Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Induction of anesthesia can be a psychologically demanding part of the perioperative period for children undergoing elective surgery. To improve the patient experience, anesthesia providers should have two primary goals. First, they should aim to minimize preoperative distress, which has well-documented links to emergence delirium, increased analgesic requirements, and adverse postoperative behavioral changes such as sleep disturbance and new-onset enuresis. Second, they should seek to reduce the risk of perioperative respiratory adverse events, which remain among the most common and preventable causes of serious harm in this population (Dave, 2019). A significant body of research has investigated best practices in anesthesia induction for pediatric elective surgery.
Anxiety at induction is age-dependent. Infants under nine months generally tolerate separation and inhalational induction well, whereas children between one and three years are prone to marked separation anxiety and difficult venous access, making inhalational induction with sevoflurane the more practical choice in the absence of contraindications. Older children can often participate meaningfully in choosing their induction method, and behavioral preparation—including child-life involvement, distraction techniques, and family-centered communication—has been shown to reduce anxiety, even though parental presence at induction itself has not consistently demonstrated benefit in controlled comparisons (Dave, 2019).
The choice between inhalational and intravenous induction should be individualized, but emerging evidence increasingly favors intravenous propofol induction in children at elevated risk of perioperative respiratory adverse events despite the higher risk of anxiety. In a randomized controlled trial of 300 children with at least two risk factors for such events, inhalational sevoflurane induction was associated with a significantly higher incidence of adverse respiratory events compared with intravenous propofol, both overall (43.0% vs. 26%) and specifically during the induction phase (31.5% vs. 10.7%), with serious events such as laryngospasm and bronchospasm also occurring more frequently in the inhalational group (Ramgolam et al., 2018).
These findings support a more selective approach to anesthesia induction in high-risk pediatric patients, while acknowledging that inhalational induction retains clear advantages in children with needle phobia or difficult intravenous access.
Pharmacologic premedication remains a valuable adjunct where anxiolysis, amnesia, or reduction of aspiration risk is needed, with oral midazolam being the most commonly used agent, though alpha-2 agonists such as clonidine and dexmedetomidine offer additional benefits in reducing emergence agitation and postoperative nausea (Dave, 2019). In children at risk of pulmonary aspiration, controlled rapid sequence induction without cricoid pressure is now considered a safer alternative to the classic adult-derived technique, given the anatomic and physiologic differences that make cricoid pressure less reliable and potentially harmful in young children (Dave, 2019).
Beyond technique selection, safe induction depends on the broader periprocedural environment. The American Academy of Pediatrics emphasizes that facilities caring for children must maintain age-appropriate equipment and drug dosing, robust preoperative evaluation processes, and structured quality improvement programs, noting that 85% of serious anesthesia-related adverse events in children are considered preventable (Long, Houck, & Varughese, 2026). This underscores that the technical decision of induction agent cannot be separated from institutional readiness, including immediate availability of pediatric-specific airway equipment and providers trained in pediatric resuscitation.
Taken together, these sources indicate that safe and effective induction of anesthesia in pediatric elective procedures requires a tailored approach that accounts for the child’s age, temperament, and respiratory risk profile and is supported by an institutional infrastructure capable of anticipating and managing the complications unique to this population.
References
- Dave, N. M. (2019). Premedication and induction of anaesthesia in paediatric patients. Indian Journal of Anaesthesia, 63(9), 713–720. https://doi.org/10.4103/ija.IJA_491_19
- Ramgolam, A., Hall, G. L., Zhang, G., Hegarty, M., & von Ungern-Sternberg, B. S. (2018). Inhalational versus IV induction of anesthesia in children with a high risk of perioperative respiratory adverse events: A randomized controlled trial. Anesthesiology, XXX, 1–10. https://doi.org/10.1097/ALN.0000000000002152
- Long, J. B., Houck, C. S., Varughese, A. M., & the Section on Anesthesiology and Pain Medicine. (2026). Critical elements for the pediatric periprocedural anesthesia environment: Policy statement. Pediatrics, 157(3), e2025075746. https://doi.org/10.1542/peds.2025-075746