ORIGINAL ARTICLE
Anesthesia for Children With Craniofacial Abnormalities
in the Developing Countries: Challenges and
Future Directions
Ann M. Melookaran, MD, Sirisha A. Rao, MD, Sible B. Antony, MD, and Adriana Herrera, MD
Abstract: Interest in global health to provide safer pediatric surgical
care in developing countries has increased during the last decade. A
collaborative effort between surgeons and anesthesiologists has pro-
vided the opportunity to deliver specialized care to children, particu-
larly in the areas of cleft lip and palate repair. However, medical
resources, facilities, and adequately trained personnel, especially in
pediatric anesthesia, are often limited in these countries. Challenges,
educational efforts, and future directions for the globalization of
anesthesia are discussed. Involvement of international entities may
help raise awareness, channel efforts, expand programs and encourage
volunteerism to ultimately provide safer care to pediatric patients,
have better outcomes and reduced anesthesia-related morbidity and
mortality.
Key Words: Anesthesia in developing countries, anesthesia
training, craniofacial abnormalities, global health, medical
missions, pediatric anesthesia
(J Craniofac Surg 2015;26: 10691072)
C raniofacial abnormalities are a diverse group of complex
congenital defects that affect the face and head. Approxi-
mately, 1 case of orofacial cleft occurs in every 500550 births,
with variations in prevalence among different ethnic groups, geo-
graphic distribution and socioeconomic classes. According to the
Centers for Disease Control and Prevention, there are about 2651
babies born with cleft palate and about 4437 babies born with cleft
lip with or without cleft palate annually in the United States.1
Providing pediatric anesthesia in the United States for these patients
with greater complexity is done regularly. There are even centers
that specialize in these patients around the country. This is not the
case in the developing world. Several international organizations
that have traveled to developing countries for surgical missions
have provided insight into the unique challenges they met in
providing and optimizing anesthetic care for these patients.
Countries may be classified according to their Gross National
Income (GNI) per capita per year. Countries with a GNI of US$
11 905 and less are classified to be developing countries.2 They are
distributed around the globe. In addition to lower income, these
From the Yale-New Haven Hospital, New Haven, CT.
Received December 3, 2014.
Accepted for publication December 9, 2014.
Address correspondence and reprint requests to Ann Marie Melookaran,
Yale Department of Anesthesia, 333 Cedar Street, TMP 3, P.O. Box
208051, New Haven, CT 06520-8051.
E-mail: ann.melookaran@yale.edu
There are no conflicts of interest.
Copyright # 2015 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000001674
The Journal of Craniofacial Surgery  Volume 26, Number 4, June 2015
Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
countries also have lower standard of living, lower life expectancy,
and poorer education. Interest in global health awareness has
increased in the last decade and has generated reflection into ways
to improve surgical care in the developing countries. Anesthesiol-
ogy involvement in this change is critical. Many efforts have been
made by multiple groups around the world to try to find the best way
to deliver specialized surgical care such as plastic surgery for
patients with craniofacial and cleft lip/cleft palate abnormalities.
The majority of cases are children and a priority to provide safe
care to this population is crucial. The lack of trained personnel
compromises the ability to provide appropriate medical care, which
affects safety and outcomes. There is a need for anesthesiologists in
the developing world. Promoting both anesthesiology and surgery is
essential as part of global health initiatives. The problem remains as
to how do we facilitate education, quality improvement, and assure
the effort is sustainable by the community.
Volunteer medical trips to developing countries include a team
of surgeons, anesthesiologists, and perioperative care providers
who work together to deliver safe medical care.3,4 It is well known
that access to specialized health care in developing nations is
often limited or nonexistent. The challenges include the shortage
of physician providers, the lack of adequately trained anesthesia
providers with expertise in pediatric patients, and also the lack of
adequate equipment and facility capabilities.5 7 The training of the
anesthesia providers in developing countries varies and the skills
and abilities learned are not always standardized. Many of the
anesthesia providers have not attended medical school or anesthesia
residency, much less a pediatric anesthesiology fellowship. Instead,
they have completed either a few months course, a shadowing
experience, or are working under the supervision of a surgeon.7 The
problem is even more serious with neonatal anesthesia care. For
craniofacial procedures such as cleft lip and cleft palate repairs,
a pediatric-trained anesthesiologist is preferred but not always
available; anesthesiologists experienced in the care of children
may also help fill this need.8,9 When complex craniofacial pro-
cedures are to be performed a higher level of expertise from the
anesthesia care team is recommended.
Challenges regarding the facility capabilities and access are
of constant concern when providing anesthesia in developing
countries.6 One of the major concerns in practicing in the devel-
oping world is the reliability of electricity in hospitals.10,11 This is
especially critical when oxygen supplies are provided by an oxygen
concentrator. Teams must ensure there is a backup plan in place if
electricity is cut off.11 This is not an uncommon scenario around the
developing world.
Many surgical protocols have been described based on age,
weight, and the extent of the craniofacial surgical procedure. The
anesthetic technique varies based on the age, expertise, equipment,
medication availability, and the facility capacity.3 5,12,13 Monitor-
ing equipment is often limited in host countries. Medications are
scarce and medical supplies such as endotracheal tubes, facemasks,
oral airways, nasal airways are frequently disinfected and reused
because of limited resources.4,5,10,11,14 Anesthesia machines are
1069
Melookaran et al The Journal of Craniofacial Surgery
usually in short supply or unreliable and other techniques such as
total intravenous anesthesia or regional anesthesia may be preferred.
Challenges are also encountered in postoperative care. Limited
staff, lack of training in complication management and postopera-
tive pain control, constrained resources, and lack of monitoring and
resuscitation equipment are to be considered.4,11,12,14 The neonatal
group brings additional challenges. Limitations include lack of not
only personnel with adequate training but also specialty equipment.
Safety is the primary concern and appropriate knowledge about
medications and resuscitation in this age group is critical. Other
considerations include the long-term effects of surgery on a neo-
nate, the occasional need for a neonatal ICU, or trained personnel in
the recovery room, as well as long-term follow-up and management
of these children.14
ANESTHESIOLOGY AND GLOBAL HEALTH
There is a recognized need and desire to assist in the delivery of
surgical care, especially to children, in countries where there are
scarce clinical resources and a deficiency of trained subspecialty
surgeons.15,16 Providing safe anesthesia in developing countries
although difficult will contribute to reduced morbidity and
mortality in these countries. During the years, many models of
assistance and surgical or anesthesia partnerships have been
described in the literature, describing services and education con-
cepts that may be afforded by low-income nations.16 The goal of
many of them has been to create opportunities for service, edu-
cation, and self-sustainability. Most of the models have been
successful, demonstrating there is probably not a unique solution.
As global health practitioners, it is important to recognize and
accept that our interactions will be influenced by local cultural,
historical, socioeconomic, and educational issues. This can con-
tribute to the success or failure of these initiatives. Being sensitive
to these differences will allow for a better understanding between
local communities and visitors and generate less conflict. There will
be a bidirectional learning experience17 and a close collaboration
that will affect positively any effort.
Medical Supplies and Equipment
The availability of anesthesia machines in developing countries
may be limited, broken, poorly maintained, or even obsolete. The
development of anesthesia machines that can be safely used in
remote locations, or places with scarce resources where there is no
reliable oxygen supply or electricity, is indispensable. Development
of the Glostavent anesthesia machine (Diamedica (UK) Ltd.,
Devon, United Kingdom) for developing countries18,19 is to be
applauded. It allows providing inhalational anesthesia without a
compressed gas supply. This machine will continue to function
during an interruption of electricity or oxygen supply. It has been
modified during the years with the input of anesthesia providers that
have used it in hostile conditions. A portable version is available
and is now widely accepted for use in both adult and pediatric
patients in the operating room and as a ventilator in recovery room
areas and ICUs. Equipment development like this will help anesthe-
sia providers to administer safer care.
The lack of appropriate monitoring equipment in developing
countries is enormous. The American Society of Anesthesiologists
(ASA) also took an initiative to improve anesthesia safety world-
wide in 2009 by forming the Global Humanitarian Outreach (GHO)
Committee. One of the GHO programs through the ASA is the
Lifebox program.20 This program was started in 2010 after a
collaboration of the WHO, World Federation of Societies of
Anaesthesiologists (WFSA), the Harvard School of Public Health,
and the Association of Anaesthetists of Great Britain and Ireland.6
In the United States, it is led by a team of ASA volunteers that
1070
Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 26, Number 4, June 2015
provide pulse oximeters as well as training for their use in patient
monitoring in low- and middle-income countries. Each Lifebox
costs $250, which includes training materials for classrooms and
self-learning. Between 2013 and 2014, the GHO sent volunteers to
Guatemala, Nicaragua, Bolivia, and Guyana to help fill the pulse
oximeter gap. Many anesthesia societies around the world have
joined and supported this effort.
Another extremely important challenge is related to lack of
supplies. Initiatives such as REMEDY (Recovered Medical Equip-
ment for the Developing World) started in 1991 by Dr. William
Rosenblatt, an anesthesiologist at Yale University, is a non-profit
organization that works to promote nationwide recovery of opened
but unused surplus surgical supplies. Its goal is to help reduce waste
and distribute these supplies with teaching packets about the
recovery process to areas of need.21 They have also helped imple-
ment this program in many hospitals around the country. Protocols
for recovery and which supplies can and should be recovered can all
be found on the REMEDY website as well as teaching packets
and recommendations.
Outcomes and Quality Improvement
Standards for volunteer missions are essential for successful and
safe trips.4,5,8,9 Volunteer missions are rewarding experiences for
many surgeons and anesthesiologists but such efforts require appro-
priate planning to guarantee providing the best surgical and anes-
thetic care.
Politis et al8 in conjunction with the Society of Pediatric
Anesthesia (SPA) published the anesthesiology guidelines for care
of children in developing countries. These were reviewed and
endorsed by the boards of the American Society of Plastic Surgeons,
the Plastic Surgery Educational Foundation, the SPA, the American
Cleft Palate Craniofacial Association, the American Society of
Maxillofacial Surgeons, European Society of Plastic, Reconstruc-
tive and Aesthetic Surgery, and the American Association for Hand
Surgery, Interplast, Operation Smile International and Smile Train.
Those guidelines can be found in Guidelines for the Care of
Children in the Less Developed World.8
In addition, Schneider et al. published the plastic surgery
guidelines for providing care to children in developing countries.9
These were reviewed and approved by the American Society of
Plastic Surgeons/Plastic Surgery Educational Foundation, and the
SPA. There are presently many professional organizations that help
organize and support such volunteer efforts and these documents
are a source when planning an international mission trip.
Even though many of the short-term trips are not the ideal way to
approach globalization, there is still value to surgical missions that
focus on specific surgeries such as cleft lip/cleft palate, especially in
communities with extreme poverty that cannot have access to any
specialized care.15 In the long term, as new efforts for access to
specialized surgical and anesthetic care are being addressed by the
WHO and the WFSA, finding ways to integrate short-term trips
into a bigger model would be optimal. Over time, many types of
partnerships between developing countries and the developed world
have been established, all in an effort to globalize health and find
ways to empower communities to sustain education and offer better
and safer care to their own people.
One of the present obstacles when trying to improve the
standards and quality of care in developing countries is the need
for more robust data collection to identify deficient areas and
outcomes. Fisher et al5 was one of the first large scale cohort
analysis that looked at anesthesia outcomes and established areas of
quality improvement in such medical missions, specifically Oper-
ation Smile. Some of the barriers identified included a lack of
accountability with variability in charting and reporting, poor
# 2015 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery  Volume 26, Number 4, June 2015
volunteer screening in terms of level of expertise and adaptability,
and the lack of standards for monitoring, charting, and reporting
adverse events. In 2005, Operation Smile took an initiative to better
account for critical events by establishing an electronic medical
record with the ability to retrospectively evaluate cases from
previous missions.4,5,22 In 2012, Bainbridge et al23 presented an
assessment of perioperative and anesthetic-related mortality in
developed and developing countries. They showed a decline in
perioperative mortality, although the decline was much more
significant in developed countries. This confirms that there is a
big discrepancy between the developed and developing countries
and there is a need for global health improvement to help reduce this
gap. It was recommended that every organization should have a way
to collect data regarding critical events, anesthesia quality markers,
and surgical complications.9 This data can be later used for devel-
oping plans to improve quality of care, safety, and outcomes.
Education
Many developing countries have less than 1 anesthesiologist per
100 000 people.17 Children that undergo anesthesia should be
managed by anesthesiologists whose competence in pediatric
anesthesia is adequate. When thinking about quality improvement
and outcomes, education becomes a crucial piece. The degree of
expertise in anesthesia has affect on quality of care and safety.
Complications such as intraoperative cardiac arrest are significantly
lower in pediatric patients anesthetized by a pediatric anesthesiol-
ogist; however, the educational level is low for both physicians and
nonphysicians in many countries. There is evidence that life-saving
interventions can be delegated to midlevel health care workers, but
only if they are appropriately educated and trained.24 Projects to
expand education and anesthesia training have been started around
the world. We describe some of the efforts below.
The Overseas Teaching Program (OTP) was established in 1990
by The ASA to address the need to train anesthesia providers in
Africa at a time when there was 1 anesthesiologist for several
million people. Since its establishment, the OTP has supported
educational programs in Ghana, Rwanda, Tanzania, and Zambia.
These programs evolved to become a collaboration with the WFSA.
Today, the Rwanda program remains supported by the ASA;
however, this commitment is expected to end in 2015 as the
ASA tries to expand the program to other countries.17 The WFSA
has developed a pediatric fellowship in which groups of anesthe-
siologists are being trained in Chile, Rwanda, Tunisia, India, Kenya,
and South Africa.7,14 The goal of the WFSA fellowship is to expose
these clinicians to pediatric scenarios they will eventually encounter
in the own country with limited resources. At the end of their
training, the physicians return to their home country with the ability
to train more anesthesiologists in craniofacial abnormalities.
The GHO has also collaborated with a number of medical
schools to facilitate their mission. The Medical University of South
Carolina and University of Virginia send residents and faculty
throughout the year to Weill-Bugando Center in Mwanza, Tanza-
nia, for a continuing anesthesia education program. Residents are
supervised by senior faculty but take on the responsibility for
providing anesthesia education both in the operating room as well
as the medical school. The hope is to eventually develop and sustain
an anesthesiology residency program. Many residency programs
around the country including Yale, our residency program, have a
long history of mission trips with opportunities for residents
supervised by faculty to join voluntary missions. Their experience
may vary from group to group but residents still have the oppor-
tunity to share teaching experiences inside and outside the operating
room in the visiting countries.
# 2015 Mutaz B. Habal, MD
Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Anesthesia and Craniofacial Abnormalities
Another interesting program for trainees is the traveling fellow-
ship for senior anesthesiology residents offered by The Society for
Education in Anesthesia (SEA) and Health Volunteers Overseas
(HVO).2527 Residents spend 34 weeks in a developing country
providing anesthesia education, including helping providers in the
host country develop quality assurance tools, track progress, and
collect outcomes data. The SEA-HVO presently has active projects
in Blantyre, Malawi, and Ho Chi Minh City, Vietnam. HVO also
has a number of programs to expand nurse anesthetists within
Belize, Bhutan, and Cambodia.
Access to general medicine books, anesthesia-specific books and
journals may be difficult and limited. The use of multimedia tech-
nologies allows information and education to be available to more
people and countries; however, not every place has access to this
technology. In other areas, the lack of reliable electricity makes this
effort even more difficult. Educational videos for skills and pro-
cedures, lectures, resuscitation modules, group discussions, and
interactive learning are tools that can be used. This can also be a
way to provide continued medical education and start considering
accreditation. Only after providing better training tools and improv-
ing medical knowledge, can expectations for changes in the standards
for providing safer care be addressed. Many institutions already have
these types of programs that are shared with developing countries.
An initiative by the WFSA is to create a ListServ account with the
University of Ottawa. It will allow them to have hundreds of
participants worldwide.24Their plan is to use an e-mail based system
that guarantees timely replies and consultation about upcoming
complex cases and debriefing of cases. Other uses would include
discussions about issues relevant to pediatric anesthesia globally.24
Without doubt, exchanges like these would facilitate collaboration
and multidisciplinary team work. Once this type of collaboration is
widespread, we may see safer care with a reduction in anesthesia-
related mortality.
Earlier, it was stated that pediatric and neonatal population
requires practitioners with a level of expertise and adequate resus-
citation skills to deliver safer care. The training that many prac-
titioners have in developing countries is mainly for the adult
population. In many places, younger children do not receive any
surgical care because of this lack of pediatric anesthesia expertise.
To lead our specialty in globalization of anesthesia, WFSA has
supported some programs in education. One of the programs WFSA
supports is SAFE Paediatrics, a 3-day course for anesthetists
(physicians and nonphysicians) working in developing countries to
enhance their skills in providing quality pediatric anesthesia care.
Opportunities for research are many. Health providers trained in
developed countries can contribute to research in areas of patient
advocacy, medical education, health systems, policy making and
changes, equipment design, funding initiatives, and many others.
In many countries, health care, and especially anesthesia delivery
in pediatric population, is not a priority. There is a need to raise
awareness of this problem and promote community involvement.
Once this process is started, opportunities for research may increase as
there will be a better support system, ability to create databases, follow
patients, and even funding sources that will facilitate this effort.
Steps to create sustainable globalization changes will need to be
more profound. Some of those steps have been taken in many
developed countries. Awareness needs to be raised in all of the
younger generations of physicians in training that will help in this
health globalization process. Medical schools around the country
are more frequently offering international experiences in develop-
ing countries. As an example, Yale University and their Yale Global
Health Initiative has involved the medical school as well as many of
their other schools in the university. This is a great way to generate
enthusiasm and interest for more physicians and nonphysicians to
join this project and take leadership roles in time.
1071
Melookaran et al The Journal of Craniofacial Surgery
CONCLUSION
Globalization of safe health care around the world is a priority;
however, this will be a slow and long process. We should not feel
discouraged but indeed we should be motivated. To succeed and
sustain, many people and parties must be committed. Charity and
funding must continue to be encouraged. Volunteers need to be
continually recruited. All of these efforts will facilitate campaigns
and raise awareness of the need for anesthesiologists, especially
pediatric anesthesiologists in developing countries. International
entities can also support educational initiatives, help with funding
and improving the opportunities for globalization. Entities such as
WHO and WFSA can help organize and channel efforts. Education
and recruitment of younger generations of physicians and nonphy-
sicians will contribute in the process. They will be the ones leading
our specialty and who will continue any endeavors that have already
started and the new ones to come. As health care providers,
educators, and volunteers, we are constantly challenged, working
toward improvements in how we provide safer and higher quality
care with better outcomes. Our surgical colleagues are looking into
ways to provide better and safer surgical care; providing safer
and expert anesthesia care needs to be part of that. Globalization
of anesthesia is a huge task. Anesthesiologists should be active
participants in this process and not just spectators.
REFERENCES
1. Centers for Disease Control and Prevention. http://www.cdc.gov/
ncbddd/birthdefects/data.html. Accessed November 26, 2014
2. The International Statistical Institute. http://www.isi-web.org/component/
content/article/5-root/root/81-developing. Accessed November 28, 2014
3. Aziz SR, Rhee ST, Redai I. Cleft surgery in rural Bangladesh:
reflections and experiences. J Oral Maxillofac Surg 2009;67:15811588
4. Fisher QA, Politis GD, Tobias JD, et al. Pediatric anesthesia for
voluntary services abroad. Anesth Analg 2002;95:336350
5. Fisher QA, Nichols D, Stewart FC, et al. Assessing pediatric anesthesia
practices for volunteer medical services abroad. Anesthesiology
2001;95:13151322
6. Ivani G, Walker I, Enright A, et al. Safe perioperative pediatric care
around the world. Paediatr Anaesth 2012;22:947951
7. Jacob R. Pro: anesthesia for children in the developing world should be
delivered by medical anesthetists. Paediatr Anaesth 2009;19:3538
8. Politis GD, Schneider WJ, Van Beek AL, et al. Guidelines for pediatric
perioperative care during short-term plastic reconstructive surgical
projects in less developed nations. Anesth Analg 2011;112:183190
1072
Copyright 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 26, Number 4, June 2015
9. Schneider WJ, Politis GD, Gosain AK, et al. Volunteers in plastic
surgery guidelines for providing surgical care for children in the less
developed world. Plast Reconstr Surg 2011;127:24772486
10. Hodges SC, Hodges AM. A protocol for safe anasthesia for cleft lip and
palate surgery in developing countries. Anaesthesia 2000;55:436441
11. Hodges SC, Mijumbi C, Okello M, et al. Anaesthesia services in
developing countries: defining the problems. Anaesthesia 2007;62:411
12. Hariharan S, Chen D, Merritt-Charles L, et al. Performance of a pediatric
ambulatory anesthesia program: a developing country experience.
Paediatr Anaesth 2006;16:388393
13. Khambatta HJ, Schechter WS, Navedo AT. Good outcome and volunteer
medical services in developing countries are compatible. Anesthesiology
2002;97:755756
14. Bosenberg AT. Neonatal anesthesia with limited resources. Paediatr
Anaesth 2014;24:98105
15. Farmer PE, Kim JY. Surgery and global health: a view from beyond the
OR. World J Surg 2008;32:533536
16. Blair GK, Duffy D, Birabwa-Male D, et al. Pediatric surgical camps as
one model of global surgical partnership: a way forward. J Pediatr Surg
2014;49:786790
17. Bould MD, Clarkin CL, Boet S, et al. Faculty experiences regarding a
global partnership for anesthesia postgraduate training: a qualitative
study. Can J Anaesth 2015;62:1121
18. Beringer RM, Eltringham RJ. The Glostavent: evolution of an
anaesthetic machine for developing countries. Anaesth Intensive Care
2008;36:442448
19. Tully R, Eltringham R, Walker IA, et al. The portable Glostavent: a new
anaesthetic machine for use in difficult situations. Anaesth Intensive
Care 2010;38:10851089
20. Lifebox Foundation. http://www.lifebox.org. Accessed November 16,
2014
21. REMEDY. http://remedyinc.org/. Accessed November 25, 2014
22. McQueen KA, Magee W, Crabtree T, et al. Application of outcome
measures in international humanitarian aid: comparing indices through
retrospective analysis of corrective surgical care cases. Prehosp
Disaster Med 2009;24:3946
23. Bainbridge D, Martin J, Arango M, et al. Perioperative and anaesthetic-
related mortality in developed and developing countries: a systematic
review and meta-analysis. Lancet 2012;380:10751081
24. World Federation of Societies of Anaesthesiologists. WFSA. http://
www.wfsahq.org/. Accessed November 20, 2014
25. American Society of Anesthesiologists. Global Humanitarian Outreach.
http://www.asahq.org/GHO. Accessed November 15, 2014
26. SEA. SEA-HVO Traveling Fellowship. http://www.seahq.net/. Accessed
November 16, 2014
27. Health Volunteers Overseas. Anesthesia Programs. http://www.hvousa.
org/ourwork/programs/anesthesia/. Accessed November 15, 2014
# 2015 Mutaz B. Habal, MD