Pharmacological behaviour management

Eduardo A Alcaino, Jane McDonald, Michael G Cooper and Simrit Malhi

Pain management for children

The proper treatment of pain in children is often inadequate and involves misconceptions that:

• Children experience less pain than adults.

• Neonates do not feel or remember pain.

• Pain is character-building for children.

• Opioids are addictive and too dangerous in terms of respiratory distress.

• Children cannot localize or describe their pain.

Development of pain pathways

Even premature neonates have the physiological pathways and mediators to feel pain. The statement that infants and children do not experience pain, either partially or completely, is not physiologically valid.

Measurement of pain in children

There are individual circumstances for each child that affect how they respond to pain and, subsequently, how that pain will be assessed. These include:

• Age and developmental level.

• Social and medical factors.

• Previous pain experience.

Observation of non-verbal cues and behaviour is important. A quiet, withdrawn child may be in severe pain. Simple measures are there to measure pain in children of all ages.

Table 3.1

Analgesic agents for children

IMI, intramuscular injection; IVI, intravenous injection; SCI, subcutaneous injection.

Paracetamol

• Dosage 20 mg/kg orally, then 15 mg/kg every 4 h.

• 30 mg/kg rectally as a single dose.

• Maximum 24-hour dosage of 90 mg/kg (or 4 g) for 2 days, then 60 mg/kg per day by any route of administration.

• Ensure adequate hydration.

• Useful as a pre-emptive analgesic.

• No effect on bleeding.

• Intravenous paracetamol is available (10 mg/mL). The same dose is used and administered over 15 min.

• Take care with dosing, as many different strengths and preparations are available.

Non-steroidal anti-inflammatory drugs (NSAIDs)

• Effective alone after oral and dental procedures.

• May be used in conjunction with paracetamol.

• Have an opioid-sparing effect.

• Increased bleeding time due to inhibition of platelet aggregation.

• Useful analgesic once haemostasis has been achieved.

• Best given if tolerating food and drink.

• Can be used in infants over 6 months of age.

Contraindications for the use of NSAIDs in children

• Bleeding or coagulopathies.

• Renal disease.

• Haematological malignancies, in children who may have or develop thrombocytopenia.

• Severe asthma, especially if the child is sensitive to aspirin, steroid-dependent or have coexisting nasal polyps.

Aspirin

• Rarely used in children for mild pain due to the risk of Reye syndrome.

• However, aspirin is commonly used in the management of juvenile rheumatoid arthritis.

Ibuprofen

• Commonly used in children for mild pain with less gastrointestinal side-effects compared with aspirin.

• Should be avoided in patients with renal impairment.

Codeine

• Repeated administration causes constipation.

• Main action is due to metabolism to morphine (approximately 15%).

• 10% of Caucasians and up to 30% of Hong Kong Chinese cannot metabolize codeine and find it an ineffective analgesic.

• Intravenous use may cause profound hypotension.

Oxycodone

• Good oral bioavailability.

• No pharmacological differences in metabolism.

• Available as a liquid.

• Useful alternative to codeine.

Morphine

• About 30% oral bioavailability as morphine sulphate.

• May cause nausea and constipation similar to all opioids.

• There is no risk of addiction for supervised analgesic use in children.

Tramadol

• Can be used for moderate pain in children over 12 years of age.

• A weak µ-opioid agonist and has two other analgesic mechanisms (increasing neuronal synaptic 5-hydroxytryptamine and inhibition of noradrenaline uptake).

• 70% oral bioavailability.

• No effect on clotting.

• Avoid use in children with seizure disorders and those taking tricyclic or selective serotonin reuptake inhibitor (SSRI) antidepressants.

Clinical Hint – Scenario

A compliant 8-year-old boy is having several teeth extracted under local infiltration and inhalation sedation with nitrous oxide. Consider:

• Preoperatively: paracetamol 20 mg/kg orally, 30 min preoperative.

• Postoperatively – ibuprofen 10 mg/kg and paracetamol 15 mg/kg every 6 h or 30 min before bedtime that night.

• Occasionally, an oral opioid may be required if analgesia is inadequate when local anaesthesia wears off, i.e. oxycodone syrup 0.1 mg/kg every 4–6 h for 2–3 doses.

Discharge criteria

Many drugs that are used for combination sedation and analgesia in children have a long half-life of several hours. Discharge criteria should be used to assess that the child is well enough prior to discharge from a free-standing facility. Criteria should include:

• Self-maintenance of airway.

• Easily rousable and able to converse.

• No ataxia, i.e. can walk properly.

• Tolerating oral fluids.

• Discharge in the care of a responsible adult with appropriate information about after-hours contact if a problem arises.

Local anaesthesia

The use of local anaesthesia in paediatric dentistry varies significantly between countries and there are also individual preferences. Every clinician must be proficient at administering painless local anaesthesia. While it is the mainstay of our pain control for operative treatment, it also represents one of the greatest fears in our patients. Use of many of the non-pharmacological techniques described in the previous chapter may enable the dentist to deliver an injection without the child being aware. There are few patients, old or young, who are not genuinely afraid of injections, and there are obvious disadvantages in the physical size of the dental cartridge syringe.

Techniques and tips

• It makes sense NOT to hold the syringe in front of a young child to see. While it is essential not to lie to the child, distractions such as having the dental assistant talk, or use of the low velocity suction are useful.

• The use of topical anaesthetics is essential to create the optimal experience for the child. While a multitude of agents are available with different flavours and properties, newer anaesthetics such as EMLA^® (Eutectic Mixture of Local Anaesthetic) penetrate deeper through the mucosa.

• Newer products such as electronic devices for slow injection techniques may replace more conventional techniques (The Wand^®).

• The use of infiltration versus block injections in the mandible is also the subject of debate, and clinicians differ in their choice of technique. The approach of the needle to the mandibular foramen differs in younger children, as the angle of the mandible is more obtuse and a shorter needle (25 mm) may be sufficient. However, even with the best technique, a mandibular block injection may still be uncomfortable.

• Infiltration injections supplemented with intra-periodontal injection may be useful.

• Palatal anaesthesia is best achieved by slowly infiltrating through the inter-dental papilla after adequate labial or buccal anaesthesia to minimize discomfort to the child (Figure 3.1).

Figure 3.1 Techniques for administering palatal anaesthesia by injecting from the already anaesthetized buccal side, through the interdental papilla. Note the blanching of the palatal mucosa indicating spread of the anaesthetic solution.

Need for local anaesthesia under sedation and general anaesthesia

Some form of pain control is required when invasive procedures are performed under any form of sedation (including inhalation sedation, oral sedation, etc.). However, the need for local anaesthetic under general anaesthesia is controversial. It is well recognized that a patient’s vital signs may change in response to painful stimuli (e.g. extraction), depending on the depth of anaesthesia. Local anaesthesia is not routinely used for extractions of primary teeth under general anaesthesia. Studies have observed that the child’s postoperative recovery is usually independent of the procedure performed, and preschool children waking after having a general anaesthetic can be more distressed by the sensation of numbness in the mouth. However, the use of local anaesthesia is recommended when removing permanent teeth, especially first permanent molars.

Clinical Hints – Local anaesthesia

Successful local anaesthesia depends on:

• Communication with the child and parent.

• Routine use of topical anaesthesia, and leaving adequate time for it to act.

• Slow injection of warm solution.

• Avoiding direct palatal injections.

• Adequate anaesthesia for procedure being performed.

Complications with local anaesthesia

The most significant complication encountered is overdosage. Consequently, maximum doses (Table 3.2) need to be calculated according to weight and preferably written in the notes if more than just a short procedure is being performed. This clinical complication is highlighted in a paper that reviewed significant negative outcomes (death or neurological damage) in children due to local anaesthetic overdose (Goodson & Moore 1983).

Table 3.2

Maximum dosages for local anaesthetic solutions

Anaesthetic agent	Maximum dose
2% Lidocaine without vasoconstrictor	3 mg/kg
2% Lidocaine with 1 : 100 000 adrenaline	7 mg/kg
4% Prilocaine plain	6 mg/kg
4% Prilocaine with felypressin	9 mg/kg
0.5% Bupivacaine with 1 : 200 000 adrenaline	2 mg/kg
4% Articaine with adrenaline 1 : 100 000 (approximately 1.5 cartridge of 2.2 mL in 20 kg child)	7 mg/kg

Calculation of local anaesthetic dosage:
2% lidocaine = 20 mg/mL
2.2 mL/carpule = 44 mg/carpule
A 20 kg child (approximately 5 years old) can tolerate a maximum dose of 2% lidocaine with vasoconstrictor of:
7 mg/kg × 20 kg = 140 mg Equivalent of 3 carpules (6.6 mL)

Other complications include:

• Failure to adequately anaesthetize the area.

• Intravascular injection (inferior alveolar nerve blocks or, infiltration in the posterior maxillae, directly into the pterygoid venous plexus).

• Biting of the lower lip or tongue postoperatively.

• Facial nerve paralysis by injecting too far posteriorly into the parotid gland.

Consequently, adequate postoperative instructions to both children and parents are necessary to minimize these complications. In addition, inadequate local anaesthetic technique (inexperienced operator, fast delivery of solution and inadequate behaviour management) may jeopardize a successful outcome in an otherwise cooperative child. Allergic reactions to local anaesthetic solutions and needle breakage are rare in children.

The use of articaine with adrenaline has gained popularity recently. However, its safety and effectiveness in children under the age of 4 years has not been established. Finally, it is worth noting that there is significant evidence that inadequate local anaesthesia for initial procedures in young children may diminish the effect of adequate analgesia in subsequent procedures (Weisman et al. 1998).

Sedation in paediatric dentistry

The decision to sedate a child requires careful consideration by an experienced team. The choice of a particular technique, sedative agent and route of delivery should be made at a prior consultation appointment to determine the suitability of the child (and their parents) to a specific technique.

The use of any form of sedation in children presents added challenges to the clinician. During sedation, a child’s responses are more unpredictable than that of adults. Their proportionally smaller bodies are less tolerant to sedative agents and they may be easily over-sedated. Anatomically differences in the paediatric airways include:

• The vocal cords positioned higher and more anterior.

• The smallest portion of paediatric airway is at the level of the subglottis (below cords) at the level of the cricoid ring.

• Children have relatively larger tongue and epiglottis.

• Possible presence of large tonsillar/adenoid mass (Figure 3.2).

Figure 3.2 Large tonsils cause a significant risk of airway obstruction.

• Larger head to body size ratio in children.

• The mandible is less developed and retrognathic in younger children and infants.

• Children have smaller lung capacity and higher metabolic rate resulting in a smaller oxygen reserve. Hence children desaturate more quickly than adults.

Patient assessment

The preoperative assessment is among the most important factors when choosing a particular form of sedation. This assessment must include:

• A thorough medical and dental history (including current medications, previous hospitalization and past operations).

• Patient medical status (see ASA classification, below).

• History of recent respiratory illness or current infections.

• Assessment of the airway to determine suitability for conscious sedation or general anaesthesia (GA).

• Fasting requirements and the ability of the carer to comply with instructions.

• Proposed procedures being performed.

• Patient’s weight and vital signs.

The clinician should be aware that children have resting vital signs that differ according to their age (Table 3.3).

Table 3.3

Resting vital signs in children

The use of monitoring devices such as pulse oximetry is desirable for lighter sedation techniques and mandatory for moderate and deep sedation. While not currently mandated during relative analgesia, it is suggested that pulse oximetry should be used in all instances when a child is sedated. Sedation and anaesthesia is a continuum and any dentist who sedates children must be capable of resuscitating the patient from any level of sedation deeper than intended (Cote & Wilson 2006). Furthermore, regulations in each country, cultural and socioeconomic factors will determine whi/>

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Tags: Handbook of Pediatric Dentistry 4e

Jan 14, 2015 | Posted by mrzezo in Pedodontics | Comments Off

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3. Pharmacological behaviour management

Pharmacological behaviour management