Children’s Anesthesia Options

My son was recently at the dentist and we were told that he has 8 cavities. My husband and I take average care of his and his sister’s teeth. His sister is 6 and has no cavities. Luckily, we only have to have 2 filled: in his molars. This led me to wonder what types of anesthesia are available to children having procedures or surgery. Our dentist suggested 3 different options: sedate my son with Lorazepam (Ativan) so that he is relaxed, but awake, go with no sedation at all, and use the gum numbing cream, then the freezing needle; which is what most adults experience, or to completely put him under general anesthesia. Another suggestion was to use nitrous oxide which yields the “I can feel the pain, but I don’t care” feeling. I had to have nitrous when receiving my epidural before my cesarean section, and it didn’t make me feel too altered. You should be aware,  that patients have a restricted food and fluid intake prior to any sedation. This is because there is a risk that the patient will lose control over airway management, and are at risk for aspiration; basically, many drugs that sedate you, also make you nauseous. If you lose control of your airway, and happen to vomit, the vomit may go into your lungs and drown you, or severely damage you. Over the age of 3, your little ones will have to fast for 8 or more hours prior to their procedure. My dentist seemed to feel that it was important that my son not have a traumatic experience at the dentist and thought it was appropriate to use some sort of sedation, and I agreed, but my husband felt that any sedation was too risky and my son would be fine going the normal, adult route. So, what are all of the different options for anesthesia for children and what are the inherent risks involved?

The area of children’s surgical pain management is filled with some controversy as most drug companies are extremely hesitant (with good reason) to test safe dosages for children. As a result, anesthesiologists make up their own formulas from years of experience. Many children undergoing surgery are undermedicated, but there is obviously a fine line between undermedication/proper/overmedication. Physicians fear respiratory depression as a side effect of anesthetics; which is a risk for adult as well. Thus, there is a significant gap in the marketplace for analgesic/anesthetic medications for children and babies.

Firstly, I would like to point out that I am in no way a medical professional and you should always consult with your doctor or medical professional about any medications. I am coming from a place of a mom who is looking at the different options available for her son and sharing the information that I found to be useful in my quest for an answer.

Lorazepam (Ativan and other brand names) is a benzodiazepine that is a strong anti anxiety medication and sedative used in some surgeries. It is not recommended for use over a long term hospital visit due to both its addictive nature and the benzyl alcohol solution that it is carried in has at times been toxic to some patients. According to Wikipedia, this drug is not recommended for patients under 16 years of age, but there is always debate in the medical community. I have not yet talked to our family doctor, but since I have taken Ativan on and off for many years to control anxiety, I feel like I have a relationship with this medication, making me more comfortable with the possibility of using it on my son under doctors orders with the proper dose. One website that I found stated that the minimum pediatric dose for this drug is .02mg/kilogram and the maximum was .6mg/kilogram. Also stated, was the increased half life of the drug in pediatric patients. Half life is the amount of time for half of the drug to leave your system. It has an increased risk of excitation, agitation and hallucinations in patients under 8 years old.

Propofol is given intravenously to induce sedation. Two common side effects (these occur with many anesthesia drugs) include respiratory depression resulting in airway management issues during surgery and hypotension (low blood pressure). One very problematic side note is that this drug can be very painful to receive and some anesthetic prep may be needed to get this drug into the body, such as lidocane. Propofol may be prepared with soy bean oil and purified egg phospholipid so watch out for allergies. One source says that Propofol may be contraindicated for any pediatric sedation. This drug is administered in two phases; each with differing half lives: phase one is 2 to 4 minutes and phase two is 30 to 64 mintues. Total clearance from the system may take up to 12 hours.

Midazolam is another benziodiazpeine used in dental surgeries. It is short acting, making it a possible choice for dental procedures. This is the drug that is offered to inmates on death row to calm them before being put to death! Midazolam can be given orally, intranasally, sublingually, or rectally. One study showed that children who received the nasal spray version experienced irritation and pain after administration. Although widely used, this drug has not officially been approved for pediatric use.

Nitrous Oxide/Oxygen is, according the American Acadamy of Pediatric Dentistry, may be the safest sedative used in pediatric dentistry. As its name implies, it is a mixture of nitrous oxide and oxygen that is given via a mask worn on the child’s face. If you little one isn’t accustomed to the mask, it may be a bit frightening for them, but you could prep them ahead of time by buying a medical mask from the local pharmacy, or ask your doctor/dentist to give you one in order to give your child practice. While wearing the mask, your child will smell a gentle aroma and feel relaxed, but awake. Normal breathing clears the drug from their system relatively quickly after the removal of the mask.

Oralet is a new drug on the market specifically designed for children, It contains the narcotic fentanyl which induces sleep and provides pain relief. It was introduced in 1993 and watched very closely for overprescription by the FDA. It comes in a raspberry flavored hard candy on the end of a stick or in lozenge form.

Whatever route you decide to go: completely asleep, drowsy and relaxed or totally alert will depend upon the personality of your child. My eldest is a really nervous kid and I would probably opt for drowsy or even asleep for her. Some the the medications to induce drowsiness don’t work as well on very anxious kids. Adequate preparation and talking about what will happen may alleviate your child’s fear of the procedure. I used to buy a lot of Berenstain Bears books because they go through many experiences that happen in a family and help to answer questions; from going to the dentist, to the first day of school, to consumerism, moving and babysitters, these books pretty much cover them all. Preachy at times, but effective in getting the concept across.

Good luck and remember to talk to your doctor about anything you are considering. There may be new products available that I haven’t listed here.

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