In the present study, spinal anesthesia was scheduled for 69 babies. This series represents the first pediatric spinal anesthesia, performed since 2013, in Madagascar. In developed countries, such as in the United States, SA has been included since 1977, with 262 SA, on less than 1-year patients, in 15 years . Williams R.K. et al.  reported 95.4% pediatric spinal anesthesia. In Europe, 400 to 500 SA are performed annually, (18% in preterm and 5% newborns) [3, 10]. In other countries, like India, in a one-year period study, 102 children (from 6 months to 14 years) received spinal anesthesia for sub umbilical and lower limb orthopedic surgeries . In low-income countries, few studies on pediatric spinal anesthesia have been related. Ela A.A. et al. , in Cameroon, report a series of 55 children operated under spinal anesthesia. However, the use of spinal anesthesia especially in “precarious” or “difficult” situations is attractive because it requires fewer perioperative resources .
Spinal anesthesia in the present study was performed, even at very young age (27 preterm) and low weight patients, and 14 children had a medical history of respiratory diseases. Spinal anesthesia is primarily indicated when general anesthesia presents a high risk (= respiratory complications or postoperative apnea because of pulmonary disease or prematurity) [1, 7, 10, 13]. SA is the “gold standard” technique in preterm (gestational age ≤37 weeks) and high-risk patients (preterm infants with postconceptual age <60 CW) [2, 9]. Indeed, this population is at high risk of postoperative apnea, especially if general anesthesia is performed. Spinal anesthesia is a safe alternative when tracheal intubation should be avoided (due to bronchopulmonary dysplasia or respiratory diseases …) [1, 4]. Indeed, spinal anesthesia can reduce or avoid apnea [9, 10]. Also, SA causes minimum respiratory complications [2, 10, 14, 15]. In this study, most of the patients had respiratory diseases (20.3% rhino-bronchitis) and 39.1% were premature. In the present study, all these facts motivated spinal anesthesia. In addition, patients’ characteristics were quite similar to a study by Hermanns H. et al. : 34.5 (24–40) weeks at birth, 10 (5–24) weeks postnatal age at the time of the intervention, and 3.5 (2.2–5.2) kg in weight.
The surgeries (lasting 27.5 [17.5 - 40.0] minutes), in the present study, were mostly hernia repairs. Spinal anesthesia is the gold standard for lower abdominal and lower limbs surgeries under 90 minutes duration [1, 2, 5, 7]. This was similar to a study of Ela A.A. et al.  (from 25 minutes to 78 minutes) and shorter than results in a study of Frumiento C. et al.  (48 [15-130] minutes). The most concerned surgeries are inguinal hernia repair [1, 2, 5, 7]. But other surgeries (resection of ileostoma, sacral teratoma …) can also be performed under SA [11, 13].
The spinal puncture (2 [1 - 2] attempts) was performed in sitting or lateral position, in the intersection point between the line connecting the highest point of both iliac crests (Tuffier’s line) and the vertebral axis, with an 80mm – G25 Quincke spinal needle. This midline approach is the most used in SA in small children, in lateral or seated position [6, 13, 16]. A 25G pencil-point needle such Whitacre (avoiding post lumbar puncture headache) or 25G neonatal spinal needle are recommended [11, 13]. These types of needles are not available in the CHU JRA, so 25G Quincke spinal needle was used for all patients.
Hyperbaric bupivacaine 0.5% was used with a dose of 4 [3.5 - 4] mg. The most used local anesthetics are tetracaine 0.5% and bupivacaine 0.5% lasting 90 to 120 minutes . Hyperbaric bupivacaine (0.5%) is mostly used in a dose from 0.3 mg/kg to 1 mg/kg [1, 6, 13, 17].
In the present study, for all patients, 2 anesthetists who had prior training on this technique performed the SA to limit performance bias. Even the spinal anesthesia can be performed by either an anesthetist-intensivist, or an anesthesia-intensivist trainee, or a state-certified nurse anesthetist, SA performer should be well trained for the technique . Trainees in anesthesia have a significant different success rate compared to anesthesiologists (83% versus 98.9%); the failure rate is 28% and the risk of total spinal anesthesia is approximately 0.63 to 0.8%, if the performer is not trained [1, 5].
The success of the lumbar puncture was 97.1% after 2 [1 - 2] attempts and SA success was 94.2%. Since the Bromage score is not assessable among this pediatric population, the success of the spinal anesthesia is estimated and based on the sudden loss of leg movement while normal tonus in the arms and/or the relaxation of the anal sphincter and the possibility of performing the surgical procedure [14, 18]. Williams R.K. et al.  reported a success rate of 97.4%, quite similar with our results. In the present study, no complementary local anesthesia by the surgeon was required and the GA conversion was 5.8%. This failure rate was similar to literature, varying from 1.04% to 24.6% [7, 9, 17, 19]. Dohms K. et al.  find a failure rate of 7.5% and 16% required supplemental anesthesia, also more than two punctures were needed in 28%. In Kachko L. et al.'s  study, conversion to general anesthesia was 1.04%. In inguinal hernia repair, Frumiento C. et al.  describe 91.4% of adequate spinal anesthesia, 78.6% no supplemental anesthesia, 4.5% complementary local anesthesia and 2.2% general anesthesia conversion.
The heart rates were stable throughout the perioperative period. Spinal anesthesia allows remarkable cardiovascular stability and can avoid bradycardia with minimum cardiac complications [2, 8, 10, 14, 15, 18]. But in some cases, 1.5% patients experienced bradycardia in the operating room, and 1.9% received vagolytics .
Spinal anesthesia offers a good balance between safety and perioperative risks and appears to be a safe technique, provided that the contraindications are respected; the frequency of complications is 30% [1, 5, 10, 15]. SA causes less bradycardia, apnea, desaturation, requiring postoperative respiratory assistance than GA; ventilation and oxygenation are not generally compromised, even in patients at high risk [8, 18, 20]. In the present study, no perioperative complications were observed.
In Antananarivo, this series is the first to have been reported. The strength of this study is the characteristics of the population (preterm, newborns, and infants).