I read with great interest the retrospective cross-sectional cohort study by Galvez et al.,1  addressing the incidence of hypoxemia and bradycardia and the need for multiple direct laryngoscopy attempts in neonates and infants who were classified as American Society of Anesthesiologists (Schaumburg, Illinois; ASA) Physical Status I or II patients at the authors’ center. Their findings of the incidence of multiple direct laryngoscopy attempts (16%) and associated hypoxemia in patients younger than 12 months support other retrospective and observational studies2,3  suggesting that being an infant or neonate is an independent predictor of difficult direct laryngoscopy.

ASA Physical Status, the most widely used preoperative risk stratification system, has been shown to be marred by high interoperator variability, including in pediatric patients.4,5  ASA Physical Status I patients are considered healthy individuals with no anticipated added risk to the low incidence of the inherent risks of anesthesia management. However, a high percentage of pediatric patients who had been initially assigned to that category were subsequently reclassified as ASA Physical Status II patients in a prospective analysis.5  A highly reliable and universally accepted preoperative stratification system for pediatric patients has not been routinely implemented in practice yet, and most of us still use the ASA Physical Status classification for that patient population. Although the classification considers age as unrelated to perioperative risks, based on the above data, age clearly does impact such risk for otherwise healthy infants and neonates.

I believe that mounting evidence supports age as a predictor of difficult airway management in pediatric anesthesia. As long as we continue to use the preoperative ASA classification system in pediatric anesthesia, we could reduce some interobserver variability if we agreed that healthy children younger than 12 months of age are ASA Physical Status II patients based on the incidence of perioperative complications associated with their developmental status.

The author declares no competing interests.

1.
Gálvez
JA
,
Acquah
S
,
Ahumada
L
,
Cai
L
,
Polanski
M
,
Wu
L
,
Simpao
AF
,
Tan
JM
,
Wasey
J
,
Fiadjoe
JE
.
Hypoxemia, bradycardia, and multiple laryngoscopy attempts during anesthetic induction in infants: A single-center, retrospective study.
Anesthesiology
.
2019
;
131
:
830
9
2.
Heinrich
S
,
Birkholz
T
,
Ihmsen
H
,
Irouschek
A
,
Ackermann
A
,
Schmidt
J
.
Incidence and predictors of difficult laryngoscopy in 11.219 pediatric anesthesia procedures.
Pediatric Anesthesia
.
2012
;
22
:
729
36
3.
Engelhardt
T
,
Virag
K
,
Veyckemans
F
,
Habre
W
;
APRICOT Group of the European Society of Anaesthesiology Clinical Trial Network
.
Airway management in paediatric anaesthesia in Europe-insights from APRICOT (Anaesthesia Practice In Children Observational Trial): A prospective multicentre observational study in 261 hospitals in Europe.
Br J Anaesth
.
2018
;
121
:
66
75
4.
Aplin
S
,
Baines
D
,
DE Lima
J
.
Use of the ASA physical status grading system in pediatric practice.
Paediatr Anaesth
.
2007
;
17
:
216
22
5.
Ferrari
LR
,
Leahy
I
,
Staffa
SJ
,
Johnson
C
,
Crofton
C
,
Methot
C
,
Berry
JG
.
One size does not fit all: A perspective on the American Society of Anesthesiologists physical status classification for pediatric patients.
Anesth Analg
.
2019
.
[Epub ahead of print]