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Adultification of Black Children in Pediatric Anesthesia

Baetzel, Anne MD; Brown, David J. MD; Koppera, Prabhat MD; Rentz, Andrea CCLS; Thompson, Aleda MS; Christensen, Robert MD*

doi: 10.1213/ANE.0000000000004274
Pediatric Anesthesiology: Original Clinical Research Report

BACKGROUND: Unconscious racial bias in anesthesia care has been shown to exist. We hypothesized that black children may undergo inhalation induction less often, receive less support from child life, have fewer opportunities to have a family member present for induction, and receive premedication with oral midazolam less often.

METHODS: We retrospectively collected data on those <18 years of age from January 1, 2012 to January 1, 2018 including age, sex, race, height, weight, American Society of Anesthesiologists (ASA) physical status, surgical service, and deidentified anesthesiology attending physician. Outcome data included mask versus intravenous induction, midazolam premedication, child life consultation, and family member presence. Racial differences between all outcomes were assessed in the cohort using a multivariable logistic regression model.

RESULTS: A total of 33,717 Caucasian and 3901 black children were eligible for the study. For the primary outcome, black children 10–14 years were 1.3 times more likely than Caucasian children to receive mask induction (adjusted odds ratio [AOR], 1.3; 95% confidence interval [CI], 1.1–1.6; P = .001). Child life consultation was poorly documented (<0.5%) and not analyzed. Black children <15 years of age were at least 31% less likely than Caucasians to have a family member present for induction (AOR range, 0.4–0.6; 95% CI range, 0.31–0.84; P < .010). Black children <5 years of age were 13% less likely than Caucasians to have midazolam given preoperatively (AOR, 0.9; 95% CI, 0.8–0.9; P = .012).

CONCLUSIONS: This study suggests that disparities in strategies for mitigating anxiety in the peri-induction period exist and adultification may be 1 cause for this bias. Black children 10 to 14 years of age are 1.3 times as likely as their Caucasian peers to be offered inhalation induction to reduce anxiety. However, black children are less likely to receive premedication with midazolam in the perioperative period or to have family members present at induction. The cause of this difference is unclear, and further prospective studies are needed to fully understand this difference.

From the *Department of Anesthesiology

Department of Otorhinolaryngology

Department of Child and Family Life, University of Michigan, Ann Arbor, Michigan.

Published ahead of print 5 July 2019.

Accepted for publication May 7, 2019.

Funding: None.

The authors declare no conflicts of interest.

This report describes human research. Institutional review board (IRB) contact information: Institutional Review Boards of the UM Medical School, 2800 Plymouth Rd, Building 200, Room 2086, Ann Arbor, MI 48109; e-mail: The requirement for written informed consent was waived by the IRB. This report describes an observational clinical study. The author states that the report includes every item in the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) checklist for case–control observational clinical studies.

Reprints will not be available from the authors.

Address correspondence to Anne Baetzel, MD, Department of Anesthesiology, University of Michigan Medical School, 4–911 CS Mott Children’s Hospital, 1540 E Medical Center Dr, Ann Arbor, MI 48109. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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