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:
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:
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 A quiet, withdrawn child may be in severe pain.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.
Methods for paediatric pain assessment include
• Children with severe developmental delay can be extremely difficult to assess regarding pain, even by their regular carers. Unusual changes in behaviour from normal may represent an expression of pain.
Analgesia prior to procedures (pre-emptive analgesia)
Routes of administration
• The rectal route of administration can be valuable in a child not tolerating oral fluids. Doses and time to peak levels may vary compared with oral preparations and are usually much longer. Peak levels after rectal paracetamol may take 90–120 min. Adequate explanation should be given and consent should be obtained for the rectal administration of a drug. This route is not used in an immunocompromised child due to the risk of infection or fissure formation.
• Repeated intramuscular injection should be avoided in children, they will often tolerate pain rather than have a painful injection. A subcutaneous cannula, inserted after using topical local anaesthetic cream (EMLA) can be used for repeated parenteral opioid analgesia.
See Table 3.1.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Contraindications for the use of NSAIDs in children
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:
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.
• 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.
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.
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).
|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:
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 preoperative assessment is among the most important factors when choosing a particular form of sedation. This assessment must include:
The clinician should be aware that children have resting vital signs that differ according to their age (Table 3.3).
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/>