages. In addition
known to cause tracheal mucosal necrosis, and the short cuff is located to its widely accepted role in regional anesthesia and vascular access,
more distally near the tip of the endotracheal tube shaft, allowing more ultrasonography can facilitate diagnostic procedures including airway
reliable placement of the cuff below the nondistensible cricoid ring management, pulmonary pathology like pneumothorax, fluid man-
and reducing the chance of endobronchial intubation (Dullenkopf agement, and nasogastric tube positioning. (See Chapter 20: Point of
et al. 2005; Litman and Maxwell 2013). Whether the new, more costly Care Ultrasonography.)
endotracheal tube actually reduces the incidence of intubation-related
airway injury is being investigated. REGIONAL ANALGESIA IN INFANTS
A main concern with cuffed endotracheal tubes relates to excessive
AND CHILDREN
pressure in the cuff. The exact pressure a cuff needs to exert against the
wall of the tracheal mucosae to induce ischemia is not known; recom- Although conduction analgesia has been used in infants and children
mendations range from 20 to 30 cm H2O. In an observational trial of since the beginning of the 20th century, the controversy about whether
200 pediatric patients, Tobias and colleagues (2012) noted that when anesthetic agents can be neurotoxic has caused a resurgence of interest
cuff pressures were measured, 23.5% of the patients had pressures in regional anesthesia (Abajian et al. 1984; Williams et al. 2006).
greater than 30. Various devices have been prepared to monitor intra- As newer local anesthetic agents with less systemic toxicity become
cuff pressure (Krishna et al. 2014; Ramesh et al. 2014; Kako et al. available, their role in the anesthetic/analgesic management of chil-
2015; Tobias 2015). Although the role of cuffed ETTs in neonates and dren is increasing. Studies of levobupivacaine and ropivacaine have
infants who require prolonged ventilation has yet to be determined demonstrated safety and efficacy in children that are greater than that
(Sathyamoorthy et al. 2015), it is clear that in neonates undergoing of bupivacaine, the standard regional anesthetic used in the 1990s
minimally invasive surgery, cuffed endotracheal tubes allow for more (Ivani et al. 1998, 2002, 2003; Hansen et al. 2000, 2001; Lönnqvist et al.
effective ventilation and more reliable end-tidal gas monitoring while 2000; McCann et al. 2001; Karmakar et al. 2002). A single dose of local
likely maintaining safety (de Wit et al. 2018; Thomas et al. 2018). anesthetics through the caudal and epidural spaces is most often used
for a variety of surgical procedures as part of general anesthesia and for
INTRAOPERATIVE AND POSTOPERATIVE postoperative analgesia. Insertion of an epidural catheter for continu-
ous or repeated bolus injections of local anesthetics (often with opi-
ANALGESIA IN NEONATES oids and other adjunct drugs) for postoperative analgesia has become
It has long been thought that newborn infants do not feel pain the way a common practice in pediatric anesthesia. The addition of adjunct
older children and adults do and therefore do not require anesthetic or medications, such as midazolam, neostigmine, tramadol, ketamine,
analgesic agents (Lippmann et al. 1976). Thus in the past, neonates and clonidine, to prolong the neuroaxial blockade from local anes-
undergoing surgery were often not afforded the benefits of anesthesia. thetic agents has become more popular, even though the safety of these
Later studies, however, indicated that pain experienced by neonates agents on the neuroaxis has not been determined (Ansermino et al.
can affect behavioral development (Dixon et al. 1984; Taddio et al. 2003; de Beer and Thomas 2003; Walker and Yaksh 2012) (see also
1995; Taddio and Katz 2005). Rats exposed to chronic pain without the Part IV: Pain Management).
benefit of anesthesia or analgesia showed varying degrees of neuro- In addition to neuroaxial blockade, specific nerve blocks that are
apoptosis (Anand et al. 2007). However, to add further controversy performed with or without ultrasound guidance have become an
to the issue of adequate anesthesia for infants, concerns have been integral part of pediatric anesthesia (see Chapter 24: Regional Anes-
raised regarding the neurotoxic effects of both intravenous and inha- thesia) (Boretsky et al. 2013; Hall-Burton and Boretsky 2014; Long
lational anesthetic agents (GABAergic and NMDA antagonists) (see et al. 2014; Visoiu et al. 2014; Suresh et al. 2015). The use of ultra-
Chapter 2: Behavioral Development). sound has allowed for the administration of smaller volumes of local
Although postoperative cognitive dysfunction (POCD) is an adult anesthetic and for more accurate placement of the local anesthetic
phenomenon, animal studies by multiple investigators have raised (Willschke et al. 2006; Gurnaney et al. 2007; Ganesh and Gurnaney
concerns about anesthetic agents being toxic to the developing brains 2009). The use of catheters in peripheral nerve blocks has also
of infants and small children (Jevtovic-Todorovic et al. 2003; Mellon changed the perioperative management for a number of pediatric
et al. 2007; Jevtovic and Olney 2008; Wang and Slikker 2008; Rappa- surgical patients. Continuous peripheral nerve catheters with infu-
port et al. 2015). Early work by Uemura and colleagues (1985) noted sions are being used by pediatric patients at home after they have been
that synaptic density was decreased in rats exposed to halothane in discharged from the hospital (Ganesh et al. 2007; Gurnaney et al.
utero. Further work with rodents, by multiple investigators, has shown 2014; Visoiu et al. 2014). The use of these at-home catheters has
evidence of apoptosis in multiple areas of the central nervous system allowed for shorter hospital stays.
during the rapid synaptogenesis period. This window of vulnerability As pediatric regional anesthesia becomes more prevalent, the abil-
appears to be a function of time, dose, and duration of anesthetic ex- ity to collect data, audit practice patterns, and report on complications
posure. In addition to the histochemical changes of apoptosis, the ex- in infants and children undergoing regional anesthesia becomes es-
posed animals also demonstrated learning and behavioral deficits later sential to improving care for children. In this context, the Pediatric
in life. The potential neurotoxic risk of anesthetic agents is less clear in Regional Anesthesia Network (PRAN) was formed (Polaner et al. 2012;
human pediatric patients. Studies performed on this population have Long et al. 2014; Taenzer et al. 2014; Suresh et al. 2015). Walker and
helped to clarify this risk, and it appears that a single short anesthetic colleagues (2018) reported on over 100,000 blocks in children from the
in early infancy has no adverse effects on IQ at 2 and 5 years of age. See PRAN registry and noted that there was no added risk of placing a
Chapter 2 (Behavioral Development) for a more in-depth discussion. block in the anesthetized child. The risk of transient neurologic deficit
was 2.4:10,000 patients and severe local anesthetic systemic toxicity
was 0.76:10,000 patients.
POINT OF CARE ULTRASOUND In addition to advances in anesthetic pharmacology and equip-
Ultrasound has advanced the care of many medical specialties, in- ment, advances in the area of pediatric minimally invasive surgery (MIS)
cluding pediatric anesthesiology. This technology has diagnostic and have improved patient morbidity, shortened the length of hospital
stays, and improved surgical outcomes (Fujimoto et al. 1999). Al- TABLE 1.2 Aspects of Developmental
though MIS imposes physiologic challenges in the neonate and small
Assessment and Common Developmental
infant, numerous neonatal surgical procedures can nevertheless be
successfully approached with such methods, even in infants with single-
Milestones
ventricle physiology (Georgeson 2003; Ponsky and Rothenberg 2008). Follows dangling object from midline through 1 month
The success of MIS has allowed for the evolution of robotic techniques, a range of 90 degrees
stealth surgery (scarless surgery), and Natural Orifice Transluminal Follows dangling object from midline through 3 months
Endoscopic Surgery (NOTES) (Dutta and Albanese 2008; Dutta et al. a range of 180 degrees
2008; Isaza et al. 2008). Consistent conjugate gaze (binocular vision) 4 months
Alerts or quiets to sound 0–2 months
FUNDAMENTAL DIFFERENCES IN INFANTS
Head up 45 degrees 2 months
AND CHILDREN Head up 90 degrees 3–4 months
Regardless of all the advances in equipment, monitoring, and patient Weight on forearms 3–5 months
safety initiatives, pediatric anesthesia still requires a special under- Weight on hands with arms extended 5–6 months
standing of anatomic, psychological, and physiologic development.
Complete head lag, back uniformly rounded Newborn
The reason for undertaking a special study of pediatric anesthesia is
that children, especially infants younger than a few months of age, Slight head lag 3 months
differ markedly from adolescents and adults. Many of the important Rolls front to back 4–5 months
differences, however, are not the most obvious. Although the most Rolls back to front 5–6 months
apparent difference is size, it is the physiologic differences related to Sits with no support 7 months
general metabolism and immature function of the various organ Hands predominantly closed 1 month
systems (including the heart, lungs, kidneys, liver, blood, muscles,
Hands predominantly open 3 months
and central nervous system) that are of major importance to the
anesthesiologist. Foot play 5 months
Transfers objects from hand to hand 6 months
Psychological Differences Index finger approach to small objects 10 months
For a child’s normal psychological development, continuous support and finger-thumb opposition
of a nurturing family is indispensable at all stages of development; Plays pat-a-cake 9–10 months
serious social and emotional deprivation (including separation from
Pulls to stand 9 months
parents during hospitalization), especially during the first 2 years of
Walks with one hand held 12 months
development, may cause temporary or even lasting damage to psycho-
social development (Forman et al. 1987). A young child who is hospi- Runs well 2 years
talized for surgery is forced to cope with separation from parents, to Social smile 1–2 months
adapt to a new environment and strange people, and to experience Smiles at image in mirror 5 months
the pain and discomfort associated with anesthesia and surgery Separation anxiety/stranger awareness 6–12 months
(see Chapter 2: Behavioral Development; Chapter 15: Psychological
Interactive games: peek-a-boo and pat-a-cake 9–12 months
Aspects of Pediatric Anesthesia).
The most intense fear in an infant or a young child is created Waves “bye-bye” 10 months
by separation from the parents, and it is often conceived as loss of Cooing 2–4 months
love or abandonment. The sequence of reactions observed is often Babbles with labial consonants (“ba,” “ma,” “ga”) 5–8 months
as follows: angry protest with panicky anxiety, depression, and de- Imitates sounds made by others 9–12 months
spair, and eventually apathy and detachment (Bowlby 1973). Older
First words (approximately four to six, including 9–12 months
children may be more concerned with painful procedures and the
“mama,” “dada”)
loss of self-control that is implicit with general anesthesia (Forman
Understands one-step command (with gesture) 15 months
et al. 1987). Repeated hospitalizations for anesthesia and surgery
may be associated with psychosocial disturbances in later childhood Ages are averages based primarily on data from Arnold Gesell.
(Dombro 1970). In children who are old enough to experience Modified from Illingworth, R. S. (1987). The development of the infant
fear and apprehension during anesthesia and surgery, the emotional and young child: normal and abnormal. New York: Churchill Livingstone.
factor may be of greater concern than the physical condition; in fact,
it may represent the greatest problem of the perioperative course
(see Chapter 15: Psychological Aspects of Pediatric Anesthesia) Differences in Response to Pharmacologic Agents
(Smith 1980). The extent of the differences among infants, children, and adults in
All of these responses can and should be reduced or abolished response to the administration of drugs is not just a size conversion.
through preventive measures to ease the child’s adaptation to the hos- During the first several months after birth, rapid development and
pitalization, anesthesia, and surgery. The anesthesiologist’s role in this growth of organ systems take place, altering the factors involved in
process, as well as having a basic understanding of neurobehavioral uptake, distribution, metabolism, and elimination of anesthetics and
development, is important (Table 1.2). Anesthesiologists must also related drugs. Interindividual variability of a response to a given drug
be open to new ideas regarding the role of family-centered care, spe- may be determined by a variety of genetic factors. Genetic influences
cifically in regard to pediatric patients with psychiatric diagnoses or in biotransformation, metabolism, transport, and receptor site all
special needs who may benefit from the presence of service animals. affect an individual’s response to a drug. These changes appear to
Ambardekar and colleagues (2013) reported on the use of a service be responsible for developmental differences in drug response and
animal to help with the induction of anesthesia. can be further modified by age-related and environmental factors.
The pharmacology of anesthetics and adjuvant drugs and their differ-

ent effects in neonates, infants, and children are discussed in detail in 30
65
Part II (Pharmacology). 60
55 25
0.8
Anatomic and Physiologic Differences 50
Body Size 95 0.7 45
3 90 20
As stated, the most striking difference between children and adults is 34 40
85 0.6
size, but the degree of difference and the variation even within the 32 35
80
pediatric age group are hard to appreciate. The contrast between an 30 15
75 0.5
infant weighing 1 kg and an overgrown and obese adolescent weighing 30
28 70
more than 100 kg who appear in succession in the same operating
26
Surface area in square meters

65 25
room is overwhelming. It makes considerable difference whether body 0.4
weight, height, or body surface area (BSA) is used as the basis for size 2 60 10
comparison. As pointed out by Harris (1957), a normal newborn in- 20
22 55
fant who weighs 3 kg is 1/3 the size of an adult in length, but 1/9 the
Height in centimeters
0.3
20
Weight in kilograms
adult BSA and 1/20 the adult weight (Fig. 1.1). Of these body measure- 50
Weight in pounds
15
Height in feet
ments, BSA is probably the most important, because it closely parallels
18 45
variations in basal metabolic rate measured in kilocalories per hour
per square meter. For this reason, BSA is believed to be a better crite- 5
16 40
rion than age or weight in judging basal fluid and nutritional require- 0.2
10
ments. For clinical use, however, BSA proves somewhat difficult to
14 35
determine, although a nomogram such as that of Talbot and associates
(1952) facilitates the procedure considerably (Fig. 1.2). For the anes-
thesiologist who carries a pocket calculator, the following formulas may 1 30
be useful to calculate BSA:
10
Formula of DuBois and DuBois (1916 ) 9 5
25 0.1
BSA (m2 ) 0.007184 Height 0.725 Weight 0.425 8
Formula of Gehan and George (1970 )

20
BSA (m 2
) = 0.0235 Height 0.42246
Weight 0.51456
.
Fig. 1.2 Body Surface Area Nomogram for Infants and Young Children.

(From Talbot, N. B., Sobel, E. H., McArthur, J. W., & Crawford, J. D. (1952).

Functional endocrinology from birth through adolescence. Cambridge, MA:

Harvard University Press.)
At full-term birth, BSA averages 0.2 m2, whereas in the adult it aver-
ages 1.75 m2. Table 1.3 shows the relation of age, height, and weight to
BSA. A simpler, crude estimate of BSA for children of average height
and weight is given in Table 1.4. The formula is also reasonably accu-
rate in children of normal physique weighing 21 to 40 kg (Vaughan
and Litt 1987):
BSA (m2 ) ( 0.02 kg) 0.40.
The caloric need in relation to BSA of a full-term infant is about

30 kcal/m2 per hour. It increases to about 50 kcal/m2 per hour by
2 years of age and then decreases gradually to the adult level of 35 to
40 kcal/m2 per hour.
Relative Size or Proportion

Weight Surface Length
1/21 area 1/3.3
Less obvious than the difference in overall size is the difference in rela-
1/9 tive size of body structure in infants and children. This is particularly
Fig. 1.1 Proportions of Newborn to Adult With Respect to Weight,

true with the head, which is large at birth (35 cm in circumference)—
Surface Area, and Length. (Data from Crawford, J. D., Terry, M. E., &

in fact, larger than chest circumference. Head circumference increases
Rourke, G. M. (1950). Simplification of drug dosage calculation by by 10 cm during the first year and an additional 2 to 3 cm during the
application of the surface area principle. Pediatrics, 5, 785.) second year, when it reaches three-fourths of the adult size (Box 1.1).
TABLE 1.3 Relation of Age, Height,

and Weight to Body Surface Area (BSA)*
Age (years) Height (cm) Weight (kg) BSA (m2)
Premature 40 1 0.1
Newborn 50 3 0.2
1 75 10 0.47
2 87 12 0.57
3 96 14 0.63
5 109 18 0.74
10 138 32 1.10
13 157 46 1.42
16 (Female) 163 50 1.59
16 (Male) 173 62 1.74
*Based on standard growth chart and the formula of DuBois and
DuBois (1916): BSA (m2) 5 0.007184 3 Height0.725 3 Weight0.425.
Fig. 1.3 A Normal Infant Has a Large Head, Narrow Shoulders and

Chest, and a Large Abdomen.

TABLE 1.4 Approximation of Body Surface
Area (BSA) Based on Weight
Weight (kg) Approximate BSA (m2) muscles. Furthermore, the rib cage is cartilaginous, and the thorax is
1–5 0.05 3 kg 1 0.05
too compliant to resist inward recoil of the lungs. In the awake state,
the chest wall is maintained relatively rigid with sustained inspiratory
6–10 0.04 3 kg 1 0.10
muscle tension, which maintains the end-expiratory lung volume
11–20 0.03 3 kg 1 0.20 (i.e., FRC). Under general anesthesia, however, the muscle tension is
21–40 0.02 3 kg 1 0.40 abolished and FRC collapses, resulting in airway closure, atelectasis,
and venous admixture unless continuous positive airway pressure
Modified from Vaughan, V. C., III, & Litt, I. F. (1987). Assessment of
growth and development. In R. E. Behrman & V. C. Vaughn III (Eds.),
(CPAP) or positive end-expiratory pressure (PEEP) is maintained. (See
Nelson’s textbook of pediatrics (13th ed.). Philadelphia: Saunders. Chapter 3: Respiratory Physiology.)
Central and Autonomic Nervous Systems

The brain of a neonate is relatively large, weighing about 1/10 of the
BOX 1.1 Typical Patterns of Physical Growth body weight compared with about 1/50 of the body weight in an adult.
Weight The brain grows rapidly; its weight doubles by 6 months of age and
Birth weight is regained by the 10th to 14th day. triples by 1 year of age. By the third week of gestation, the neural plate
Average weight gain per day: 0 to 6 months 5 20 g; 6 to 12 months 5 15 g. appears, and by 5 weeks’ gestation, the three main subdivisions of the
Birth weight doubles at 4 months, triples at 12 months, and quadruples at forebrain, midbrain, and hindbrain are evident. By the eighth week of
24 months. gestation, neurons migrate to form the cortical layers, and migration is
During the second year, average weight gain per month: 0.25 kg. complete by the sixth month. Cell differentiation continues as neu-
After 2 years of age, average annual weight gain until adolescence: 2.3 kg. rons, astrocytes, oligodendrocytes, and glial cells form. Axons and
synaptic connections continually form and remodel. Fig. 1.4 plots
Length/Height gestational brain growth as a percentage of brain weight at term
By the end of the first year, birth length increases by 50%. (Kinney 2006). At birth, about one-fourth of the neuronal cells are
Birth length doubles by 4 years of age and triples by 13 years of age. present. The development of cells in the cortex and brain stem is nearly
Average height gain during the second year: 12 cm. complete by 1 year of age. Myelinization and elaboration of dendritic
After 2 years of age, average annual growth until adolescence: 5 cm. processes continue well into the third year. Incomplete myelinization
is associated with primitive reflexes, such as the Moro and grasp re-
Head Circumference
flexes in the neonate; these are valuable in the assessment of neural
Average head growth per week: 0 to 2 months 5 0.5 cm; 2 to 6 months 5
development. (See Chapter 27: Neonatology for Anesthesiologists.)
0.25 cm.
At birth, the spinal cord extends to the third lumbar vertebra. By
Average total head growth: 0 to 3 months 5 5 cm; 3 to 6 months 5 4 cm;
the time the infant is 1 year of age, the cord has assumed its permanent
6 to 9 months 5  2 cm; 9 to 12 months 5 1 cm.
position, ending at the first lumbar vertebra (Gray 1973).
In contrast to the central nervous system, the autonomic nervous
system is relatively well developed in the newborn. The parasympa-
At full-term birth, the infant (Fig. 1.3) has a short neck and a chin thetic components of the cardiovascular system are fully functional at
that often meets the chest at the level of the second rib; these infants birth. The sympathetic components, however, are not fully developed
are prone to upper airway obstruction during sleep. In infants with until 4 to 6 months of age (Friedman 1973). Baroreflexes to maintain
tracheostomy, the orifice is often buried under the chin unless the head blood pressure and heart rate, which involve medullary vasomotor
is extended with a roll under the neck. The chest is relatively small in centers (pressor and depressor areas), are functional at birth in awake
relation to the abdomen, which is protuberant with weak abdominal newborn infants (Moss et al. 1968; Gootman 1983). In anesthetized
Cardiovascular System
HUMAN BRAIN GROWTH During the first minutes after birth, the newborn infant must change
100 his or her circulatory pattern dramatically from fetal to adult types of
90 circulation to survive in the extrauterine environment. Even for several
months after initial adaptation, the pulmonary vascular bed remains
80
% Full-term brain weight
exceptionally reactive to hypoxia and acidosis. The heart remains ex-

70 tremely sensitive to volatile anesthetics during early infancy, whereas
60 the central nervous system is relatively insensitive to these anesthetics.
50 Complicating factors involving the cardiovascular system are the
40 age-related changes and large variability in vital signs that occur with
age. This is especially pronounced in newly born term and premature
30
infants. As a result, defining hypotension in these infants becomes
20 challenging. Cardiovascular physiology in infants and children is dis-
10 cussed in Chapter 5 (Cardiovascular Physiology) and Chapter 27
0 (Neonatology for the Anesthesiologist).
18 20 22 24 26 28 30 32 34 36 38 40
Fluid and Electrolyte Metabolism
Gestational age (wks)
Like the lungs, the kidneys are not fully mature at birth, although the
Fig. 1.4 Normal Brain Growth From 20 to 40 Weeks’ Gestation.

formation of nephrons is complete by 36 weeks’ gestation. Maturation
Brain weight is expressed as a percentage of term brain weight. (From
continues for about 6 months after full-term birth. The glomerular fil-
Kinney, H. C. (2006). The near-term (late preterm) human brain and risk tration rate (GFR) is lower in the neonate because of the high renal
for periventricular leukomalacia: A review. Seminars in Perinatology, 30, vascular resistance associated with the relatively small surface area for
81–88. Data from Guihard-Costa, A. M., & Larroche, J. C. (1990). Dif- filtration. Despite a low GFR and limited tubular function, the full-term
ferential growth between the fetal brain and its infratentorial part. Early newborn can conserve sodium. Premature infants, however, experience
Human Development, 23(1), 27–40.) prolonged glomerulotubular imbalance, resulting in sodium wastage
and hyponatremia (Spitzer 1982). On the other hand, both full-term and
premature infants are limited in their ability to handle excessive sodium
newborn animals, however, both pressor and depressor reflexes are loads. Even after water deprivation, concentrating ability is limited at
diminished (Wear et al. 1982; Gallagher et al. 1987). birth, especially in premature infants. After several days, neonates can
The laryngeal reflex is activated by the stimulation of receptors produce diluted urine; however, diluting capacity does not mature fully
on the face, nose, and upper airways of the newborn. Reflex apnea, until after 3 to 5 weeks of life (Spitzer 1978). After water deprivation in
bradycardia, or laryngospasm may occur. Various mechanical and the term infant, the urine concentrating ability is only about 50% to 60%
chemical stimuli, including water, foreign bodies, and noxious gases, that of an adult. The premature infant is prone to hyponatremia when
can trigger this response. This protective response is so potent that it sodium supplementation is inadequate or with overhydration. Further-
can cause death in the newborn (see Chapter 3: Respiratory Physiology; more, dehydration is detrimental to the neonate regardless of gesta-
Chapter 5: Cardiovascular Physiology). tional age. The physiology of fluid and electrolyte balance is detailed in
Chapter 6 (Regulation of Fluids and Electrolytes).
Respiratory System
At full-term birth, the lungs are still in the stage of active development. Temperature Regulation
The formation of adult-type alveoli begins at 36 weeks postconception Temperature regulation is of particular interest and importance in
but represents only a fraction of the terminal air sacs with thick septa pediatric anesthesia. There is a better understanding of the physiology
at full-term birth. It takes more than several years for functional and of temperature regulation and the effect of anesthesia on the control
morphologic development to be completed, with a 10-fold increase in mechanisms. General anesthesia is associated with mild to moderate
the number of terminal air sacs to 400 to 500 million by 18 months of hypothermia, resulting from environmental exposure, anesthesia-
age, along with the development of rich capillary networks surround- induced central thermoregulatory inhibition, redistribution of body
ing the alveoli. Similarly, control of breathing during the first several heat, and up to 30% reduction in metabolic heat production (Bissonette
weeks of extrauterine life differs notably from control in older children 1991). Small infants have a disproportionately large BSA, and heat loss
and adults. Of particular importance is the fact that hypoxemia de- is exaggerated during anesthesia, particularly during the induction of
presses, rather than stimulates, respiration. Anatomic differences in the anesthesia, unless the heat loss is actively prevented. General anesthesia
airway occur with growth and development. Recently, the age-old decreases but does not completely abolish thermoregulatory threshold
concept of the child having a funnel-shaped larynx with the cricoid as temperature to hypothermia. Mild hypothermia can sometimes be
the narrowest portion of the airway has been challenged (Holzki et al. beneficial intraoperatively, and profound hypothermia is effectively
2018). Findings by Litman and colleagues (2003) using MRI and used during open heart surgery in infants to reduce oxygen consump-
video-bronchoscopic images by Dalal and colleagues (2009) both re- tion. Postoperative hypothermia, however, is detrimental because of
vealed that the shape of the infant larynx was more cylindrical (as for marked increases in oxygen consumption, oxygen debt (dysoxia), and
adults) than funnel shaped and did not change much with growth. resultant metabolic acidosis (Bissonette 1991). In the surgical neonate,
They also suggested for infants and children that the glottis, not the hypothermia in the perioperative period occurs frequently and has
cricoid, may be the narrowest portion in the paralyzed or cadaveric been associated with adverse events (Morehouse et al. 2014; Engorn
position (which can be gently widened with an ETT); the cricoid re- et al. 2017). The use of forced-air warming devices has become an
mains the solid narrowest segment of the upper airway system. The important component in the prevention of intraoperative hypother-
development of the respiratory system and its anatomy and physiology mia. Though concerns about its use and association with surgical
are detailed in Chapter 3 (Respiratory Physiology). site infection have been raised, clinical evidence for this is lacking.
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into unconsciousness, with her heart hammering again, and her wild
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familiar peace lulled her into calm again.
That writhing, shadowy white-and-gray thing, in the white-and-gray
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snow. Horse—big dog—child—no, it was a terrible yellow-faced old
woman! What a whining cry she had given! And how astonishing
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Well, whether she had walked home in the blizzard or gone up the
chimney on a broomstick was, after all, not Gay’s affair. But she had
most assuredly not been driven in to Keyport or Crowchester by
John! Gay thought that she was meeting this old forlorn, half-witted
thing again in the snowy lane—but this time David was with her....
CHAPTER VIII
The rest of the house party was to her a thrilling, but too rapidly
flying, dream. The young people walked, rosy and whirled and
beaten and shouting with laughter, in the formidable ending of the
storm the next day; they ate ravenously, laughed a great deal, and
formed a whole new series of those special jokes and phrases that
come into being in every successful house party. A dozen small
incidents a day sent them into gales of mirth, and the recollection
and recounting of these same incidents rendered everyone
incoherent and hysterical at meals.
On the third day of the five the sun came out resplendent and
dazzling, if not very warm, and the sea turned a clear sapphire, with
jade-green lights where the chastened waves broke over the rocks.
The sky was pale, high, clear, and bright as enamel, and the snow
frozen hard underfoot. Skating was attempted in the old tennis-court;
there was snowballing, faces grew hot, and deluges of the soft and
silent cotton fell from low branches and spattered the girls’ coats and
the men’s shoulders. Maids were always sweeping the mud- and
snow-strewn side entry now, and hurrying away with wet wraps.
On the last night came the Christmas dance, when everybody knew
everybody else, and the mere hasty dinner beforehand and the
ecstasy of dressing after dinner were—Gabrielle thought—delight
enough. They had trimmed the house yesterday with holly and
greens, and even the Montallens had pushed chairs about with
hearty good-will and climbed on ladders to try out chandeliers.
Gabrielle told herself a hundred times that she must refuse to dance
—she did not really know how to dance well—she was the youngest,
anyway, and must make herself Sylvia’s right hand, as hostess.
But in the end, studying herself in the café-au-lait lace gown, which
came up almost to the round creamy column of her throat and down
almost to her ankles, and which had long, delicately fluted sleeves to
her very wrists and was altogether demure to the point of affectation,
Gay hoped that she would be asked to dance. Frank du Spain would
surely be kind if she did not dance very well.
“There will be a dozen prettier dresses to-night than this one!” she
told herself, going slowly downstairs and wishing in a panic that the
others had waited for her. Suppose they laughed at this dress—nuns
and graduate pupils as old as the Countess might not be supposed
to know much about clothes.
However, only a few guests had arrived, shy charming girls and boys
from the old mansions in and about Crowchester; the musicians
were tuning up deliciously, and the big floor shone inviting and bare.
Sylvia, being introduced and introducing with her mother’s and
David’s help, had time to say generously, “It’s charming! It’s just right
for you, Gay, absolutely suitable!” and Gay’s heart soared and her
cheeks warmed; she became the pleasantest and most efficient of
hostesses: piloting mothers and guardians to chairs, chatting simply
and merrily, and too absorbed in the delightful scene to know or care
what was happening to herself.
Aunt Flora was quite magnificent in plum colour; her nearest
approach in many years to clothing that was not mourning. The
Montallen girls were pretty in pink-and-silver and blue-and-silver
gauze. Sylvia was superb in a simple white brocade with a thread of
gold—her gold slippers made her look unusually tall—and there was
a gold spray of something that looked like thistledown in her hair.
Gabrielle was near enough to her sometimes to hear the pleasant
sweetness of her replies to neighbourly greetings.
“Indeed I remember the Robinsons! I shall be coming home very
soon now, you know, Doctor, and I certainly mean my good
neighbours to be part of the new life! Mrs. George, and this is never
Betty! Well, Betty——! No, but I shall really be home in June, and
then we’ll make some changes here, and see if we can’t make
Wastewater a little more comfortable!”
And now and then she turned to David, in a fashion that was sisterly,
yet not quite sisterly either, and with her lovely smile.
“David, I wonder if you’d call Maria’s or Daisy’s attention to those
candles? They’ll be dripping directly.” Or, “David, will you send Mrs.
Wilkinson’s coat upstairs? She doesn’t want to go up——”
Gabrielle was talking to a nice old couple, established expectantly at
one of the two card tables that had been provided, when the first
dance started. Sylvia was still in the receiving line beside her mother,
but David came up to the card table with another bridge-playing
elderly couple, and when the four had settled themselves and cut the
new pack, he stood smiling before Gay, with his tall, sleek black
head a little bent, and his smiling eyes on her, and his arms open.
“Come on, Gay!”
“Oh, but, David,” she said, flurried, “I don’t dance! At least, I know I
dance badly, for it’s been mostly with girls! Really—really I’d rather
not——”
David altered neither his position nor his expression.
“Come on!” he said. And Gay, with her face flushing exquisitely
under the warm, colourless skin, put herself into his arms. And this
was for her the wonderful moment of a wonderful evening; she liked
to remember that happy second, when the lights and music and
flowers and voices were all shining and flashing together in the
shabby old ballroom, and David had made her dance with him.
They moved off smoothly. There were a few other couples already
dancing, and presently David said: “I got the book, Miss Mansfield’s
book, with your dolls’-house story in it, and it is truly remarkable.”
“Oh, I’m so glad you read it for yourself!” Gay exclaimed.
“You gave it to me quite as effectively,” David commented, and was
still again. But after a few moments, while they were walking before
the first encore, he said: “You dance delightfully. Don’t have the
slightest hesitation about dancing!” And later, when they came up to
Sylvia and Aunt Flora, he repeated to them: “She dances perfectly,
of course. I’ve been trying her out. I hope we’ll hear no more of this
not-being-able-to-dance!”
Gay had a second’s uncomfortable impression that Sylvia was not
quite pleased; but as David immediately carried Sylvia off for the
second dance, there was no time to wonder at it. Gay dutifully took
Sylvia’s place beside her aunt, but almost all the guests had arrived
now; the girls and Aunt Flora had counted them, forty-three, a
hundred times, but now Flora whispered with a sort of agitated pride
that there were fifty-one, and, with the household, sixty-one. It was
many years since Wastewater had had a party of this size!
“Sylvia says that we must have a furnace put in,” sighed Flora, “and
that means tearing up floors—goodness knows what——”
Gay now plunged into the delights of her first real dance with all the
ecstasy of eighteen. She danced with any one and everyone, she
scarcely knew or cared with whom, but she was always conscious of
David, who, in his character as host, was obviously taking upon
himself the responsibility for whatever girl looked momentarily like a
wallflower, or whatever elderly woman needed an escort across the
room.
The glorious, crowded hours flew by, with laughter and compliments
and music, with icy brief drinks, and the exchanges of
congratulations.
“Isn’t it all wonderful! We’re having the most wonderful time!”
“Isn’t it! I’m so glad you’re liking it!”
Then presently there was an old-fashioned and lavish supper, with
bonbons and laughter, and Sylvia in a red-white-and-blue tissue cap
that made her look like a beautiful, proud young Liberty, and Gay
mischievous and delicious under a pomponned black-and-white
Pierrette hat. It was long after midnight, and the first good-byes were
being said, when Gay found herself sitting on the first step above the
dim landing with David.
“I discovered this place,” said David, panting, and wiping his
forehead frankly. “You can look down on them and they can’t see
you. Glory——! It’s warm.”
Gay sat sweetly cool and radiant beside him; her little slippers were
planted neatly in front of her, not a hair of the bright waves was
disordered, her skin had the cool dewy freshness of a child’s skin.
“Having a good time, Gay?”
“Oh, David!”
“What did you want to speak about?” he asked. For she had begged
him for a quiet word.
“It’s this,” Gay began. She was still talking rapidly and earnestly, five
minutes later, when Sylvia came tripping down behind them from the
dimly lighted upper hall, with some well-wrapped women following.
“Sorry to disturb you! David, I think perhaps you’d better come
down,” said Sylvia. “People are going.”
Gay and David stood up, and Gay realized then for the first time that
she had had her fingers gripped tightly on David’s arm, and for some
obscure reason felt a little self-conscious about it.
They all went downstairs, and there were no more confidences that
night. To Gay, who was tired out with felicity, the rest was all a blur.
She managed to hang up the lace gown carefully, but left her other
clothing and her slippers where they fell, and tumbled into bed with
her massed hair untouched, nearer sleep already than waking.
And the next day was confusing, too. Even the girls looked weary,
and the packing went on between yawning and laughing
reminiscences, and congratulations upon what had really been a
great success.
Outside were a low unfriendly sky and a strong wind across the
snow. The sea was rough and wild, bare branches bent and whipped
noisily about in the garden, and windows rattled. The house seemed
big and blank this morning, with fallen leaves and oddly disposed
furniture standing in the forlornly empty rooms that had looked so
bright and gay last night. John was in the house, with dry sacking
bagged over his boots as he moved palms about. But there was a
roaring fire in the airtight stove in the dining room, and another in the
downstairs sitting room, and the young persons, waiting for the
sleigh to take them to their train, gathered there.
David kept rather close to Gay, in an unobtrusive big-brotherly
manner, during the good-byes, and once he nodded to her and said
briefly: “All fixed. Don’t worry,” but if Sylvia saw these cryptic
indications she had no explanation of them until the following day.
She did note, she remembered afterward, that Frank du Spain’s
farewells to them all, and especially to David and Gay, were rather
odd; not quite pugnacious, not quite defiant, but with an odd touch of
some such quality. David enlightened her on the next afternoon,
when the family was alone again.
This was Christmas Day, and they had all gone in the sleigh to
Crowchester to church in the morning, and, although Wastewater
had hardly even now recovered from its unwonted festivities, there
had been the usual great turkey, icy red cranberry jelly, crackling
celery, and bubbling mince pies that indicated a fresh celebration.
This meal, served in the warm dining room at half-past two, after the
cold drive and wait, had reduced all the family to a state bordering
upon comfortable coma. Sylvia, sleepily declaring that she meant to
take a brisk walk, collapsed into an armchair before the fire
immediately after the mid-afternoon dinner. David, determining from
moment to moment to go upstairs and get into tramping clothes, took
a chair on the other side; Flora went up to her room, where she
indulged in the unheard-of relaxations of her wrapper and a nap on
the top of her stiff, cold bed, with a comforter over her; and Gay,
whose skin felt prickly and whose head heavy, and who had enjoyed
the mince pies and the chestnut dressing and the walnuts only too
well, wrapped herself up warmly, left a message with Maria, and
slipped quietly out of the side door.
John was going into Keyport at five to take Margret home after the
last of the Christmas dinner had been discussed in the kitchen;
Gabrielle would walk the three miles in the roaring wind, and he
could bring her home.
The gale tore at her gaily, whistled in her ears, stung her flushed
face into chilly bloom again; rushes of spray blew across the dune
road, and the sea boiled and tumbled beside her. Gulls were blown
overhead, balanced yet tipped sidewise in the wild airs. The wind
sang high above her.
Other pedestrians, similarly affected by Christmas cheer, were
walking bundled and blown and bent forward, along the roads, and
these and Gay exchanged joyous shouts of “Merry Christmas!” It
was good—it was good—the girl exulted, to be out on such a day!
Meanwhile Sylvia and David, left alone by the sitting-room fire, with
only the occasional dropping of a coal or the onslaught of wind
against the shutters to interrupt them, could have the first real talk
they had had since their arrival at Wastewater. David, stretched
luxuriously in his chair, was free to study her, as she sat erect and
beautiful in the pleasant mingling of gray afternoon light and warm
firelight. He had always had a definite feeling of admiration, loyalty,
affection for and confidence in Sylvia, and he felt it still. But for the
first time, in this past week, she had seemed oddly to take her place
down on the comfortable level of other human beings. She no longer
seemed—as she so long had seemed—a creature unique and apart,
a little more beautiful, more fortunate, more clever than the rest. Her
mother and he had watched her grow up—a bright little
conscientious girl with dark braids, a splendid twelve-year-old,
fifteen-year-old, meeting all the problems and the increasing
responsibilities of life so willingly, so conscientiously; prettier every
year, more responsive and satisfactory every year.
And then presently she had been recognized as Uncle Roger’s
heiress, and she was to own Wastewater one of these days, and the
very substantial properties that went with Wastewater. David had
initiated her, responsive and serious, into the secrets of her first
allowance, her checkbook, her accounts. Did she know that she
would be rich some day?
She had answered in Victoria’s grave little phrase: “I had not known I
was so near the throne!” And since that time, now several years ago,
David had more than once thought that the proud beautiful young
creature had really felt herself, in a certain sense, a queen, had
really been a queen in her own little circle. Quite without realizing it,
he had always seen a little halo, a little aura, about Sylvia.
Always—until now. David had always told himself that he dare not
ask Sylvia to be his wife, although she was the woman he knew best
and admired most in the world. It was an old habit of his to think of
her as the person he would have wished to marry had it been
possible to unite her youth and beauty and wealth to the small
income, the uncertain profession, and the ten years’ seniority of a
man who was to her a sort of older brother.
But he knew to-day that he could ask her. She had oddly seemed to
come into his zone during this holiday week; it was not that she was
less beautiful, less rich, less admirable. But she was—different, or he
was. She was just an extremely charming and fortunate girl of
twenty, who might love him as well as, perhaps better than, any
other man. She was splendidly high-principled and intelligent, but
even these qualities, at self-confident twenty, were not the surest
guides in the world. Oddly and unexpectedly enough, he had once or
twice experienced, just lately, a queer little pang of something like
pity for Sylvia. She impressed him as someone who had little to
learn, but much to experience.
Gay, on the other hand, was engagingly diffident and teachable. She
had a well-balanced little head, she had excellent judgment, she
played the piano nicely, spoke French perfectly, the Montallen girls
had said, and danced even better than she knew. But one felt that
there were no falls ahead of Gay, no humiliating descents from any
heights, simply because she had never scaled any heights. David
was not analytical enough to know that it was the sisterly little Gay
who had quite innocently and unconsciously shifted his attitude
toward Sylvia. Gay had told him of a delightful book that Sylvia called
“pretty thin.” Gay had said fervently, “Oh, thank you, David, you’ve
saved me!” when he had done her a small service yesterday. Gay
had quoted him, followed him with her eyes, consulted him, paid him
a score of compliments in her charming little-girl way; and Gay was
an exceptionally lovely young woman. Whatever her antecedents,
she was delightful, eager, receptive, unaffected, and like a nice child,
with her willing flying feet, her big eyes, her softly tumbled tawny
hair, and her husky, protestant, velvety little voice.
To-day, while he was idly thinking of what life would be when Sylvia
had taken possession of her inheritance, and had had her year or
two of independence, and then had agreed to be his wife, Sylvia
suddenly spoke of Gay.
“Have you any idea what she wants to do with herself, David?”
“Gay?”
Sylvia nodded.
“Mamma seems to feel nothing definite about it, and I couldn’t get
anything out of her. She said something vague about being an
actress! I suppose she’s at that age.”
And Sylvia smiled good-naturedly as she looked into the fire.
“She’s not happy here?” David asked, slowly.
“Yes, in a way I think she is. She’s young, of course, to try her wings,
and Mamma says she is really very conscientious about her
practising and languages. But of course this isn’t the place for her.”
“Isn’t?” David asked, looking up.
“No. In the first place, it’s too dull. In the second——”
“Why, there are some nice kids over at Crowchester,” David
suggested, “and she seems happy here. Then you’ll be home at
midsummer——”
“Yes, I know, David,” Sylvia said, with a sudden colour in her face.
“But at the same time I don’t feel that just idling here is quite the right
solution for Gay. And I think it my duty, in a way, to think out, for her,
what is the right solution,” added Sylvia, with a smile. “She’s
handsome—she has her mother’s most unfortunate experience back
of her, and—if she should marry even six or eight years from now, it
would surely be better to launch her first into some interesting and
absorbing line of work.”
“She may marry before that!” David said, with a significant half smile.
“She had her first offer, it appears, on the night of the dance, and she
was quite upset about it.”
“Her first offer!” Sylvia echoed, in stupefaction. “One of the
Crowchester boys?”
“No, I don’t think she knows any of them well. Aunt Flora doesn’t
encourage any neighbourliness exactly. No, it was young Du Spain,”
David said.
“Frank du Spain!”
“It would appear that it was love at first sight with him.”
Sylvia stared a moment; hot colour in her face.
“I don’t believe it!” she said, finally.
“Oh, it was honest and above-board enough. That was the very point
of her speaking to me as she did,” David assured her, half amused
and half serious. “It seems he spoke to her at the dance——”
“He must be twenty!” Sylvia broke in, impatiently.
“Twenty-four, he says. I don’t imagine,” David said, leniently, “that he
had any immediate hopes, or indeed plans. But he assured her that
he was free, and that his father was only too anxious to have him
settle down; he said that his mother would ask her to visit them—at
Lake Forest, I believe, this summer. He wanted a promise of some
sort—he was in an absolute fever of excitement and eagerness
when he left—almost wrenched my hand off!”
“David, you didn’t——But it’s all too absurd! You didn’t encourage
them in this sort of nonsense?”
“Them? My dear Sylvia, you couldn’t have disposed of an
unwelcome suitor more calmly yourself than Gay did!” said David.
“She told him, it appears, that she was very much honoured, and she
really liked him, but he please wasn’t to say anything more about it
for months, until after midsummer, in short. She only told me
because he insisted that somebody—anybody—be informed that he
never would change, and was in earnest, and all that. And he wants
to correspond, and she felt that she ought to speak to Aunt Flora
about that.”
“One wonders why she didn’t speak to Mamma in the first place,”
Sylvia said, slowly, remembering the farewells, and perhaps
unreasonably resenting a little Gay’s secret and Gay’s handling of it.
“She seems to want to dismiss the whole thing,” David explained. “I
only mention it as a suggestion that she may solve her own
problems in her own way one of these days.”
“And you really think she ought to live along here calmly, doing
nothing, and dependent upon other people?” Sylvia asked, with an
anxious and appealing little frown.
“Who, Gay?” said Flora Fleming, who had come downstairs and was
now being settled by David in her usual chair. “But there is no talk
about her going away, is there?” she asked, blinking through her
glasses from one face to another.
“Not immediately, Mamma dear,” Sylvia answered, with just a faint
hint of impatience in her voice that amused David with the realization
that he had never before seen Sylvia so human, and incidentally so
approachable. “But I suppose she will not stay here always. That
wouldn’t be fair to her or to you!”
“Oh, but what would you have her do, Sylvia?” demanded her
mother in alarm.
“Nothing definite, and don’t you two dear good people talk as if I
were an ogre!” Sylvia said, with a laugh. “What I had vaguely in mind
was some nice place—there are hundreds near the college—where
she could have some young life and at the same time, by courses or
special instruction, be fitting herself for her life work, whatever it’s to
be! That was my entire idea, I assure you.”
David took refuge in his usual thoughtful study of the fire; Aunt Flora
flung her yarn free with nervous fingers. Winter twilight was turning
the windowpanes opaque, and the room was warm and close.
“You mean that we should make her an allowance, Sylvia?” her
mother asked.
“Well—until she is on her own feet, of course. Pay her board, see
that she has the right clothes, and pocket money. But the quickest
way to be sure that she will take life seriously,” Sylvia said, “is not to
make it too easy for her!”
“But would you want her really to—to work, Sylvia?” demanded her
mother, as David, staring into the embers, with his locked hands
dropped between his knees, was still silent.
“Well, but, Mamma, wouldn’t you?” Sylvia countered. “With her
antecedents, perhaps inheriting that unfortunate nature of poor Aunt
Lily’s——”
“You never saw Aunt Lily!” David was upon the point of saying, good-
naturedly. But although Sylvia had indeed been only three or four
years old when frail, melancholy Aunt Lily had made the final
disappearance into a sanitarium that ended much later with her
death, he realized that Aunt Flora had talked frequently about her
and held his peace.
“Inheriting that unhappy nature from Aunt Lily,” pursued Sylvia, “and
inheriting goodness knows what from that casual father of hers—
who might, I suppose, turn up here any day and make trouble for all
of us—it does seem to me wisest to lay the basis of a normal, useful
life of her——”
“Her father’s dead!” Flora interrupted, with a sort of pain in her voice,
as Sylvia paused.
“You don’t know that, Mamma.”
“No, but if he isn’t,” David said, “he’s dead to us. He has built up a
new life somewhere that he is only too anxious to keep from our
knowledge. If he had been in trouble he would have appeared fast
enough!”
“Still, Sylvia,” said Flora, trembling, “I should wish—and I know David
would—that Gay should have some sort of allowance made for her,
always. I know your uncle—I know Roger would want her not to have
to worry about money—say, a hundred and fifty a month! Or two
hundred——”
“Do you mean just paid out of the estate?” Sylvia demanded, in
honest astonishment, and with a natural little resentment that her
plans for Gay should be so outdistanced by the others’ ideas. “But,
David—don’t you think that would be too ridiculous?” she asked,
anxiously turning toward him, after a surprised study of her mother’s
flushed face.
“I think we can arrange it very nicely, somehow,” David said,
soothingly. “No need to go into it now, for she will certainly stay here
with Aunt Flora until you come home, at midsummer. And in the
meantime she may either form her own plans, or perhaps,” he added
more lightly, “perhaps another Frank du Spain will come on the
scene, with better success!”
Flora, diverted, asked him his meaning, and Sylvia thought she took
a surprising amount of interest in the immature affair. Young Du
Spain had told her he would inherit something, Flora said, and he
seemed a nice, cheerful young fellow. It seemed a great pity that
they were not older—that something definite might not come of it!
“Even now,” Flora argued, knitting fast, “if he really got a position,
through his father—Gay will have something—I would certainly not
let her go to him entirely empty-handed,” she went on, half aloud, as
if reasoning with herself. David remembered suddenly that, after all,
he and she were administrators of the estate until mid-June; they
would solve Gay’s problem somehow before that; he hardly
imagined Sylvia afterward disputing or changing any arrangement
that they made about Gay.
Perhaps Sylvia remembered this, too, and decided that her only
policy was a waiting one, until her full inheritance and liberty should
be put into her hands. She fell into kindly desultory talk about Gay,
how pretty the girl had grown, and how nicely mannered she was.
But when Flora, who seemed nervous and disturbed, presently got
up and went out of the room, Sylvia said to David:
“What I really have in the back of my head is that Mamma and I shall
have a long holiday in Europe next winter. I’ve never been, and it
would be wonderful to see England in the fall, and Paris, with all the
chestnuts turning red, and then settle down somewhere for two or
three months, perhaps, on the Riviera. It would do her a world of
good, and she seems upset of late. I think Gay’s being here,” Sylvia
added, thoughtfully, looking straight up into David’s eyes now, as
they stood together before the hearth, “has roused old, sad
memories, and I feel that I—well, I owe Mamma this holiday, after
these years when I’ve seen so little of her! I’ll get all my new
responsibilities here straightened out as soon as I can, graduate,
perhaps get paperers and furnace men working here, under Hedda
and Trude, before we go, and then have a real vacation before we
come back,” she finished, smiling, “to be the Flemings of Wastewater
for the next forty or fifty years!”
“And of course there’s one more responsibility I hope you’ll decide to
assume, Sylvia,” David said, significantly, quite unexpectedly to
himself, but with his pleasant even voice and smile unchanged.
She understood him instantly and flushed rosily.
“Perhaps I will!” she answered, bravely.
“Be thinking it over?” he pursued.
Sylvia looked down at the pretty foot she had rested on the bright
brass and iron fire rods.
“It’s rather formidable,” she said, appealingly, looking up, “all the
business, the insurance and taxes and signatures—and my
graduation—and Wastewater, and the servants coming to me! I feel
—feel a little bit overwhelmed.”
“Of course you do!” David conceded, sympathetically.
“But I think,” Sylvia said, now with one hand on his shoulder and her
dark eyes raised seriously to his, “I think I’ve always had you in
mind, David—is that a very unwomanly thing to say? Give me a little
time to get my bearings.”
“All the time you want, dear!” David said, tenderly, as she paused.
For answer Sylvia raised her flushed and lovely face, and he kissed
her solemnly. Then the girl laughed a little excitedly and held him off
with both her hands linked in his, as she said:
“There, then! Is it ‘an understanding’?”
“It’s just what you wish, Sylvia.”
“Then that’s what I wish!” Sylvia answered, gaily. “Now let’s get our
coats on and race once or twice about the garden before it’s quite
dusk. Otherwise we sha’n’t be able to eat any of that cold turkey and
peach preserve dinner that Mamma’s probably fussing about now.”
But it was quite dark in the garden, and bitterly cold and windy, and
they had made only one turn when John rattled up to the side door
with the little car, from which Gay descended, weary, blown, but in
high spirits, hungry, comfortably weary, glad to be at home again.
David thought their all coming into the house together very homelike
and pleasant; the company was gone, but the family was gathered
together to discuss the remains of the big turkey and the memories
of the house party. He thought it would be charming to have this old
house home for them all, always; Gay was all the more attractive,
after all, because of the clouds and mists that hung over her birth
and parentage, and Sylvia would quickly get her bearings; she was
too sane and fine to be upset long even by her new importance.
Then the two girls, one so dark and the other so oddly fair, would
always be great friends, and even with Uncle Roger gone, and poor
old Tom gone, and so many other voices and faces gone for ever,
Wastewater would be a home for new Toms and Rogers, and again
a hospitable and imposing landmark in the countryside.
So musing, David thought with deep satisfaction of the future. Only a
few weeks before he had felt it would be an injustice to speak to
Sylvia, Sylvia the beauty, the heiress, barely of age. But Sylvia had
been brought into his own zone, in some strange manner, during
these Christmas holidays; for the first time in her life David had seen
her as perhaps needing affectionate guidance, sympathetic advice,
as indeed the young girl she really was, for all her superiorities.
College was all very well, thought David, for the nice, ordinary sort of
girl like Gwen or Laura Montallen; it helped them to form character, a
sense of balance and proportion, to make them into real women. But
Sylvia was different, she had been born balanced and conscientious
and intelligent and industrious, she needed softening now, and the
interruption of her own serene and unquestioned will. There was
beginning to be just a hint of the pedant, just a suggestion of the rut,
about her.
It was sweet to him to think that with his love for her, his knowledge
of her affairs, his happy familiarity here at Wastewater, he might
actually give to a marriage with Sylvia more than any other man was
apt to give. That confident, straightforward decisiveness of hers was
exactly what led so many fine women into ridiculous marriages. He
could imagine Sylvia seriously telling him that she was about to
marry some engaging penniless idler: “He’s a count, you know,
David—one of the finest families in Europe!” Or perhaps she would
not marry at all; she had said laughingly of some young admirer
months ago, “Possibly he heard of Uncle Roger’s money, David!”
That wouldn’t do, either. Sylvia, pretty and spectacled, and
entertaining other nice unmarried college women here twenty years
from now was a dreadful thought.
For the world’s opinion of the proverbial guardian wedding with the
heiress David cared nothing at all. He was largely indifferent to
money; the little that he had sufficed him comfortably; his chief
expenses were for canvases and oils, and Wastewater and Keyport
supplied him with subjects the year round. Less than a dozen close
friends, a city club, an occasional dress rehearsal or first night, and a
seat alone five times a season at the opera were enough for David,
and for the rest he liked his comfortable old painting clothes, the
panorama of the seasons steadily moving onward—and always,
behind and through and above the leisurely tenor of his ways,
Wastewater.
He roused from his reverie after supper to see Gay smiling at him
from the opposite chair.
“What are you thinking about, David? You looked so serious.”
“I was thinking very happy things about the future,” David answered,
exchanging just the fleeting shadow of a half smile with Sylvia.
“Look, Sylvia, I see a likeness to Uncle Roger in Gay now!” he
added, interestedly. “It’s stronger in this picture than in the one
downstairs!”
They all three looked up at the large portrait of Roger Fleming that
was above the mantel in Flora’s upstairs sitting room. Gay was just
below it, and she twisted her tawny head to look upward, too.
“I don’t see it!” Sylvia said, narrowing her eyes to scrutinize the
painted face and the living one. “But yes, I do, the mouths are
exactly alike!” she added, animatedly. “David, is mine like that?”
Flora was not in the room; they all glanced with instinctive caution at
the door now, as it rattled in a rising wind, perfectly aware that to her
nervous self-consciousness where all family discussions were
concerned even this much would be unwelcome.
But nobody came in, and Gay ended the debate about likenesses by
reminding them cheerfully:
“Turn, Flemynge, spin agayne;
The crossit line’s the kenter skein.”
CHAPTER IX
The next morning David was surprised, and a little touched, to have
his aunt come up to him in the shadowy upper hall and embrace him
warmly. It was a long time since he had had such a kiss from Aunt
Flora.
“Sylvia’s just hinted it to me—I’m so glad, my dear, dear boy!” said
Flora. “She doesn’t want anything said of it—I understand! She
wants it just as if nothing had happened, until June—I understand!
But I must let you know that I am so delighted, David.”
And pressing his hands with a display of emotion very rare in her she
hurried on. But for this David might almost believe that he had
dreamed that little conversation with Sylvia in the firelight last night.
Sylvia really showed less feeling than her mother; Aunt Flora was
quite visibly beaming over the thought.
Yet Sylvia did show some; she was demure and sweet with David,
and on New Year’s Eve they had a few moments’ grave conversation
about the future.
“Perhaps there’ll be a young Mrs. Fleming here next year, Sylvia?”
“Oh, not quite so soon, I think. Promise me, promise me you won’t
hurry matters! But some day——” And she let her smooth, warm
hand rest in his until they were interrupted by her mother’s entrance
into the room.
Sylvia went back to college early on the day after New Year’s Day,
and David took her in to Boston, promising his aunt, however, that he
would return to Wastewater that night. And late in the afternoon,
before Sylvia went, she found an opportunity to give Gay a hint of
the state of affairs.
The two girls had managed to establish a real friendliness and were
merry and confidential and full of chatter together. Now Gay had
asked curiously, as in an ice-cold bedroom she watched Sylvia
packing her things:
“Sylvia, do you hate to go back?”
“Well, yes and no,” Sylvia said, thoughtfully. “In a way, I wish June
would hurry, and in another way I want to get every scrap of
sweetness out of my last college days. I shall be tremendously busy
when I get home, of course, for weeks and weeks, and then it’s
possible—I won’t say definitely, but it’s possible that Mamma and I
may go abroad for a few months, after that. I feel as if, in a way, I
owed Mamma a holiday.”
Gay’s face was radiant with sympathy.
“Oh, you will love it!” she said, enthusiastically, as she wrapped the
big comforter tightly about her and curled her feet up in the big
armchair. Sylvia, shuddering, blew upon her own fingers as she gave
a last look about the room.
“There, everything’s in!” she said. “Do let’s get downstairs and have
some tea as a celebration!” And to herself Sylvia added, “I wonder if
she realizes that I don’t plan to take her with us?”
But Gay was thinking: “She can’t care for David or she wouldn’t be
making plans to go away!” and in the queer, indefinable happiness
that came with this conviction, she could well afford to be indifferent
to her own plans for the summer.
When they were downstairs again and shuddering with cold, as the
heavenly warmth of the sitting room enveloped them Sylvia said:
“I should love to give Mamma a really happy time, because—next
winter—there may be changes——”
Gay, kneeling by the hearth and hammering a great smoking lump of
coal with a poker, felt salt in her mouth, and her heart sank like a
leaden weight. Sylvia’s serious yet happy tone was unmistakable.
The younger girl did not turn.
“You mean—you and David——?” she said, thickly, putting one arm
across her eyes as if the smoke had blinded her.

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Smith's Anesthesia for Infants and

Children 10th Edition Peter J. Davis

Infants and Children

Infants and Children

Franklyn P. Cladis, MD, FAAP

SMITH’S ANESTHESIA FOR INFANTS AND CHILDREN, ISBN: 978-0-323-69825-2

Chapter 30: Barry. D. Kussman retains copyright.

Library of Congress Control Number: 2021939106

Content Strategist: Sarah Barth

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Peter J. Davis, MD Branden M. Engorn, MD Jessica A. George, MD, MEd

Mary Landrigan-Ossar Ronald S. Litman, DO, ML* Lynn Martin, MD

Mark A. Rockoff, MD Donald H. Shaffner, MD Deborah Studen-Pavlovich, DMD

The appendices, which can be found online at

Finally, this edition, like the previous edition, also

In summary, considerable developments and prog-

Peter J. Davis, MD, FAAP

Peter J. Davis, MD, FAAP

Contributors, vi 22 Transfusion Medicine, 455

PART I Basic Principles and Physiology PART IV Pain Management

4. Airway Physiology and Development, 78

Although pulse oximetry greatly improved patient monitoring,

ID, Inner diameter; OD, outer diameter.

The pharmacology of anesthetics and adjuvant drugs and their differ-

Surface area in square meters

Formula of Gehan and George (1970 )

Functional endocrinology from birth through adolescence. Cambridge, MA:

BSA (m2 )  ( 0.02  kg)  0.40.

The caloric need in relation to BSA of a full-term infant is about

Relative Size or Proportion

TABLE 1.3 Relation of Age, Height,

Chest, and a Large Abdomen.

Central and Autonomic Nervous Systems

exceptionally reactive to hypoxia and acidosis. The heart remains ex-

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BSA (m2 ) ( 0.02 kg) 0.40.