Felipe Alves MD.1,2, Anderson Goncalves MD.1,2, Gabriel de Sousa MD.1,2,3, Luiza Lino MD.1,2, Ricardo Carlos MD, PhD.1,2, Vinicius Quintao MD, MSc, PhD.1,2*
ORCIDRecibido: 18-08-2025
Aceptado: 19-10-2025
©2025 El(los) Autor(es) – Esta publicación es Órgano oficial de la Sociedad de Anestesiología de Chile
Revista Chilena de Anestesia Vol. 54 Núm. 5 pp. 603-610|https://doi.org/10.25237/revchilanestv54n5-16
PDF|ePub|RIS
Brechas y desafíos en la investigación en Anestesia Pediátrica en América Latina
Abstract
Pediatric anesthesia in Latin America faces multiple barriers that compromise safe and effective perioperative care for children. Profound social and economic inequalities, shortages of specialists, fragmented educational systems, and limited scientific productivity remain persistent obstacles. The low density of anesthesiologists with formal training in pediatric anesthesia, particularly in rural areas and low-income countries, is directly associated with poorer surgical outcomes and higher complication rates. Structural limitations include insufficient fellowship programs, inconsistent regulations, and the lack of recognition of pediatric anesthesiology as a distinct discipline. Research productivity is restricted by limited funding, bureaucratic obstacles, weak infrastructure, and barriers to accessing scientific journals, which perpetuate dependence on evidence generated in high-income countries. Recent collaborative initiatives, including multinational studies and international educational programs, show promising progress by building networks and strengthening training. However, sustained investment, professional retention, and equitable access to knowledge are essential to close existing gaps and improve child health outcomes.
Resumen
La anestesia pediátrica en América Latina enfrenta múltiples barreras que comprometen la seguridad y eficacia de la atención perioperatoria infantil. Persisten profundas desigualdades sociales y económicas, escasez de especialistas, sistemas educativos fragmentados y baja productividad científica. La limitada densidad de anestesiólogos con formación específica en anestesia pediátrica, especialmente en áreas rurales y países de bajos ingresos, se asocia directamente con peores resultados quirúrgicos y mayores tasas de complicaciones. Entre las limitaciones estructurales destacan la falta de programas de formación estandarizados, la variabilidad regulatoria y el escaso reconocimiento de la anestesiología pediátrica como disciplina independiente. La producción científica está restringida por fondos insuficientes, burocracia, infraestructura débil y barreras de acceso a las revistas, lo que mantiene la dependencia de datos de países de altos ingresos. Iniciativas recientes, como estudios multinacionales y programas internacionales de formación, muestran progresos alentadores. No obstante, se requiere inversión sostenida, retención profesional y acceso equitativo al conocimiento para mejorar la salud infantil.
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Introduction
Pediatric anesthesia represents a vital subspecialty within anesthesiology, focused on ensuring the safety and efficacy of anesthetic care in the pediatric population. In Latin America, despite significant progress in healthcare delivery and clinical practice, pediatric anesthesia still faces significant challenges, primarily driven by socioeconomic disparities, a shortage of specialized training, and unequal healthcare infrastructure across the region’s health systems[1]-[3]. Besides that, the region continues to experience a low density of pediatric anesthesiologists and a lack of sufficient hospital infrastructure to meet the demands of the pediatric population[4].
The advancement of pediatric anesthesia is intrinsically linked to rigorous research efforts that inform evidence-based practice, ultimately improving patient outcomes and safety. Nonetheless, the volume and scope of pediatric anesthesia research in Latin America remain limited, which constrains the development and implementation of context-specific clinical guidelines and innovations[5]-[9]. Since research in pediatric anesthesia is essential for addressing the unique physiological, developmental, and pharmacological considerations inherent to pediatric patients research output from Latin America in this field remains limited, largely due to structural constraints such as insufficient funding, the lack of formal training programs, limited protected time for research, and the absence of official recognition of pediatric anesthesia as a distinct subspecialty in several countries[10]-[13].
Therefore, this narrative review aims to analyze the principal structural, educational, and systemic barriers impeding research in pediatric anesthesia throughout Latin America. It also seeks to highlight current initiatives and identify future opportunities to strengthen regional scientific production and, consequently, improve the quality of anesthetic care delivered to the pediatric population. Addressing these challenges and leveraging potential strategies are essential steps toward promoting equitable and sustainable progress in the field, ultimately ensuring better clinical outcomes for children across the region.
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Regional context: Disparities and common challenges
The landscape of pediatric anesthesia in Latin America is deeply influenced by persistent socioeconomic inequalities that significantly affect healthcare access and outcomes. The region is characterized by marked disparities in income distribution, education, and healthcare infrastructure, which collectively impact the availability and quality of perioperative care for children[1],[14]-[16].
These inequalities are reflected in unequal access to specialized healthcare services, particularly pediatric anesthesia, which is often concentrated in urban centers and tertiary hospitals, leaving rural and underserved populations at a disadvantage[1],[17]. The repercussions of these disparities extend beyond clinical care, affecting the generation and application of robust perioperative data critical for improving pediatric anesthesia practices regionally.
Healthcare systems across Latin America are heterogeneous, varying widely in structure, funding, and governance. This heterogeneity complicates efforts to standardize pediatric anesthesia services and establish comprehensive perioperative
registries that could facilitate research and quality improvement initiatives[18],[19]. The lack of consistent and centralized data collection on pediatric surgical outcomes impedes the assessment of current practices and the identification of areas requiring targeted interventions. Moreover, variability in health insurance coverage, resource allocation, and institutional capacities exacerbates inequities in access to high-quality anesthetic care for children[20],[21].
One of the most pressing challenges identified across the region is the low density of trained pediatric anesthesiologists. Many Latin American countries face a critical shortage of specialists who have received dedicated pediatric anesthesia training, a factor directly linked to disparities in surgical outcomes and perioperative safety. This shortage is especially acute in lower-income countries and peripheral regions of larger countries, where general anesthesiologists or non-specialists often provide pediatric anesthesia care without sufficient specialized training [1],[12],[22].
According to World Bank data, and comparisons with global surgical workforce metrics, disparities in specialist availability correlate with poorer perioperative outcomes in children, including higher rates of anesthesia-related complications and mortality[4],[23]. Global data indicate that many Latin American countries have a low density of anesthesiologists, often fewer than 5 per 100,000 inhabitants, with even lower densities in the public sector. For example, in Guatemala, there are only 1.3 anesthesiologists per 100,000 population, which is below the estimated regional average of 2.17 per 100,000[1],[24]. These figures are likely even lower when considering subspecialists, such as pediatric anesthesiologists.
Adding complexity to this challenge is the fragmentation of pediatric anesthesia training, regulation, and institutional recognition throughout Latin America. There is significant variability in the availability of formal pediatric anesthesia fellowships or certification programs, with some countries lacking standardized curricula or accreditation processes. Regulatory frameworks governing the practice of pediatric anesthesia also differ markedly, impacting the quality assurance mechanisms in place. Institutional recognition of pediatric anesthesiology as a distinct specialty remains limited in several contexts, hindering the professional development of specialists and the establishment of dedicated pediatric anesthesia services[1],[25].
Comparisons with global standards further underscore the regional challenges. Latin America’s pediatric anesthesia workforce density lags behind that of high-income countries, correlating with differences in surgical outcomes and perioperative mortality rates. Studies have demonstrated that regions with higher densities of trained pediatric anesthesiologists and robust perioperative data systems exhibit better patient safety indicators and lower complication rates[22],[23],[26]. These global benchmarks emphasize the necessity for Latin America to enhance its pediatric anesthesia workforce and infrastructure to align with international best practices.
The regional context of pediatric anesthesia in Latin America is marked by significant socioeconomic inequalities and a fragmented healthcare landscape that together limit equitable access to specialized perioperative care. The shortage of trained pediatric anesthesiologists, coupled with inconsistent training and regulatory frameworks, presents substantial barriers to improving surgical safety and outcomes for children. Addressing these challenges requires coordinated efforts to strengthen workforce capacity, harmonize training programs, and develop comprehensive perioperative data systems.
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Pediatric anesthesia training and workforce limitations
The pediatric anesthesia workforce in Latin America faces considerable limitations, which significantly impede the delivery of safe and effective anesthetic care to children and hinder the advancement of pediatric anesthesia research in the region. Central to these challenges is the limited availability of formal training programs dedicated to pediatric anesthesia and the lack of widespread subspecialty recognition in many countries. Unlike high-income regions, where pediatric anesthesiology is a well-established subspecialty with standardized fellowship pathways and certification processes, many Latin American nations either lack formalized pediatric anesthesia training programs or have nascent initiatives that remain insufficient to meet regional needs[1],[2],[12],[27].
This scarcity of specialized training opportunities directly contributes to workforce shortages. Most anesthesiologists who provide care to pediatric patients have not undergone dedicated subspecialty training, relying instead on general anesthesia training supplemented by on-the-job experience. Such an approach can compromise the quality of perioperative care, as pediatric anesthesia demands unique skills and knowledge distinct from adult practice. Complex physiological differences, age-specific pharmacokinetics, and the psychosocial needs of children require specialized competencies that are best developed through formal training and continuous professional development[12],[27].
Moreover, access to high-fidelity simulation and mentorship programs-cornerstones of modern anesthesia education-is inconsistent and often limited to major urban centers or private institutions. Simulation-based training allows clinicians to practice rare or high-risk scenarios in a controlled environment, improving readiness and patient safety[28]-[30]. However, many training centers in Latin America lack the resources to provide such educational modalities systematically. Similarly, mentorship opportunities with experienced pediatric anesthesiologists are sparse, limiting the transfer of tacit knowledge, clinical judgment, and research skills necessary for building a robust pediatric anesthesia community[1],[2],[25],[31].
Continuing education and access to updated evidence-based guidelines are also irregular, exacerbating disparities between urban and rural providers. Pediatric anesthesia is a rapidly evolving field, with ongoing advancements in pharmacology, monitoring technology, and perioperative management protocols[12],[31]. Without consistent continuing medical education (CME), practitioners may not stay abreast of best practices, which could negatively affect clinical outcomes[32],[33]. The lack of CME infrastructure further restricts the ability to conduct and disseminate research, weakening the evidence base vital for informed policy and practice improvements[34].
These workforce limitations have direct consequences on clinical practice. The shortage of formally trained pediatric anesthesiologists means that many children receive care from providers with variable expertise, increasing the risk of perioperative complications and mortality [1],[23],[35]. This variability also complicates efforts to standardize care protocols and
implement quality improvement initiatives across institutions and countries. Furthermore, the limited workforce restricts the capacity for research and data collection, perpetuating gaps in knowledge regarding pediatric anesthesia outcomes and best practices in Latin America[36].
Adding to the complexity of these challenges is the phenomenon of “brain drain,” or the emigration of trained professionals[37]. Pediatric anesthesiologists and other healthcare specialists often migrate from Latin America to higher-income countries seeking better professional opportunities, higher salaries, improved working conditions, and access to advanced training[38]-[40].
This migration exacerbates workforce shortages and impairs the region’s ability to develop sustainable pediatric anesthesia programs and research infrastructure[41]. The loss of skilled practitioners not only diminishes clinical capacity but also hinders mentorship and education of future generations, creating a vicious cycle of limited expertise and inadequate training. Efforts to address these limitations require coordinated, multilevel strategies. Expansion of formal pediatric anesthesia fellowship programs with standardized curricula and accreditation processes is essential[42],[43]. Governments, academic institutions, and professional societies should collaborate to establish regional centers of excellence that can serve as hubs for training, simulation, and research. Investment in technology to support simulation training and virtual mentorship can help overcome geographic and resource barriers, especially in underserved areas.
Additionally, creating incentives to retain trained pediatric anesthesiologists within their home countries is critical. Such incentives might include competitive compensation, opportunities for professional growth, and improved working conditions. Strengthening regional networks for knowledge exchange and research collaboration can also help mitigate the impact of workforce migration by fostering a sense of community and shared purpose among pediatric anesthesia providers[26],[44],[45].
The limitations in pediatric anesthesia training and workforce capacity represent significant barriers to improving child perioperative care and advancing research in Latin America. Addressing these challenges requires strategic investment in education, infrastructure, and professional retention policies. Through collaborative regional efforts, it is possible to build a sustainable pediatric anesthesia workforce equipped to deliver high-quality care and contribute to the growing body of evidence that will guide future improvements in the field.
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Barriers to scientific research in pediatric anesthesia
The field of pediatric anesthesia has seen a steady increase in scientific literature over the past decades. In 2023, an analysis by Miller et al., reported an average annual growth rate of 7.9% in the number of publications over a 20-year period[46]. However, both the total number of publications and the growth rate remain modest compared with trends observed in the broader field of anesthesiology. Using a similar methodology, Chen et al. found an average annual growth of approximately 10% in publications related to general anesthesia topics[47]. These findings suggest that pediatric anesthesia still lags behind other subfields in terms of scientific output. Furthermore, research in this area is disproportionately concentrated in a small number of countries and institutions, while other regions-such as Latin America-face a significant shortage of published studies[46]-[48]. This lack of geographic diversity in scientific production limits our ability to understand the field from a truly global perspective[48].
Several well-recognized barriers contribute to the relatively lower scientific productivity in pediatric anesthesia worldwide. These include lower case volumes, the requirement for legal guardian consent before enrolling children in research, and the heavy workload borne by professionals trained in pediatric anesthesia. In many hospitals, even large institutions, pediatric anesthesiologists are relatively few in number and are often pressured to prioritize clinical duties over research activities[49]-[52]. In Latin America, these general challenges are compounded by additional region-specific difficulties, which are discussed below.
One study gathered the opinions of experts from 13 Latin American countries to better understand the unique characteristics of this scientific community. The participants agreed that research is considered important for career development in their home countries. However, most institutions either lack formal research programs or have programs that are poorly established. As a result, financial and human resources dedicated to research are limited. Additionally, the difficulty in implementing well-functioning electronic databases in most hospitals further increases the challenges faced by researchers, making their work more time-consuming and less efficient[34].
The political and social context of Latin American countries also plays an important role in hindering scientific productivity. The region’s past and present are marked by periods of dictatorship, corruption, and populist governments, which have often failed to prioritize education and technological development in public policy. Deep-rooted social issues such as poverty, economic instability, and urban violence further contribute to placing science at a lower priority[53]. For instance, the Organisation for Economic Co-operation and Development (OECD) reported in 2023 the percentage of gross domestic product (GDP) spent on research and development in each country, showing that all Latin American countries invested less than 1% in this field. In contrast, the United States of America-one of the countries with the highest scientific productivity worldwide-invests around 5% of its GDP[54].
In contrast to high-income countries, Latin American nations still depend heavily on public funding for research. Consequently, the total amount of investment is insufficient. Traditionally, these countries have not positioned technology and innovation as economic commodities, which pushes private investors to fund well-established innovation centers in developed countries rather than invest in emerging ones. In addition, these territories still face complex bureaucratic processes, making investment in science and technology less attractive.
The nations of Latin America and the Caribbean collectively have a population of over 600 million people[55]. The consequence of the factors discussed above is the underrepresentation of this population in global clinical trials. This underrepresentation reduces the applicability of trial results to local health policies, thereby impairing the implementation of innovations and improvements in healthcare delivery across these countries.
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Strategic priorities to strengthen research capacity
Previously, we discussed the numerous barriers that make research particularly challenging in Latin America. In this section, we outline how scientific and international collaborations are typically structured in other regions and how the representation of pediatric anesthesia in global research can be strengthened.
Multicenter studies are essential for generating larger datasets and enhancing external validity. To conduct such research effectively, an organized steering and writing committee is required. These committees usually include principal investigators, clinical experts, and biostatisticians, who are responsible for coordinating communication among participating centers, as well as for analyzing and disseminating the final results[56].
In addition, each participating site must designate a Site Principal Investigator and establish a Site Committee to oversee local data collection. Consequently, the successful execution of such studies relies on a robust, multi-institutional research infrastructure-an element that remains scarce in many Latin American countries[56].
Another strategy for generating comprehensive datasets in pediatric anesthesia is the implementation of national and regional registries. Such platforms enable a broader understanding of anesthesia practices, challenges, and patient demographics. They also allow for the monitoring of rare but severe complications, such as broncho aspiration or intraoperative cardiac arrest, by pooling cases to identify shared pat- terns[7],[57],[58]. Although the level of evidence produced by these registries is inherently limited-being largely observational and subject to challenges in ensuring data quality-they provide a valuable foundation for hypothesis generation and for identifying areas where randomized controlled trials may be feasible[57].
Previous successful experiences with research developed in this setting have helped address important gaps in the pediatric anesthesia literature. For example, the Multicenter Perioperative Outcomes Group (MPOG) identified demographic factors associated with hypoxia during one-lung ventilation, while the Pediatric Difficult Intubation Registry (PeDiR) demonstrated the safety of using standard videolaryngoscope blades in children weighing less than 5 kg[59].
Despite these advantages, sustaining multi-institutional registries is both financially and logistically demanding. Moreover, they may inadvertently foster competition among collaborators over recognition and authorship in resulting publications. In Latin America, where structural and resource constraints are already significant, these barriers may become even more pronounced, making the establishment of such collaborative networks particularly challenging. However, underfunding in pediatric research is not an issue restricted to Latin America.
It is now well established that many adult diseases originate during childhood. Thus, investing in pediatric research has the potential not only to improve child health but also to promote healthier adult populations[60]. Nevertheless, underfunding in pediatric research is a longstanding global phenomenon. An analysis of National Institutes of Health (NIH) funding between 1992 and 2009 showed only a marginal increase in resources allocated to child health research. When adjusted for inflation, however, pediatric funding actually declined over this period[61]. Although children represent 21.7% of the U.S. population, this gap has continued to widen in recent years[62],[63]. According to the 2023 NIH budget report, pediatric research accounted for only 3.6% of the total annual funding, despite its broad scientific scope and its relevance to a significant proportion of the population[62].
In addition to financial shortages, developed countries also face a lack of young trainees interested in pursuing careers in pediatrics and pediatric research. In the United States, in particular, the burden of student debt often pushes graduates toward specialties with greater financial return. To address this challenge, strategies such as loan forgiveness programs for those who commit to careers in pediatric research have been proposed[60]. Furthermore, structured mentorship programs have proven effective in supporting early-career researchers, enhancing academic productivity, and reducing attrition rates[64].
Finally, guaranteeing equitable access to scientific journals is a crucial step toward strengthening research capacity worldwide. In many low- and middle-income countries, including much of Latin America, researchers continue to face substantial barriers due to paywalls and limited institutional subscriptions. This persistent inequity not only restricts the ability of investigators to design high-quality studies but also reinforces the cycle of scientific dependency on high-income countries. Ensuring open and affordable access to knowledge is therefore not merely an ethical imperative, but also a prerequisite for reducing global disparities in research productivity and innovation[65].
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Collaborative initiatives and emerging opportunities
Besides the challenges outlined in the previous sections, recent international programs have sought to integrate institutions from the Latin American subcontinent into worldwide pediatric anesthesia research. This section highlights several of these successful joint efforts.
Despite demographic transitions such as population aging, this part of the world still has one of the highest proportions of children globally. Consequently, studies on anesthesia in pediatric cohorts here carry significant implications for local health systems[66]. Moreover, the South African Paediatric Surgical Outcomes Study revealed substantial differences in postoperative results between children in South Africa and those in high-income nations, underscoring the limitations of applying evidence from developed settings to other contexts[67],[68].
In response to these observations, a multinational consortium launched the Latin American Surgical Outcomes Study – Pediatric (LASOS-Peds) to evaluate surgical results in this population and generate robust data to inform health policy. The project is currently in the data analysis stage and is expected to provide a clearer understanding of pediatric surgical outcomes across the subcontinent[7]. Such endeavors not only address critical evidence gaps but also foster stronger inclusion of Latin American researchers in the international academic community.
The World Federation of Societies of Anaesthesiologists (WFSA) also implements targeted strategies to expand the participation of low- and middle-income nations in the global re-
search arena. These measures include supporting training hubs that deliver short-term courses and fellowship programs in six Latin American countries, as well as providing scholarships for anesthesiologists and residents from underrepresented areas to attend major international scientific meetings[69].
In parallel, several non-governmental organizations (NGOs) contribute to the professional growth of anesthesia providers in the region. For example, Smile Train offers specialized training in 16 Latin American countries, equipping practitioners with the expertise required to safely manage patients undergoing cleft palate repair[70]. Such initiatives serve as valuable platforms for disseminating knowledge and advancing scientific capabilities in regions historically underrepresented in global research.
Moreover, the Latin American anesthesiology community strengthens its collective presence through organizations such as the Confederación Latinoamericana de Sociedades de Anestesiología (CLASA), which unites 17 national anesthesia societies. CLASA facilitates regional scientific congresses, fosters mutual support, and promotes collaborative projects. It also represents a means of showcasing the capacity and potential of the region within the global scientific landscape[71].
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Conclusion
Conducting high-quality pediatric anesthesia research in Latin America faces numerous challenges. The region continues to struggle to generate local evidence and knowledge, with persistent limitations in funding, personnel, and infrastructure maintaining the historical gap between Latin American scientists and their counterparts in Europe and North America. Multicenter studies and national or regional registries are often goals very far to be acquired since of all infrastructural constraints, as well as logistical and financial, and challenges.
Performing studies such as LASOS-Peds represent important progress in the continent. However, it is still not enough. As a result, many health policies in Latin America still rely on data from developed countries, creating the risk of misrepresenting the local reality or implementing interventions that may be inefficient or unsuitable for the regional context.
Barriers so deeply rooted in the history of Latin American science require comprehensive measures from local governments and international institutions. Dedicated funding programs and targeted grants are essential first steps, but meaningful change will require sustained increases in annual research investment, guaranteed financial and institutional support for investigators and trainees, and strategies to attract young trainees to the field. Equitable access to scientific journals, mentorship programs, and initiatives to support early-career investigators are equally important to strengthen the research ecosystem and ensure that Latin American pediatric anesthesiology can contribute meaningfully to global knowledge.
Finally, investing in pediatric research means investing in the improvement of health care for a major proportion of the global population. In Latin America, in special, the population is known to be one of the youngest in the globe. Addressing these structural, financial, and educational barriers is therefore critical both for the local advancement of science and for the broader impact of pediatric anesthesia research on global health.
Statements: This manuscript has not been submitted to any other journal and has not been previously published. The authors declare that no funding was received for this work. All authors declare no conflicts of interest. We hereby assign the intellectual property rights of this article to the Revista Chilena de Anestesiología
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References
1. Quintão VC, Concha M, Argüello LA, Cavallieri S, Cortinez LI, de Sousa GS, et al. Pediatric anesthesiology in Brazil, Chile, and Mexico. Paediatr Anaesth. 2024 Sep;34(9):858–65. https://doi.org/10.1111/pan.14886 PMID:38619275
2. Cabrera Hernández JS, Reinoso Chávez N. Current situation of pediatric anesthesiology training in Colombia. Colombian Journal of Anesthesiology. 2024 Apr 2; https://doi.org/10.5554/22562087.e1109.
3. Bösenberg AT. Pediatric anesthesia in developing countries. Curr Opin Anaesthesiol. 2007 Jun;20(3):204–10. https://doi.org/10.1097/ACO.0b013e3280c60c78 PMID:17479022
4. Health at a Glance: Latin America and the Caribbean 2023. OECD; 2023.
5. Quintão VC, Carmona MJ. A call for more pediatric anesthesia research. Braz J Anesthesiol. 2021;71(1):1–3. https://doi.org/10.1016/j.bjane.2020.12.001 PMID:33712245
6. Liston DE, Jimenez N. Promoting research in pediatric anesthesiology. Colombian Journal of Anesthesiology. 2014 Apr;42(2):120–3.
7. Quintão VC, de Sousa GS, Torborg A, Vieira A, Consonni F, Rodrigues S, et al. Latin American Surgical Outcomes Study in Paediatrics (LASOS-Peds): study protocol and statistical analysis plan for a multicentre international observational cohort study. BMJ Open. 2024 Sep;14(9):e086350. https://doi.org/10.1136/bmjopen-2024-086350 PMID:39313281
8. Carmona MJ. Brazilian Journal of Anesthesiology: seventy years fostering research in anesthesiology [English Edition]. Braz J Anesthesiol. 2021;71(6):593–4. https://doi.org/10.1016/j.bjane.2021.10.001 PMID:34715993
9. Módolo NS, Cumino DO, Lima LC, Barros GA. Advancing pediatric anesthesia in Brazil: reflections on research and education. Braz J Anesthesiol. 2024;74(5):844535. https://doi.org/10.1016/j.bjane.2024.844535 PMID:38936800
10. Maheshwari M, Sanwatsarkar S, Katakwar M. Pharmacology related to paediatric anaesthesia. Indian J Anaesth. 2019 Sep;63(9):698–706. https://doi.org/10.4103/ija.IJA_487_19 PMID:31571682
11. Cook DR. Paediatric anaesthesia: pharmacological considerations. Drugs. 1976;12(3):212–21. https://doi.org/10.2165/00003495-197612030-00004 PMID:789047
12. Schifino Wolmeister A, Hansen TG, Engelhardt T. Challenges of organizing pediatric anesthesia in low and middle-income countries [English Edition]. Braz J Anesthesiol. 2024;74(5):844525. https://doi.org/10.1016/j.bjane.2024.844525 PMID:38906364
13. Echeverry Marín PC. Promoting research in paediatric anaesthesia. Rev Colomb Anestesiol. 2014 Apr;42(2):73–5. https://doi.org/10.1016/j.rcae.2014.02.006.
14. Maceira D, Brumana L, Aleman JG. Reducing the equity gap in child health care and health system reforms in Latin America. Int J Equity Health. 2022 Feb;21(1):29. https://doi.org/10.1186/s12939-021-01617-w PMID:35197074
15. Lopez-Barreda R, Schaigorodsky L, Rodríguez-Pinto C, Salas W, Muñoz Y, Betanco B, et al. Barriers to healthcare access for children with congenital heart disease in eight Latin American countries. Paediatr Anaesth. 2024 Sep;34(9):893–905. https://doi.org/10.1111/pan.14880 PMID:38515426
16. Martin SR, Kain ZN. The intersection of pediatric anesthesiology and social determinants of health. Curr Opin Anaesthesiol. 2024 Jun;37(3):271–6. https://doi.org/10.1097/ACO.0000000000001367 PMID:38441068
17. Cockrell H, Barry D, Dick A, Greenberg S. Socioeconomic disadvantage and pediatric surgical outcomes. Am J Surg. 2023 May;225(5):891–6. https://doi.org/10.1016/j.amjsurg.2023.02.002 PMID:36754749
18. Atun R, de Andrade LO, Almeida G, Cotlear D, Dmytraczenko T, Frenz P, et al. Health-system reform and universal health coverage in Latin America. Lancet. 2015 Mar;385(9974):1230–47. https://doi.org/10.1016/S0140-6736(14)61646-9 PMID:25458725
19. Trujillo LM, Cruz LK, Laguado JS, Rincón EH. Barriers to Accessing Pediatric Healthcare in Latin America: A Scoping Review. J Racial Ethn Health Disparities. 2025 Jul. https://doi.org/10.1007/s40615-025-02510-w PMID:40721710
20. Ologunde R, Maruthappu M, Shanmugarajah K, Shalhoub J. Surgical care in low and middle-income countries: burden and barriers. Int J Surg. 2014;12(8):858–63. https://doi.org/10.1016/j.ijsu.2014.07.009 PMID:25019229
21. Kifle F, Kifleyohanes T, Moore J, Teshome A, Biccard BM. Indications, Challenges, and Characteristics of Successful Implementation of Perioperative Registries in Low Resource Settings: A Systematic Review. World J Surg. 2023 Jun;47(6):1387–96. https://doi.org/10.1007/s00268-023-06909-6 PMID:36656359
22. Schell CO, Gerdin Wärnberg M, Hvarfner A, Höög A, Baker U, Castegren M, et al. The global need for essential emergency and critical care. Crit Care. 2018 Oct;22(1):284. https://doi.org/10.1186/s13054-018-2219-2 PMID:30373648
23. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2016 Feb;25:75–8. https://doi.org/10.1016/j.ijoa.2015.09.006 PMID:26597405
24. Zha Y, Truché P, Izquierdo E, Zimmerman K, de Izquierdo S, Lipnick MS, et al. Assessment of Anesthesia Capacity in Public Surgical Hospitals in Guatemala. Anesth Analg. 2021 Feb;132(2):536–44. https://doi.org/10.1213/ANE.0000000000005297 PMID:33264116
25. Lopez MJ, Amaya S, Albornoz E, Hernandez JS. Pediatric Anesthesiology in Colombia. Paediatr Anaesth. 2025 May;35(5):404–5. https://doi.org/10.1111/pan.15085 PMID:39960143
26. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015 Apr;385 Suppl 2:S11. https://doi.org/10.1016/S0140-6736(15)60806-6 PMID:26313057
27. Nabukenya MT, Newton MW, Gray RM, Kapoor I, Kuratani N, Moore J, et al. The role of collaboration in educating the global pediatric anesthesia workforce. Paediatr Anaesth. 2024 Sep;34(9):884–92. https://doi.org/10.1111/pan.14877 PMID:38470009
28. Lorello GR, Cook DA, Johnson RL, Brydges R. Simulation-based training in anaesthesiology: a systematic review and meta-analysis. Br J Anaesth. 2014 Feb;112(2):231–45. https://doi.org/10.1093/bja/aet414 PMID:24368556
29. Griswold S, Ponnuru S, Nishisaki A, Szyld D, Davenport M, Deutsch ES, et al. The emerging role of simulation education to achieve patient safety: translating deliberate practice and debriefing to save lives. Pediatr Clin North Am. 2012 Dec;59(6):1329–40. https://doi.org/10.1016/j.pcl.2012.09.004 PMID:23116529
30. Turkot O, Banks MC, Lee SW, Dodson A, Duarte S, Kaino M, et al. A Review of Anesthesia Simulation in Low-Income Countries. Curr Anesthesiol Rep. 2019 Mar;9(1):1–9. https://doi.org/10.1007/s40140-019-00305-4.
31. Armijo-Rivera S, Machuca-Contreras F, Raul N, de Oliveira SN, Mendoza IB, Miyasato HS, et al. Characterization of simulation centers and programs in Latin America according to the ASPIRE and SSH quality criteria. Adv Simul (Lond). 2021 Nov;6(1):41. https://doi.org/10.1186/s41077-021-00188-8 PMID:34772461
32. O’Brien MA, Freemantle N, Oxman AD, Wolfe F, Davis D, Herrin J. Continuing education meetings and workshops: effects on professional practice and health care outcomes. In: O’Brien MA, editor. Cochrane Database of Systematic Reviews. Chichester, UK: John Wiley & Sons, Ltd; 2001. https://doi.org/10.1002/14651858.CD003030.
33. Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA. 1999 Sep;282(9):867–74. https://doi.org/10.1001/jama.282.9.867 PMID:10478694
34. Chomsky-Higgins K, Miclau TA, Mackechnie MC, Aguilar D, Avila JR, Dos Reis FB, et al. Barriers to Clinical Research in Latin America. Front Public Health. 2017 Apr;5:57. https://doi.org/10.3389/fpubh.2017.00057 PMID:28459047
35. Pulvirenti R, Gortan M, Cumba D, Gamba P, Tognon C. Pediatric Surgery and Anesthesia in Low-Middle Income Countries: Current Situation and Ethical Challenges. Front Pediatr. 2022 Jul;10:908699. https://doi.org/10.3389/fped.2022.908699 PMID:35967563
36. Niconchuk JA, Newton MW. Global pediatric surgery and anesthesia inequities: how do we have a global effort? Curr Opin Anaesthesiol. 2022 Jun;35(3):351–6. https://doi.org/10.1097/ACO.0000000000001122 PMID:35671023
37. Horn JJ. The medical “brain drain” and health priorities in Latin America. Int J Health Serv. 1977;7(3):425–42. https://doi.org/10.2190/ERF7-RVJD-PPUT-LE6V PMID:328414
38. Kudsk-Iversen S, Shamambo N, Bould MD. Strengthening the Anesthesia Workforce in Low- and Middle-Income Countries. Anesth Analg. 2018 Apr;126(4):1291–7. https://doi.org/10.1213/ANE.0000000000002722 PMID:29547423
39. Muffly MK, Singleton M, Agarwal R, Scheinker D, Miller D, Muffly TM, et al. The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035. Anesth Analg. 2018 Feb;126(2):568–78. https://doi.org/10.1213/ANE.0000000000002535 PMID:29116973
40. Astor A, Akhtar T, Matallana MA, Muthuswamy V, Olowu FA, Tallo V, et al. Physician migration: views from professionals in Colombia, Nigeria, India, Pakistan and the Philippines. Soc Sci Med. 2005 Dec;61(12):2492–500. https://doi.org/10.1016/j.socscimed.2005.05.003 PMID:15953667
41. Mullan F. The metrics of the physician brain drain. N Engl J Med. 2005 Oct;353(17):1810–8. https://doi.org/10.1056/NEJMsa050004 PMID:16251537
42. Matava CT, Kurth D. Global perspectives on pediatric anesthesia. Paediatr Anaesth. 2024 Sep;34(9):821–3. https://doi.org/10.1111/pan.14956 PMID:38958561
43. Munshey F, McDonnell C, Matava C. Pediatric anesthesia training to early career stage: opportunities for firm foundations. Paediatr Anaesth. 2021 Jan;31(1):24–30. https://doi.org/10.1111/pan.13978 PMID:32726879
44. Rowan K, Shah SV, Knudson A, Kolenikov S, Satorius J, Robbins C, et al. Health professional retention in underserved areas: findings from the National Health Service Corps Loan Repayment Program participants in the United States, 2019-2021. J Public Health Policy. 2024 Dec;45(4):639–53. https://doi.org/10.1057/s41271-024-00516-y PMID:39181963
45. Malinzak EB, Vail EA, Wixson M, Lee A. Enhancing Our Workforce: Recruitment and Retention in Anesthesiology. Int Anesthesiol Clin. 2024 Jul;62(3):26–34. https://doi.org/10.1097/AIA.0000000000000442 PMID:38785107
46. Miller C, Dejaco A, Gumz N, Nemeth M. The pediatric anesthesiology publication activity and landscape over the past two decades: A longitudinal scientometric analysis. Paediatr Anaesth. 2024 Mar;34(3):243–50. https://doi.org/10.1111/pan.14811 PMID:38084801
47. Chen SY, Wei LF, Ho CM. Trend of academic publication activity in anesthesiology: A 2-decade bibliographic perspective. Asian J Anesthesiol. 2017 Mar;55(1):3–8. https://doi.org/10.1016/j.aat.2016.06.005 PMID:27543199
48. Ruan D, Tang X, Li X, Li L, Hua J. Trends and bibliometric analysis on pediatric anesthesia from 2002 to 2022: A review. Medicine (Baltimore). 2023 Oct;102(43):e35626. https://doi.org/10.1097/MD.0000000000035626 PMID:37904397
49. Brambrink AM, Ehrler D, Dick WF. Publications on paediatric anaesthesia: a quantitative analysis of publication activity and international recognition. Br J Anaesth. 2000 Oct;85(4):556–62. https://doi.org/10.1093/bja/85.4.556 PMID:11064614
50. Ramsdell R, Lerman J, Pickhardt D, Feldman D, Foster J, Houle TT. Subspecialty impact factors: the contribution of pediatric anesthesia and pain articles. Anesth Analg. 2009 Jan;108(1):105–10. https://doi.org/10.1213/ane.0b013e31818f0e89 PMID:19095837
51. Putzer G, Ausserer J, Wenzel V, Pehböck D, Widmann T, Lindner K, et al. [Publication performances of university clinics for anesthesiology: Germany, Austria and Switzerland from 2001 to 2010]. Anaesthesist. 2014 Apr;63(4):287–93. https://doi.org/10.1007/s00101-014-2298-7 PMID:24718414
52. O’Leary JD, Crawford MW. Bibliographic characteristics of the research output of pediatric anesthesiologists in Canada. Can J Anaesth. 2010 Jun;57(6):573–7. https://doi.org/10.1007/s12630-010-9292-6 PMID:20229218
53. Ciocca DR, Delgado G. The reality of scientific research in Latin America; an insider’s perspective. Cell Stress Chaperones. 2017 Nov;22(6):847–52. https://doi.org/10.1007/s12192-017-0815-8 PMID:28584930
54. https://www.oecd.org/en/data/indicators/gross-domestic-spending-on-r-d.html?oecdcontrol-8027380c62-var3=2023 [Internet]. 2025. Gross domestic spending on R&D.
55. Demographic Observatory of Latin America and the Caribbean 2024. Population Prospects and Rapid Demographic Changes in the First Quarter of the Twenty-first Century in Latin America and the Caribbean. 2024.
56. Sprague S, Matta JM, Bhandari M, Dodgin D, Clark CR, Kregor P, et al.; Anterior Total Hip Arthroplasty Collaborative (ATHAC) Investigators. Multicenter collaboration in observational research: improving generalizability and efficiency. J Bone Joint Surg Am. 2009 May;91 Suppl 3:80–6. https://doi.org/10.2106/JBJS.H.01623 PMID:19411504
57. Nelson O, Wang JT, Matava CT, Stricker PA. Registries in pediatric anesthesiology: A brief history and a new way forward. Paediatr Anaesth. 2024 Jan;34(1):7–12. https://doi.org/10.1111/pan.14775 PMID:37794755
58. https://www2.pedsanesthesia.org/newsletters/2019fall/registries.html?utm_source=chatgpt.com [Internet]. Society for Pediatric Anesthesia – SPA News.
59. Cravero J, Brown ML. Database and registry research in pediatric anesthesiology. Curr Opin Anaesthesiol. 2025 Jun;38(3):217–21. https://doi.org/10.1097/ACO.0000000000001502 PMID:40260597
60. Cabana MD, Cheng TL, Bauer AJ, Bogue CW, Chien AT, Dean JM, et al.; Committee on Pediatric Research. Promoting education, mentorship, and support for pediatric research. Pediatrics. 2014 May;133(5):943–9. https://doi.org/10.1542/peds.2014-0448 PMID:24777211
61. Gitterman DP, Hay WW Jr. That sinking feeling, again? The state of National Institutes of Health pediatric research funding, fiscal year 1992-2010. Pediatr Res. 2008 Nov;64(5):462–9. https://doi.org/10.1203/PDR.0b013e31818912fd PMID:18787420
62. https://officeofbudget.od.nih.gov/cy.html [Internet]. 2023. NIH — Office of Budget —Fiscal Year 2023.
63. https://www.childstats.gov/americaschildren/glance.asp [Internet]. 2019. Childstats.gov – America’s Children: Key National Indicators of Well-Being.
64. Szilagyi PG, Haggerty RJ, Baldwin CD, Paradis HA, Foltz JL, Vincelli P, et al. Tracking the careers of academic general pediatric fellowship program graduates: academic productivity and leadership roles. Acad Pediatr. 2011;11(3):216–23. https://doi.org/10.1016/j.acap.2011.02.005 PMID:21570006
65. Logullo P, de Beyer JA, Kirtley S, Schlüssel MM, Collins GS. Open access journal publication in health and medical research and open science: benefits, challenges and limitations. BMJ Evid Based Med. 2024 Jul;29(4):223–8. https://doi.org/10.1136/bmjebm-2022-112126 PMID:37770125
66. https://www.cepal.org/en/news/world-has-8-billion-people-662-million-whom-live-latin-america-and-caribbean [Internet]. 2022. The World Has 8 Billion People, 662 Million of Whom Live in Latin America and the Caribbean.
67. Torborg A, Cronje L, Thomas J, Meyer H, Bhettay A, Diedericks J, et al.; South African Paediatric Surgical Outcomes Study Investigators. South African Paediatric Surgical Outcomes Study: a 14-day prospective, observational cohort study of paediatric surgical patients. Br J Anaesth. 2019 Feb;122(2):224–32. https://doi.org/10.1016/j.bja.2018.11.015 PMID:30686308
68. ASOS-Paeds Investigators. Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study. Lancet. 2024 Apr;403(10435):1482–92. https://doi.org/10.1016/S0140-6736(24)00103-X PMID:38527482
69. WFSA. https://wfsahq.org/our-work/education-training/. 2025. Education & Training.
70. Smile Train Brasil. https://www.smiletrainbrasil.com/nossa-abordagem. 2025. Cuidados Gratuitos, Sustentáveis e Locais em 5 Continentes.
71. https://www.anestesiaclasa.org/organizacion [Internet]. 2018. Organización CLASA.
