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A child is not a mini adult. They differ from adults in terms of weight, shape, anatomical size and major body systems such as cardiovascular and respiratory as well as psychologically. Each organ system is immature in paediatric age group and their growth and development can dramatically affect the pharmacokinetics of different drugs. Children differ in every way from an adult thus mandating to have a basic knowledge of the pharmacokinetic and pharmacodynamic principles in paediatric population to prevent under dosing or toxicity of drugs. This review article aims to simplify the basic principles of pharmacokinetics and pharmacodynamics in paediatric population. It also highlights physiological and pharmacological differences between adults and paediatric age. We performed a PUBMED search for English language articles using keywords including pharmacology, child, paediatric anaesthesia. We also hand searched references from relevant review articles and text book chapters. We have also discussed drug interaction in anaesthesia, pharmacology pertaining to neuromuscular junction and effects of anaesthesia over the developing brain.

Background: Opioids remain the most effective component of systemic analgesia and are considered safe and beneficial when administered at the lowest effective dose. Nevertheless, their potential adverse effects may diminish the quality of the postoperative period or, in some cases, lead to life-threatening complications. This analysis examines whether the mandatory implementation of a standardised protocol offers opioid-sparing potential. Methods: In this single-centre retrospective cohort study, intraoperative opioid consumption during laparoscopic appendectomy was compared between patients anaesthetised according to a standardised protocol (n1 = 132) and those managed at clinicians’ discretion in line with good medical practice (n2 = 212). Length of hospital stay and use of intraoperative non-opioid analgesics were also assessed. Results: The total fentanyl dose administered during anaesthesia was significantly lower in the standardised protocol cohort compared to the cohort without a protocol: 3.13 μg·kg−1 (IQR: 2.98–4.08) vs. 5.19 μg·kg−1 (IQR: 3.89–6.67), p < 0.001. In the protocol cohort, the percentage of patients who received acetaminophen and metamizole was significantly higher—increasing by 57% and 23%, respectively (p < 0.001). No significant inter-cohort difference was observed in terms of length of hospital stay. Conclusions: The use of a mandatory anaesthetic protocol based on a multimodal approach had an opioid-sparing effect in children undergoing laparoscopic appendectomy. This retrospective analysis was approved by the Ethics Committee of the Medical University of Warsaw (identifier: AKBE/118/2025; date of acceptance: 12 May 2025), and the primary trial was registered in the U.S. National Library of Medicine Clinical Trials Registry (registration number: NCT05238506; date of first registration: 14 February 2022).

Background The ‘Melatonin for Anxiety prior to General anaesthesia In Children’ (MAGIC) trial was designed to compare midazolam and melatonin as pre-medications for anxious children (aged five to fourteen), undergoing day-case surgical procedures under general anaesthesia. Low recruitment is a challenge for many trials, particularly paediatric trials and those in ‘emergency’ settings. A qualitative study as part of MAGIC aimed to gather stakeholder perspectives on barriers and enablers to recruitment. Methods Sixteen stakeholders from six sites participated in semi-structured interviews about their experiences of setting up the MAGIC trial and recruiting patients as part of the internal pilot. Data was analysed using framework analysis. Results Participants identified barriers and enablers to recruitment. Barriers and enablers related to the study, participants, the population of anxious children, practitioners, collaboration with other health professionals, ethics, specific settings and the context of surgical day units and the wider health system. Attempting to recruit anxious children from a surgical day unit is particularly challenging for several reasons. Issues include the practicalities of dealing with a child experiencing anxiety for parents/guardians; professional unwillingness to make things more difficult for families and clinicians and nurses valuing predictability within a busy and time-sensitive setting. Conclusions Multi-site RCTs face recruitment barriers relating to study-wide and site-specific factors. There are multiple barriers to recruiting anxious children due to undergo day-case surgery. Barriers across domains can interrelate and reinforce each other, reflecting challenges relating to populations and settings. For example, in the case of anxious children, parents and other health professionals are concerned about exacerbating children’s anxiety prior to surgery. They may look for ways to keep things predictable and avoid the uncertainty of an RCT. Pre-trial engagement work could help address concerns among collaborating health professionals. Using rapid ethnography during set-up or an internal pilot to focus on how the protocol will be or has been operationalised in practice may help identify issues. Allowing time to reflect on the findings of internal pilots and implement necessary changes could facilitate higher recruitment during the main phase of a trial. Trial registration NIHR Trial Registration Number: ISRCTN18296119 . Registered on October 01, 2019.

Objective:Millions of children are exposed to anaesthetic drugs every day; however, the possible adverse effects of these agents on the central nervous system remain controversial. This study evaluated anaesthesiologists’ and pediatric surgeons’ knowledge and daily practices regarding anaesthesia-induced neurotoxicity.Methods:A survey consisting of 12 questions was sent to members of the Turkish Anaesthesiology and Reanimation Association and the Turkish Pediatric Surgery Association via the Google forms program.Results:A total of 202 anaesthesiologists and 51 pediatric surgeons participated in this survey. The results demonstrate that anaesthesiologists and surgeons are aware of the risk of anaesthesia-related neurotoxicity and are willing to take action. Approximately, half of the anaesthesiologists and pediatric surgeons expected to postpone operations lasting at least 3 hours for patients <3 years of age. Also, one-third of the anaesthesiologists would seek feasible and more reliable alternative anaesthetic strategies.Conclusions:More than two-thirds of the participants knew about the US Food and Drug Administration neurotoxicity warning; however, uncertainty about anaesthesia-related neurotoxicity is ongoing. Many questions remain unanswered. The results of large-scale prospective randomized studies to evaluate the effect of anaesthetics and surgery on the cognitive development of pediatric patients are needed.

Background/Objectives: Dexmedetomidine, an alpha-2 adrenergic agonist, has gained significant attention for its sedative, analgesic, and anxiolytic properties in paediatric anaesthesia. This review explores its pharmacokinetics and pharmacodynamics, perioperative applications and efficacy, and safety profile in paediatric patients. Findings: Dexmedetomidine has emerged as a highly effective adjunct in paediatric anaesthesia, offering significant advantages across various perioperative settings. It reduces the need for other anaesthetics and opioids, leading to smoother recoveries with lower postoperative pain and agitation. Studies highlight its role in enhancing procedural sedation, improving patient cooperation, and providing superior analgesia in neuraxial and general anaesthesia. Its neuroprotective properties and stable haemodynamic profile make it particularly valuable in the perioperative and critical care settings. Conclusions: Dexmedetomidine has shown a favourable safety and efficacy profile in paediatric anaesthesia when doses are carefully titrated within the ranges recommended in the literature. While its use remains off-label in paediatric populations, increasing clinical experience and evidence support its integration into perioperative protocols.

Objective:The objective of this observational study was to determine the incidence of emergence delirium (ED) and its association with preoperative anxiety using the modified Yale preoperative anxiety scale and paediatric anaesthesia emergence delirium scale, in a tertiary care institution in South Asia.Methods:A total of 250 children of 2–8 years of age (of either gender, American Society of Anaesthesiology classification I or II, undergoing infra umbilical surgery, using caudal block for analgesia) were enrolled and the study was completed. The primary outcome measure was the presence of ED using the paediatric anaesthesia emergence delirium score. A cut-off value equal to or more than 12 at any time point was taken as ED. The secondary measure was preoperative anxiety, measured using the modified Yale preoperative anxiety scale at 30 minutes before going into the operating room. A cut-off score of 30 was used.Results:The median age of the children was thirty-six months IQR (24–60). There were 230 (91%) males and 20 (9%) females. Twenty-two percent of the children experienced emergence delirium. One-point increase of modified Yale preoperative anxiety scale anxiety score was significantly associated with 1.23 times the odds of emergence delirium OR =1.23 (1.16–1.29) as compared with those without emergence delirium.Conclusions:The incidence of emergence delirium in our cohort was 22.4%, and there was a significant association between preoperative anxiety and emergence delirium.

Brain tumours are among the most common neoplasm in children. Therefore, paediatric anaesthesiologists face the challenge of neurosurgical interventions in all age groups. To minimize perioperative mortality and morbidity, a comprehensive understanding of age-dependent differences in anatomy and cerebrovascular physiology is a mandatory prerequisite. Advances in subspeciality training in paediatric neurosurgery and paediatric anaesthesia may improve clinical outcomes and advance communication between the teams.

Paediatric regional anaesthesia today is one of the fastest growing and exciting aspects of paediatric anaesthesia, which requires an ongoing fervour to learn. Application of paediatric regional anaesthesia in neonates, infants, toddlers and children is undertaken to treat perioperative pain without disturbing the physiological milieu with additional advantages elaborated in the review. The available choices, traditional methods and the most recently described methods are discussed with emphasis on their advantages and disadvantages. Clear pointers for selection of the blocks are also discussed. To present a holistic overview of this rapidly growing subject, a comprehensive literature search was performed in May 2019 in MEDLINE, PubMed and Google Scholar to retrieve articles pertaining to all the above topics. The keywords used in various combinations included 'Central neuraxial, blocks, Paediatric(s)', 'Peripheral Nerve blocks', 'Safety, controversies, regional, anaesthesia'.

Background and Aims: Dynamic parameters such as the respiratory variation in aortic flow peak velocity (ΔVpeak) and inferior vena cava distensibility index (dIVC) are accurate indices of fluid responsiveness in adults. Little is known about their utility in children. We studied the ability of these indices to predict fluid responsiveness in anaesthetised and mechanically ventilated children. Methods: This prospective study was conducted in 42 children aged between one to 14 years scheduled for elective surgery under general endotracheal anaesthesia. Mechanical ventilation was initiated with a tidal volume of 10 ml/kg. ΔVpeak, dIVC and stroke volume index (SVI) were measured before and after volume expansion (VE) with 10 ml/kg of crystalloid using transthoracic echocardiography. Patients were considered to be responders (R) and non-responders (NR) when SVI increased to either ≥15% or <15% after VE. ΔVpeak and dIVC were analysed between R and NR. Results: The best cut-off value for ΔVpeak as defined by the receiver operator characteristics (ROC) curve analysis was 12.2%, for which sensitivity, specificity, positive predictive value and negative predictive value were 100%, 94%, 96% and 100%, respectively, the area under the curve was 0.975. The best cut-off value for dIVC as defined by the ROC curve analysis was 23.5%, for which sensitivity, specificity, positive predictive value and negative predictive value were 91%, 89%, 91% and 89%, respectively, the area under the curve was 0.95. Conclusion: ΔVpeak and dIVC are reliable indices of fluid responsiveness in children.

Background The acceptability of a children’s premedication, prior to general anaesthesia (GA), is fundamental to ensuring positive clinical- and patient-reported outcomes. Midazolam, the current standard premedication, is known to have an unfavourable side-effects profile and presents a degree of risk which is accepted due to a need for compliance. Melatonin is a functionally diverse hormone with anxiolytic properties that offer potential benefits over midazolam. Little is currently known about how patients and health professionals view these two different premedications. This research aimed to explore the acceptability of midazolam and melatonin as premedications for anxious children undergoing GA, from the perspective of children, caregivers and health professionals involved in the Melatonin for Anxiety prior to General Anaesthesia In Children (MAGIC) trial. Methods Participants were children recruited to the MAGIC trial, their caregivers and health professionals involved in recruitment to the trial. In total, 37 participants (23 health professionals, 10 caregivers and 4 children) took part in semi-structured interviews relating to the MAGIC trial and acceptability of premedications. Interviews were carried out face-to-face, by telephone or online by a trained qualitative researcher. Interviews were transcribed verbatim and analysed using a framework approach. Results The acceptability of midazolam and melatonin is related to six main factors: effectiveness as premedication prior to GA; administration of premedication; experience of recovery; prior experiences of premedication; associations and evidence; and range of options for managing anxiety. Interviews highlighted the trade-offs involved and the relevance of the wider context in which premedications are provided. Barriers and facilitators were identified on the acceptability of premedications more generally. Conclusions Future clinical trials evaluating the effectiveness of premedications in children prior to general anaesthesia need to consider that premedication choice is multifactorial. The MAGIC study found that melatonin was less effective at reducing anxiety (pre-operative distress) when compared with the standard of care, midazolam. However, there remains a need for a premedication with a better side effects profile to midazolam. While children, caregivers and health professionals are open to alternatives to midazolam, this is likely to vary by subgroup and will involve trade-offs in terms of benefits. Trial registration ISCRCTN ISRCTN18296119 . Registered on 10/01/2019.