Discussion
In this study, we identified and analyzed the T100 most cited studies in pediatric anesthesia. The majority of these studies were clinical research, focusing on perioperative behavioral studies, postoperative outcomes, specific anesthetic use, and guidelines for perioperative anesthetic management.
Given the differences in organ development and drug metabolism between children and adults, re-evaluation of drug selection and dosage is essential in pediatric anesthesia.16 Lerman et al. indicated that sevoflurane is appropriate for neonates, infants, and children.17 However, volatile anesthetics such as sevoflurane, isoflurane, and enflurane are known to contribute to early postoperative vomiting and agitation.18 19 Dexmedetomidine, a highly selective α-2 adrenoreceptor agonist, provides sedation and analgesia without respiratory depression and is effective in attenuating sevoflurane-induced agitation without additional adverse effects.20 21 These studies highlight the importance of continued clinical research in pediatric anesthesia.
A significant proportion of the T100 most cited studies have focused on the effects of anesthetics on cognitive function in children. Sun et al. found that a single exposure to anesthesia may not adversely affect cognitive development later in childhood.22 Another study linked exposure to anesthesia before the age of 4 days with a small decline in academic performance and IQ test scores.23 Studies in juvenile animal models suggest that N-methyl-D-aspartic acid receptor antagonists and drugs targeting gamma-aminobutyric acid signaling transduction may be neurotoxic to the developing brain.24 These clinical findings contrast with previous basic research and highlight the need for further investigation into the long-term cognitive effects of anesthetic agents in children.
Kain ZN is the most prolific first author among the T100 most cited studies, focusing on pediatric perioperative anxiety and behavior. Studies on this topic emphasize the complexity of children’s anxiety, which includes fear of the surgical procedure, unfamiliar environment, separation from family, and unfamiliar medical procedures, resulting in emotional and cognitive distress. In addition, these issues are not limited to the day of surgery and can have potentially long-term negative effects on children’s psychology. This highlights the importance of early prevention and timely intervention. Non-pharmacological methods, such as play therapy and family involvement, can help mitigate anxiety and improve cooperation during surgery.25
Perioperative adverse events are critical in pediatric anesthesia, especially in infants under 1 month of age who are prone to respiratory and cardiovascular complications.26 27 These findings underscore the need for improved education and strategies within the anesthesia teams to improve the quality of pediatric anesthesia care.28 In addition, a prospective cohort study found that recent upper respiratory tract infection, family history of asthma, atopy, or smoking predicted a higher risk of adverse respiratory events.29 Additionally, Mamie et al. showed that using relaxants for tracheal intubation could reduce the risk of perioperative respiratory complications, but increases the risk associated with ear, nose, and throat surgery when performed by non-specialist pediatric anesthesiologist.30 Moreover, airway complications accounted for 64% of anesthesia-related cardiac arrests with a mortality rate of 29%, compared with a mortality rate of 70% for anesthesia-related cardiac arrests occurring during all stages of anesthesia.31
Difficult airway management is a major challenge in pediatric anesthesia. Fiadjoe et al. reported a 3% first-attempt success rate for direct laryngoscopy compared with 55% for indirect video laryngoscopy in difficult pediatric airways.32 The 2022 American Society of Anesthesiologists (ASA) Practice Guidelines emphasize optimizing oxygenation, limiting intubation attempts, and promptly seeking help or using invasive techniques when multiple intubation attempts fail.15 Sequera-Ramos et al. found similar success rates and complication rates for tracheal intubation between groups, although the sedation group had fewer severe complications.33 Napolitano et al. showed that providing apneic oxygenation via nasal cannula during the apneic period of tracheal intubation was associated with fewer adverse events in children, highlighting the importance of maintaining oxygenation during difficult airway management.34 Another study compared the efficacy of hybrid techniques (video laryngoscopy and flexible bronchoscopy) with flexible bronchoscopy alone and reported similar success rates for intubation, with fewer complications observed in the former approach group.35 These findings underline the impact of updated guidelines on anesthetic management in pediatric anesthesia.
The use of cuffed endotracheal tubes in pediatric anesthesia remains a subject of debate. Khine et al. demonstrated that cuffed endotracheal tubes can prevent repeated checks, minimize low flow rates, and lower anesthetic concentrations.36 Reports by Weiss et al.37 and Khine et al. further support this view, while Newth et al.38 reported no significant difference between the use of cuffed and uncuffed tubes. Conversely, some researchers express concerns about cuffed tubes, citing potential problems such as airway trauma, increased difficulty in intubation, and concerns about the appropriateness of airway size in children. Additionally, the use of cuffed tubes may lead to subglottic swelling, increasing the risk of postoperative laryngospasm.
Sedation is essential due to the difficulties young children face in cooperating with invasive procedures. It helps manage behavior, alleviate physical discomfort or pain, and minimize negative psychological reactions.13 Research suggests that nasal or oral sedatives in pediatrics can provide satisfactory sedation with a low incidence of adverse events. The American Academy of Pediatrics established guidelines for pediatric sedation in 1985, with updates in 1992 and 2019.39–41 In 1997, studies highlighted the risks associated with pediatric sedation and the need of appropriate monitoring by trained personnel.42 In addition, Hoffman and colleagues outlined the risks assessment and strict adherence to guidelines could reduce the incidence of complications.43 While serious adverse events are rare with pediatric procedural sedation, they are more common in ASA grade III or IV children.44–46 The above studies are all among the T100 most cited articles, indicating the importance of pediatric procedural sedation.
Non-traditional indicators, such as the FWCI, provide insight into the impact of articles by making weighted comparisons, effectively accounting for differences in size, discipline, and publication time. By comparing the FWCI with the total number of citations, we observed that articles with higher citation counts generally have higher FWCI values, suggesting that citation counts tend to reflect impact. However, the correlation between these two metrics is not always consistent, possibly due to factors such as publication year or document type. As a result, the non-traditional FWCI metric can serve as a valuable complement to traditional citation measures.
Our study examines a wide range of sources and incorporates findings from highly cited research. It highlights the predominant focus of clinical research and guidelines in pediatric anesthesia, identifies key areas of research and academic contributions, and helps shape future research directions. However, this article has several limitations. First, we selected the T100 cited articles from 1990 to 2023 for analysis, resulting in a relatively small sample size. Future research could enhance the comprehensiveness by analyzing the T100 cited articles from each decade within this period. Second, citation counts are affected by publication year, with older articles tending to accumulate more citations, potentially excluding recent high-impact publications. Moreover, classic literature may experience ‘obliteration by incorporation’, where citation rates decline as the content becomes incorporated into common knowledge, potentially missing current advances such as novel drugs like remimazolam.47 48 Third, some of the T100 articles may contain outdated information on anesthetics and techniques, such as the reduced use of halothane, which limits their relevance in current clinical guidelines. In addition, factors such as the publication language, the selected journal, and the number of similar high-impact publications within the same field can influence citation results.
