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With the COVID-19 pandemic hastening the adoption of telemedicine into clinical practice, it has also prompted an abundance of new literature highlighting its capabilities and limitations. The purpose of this review is to summarize the current state of the literature on telemedicine applied in the context of a musculoskeletal examination of the neck and upper limbs for children 3 to 18 years old. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. General examination components including inspection, guided self-palpation, range of motion, sensory and motor examination, as well as special testing are described. Although the literature is focused mainly on adult populations, we describe how each component of the exam can be reliably incorporated into a virtual appointment specific to pediatric patients. Caregivers are generally needed for most consultations, but certain maneuvers can be self-performed by older children and adolescents alone. There is general feasibility, validity, and substantial reliability in performing most examination components of the upper limbs remotely, except for the shoulder exam. Compared to those made in person, clinical diagnoses established virtually were found to be either the same or similar in most cases, and management decisions also had high agreement. Despite this, there is evidence that some pediatric providers may not be able to collect all the information needed from a telemedicine visit to make a complete clinical assessment. Lastly, currently available smartphone applications measuring joint range of motion were found to have high reliability and validity. This narrative review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase physicians’ confidence in incorporating telemedicine into their standard of care.

The severe acute respiratory syndrome coronavirus 2 (coronavirus disease 2019 [COVID-19]) pandemic has challenged medical systems and clinicians globally to unforeseen levels. Rapid spread of COVID-19 has forced clinicians to care for patients with a highly contagious disease without evidence-based guidelines. Using a virtual modified nominal group technique, the Pediatric Difficult Intubation Collaborative (PeDI-C), which currently includes 35 hospitals from 6 countries, generated consensus guidelines on airway management in pediatric anesthesia based on expert opinion and early data about the disease. PeDI-C identified overarching goals during care, including minimizing aerosolized respiratory secretions, minimizing the number of clinicians in contact with a patient, and recognizing that undiagnosed asymptomatic patients may shed the virus and infect health care workers. Recommendations include administering anxiolytic medications, intravenous anesthetic inductions, tracheal intubation using video laryngoscopes and cuffed tracheal tubes, use of in-line suction catheters, and modifying workflow to recover patients from anesthesia in the operating room. Importantly, PeDI-C recommends that anesthesiologists consider using appropriate personal protective equipment when performing aerosol-generating medical procedures in asymptomatic children, in addition to known or suspected children with COVID-19. Airway procedures should be done in negative pressure rooms when available. Adequate time should be allowed for operating room cleaning and air filtration between surgical cases. Research using rigorous study designs is urgently needed to inform safe practices during the COVID-19 pandemic. Until further information is available, PeDI-C advises that clinicians consider these guidelines to enhance the safety of health care workers during airway management when performing aerosol-generating medical procedures. These guidelines have been endorsed by the Society for Pediatric Anesthesia and the Canadian Pediatric Anesthesia Society.

Very few issues (if any) within pediatric anesthesia have caused so much concern and emotional gravity than the fact that the past roughly 15 years, a plethora of animal studies have uniformly shown that exposure to most of the currently used anesthetics possibly during a vulnerable period of brain development (i.e. brain growth spurt or peak of synaptogenesis) may lead to neurodegeneration (particularly apoptosis) and abnormal synaptic development. Importantly, the observed morphological abnormalities are associated with functional deficits in learning and behavior later in life. Initial studies were mainly performed in immature rodent pups, but more recent studies have included non-human primates (rhesus monkeys). Both gamma-aminobutyric acid (GABA) agonists (e.g. inhalational anesthetics, propofol and benzodiazepines) and n-methyl-d-aspartate (NMDA) antagonists (e.g. ketamine and nitrous oxide) are implicated. Given the number of neonates, infants and young children anesthetized annually worldwide, these findings could have significant public health impplications. So far relatively few human (cohort) studies have been published on this topic and the results have been inconclusive. Some studies have suggested an association between exposure to anesthesia (and surgery), but other studies have suggested the opposite. Ongoing prospective studies will provide new results withis few years' time.This chapter describes some of the preclinical background behind anesthesia-related neurotoxicity; however main focus is placed on human studies. Although disturbing the animal data lack verification in humans. At this point, there is no need to change current anesthetic clinical practice or to postpone or cancel truly urgent surgeries in young children.