Special Article

Specialised training in paediatric anaesthesia: Need

of the hour

Address for correspondence: Indu Sen, Nandini Dave1, Neerja Bhardwaj, Chitra Juwarkar2, Shamshad Beegum3
Prof. Neerja Bhardwaj, Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research,
Department of Anaesthesia Chandigarh, 1Department of Anaesthesia, NH SRCC Children’s Hospital, Mumbai, Maharashtra, 2Department
and Intensive Care, of Anaesthesiology, Goa Medical College, Bambolim, Goa, 3Department of Anaesthesiology and Critical Care,
Postgraduate Institute Government Medical College, Thrissur, Kerala, India
of Medical Education
and Research,
Chandigarh - 160 012, India. ABSTRACT
E‑mail: neerja.bhardwaj@
gmail.com Paediatric anaesthesia is an upcoming speciality which is gaining wide interest and can be a
Submitted: 18-Nov-2020 career choice for the new trainees. The need to develop paediatric anaesthesia as a speciality was
Revised: 19-Dec-2020 realised with the progress in the field of paediatric surgery. The profile of the ‘patient’ encountered
Accepted: 01-Jan-2021
Published: 20-Jan-2021 by a paediatric anaesthesiologist spans from an extremely premature neonate on the fringes of
survival, to a full‑grown adolescent equivalent to an adult. Perioperative morbidity and mortality are
2‑3 times higher in infants and neonates compared to adults particularly in middle and low‑income
countries. The anatomical, physiological, pharmacological variations and presence of congenital
cardiac, pulmonary and metabolic diseases in young children make perioperative management
challenging. Special expertise and training are required for anaesthetic management of these
Access this article online preverbal children. In India, 3‑years DM and 1‑year Fellowship courses in paediatric anaesthesia
Website: www.ijaweb.org are now available for specialisation. An ideal paediatric anaesthesia training centre should have
substantial paediatric and neonatal patient load with exclusive intensive care facility. Paediatric
DOI: 10.4103/ija.IJA_1445_20
anaesthesiologists, having knowledge of several facets of paediatrics and anaesthesia are capable
Quick response code
of coordinating with health care professionals performing procedures outside the operating room.
Paediatric anaesthesia, as a career thus offers a great opportunity to enhance quality and safety
of anaesthesia in this high‑risk surgical population. Persistent coordinated team efforts improve
patient outcomes, reduce stress at work and increase job satisfaction.

Key words: Anaesthesia, career, courses, paediatric, programme, specialisation

INTRODUCTION the urgent need to develop paediatric anaesthesia

in India and recommended availability of specialist
The progress of surgery as a speciality would not have anaesthesiologists to safely administer anaesthesia to
been possible without the scientific advancement in neonates, infants and children.[1]
the field of anaesthesia. The surgical field has improved
over time primarily due to the introduction of surgical Need for specialisation in paediatric anaesthesia
sub‑specialisation. However, the introduction of During the postgraduate course, the trainees are
specialisation in anaesthesia including paediatric broadly trained for providing anaesthesia to all types
anaesthesia has been slow. In fact, paediatric and of patients by rotating them in all branches of surgical
neonatal surgery as a speciality has been in existence
in India in tertiary training institutes for more This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
than 50 years. Likewise, neonatology and neonatal which allows others to remix, tweak, and build upon the work non‑commercially,
intensive care facilities have also been established as long as appropriate credit is given and the new creations are licensed under
the identical terms.
since long. Unfortunately, paediatric anaesthesia
For reprints contact: [email protected]
services have failed to match up to the demand and
it is only recently that training programs in paediatric How to cite this article: Sen I, Dave N, Bhardwaj N, Juwarkar C,
and neonatal anaesthesia have commenced at some Beegum S. Specialised training in paediatric anaesthesia: Need of
centres in India. In their editorial, Rao et al. stressed the hour. Indian J Anaesth 2021;65:17-22.

© 2021 Indian Journal of Anaesthesia | Published by Wolters Kluwer - Medknow 17

Page no. 25
 Sen, et al.: Paediatric Anaesthesia as a career choice

speciality including specialised branches. However, anaesthesiologists and their patients are incorrect drug
this is a short‑term posting and just gives an overview dosages and dilutions, inadequate oxygenation, lack
of the specialised branches. Because of this, any of knowledge of congenital anomalies and syndromes,
practical hands on training for paediatric anaesthesia as well as insufficient teaching and training.[8] It is
is limited. estimated that in most developing countries including
India, nearly half of the population is below 18 years
The consequence is that the ‘qualified’ anaesthetist of age and almost 85% will manifest with a need for a
might find himself/herself inadequate in application surgical procedure before their 15th birthday.[9]
of knowledge, skills and use of latest technology when
it comes to administering anaesthesia safely to the Courses in paediatric anaesthesia
paediatric population. In the Western world there is 1‑year specialisation for
paediatric anaesthesia after post‑graduation. In India
Specialisation in paediatric and neonatal anaesthesia there is a 3‑year DM degree as well as 1‑year Fellowship
is the need of the hour because of many reasons. First, course in paediatric anaesthesia. The American
paediatric anaesthesia represents only 12% of the College of Surgeons (ACS) guidelines recommend
total anaesthesia caseload. In most hospitals, infants that for optimum care of paediatric surgical patients,
represent 1%, and neonates or preterm babies requiring paediatric anaesthesiologists shall directly care for
anaesthesia are few.[2] Therefore, the individual patients at advanced and comprehensive paediatric
experience of an anaesthesiologist in the paediatric, surgical centres.[10] However, in India no such
especially neonatal population is maybe limited for recommendation has been proposed by surgical bodies
both the teachers and the postgraduates. Second, it or the Medical Council of India (now the National
has been seen that the perioperative mortality, cardiac Medical Commission). In our opinion, Fellowship
arrest and anaesthetic‑related serious adverse events courses are excellent for anaesthesiologists who want
are 2‑3 times higher in small children compared to gain experience in anaesthetising children. The
to adults particularly in middle‑ and low‑income DM course is demanding and gruelling and helps a
countries.[3,4] A contributing factor to this, amongst candidate in pursuing a career in teaching hospitals
many, is the non-availability of trained and specialist with opportunities in research and as a specialist
anaesthesiologists. In addition, the incidence of paediatric anaesthesiologist in stand‑alone ‘Children’s
severe complications, e.g., bradycardia, cardiac Hospitals'.
arrest, laryngospasm or adverse respiratory events in
general is highly dependent on the experience of the Both government and private hospitals in India provide
anaesthesiologist handling children and the risk is exclusive courses (DM and Fellowship) in paediatric
higher when the care is by an anaesthesiologist who anaesthesia [Tables 1 and 2]. The details of the various
manages children infrequently.[5‑7] courses are available from individual websites of the
institutes and from Indian Association of Paediatric
Thirdly the anaesthetic management of children is Anaesthesiologists (IAPA) website (for fellowship
very different from that of adults due to the anatomical, accredited by IAPA). The ideal institute for training of
physiological, pharmacological and psychological a paediatric anaesthesiologist should be the one with
differences between the two. The presence of cardiac, a substantial patient load including neonates, which
pulmonary and metabolic diseases and newborns has a neonatal and paediatric intensive care facility
and infants with congenital conditions translates as well as provides facility of Non‑Operating Room
into an anaesthetic technique which requires special Anaesthesia (NORA). It should have experience in
expertise and training as well as individualised conduct of complex surgical procedures including
treatment. The profile of the ‘patient’ encountered by foetal surgery and EXIT surgery. This essentially
a paediatric anaesthesiologist spans from an extremely provides extensive experience for managing all
premature neonate on the fringes of survival, to a children including neonates and those with complex
full‑grown adolescent equivalent to an adult. The diseases.
psychological considerations vary with age and
development; with issues such as separation anxiety MD (Anaesthesiology) curriculum is inadequate
and emergence delirium being unique to this patient to prepare a postgraduate to confidently practise
group. Assessment and management of pain can be paediatric anaesthesia. A 1‑year fellowship can bridge
challenging. Risk factors which have been cited for this gap and make a fellow proficient in the practice of

18 Indian Journal of Anaesthesia | Volume 65 | Issue 1 | January 2021

Page no. 26
 Sen, et al.: Paediatric Anaesthesia as a career choice

Table 1: Paediatric Anaesthesia DM Courses in India (Duration: Three Years Post MD)
Name of the program Institution/University Location
DM (Paediatric Anaesthesia and Intensive Care) Postgraduate Institute of Medical Education and Research Chandigarh (UT)
DM (Paediatric and Neonatal Anaesthesia) King Edward Memorial (KEM) Hospital Seth GS Medical Mumbai (Maharashtra)
College

Table 2: Fellowship in Paediatric Anaesthesia (1 year)

Name of Program Institution/ University Location
Accredited by IAPA (Indian AIMS (Amrita Institute of Medical Sciences) Kochi, Kerala
Association of Paediatric CNBC (Chacha Nehru Bal Chikitsalaya) New Delhi.
Anaesthesiologists) http://www. GKNM (G Kuppuswamy Naidu Memorial) Hospital Coimbatore, Tamil Nadu
iapaindia.com/accredited-institutions.
KMC (Kasturba Medical College) Manipal, Karnataka
html
K.G. Patel Children Hospital Vadodara, Gujarat
[Duration 1-year Post MD, 2-years
Post DA] NH SRCC Children’s Hospital Mumbai, Maharashtra
Rainbow Hospitals Hyderabad, Telangana
Rainbow Hospitals, Marathahalli Bangaluru, Karnataka
Sri Ramachandra Institute of Higher Education and Research Chennai, Tamil Nadu
Super specialty Paediatric hospital and Postgraduate Teaching Noida, Uttar Pradesh
Institute
Affiliation: Rajeev Gandhi University Bangalore Medical College and Research institute Bengaluru, Karnataka
of Health Sciences, Karnataka Indira Gandhi Institute of Child Health Bengaluru, Karnataka
[Duration 1 Year] Bapuji Medical College Davanagere, Karnataka
ICA accredited Fellowship Paediatric Narayana Hrudayalaya, Bangalore Bengaluru, Karnataka
CVS Anaesthesia
[Duration 18 months]
Fellowship in Paediatric Anaesthesia All India Institute of Medical Sciences (AIIMS) Jodhpur Jodhpur, Rajasthan
[Duration 1-Year ]
MUHS (Maharashtra University J J Hospital (Grant Medical College and Sir Jamshedjee Jejeebhoy Mumbai, Maharashtra
of Health Sciences) accredited Hospital)
paediatric anaesthesia fellowships King Edward Memorial (KEM) Hospital and Seth GS Medical College
[Duration 1 year] Lokmanya Tilak Municipal General Hospital (LTMGH) and Medical
College, Sion
Wadia Children’s Hospitals
Fellowship in Paediatric Cardiac All India Institute of Medical Sciences (AIIMS) Delhi New Delhi
Anaesthesia (Duration 1-Year)
Paediatric Cardiac Critical Care Post Graduate Institute of Medical Education & Research (PGIMER) Chandigarh, Union
Fellowship (Post DM) Duration Territory
1-Year
WFSA (World Federation of Societies Children Anaesthesia services www.suryahospitals.com Mumbai, Maharashtra
of Anaesthesiologists) Paediatric Christian Medical College Vellore, Tamil Nadu
Anaesthesia fellowship [Duration 6
months]
Fellowship in Paediatric Anaesthesia Sir Ganga Ram Hospital New Delhi
[duration 1 year]

paediatric anaesthesia, so that he/she can confidently speciality. Paediatric anaesthesiologists need to balance
manage paediatric cases. However, to gain mastery high clinical workload with academic development.
over a subject is a long, and intense process. The They are expected to develop good communication
3‑year rigorous DM (Paediatric Anaesthesia) program skills to interact with the families and understand a
provides the postgraduate student the opportunity and child’s behaviour. Besides this, a rapport needs to be
the time to master the various nuances of neonatal and maintained amongst colleagues and other staff members
paediatric anaesthesia, similar to the MCh courses in to provide satisfactory services. This is important
surgical branches.
because they will be dealing with patients of varied age
Teaching and training for specialisation in paediatric groups (neonates to teenagers). They have to master
anaesthesia various skills, be prepared for the adverse events and
Teaching and training is an essential component of perform effective resuscitation if required. Persistent
any educational course. It requires hands on practical coordinated efforts improve patient outcomes, reduce
training as well as teaching of theoretical aspects of the stress at work, and increase career satisfaction.

Indian Journal of Anaesthesia | Volume 65 | Issue 1 | January 2021 19

Page no. 27
 Sen, et al.: Paediatric Anaesthesia as a career choice

Importance during the pandemic specialities like oncology, neurosurgery, dental and
The pandemic of coronavirus disease (COVID)-19 oral surgery, ophthalmology will help in providing
has further stressed the importance of specialisation high quality anaesthesia, comfort and pain control
in the field of paediatric anaesthesia. In the present during various procedures. Being highly skilled and
COVID times, modification of anaesthesia technique qualified professionals, paediatric anaesthesiologists
is desirable to avoid and contain transmission of the are in a position to communicate authoritatively with
infection by aerosolisation. Anaesthesiologists need colleagues from other specialities managing children.
to be aware of children specific problems and their
management e.g., avoiding nasal premedication since Global appeal as a permanent career
it can cause aerosolisation.[11] In addition, anaesthesia In the past, the most appealing specialisation courses
management by a paediatric anaesthesiologist will have been in cardiac anaesthesia, critical care and
enable safe and quick performance of routine tasks like chronic pain. Recently, the focus has shifted from
intubation as well as complex tasks like placement of these courses to paediatric, obstetric and trauma
invasive lines and nerve blocks. A generalist is more anaesthesia because of their interesting, appealing
likely to struggle and take extra time for performance of and rewarding qualities. Also, at the moment there
these practical tasks thereby increasing the possibility is manpower saturation in these previous courses.
of aerosol generation. The authors feel that paediatric anaesthesia provides
a degree of stability and a reasonable family time
Merits of paediatric anaesthesia specialisation compared to other specialities.
Paediatric anaesthesia is a relatively new speciality;
the limited number of trained and qualified paediatric Encouraging the youngsters to adopt this super
anaesthesiologists, and a largely young population speciality
translates into a huge demand.[12] Increased clinical Faculty working as paediatric anaesthesiologists can
expertise can lead to higher job satisfaction, better work as role models to influence many young minds to
recognition from paediatric surgical colleagues and opt for paediatric anaesthesia as a career choice. The
higher remuneration if working in private hospitals. job of mentors would be to lead by example, conduct
There is a growing awareness amongst the lay public educational sessions during conferences, award
about the problems of anaesthesia especially in prizes for presentations by trainees (Kop’s award),
children; and informed parents are now seeking trained dissertation topics for PG students related to children
anaesthesiologists for their child’s perioperative care. and thus inspire young anaesthetists to embrace
this speciality and help carry forwards the legacy of
Awareness about paediatric anaesthesia, and its paediatric anaesthesia.[13]
risks (especially in high risk groups e.g., neonates,
children with significant comorbidities, major During their specialisation training, the trainees develop
surgical procedures) is increasing. Surgeons, hospital an in‑depth understanding of the subject thereby making
administrators, and even parents have begun to them expert in practical skills. They can thus manage
specifically ask for anaesthesiologists with paediatric safe anaesthesia on a full spectrum of young sick patients
anaesthesia experience. In such a situation, a qualified exposed to newer surgical techniques like laparoscopy,
paediatric anaesthesiologist is in a position to quote robotics, organ transplant etc.[14] A calm and cool person
his price. There is a trend for children’s hospitals to who is conscientious, meticulous and passionate to care
employ only anaesthesiologists with specific training for small sick babies and empathise with the families
in paediatric anaesthesia. would be a suitable choice.

Recognition in the medical fraternity To be trained and accredited as a specialist by a

Paediatric anaesthesiologists, having knowledge recognised institution that would provide fellowship
of several facets of paediatrics and anaesthesia are or DM degree with an ever‑increasing global demand
uniquely positioned to coordinate and cooperate will definitely be the choice of young aspiring
with health care workers from related specialities anaesthesiologists. More and more paediatric
especially those managing procedures outside the OR, anaesthesiologists trained this way will get the
diagnostic imaging, cardiac catheterisation laboratory, opportunity to settle in institutions or corporate
gastroenterology suites, dental sedation, radiotherapy, hospitals worldwide to work in this demanding
etc. Active interactions with consultants from other speciality.

20 Indian Journal of Anaesthesia | Volume 65 | Issue 1 | January 2021

Page no. 28
 Sen, et al.: Paediatric Anaesthesia as a career choice

Growth avenues exclusively provided anaesthesia by experts.[17] This

Specialisation and the associated training programs are is because the perioperative morbidity and mortality
avenues with great potential for clinical advancement is particularly higher in infants and neonates based
and research. Tertiary training institutes with large on closed claims analysis and the Perioperative
patient loads, conducting training programs for the Cardiac Arrest (POCA) registry.[3,18] A non‑paediatric
DM and Fellowship courses in paediatric anaesthesia anaesthesiologist (generalist) should be competent to
offer opportunities for enhancing knowledge and provide perioperative care for common elective and
skills, and also the opportunity to conduct scientific emergency procedures in children aged 2 years and
research. Specialist societies, such as IAPA conduct older.
regular focused meetings and workshops, and are also
instrumental in framing policies and guidelines for Limitations of specialisation
safe conduct of anaesthesia. Young, budding paediatric If specialisation becomes the norm, non‑availability of
anaesthesiologists would do well to be members of such the paediatric anaesthesiologist may lead to delays in
societies to further their own growth as well as improve treatment. Medico legal implications may arise, where
the standards of paediatric anaesthesia in India. the ‘generalist’, not the disease process, may even be
blamed for a poor outcome rather than the responsible
The qualified paediatric anaesthesiologists can be a disease process. Specialisation may lead to attrition of
part of anaesthesia departments in hospitals leading other skills e.g., the paediatric anaesthesiologist may
teaching and training or find job opportunities in not feel confident administering anaesthesia to an
corporate hospitals or freelance practice at stand‑alone adult with comorbidities or an obstetric patient.
nursing homes dealing exclusively with children.
Paediatric anaesthesia as a career choice thus offers CONCLUSION
a great opportunity to enhance quality and safety of
Paediatric anaesthesia is a high‑pressure and
anaesthesia in this high‑risk surgical population.
time‑sensitive speciality where outcome depends
Ethical aspects on communication, teamwork, in addition to
Paediatric anaesthesiologists often face dilemmas individual skill and performance. A trained paediatric
between the law, ethical issues and good anaesthesiologist can enhance safety and quality of
clinical practice.[15] Children being minor are not perioperative care thus improving surgical outcomes
eligible to give written informed consent.[16] All the in neonates, infants and children. Specialisation in
complex decisions regarding blood transfusion, paediatric anaesthesia will enable the anaesthesiologist
challenging surgical procedures with long‑term in achieving these goals.
implications and participation in a research project
Financial support and sponsorship
are taken by care‑providers. One must ensure that they
Nil.
understand the ethical and legal implications before
giving consent. This requires coordination of patient Conflicts of interest
care utilising conflict management and negotiation There are no conflicts of interest.
skills that are not formally taught in anaesthesia
residency or medical training. REFERENCES

Legal aspects 1. Rao KL, Batra YK. We need to develop pediatric anesthesiology
in India! J Indian Assoc Pediatr Surg 2015;20:8‑9.
In India, recommending that only a paediatric 2. Clergue F, Auroy Y, Péquignot F, Jougla E, Lienhart A,
anaesthesiologist will provide anaesthesia to children Laxenaire MC. French survey of anesthesia in 1996.
is not feasible at the moment. In case of such a Anesthesiology 1999;91:1509‑20.
3. Bhanaker SM, Ramamoorthy C, Geiduschek JM, Posner KL,
recommendation, if a paediatric anaesthesiologist is Domino KB, Haberkern CM, et al. Anesthesia‑related cardiac
not available it would have legal implications and it arrest in children: Update from pediatric perioperative cardiac
becomes mandatory to inform the parents about it. arrest registry. Anesth Analg 2007;105:344‑50.
4. Cronje L. A review of paediatric anaesthetic‑related mortality,
serious adverse events and critical incidents. S Afr J Anaesth
However, defining an age group below which Analg 2015;21:147‑53.
only a paediatric anaesthesiologist should provide 5. von Ungern‑Sternberg BS, Boda K, Chambers NA, Rebmann C,
Johnson C, Sly PD, et al. Risk assessment for respiratory
anaesthesia services is possible. Neonates as well complications in paediatric anaesthesia: A prospective cohort
as children below the age of 2 years should be study. Lancet 2010;376:773‑83.

Indian Journal of Anaesthesia | Volume 65 | Issue 1 | January 2021 21

Page no. 29
 Sen, et al.: Paediatric Anaesthesia as a career choice

6. Auroy Y, Ecoffey C, Messiah A, Rouvier B. Relationship 13. Munshey F, McDonnell C, Matava C. Pediatric anesthesia
between complications of pediatric anesthesia and volume of training to early career stage: Opportunities for firm
pediatric anesthetics. Anesth Analg 1997;84:234‑5. foundations. Paediatr Anaesth 2020 Jul 29. doi: 10.1111/pan.
7. Tejwani R, Wang HS, Young BJ, Greene NH, Wolf S, Wiener JS, 13978. Epub ahead of print. PMID: 32726879.
et al. Increased pediatric sub‑specialization is associated with 14. Walker I. Editors’ notes: Updates in anaesthesia. World
decreased surgical complication rates for inpatient pediatric Federation Societies Anaesthesiology 2015;30:2.
urology procedures. J Pediatr Urol 2016;12:388.e1‑7. 15. Edgar J, Morton NS, Pace NA. Review of ethics in
8. Thomas J. Paediatric anaesthesia: A risky business? Guest paediatric anaesthesia: Research issues. Paediatr Anaesth
editorial. S Afr J Anaesth Analg 2012;18:226–7. 2001;11:473‑7.
9. Hodges SC, Walker IA, Bosenberg AT. Paediatric anaesthesia in 16. Feinstein MM, Pannunzio AE, Lobell S, Kodish E. Informed
developing countries. Anaesthesia 2007;62(Suppl 1):26–31. consent in paediatric anaesthesia: A narrative review. Anesth
10. ACS guidelines: Statement on Practice Recommendations Analg 2018;127:1398‑405.
for Pediatric Anesthesia Committee of Origin: Pediatric 17. Castanelli DJ, Stevenson K, Monagle JP. The provision of
Anesthesia (Approved by the ASA House of Delegates on anaesthesia for children by non‑subspecialist anaesthetists:
October 19, 2011 and reaffirmed on October 26, 2016). Expectation of newly qualified consultant anaesthetists and
11. Gai N, Maynes JT, Aoyama K. Unique challenges in pediatric their prospective employers in Victoria. Anaesth Intensive
anesthesia created by COVID‑19. J Anesth 2020;1‑5. doi: Care 2010;38:911‑9.
10.1007/s00540‑020‑02837‑0. Online ahead of print. 18. Murray JP, Geiduschek JM, Caplan RA, Posner KL, Gild WM,
12. Desjardins G, Cahalan MK. Subspecialty accreditation: Is Cheney FW. Comparison of pediatric and adult anesthesia
being special good? Curr Opin Anaesthesiol 2007;20:572‑5. closed malpractice claims. Anesthesiology 1993;78:461‑7.

“ANAESTHESIA A COMPLETE SPECIALITY- WE ARE THE LIFELINE”

AND OUR LIFELINE IS
“ISA FAMILY BENEVOLENT FUND”

• ISA encourages members to join Family Benevolent Fund of Indian Society of Anaesthesiologists
(ISA-FBF) to help our colleagues’ and our own families when they face the testing moments of their
life.
• BECOME AN ISAFBF MEMBER, NOT FOR YOU, BUT TO HELP OUR COLLEAGUE’S FAMILIES BY
DONATING Rs.300/- per year /death.
• TO BECOME AN ISAFBF MEMBER KINDLY VISIT OUR WEBSITE isafbf.com or CONTACT YOUR
CITY BRANCH/STATE/PRESIDENT/SECRETARY
• Contact for Details & Application forms:
Dr. Sugu Varghese, Hon.Sec.ISA-FBF
Mobile: +91-9447052094
Website: www.isafbf.com/www.isaweb.in
(Or Contact: Your State/City branch President/Secretary)

22 Indian Journal of Anaesthesia | Volume 65 | Issue 1 | January 2021

Page no. 30