Am J Perinatol
DOI: 10.1055/s-0042-1754408
Original Article

Readability, Content, and Quality of Online Patient Education Materials on Anesthesia and Neurotoxicity in the Pediatric Population

Karen Freed
1   Department of Pediatric Anesthesiology, Primary Children's Hospital, Salt Lake City, Utah
Michael G. Taylor
2   Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
Paloma Toledo
3   Department of Anesthesiology, Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, Illinois
Jessica H. Kruse
4   Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
5   Department of Anesthesiology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
Elizabeth M.S. Lange
4   Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
› Author Affiliations
Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


Objective Internet-based patient education materials (PEMs) are often above the recommended sixth grade reading level recommended by the U.S. Department of Health and Human Services. In 2016 the U.S. Food and Drug Administration (FDA) released a warning statement against use of general anesthetic drugs in children and pregnant women due to concerns about neurotoxicity. The aim of this study is to evaluate readability, content, and quality of Internet-based PEMs on anesthesia in the pediatric population and neurotoxicity.

Study Design The websites of U.S. medical centers with pediatric anesthesiology fellowship programs were searched for PEMs pertaining to pediatric anesthesia and neurotoxicity. Readability was assessed. PEM content was evaluated using matrices specific to pediatric anesthesia and neurotoxicity. PEM quality was assessed with the Patient Education Material Assessment Tool for Print. A one-sample t-test was used to compare the readability of the PEMs to the recommended sixth grade reading level.

Results We identified 27 PEMs pertaining to pediatric anesthesia and eight to neurotoxicity. Mean readability of all PEMs was greater than a sixth grade reading (p <0.001). While only 13% of PEMs on anesthesia for pediatric patient mentioned the FDA warning, 100% of the neurotoxicity materials did. PEMs had good understandability (83%) and poor actionability (60%).

Conclusion The readability, content, and quality of PEMs are poor and should be improved to help parents and guardians make informed decisions about their children's health care.

Key Points

  • The FDA issued a warning statement against the use of general anesthetic drugs in children and pregnant women.

  • Readability, content, and quality of Internet-based patient education materials on the topic of neurotoxicity are poor.

  • Improving the readability, content, and quality of PEMs could aid parents in making important health care decisions.

Previous Communication

This work has not been presented at a meeting.

Supplementary Material

Publication History

Received: 21 February 2022

Accepted: 01 June 2022

Article published online:
05 December 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Ing C, Landau R, DeStephano D. et al. Prenatal exposure to general anesthesia and childhood behavioral deficit. Anesth Analg 2021; 133 (03) 595-605
  • 2 Lin EP, Soriano SG, Loepke AW. Anesthetic neurotoxicity. Anesthesiol Clin 2014; 32 (01) 133-155
  • 3 Bartels M, Althoff RR, Boomsma DI. Anesthesia and cognitive performance in children: no evidence for a causal relationship. Twin Res Hum Genet 2009; 12 (03) 246-253
  • 4 Wilder RT, Flick RP, Sprung J. et al. Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology 2009; 110 (04) 796-804
  • 5 Davidson AJ, Disma N, de Graaff JC. et al; GAS consortium. Neurodevelopmental outcome at 2 years of age after general anaesthesia and awake-regional anaesthesia in infancy (GAS): an international multicentre, randomised controlled trial. Lancet 2016; 387 (10015): 239-250
  • 6 Sun LS, Li G, Miller TL. et al. Association between a single general anesthesia exposure before age 36 months and neurocognitive outcomes in later childhood. JAMA 2016; 315 (21) 2312-2320
  • 7 Food and Drug Administraion. FDA drug safety communication: FDA review results in new warnings about using general anesthetics and sedation drugs in young children and pregnant women. Rockville, MD: National Press Office; 2018
  • 8 Fox S, Duggan M. Pew Research Center website center PR. January 15, 2013. Accessed September 8, 2020 at:
  • 9 Weiss B. Health literacy and patient safety: help patients understand. In: Manual for Clinicians. 2nd ed. Chicago, IL: American Medical Association; 2007
  • 10 Patel SK, Gordon EJ, Wong CA, Grobman WA, Goucher H, Toledo P. Readability, content, and quality assessment of web-based patient education materials addressing neuraxial labor analgesia. Anesth Analg 2015; 121 (05) 1295-1300
  • 11 Lange EM, Shah AM, Braithwaite BA. et al. Readability, content, and quality of online patient education materials on preeclampsia. Hypertens Pregnancy 2015; 34 (03) 383-390
  • 12 Eltorai AE, Thomas NP, Yang H, Daniels AH, Born CT. Readability of trauma-related patient education materials from the American Academy of Orthopaedic Surgeons. Trauma Mon 2016; 21 (01) e20141
  • 13 Kruse J, Toledo P, Belton TB. et al. Readability, content, and quality of COVID-19 patient education materials from academic medical centers in the United States. Am J Infect Control 2021; 49 (06) 690-693
  • 14 Winker MA, Flanagin A, Chi-Lum B. et al; American Medical Association. Guidelines for medical and health information sites on the internet: principles governing AMA web sites. JAMA 2000; 283 (12) 1600-1606
  • 15 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61 (04) 344-349
  • 16 Flesch R. A new readability yardstick. J Appl Psychol 1948; 32 (03) 221-233
  • 17 McLaughlin G. SMOG grading: a new readability formula. J Read 1969; 12: 639-646
  • 18 Gunning R. The Title of Clear Writing. New York, NY: McGraw-Hill; 1952
  • 19 Shoemaker SJ, Wolf MS, Brach C. Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information. Patient Educ Couns 2014; 96 (03) 395-403
  • 20 Statistic Brain Research Institute. Illiteracy statistics. Accessed September 8, 2020 at:
  • 21 Dewalt DA, Berkman ND, Sheridan S, Lohr KN, Pignone MP. Literacy and health outcomes: a systematic review of the literature. J Gen Intern Med 2004; 19 (12) 1228-1239
  • 22 McCann ME, de Graaff JC, Dorris L. et al; GAS Consortium. Neurodevelopmental outcome at 5 years of age after general anaesthesia or awake-regional anaesthesia in infancy (GAS): an international, multicentre, randomised, controlled equivalence trial. Lancet 2019; 393 (10172): 664-677
  • 23 Sørensen K, Van den Broucke S, Fullam J. et al; (HLS-EU) Consortium Health Literacy Project European. Health literacy and public health: a systematic review and integration of definitions and models. BMC Public Health 2012; 12: 80
  • 24 Berland GK, Elliott MN, Morales LS. et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA 2001; 285 (20) 2612-2621
  • 25 Pew Research Center. Information triage. Accessed May 8, 2020 at:
  • 26 Friedman M, Arja W, Batra R. et al. Informed consent for blood transfusion: what do medicine residents tell? What do patients understand?. Am J Clin Pathol 2012; 138 (04) 559-565
  • 27 Joffe S, Cook EF, Cleary PD, Clark JW, Weeks JC. Quality of informed consent in cancer clinical trials: a cross-sectional survey. Lancet 2001; 358 (9295): 1772-1777
  • 28 Lynöe N, Sandlund M, Dahlqvist G, Jacobsson L. Informed consent: study of quality of information given to participants in a clinical trial. BMJ 1991; 303 (6803): 610-613