An Ethical Framework for Deep Brain Stimulation in Children

Benjamin Davidson, MD; Lior M. Elkaim; Nir Lipsman, MD, PhD; George M. Ibrahim, MD, PhD


Neurosurg Focus. 2018;45(3):e11 

In This Article

The Technical Nuances: Ethical Challenges Introduced by Technical Considerations

Technical nuances in children may also present ethical challenges. One example of this is the need for general anesthesia in children, which may preclude microelectrode recordings, potentially decreasing the accuracy of lead placement. In adults, lead misplacement is the chief cause of suboptimal outcomes with DBS.[13] There is reasonable case-control evidence from adults with Parkinson's disease that awake and asleep DBS yield similar results.[8] This comparison has not yet been performed in children. Awake DBS has been successfully performed in many children over the age of 10, although it requires innovative strategies such as an intraoperative child-life specialist and preoperative relaxation training.[29]

In children under the age of 7, the location of DBS electrodes can also change with head growth. The deepest lead should be placed slightly ventral to the target in children with further head growth anticipated.[27] Similarly, extra wire should be loosely looped in the subcutaneous pocket to avoid lead fracture with growth.

Stimulation parameters also introduce an element of uncertainty in children, for whom no standardized protocols exist.[29] In adults, common stimulation settings have been demonstrated to be safe through autopsies on patients who had chronic DBS.[29] Safety data of this nature are not available in children. Consent discussions for pediatric DBS should outline the limitations of our current state of knowledge, especially as regards the safety profile and long-term effects of stimulation. An ethical obligation of the scientific community is to facilitate the standardization of pediatric DBS protocols, including programming.

The ethical challenges associated with these procedural differences highlight the importance of appreciating and communicating that pediatric DBS is novel not only because of the age group, but also because the basic technical procedure is still being refined.