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Neonatal age is the most vulnerable period in the life of a human being with the greatest risk of death in the pediatric age. Neonatal mortality and morbidity are is a huge burden worldwide (figures being higher in developing countries). Neonatal deaths account for 66% of infant (birth–12 months) and 40–60% of under-5 mortal­ity rates. As per United Nations’ child mortality estimates, 721,000 neonatal deaths occurred in 2018 (average 1975 deaths every day).

UNICEF, in September 2020, reported an average Global NMR (neonatal mor­tality rate) of 17 in 2020, 2.4 million neonatal deaths, with one-third occurring within the first 24 h, and three-fourth within the first week of life. India contributes to nearly one-fifth of global live births, to more than 25% of neonatal deaths, and to 27% of newborn deaths (figures may be higher as many deaths go unreported). Major causes of early neonatal deaths (birth–7 days) are birth asphyxia, infections, complications of premature birth (44%), and congenital anomalies. WHO and Maternal and Child Epidemiology Estimation Group (MCEE) 2018 (http://data.uni­cef.org) listed major causes of neonatal deaths as preterm birth complications (44%), intrapartum-related events (19%), sepsis tetanus (13%), congenital abnor­malities (11%), pneumonia (5%), diarrhea (1%), and others such as low birth weight, hypothermia, and neonatal jaundice (7%). The preterm birth rate is on the increase worldwide, and so are the related complications, with mortality being inversely proportional to the gestational age. These figures are alarming, and Indian government aims to achieve the millennium goal of NMR (17 deaths/1000 live births) by 2035. that includes premature (born at GA < 36 weeks), small for gestational age (SGA), and newborn (within 24 h of birth) babies. They are neither like adults nor like chil­dren in their anatomy physiology organ functions drug responses and their pharma­cokinetics and pharmacodynamics, endocrine development, hemopoietic, and NM system. On top of this, there is no way they can tell their presenting complaint or give a history, and there is no past history to rely on, and limited time for evaluation and optimization.

They have all the possible ingredients for high perioperative mortality; chiefly, low birth weight, prematurity, immature and sensitive vital body systems including respiratory, cardiovascular, renal, hepatobiliary, nervous and neuromuscular sys­tem, effects of the medical and surgical condition, and unknown or undiagnosed problems (chromosomal defects, genetic syndromes, medical diseases, congenital birth defects). They thus require special care in a specialized tertiary care center with trained anesthesiologist, neonatologist, pediatric surgeons, and other support­ing specialties and facilities.

Anesthesia-related morbidity and mortality are higher in newborns and neonates than in children and adults. Newborn babies must adapt to the extra uterine environ­ment, and this continues in the neonatal period. The greatest fear of the anesthetist is the risk of reverting these changes whenever adverse conditions prevail, chiefly hypoxemia, hypercarbia, acidosis, hypovolemia, and hypothermia that may increase pulmonary vascular resistance and/or decrease systemic vascular resistance, with the return of right to left intracardiac shunting. Anesthetist must remain vigilant and proactively prevent occurrence of these events.

Postoperative outcome is better if baby is operated after post-conceptual age of 60 weeks (the safe period), earliest being at 44 weeks. Hence, a baby born at 36 weeks stands better chance of survival if operated after 8 weeks of birth, and better still after 24 weeks (6 months) of age. These figures will change with the gestational age at which baby is born (more premature the baby is, longer is the age at which it should be operated). Any surgery undertaken within these periods is considered as an emergency and life threatening.

The surgical pathology also carries its own anatomical, pathophysiological, bio­chemical, volume status, acid base and gas-related adverse effects, be it necrotizing enterocolitis (NEC), congenital diaphragmatic hernia, tracheoesophageal fistula (TEF), omphalocele and gastroschisis, meningomyelocele and encephalocele, or gut malrotation and volvulus. Besides, surgery itself is extremely stressful and has negative effect on the growing organs and brain, thus advisable to conduct under anesthesia, which further adds to the risk of the developing brain, of hypothermia, and of airway and ventilation related.