Clinical observation utilizing morphine sulfate and hydroxyzine pamoate for sedating apprehensive children for dental procedures: a nine-year report.

There are few reports in the dental literature of the use of morphine sulfate in sedating a child. The findings of this 9-year study using morphine sulfate and hydroxyzine pamoate for the treatment of apprehensive and fearful children justify further investigation into its use. A total of 4363 uses of the agents were recorded between July, 1975, and June, 1984. Where any abnormal response to the medication was seen, an incomplete medical history had been given at the time of examination. Morphine sulfate should be considered as an alternative to meperidine hydrochloride and alphaprodine hydrochloride. * * Premedication is as much an art as a science and this is reflected by the many drugs or combinations of drugs which have been reported. 1 Premedication focuses on the relief of anxiety and pain during the dental procedure. Perhaps the most important factor in deciding which drugs or techniques to use is past experience with the agent. 2 The American Academy of Pediatric Dentistry has set forth the following guidelines for elective use of conscious sedation: "The primary goal must be the welfare of the patient; the second, control of patient movement to enable the practitioner to provide quality treatment; third, the patient arrives and leaves in a state of consciousness that is as close to normal for that patient as possible; and fourth, the production of a positive psychological response to treatment. ’’3 The purpose of this paper is to report a 9-year experience (July, 1975, through June, 1984) observing 4363 children who were treated with morphine sulfate (deep IM) and hydroxyzine pamoatea (oral suspension) to alleviate apprehension during extensive dental procedures. ** Alphaprodine is no longer manufactured. " Vistaril--Pfizer Laboratory Division: New York, NY. Literature Review The dental literature hardly mentions the use of morphine sulfate for dental procedures. 4,S Yet many articles appear in medical journals describing the use of morphine for the sedation of children for surgical procedures. 6-11 The use of hydroxyzine pamoate has been well documented in the dental literature. 12-1S Kopel’s double-blind study with apprehensive children using oral hydroxyzine pamoate produced results closely approximating those of an ideal drug for the premedication of the apprehensive patient. 16 Morphine is a potent, centrally active analgesic which is derived from the milky exudate of the poppy plant Papaver somniferum. Morphine and its derivatives interact with stereospecific and saturable binding sites, or receptors, in the brain and other tissues. Morphine induces drowsiness, changes in mood, and mental clouding as well as analgesia. The analgesia occurs without loss of consciousness. Nausea, however, may be an unpleasant side effect. Dosages of morphine above normal levels may result in convulsions in patients without a previous history of convulsions. Thus morphine should not be given to patients with a history of seizures. Repeated use of morphine results in additive potential. There also is respiratory depression resulting from morphine. Ninety per cent of morphine is excreted in the urine the first day, but traces have been observed for as long as 48 hr. The administration of hydroxyzine pamoate results in suppression of activity in subcortical areas of the central nervous system. Hydroxyzine pamoate is a chlorobenzhydryl piperazine derivative which is absorbed in the gastrointestinal tract; results may be seen within 45 rain with peak action at 1 hr. Hydroxyzine pamoate may potentiate meperidine hyo 280 MORPHINE SULFATE-HYDROXYZINE PAMOATE SEDATION: Schneider TABLE 1. Premedication for Children* Morphine Age (years) Sulfate (rag) Amount (cc) Weight (lbs) 1 1 0.075 20 11⁄2 1.5 0.100 26 2 2 0.150 30-35 3 3 0.200 30-35 31⁄2 3.5 0.230 30-35 4 4 0.240 35-40 5 5 0.330 40-60 6 6 0.400 40-60 7 7 0.450 40-60 8 8 0.500 60-90 12-Adult 90-150 * If Vistaril is used, cut morphine sulfate doses by 1⁄2. If Demerol is used, use 1 mg/lb of body weight; Do not give more than 100 mg/dosage. If morphine sulfate is used, use 1 mg/year of age, provided that patient IS NOT UNDER WEIGHT. If Nembutal is used instead of Demerol, use 10 mg/lb of body weight rectally in suppository form. LORFAN (Roche) 0.1 mg/Lorfan/1 mg morphine is Antidote. Courtesy, Sanchez Salazar, A.A., M.D., Chief, Department of Anesthesiology, Hope Haven Children’s Hospital, 1964-70. Narcan is now the accepted antidote. drochloride b and barbiturates. Therefore, the dosages of the drug should be adjusted in conjunction with the narcotic used. Drowsiness is a major side effect of hydroxyzine pamoate, but the effects of single dosages disappear in 2-6 hr. Hydroxyzine pamoate apparently suppresses some of the hypothalamus nuclei and extends its effect peripherally in the sympathetic portion of the autonomic nervous system. Sedation of the type discussed in this report should be attempted only by those adequately trained according to the ADA Guidelines for Teaching Pain and Anxiety Control. The original premedication formula used from 1967 until June, 1975, was morphine sulfate, scopolamine, and hydroxyzine pamoate. However, scopolamine was discontinued in June, 1975, since the necessity of its use was questioned for the patient who was not given a general anesthetic. Further, it was a convulsive drug which could potentiate the convulsive activity of morphine sulfate. Methods and Materials This clinical study had no controls and the findings represent the observations of the author. The factors which distinguish this report from standard research methods and scientific reports are noted in the discussion section of the paper. The premedications used were morphine sulfate, supplied in 20 ml vials (15 mg/ml), and hydroxyzine pamoate, supplied in pint bottles (20 mg/ 5 ml, Table 1). Morphine sulfate was dispensed by a 1 cc tuberculin syringe via a 25 g s~ needle and injected in the deltoid muscle (deep IM). Hydroxyzine pamoate was b Demerol--Winthrop Labs: New York, NY. given orally using a medication dispensing tube calibrated in teaspoons. The determination to sedate was based on patient apprehension and extent of dentistry needed (time required for treatment to be greater than 1 hr). The premedications were used in the mentally retarded child, in victims of cerebral palsy, Down’s syndrome, and sickle cell anemia, as well as the apprehensive child with a normal medical history. The medical history was designed to detect prior heart or kidney disorders, cerebral imbalance, and seizure episodes. Where a physical disorder existed, a medical examination was required before treatment. When indicated, a medical examination was requested, stating premedication to be given, and requesting a statement of permission signed by the examining physician. The parent (guardian) was given premedication instructions which included: (1) nothing by mouth 3 hr prior to sedation; (2) a record the child’s having had a bowel movement and urinating within 24 hr; and (3) discontinuation of any medication the child was taking and/or approval by the physician prior to sedation. If there was illness or a fever the treatment was delayed. The patients were presented for treatment 1 hr before the scheduled procedure at which time their weight was recorded. They were then placed in a "sedation room" (designed with bed, oxygen, suction, and a chair for the parent who remained with the child until treatment). The patients were given 1 teaspoon hydroxyzine pamoate (25 mg) if younger than 2 years of age, and 2 teaspoons (50 mg) if older than 2 years of age. Morphine sulfate was given deep IM (deltoid muscle) 30 rain following the administration of hydroxyzine pamoate. The dosage of morphine sulfate was calibrated by determining the age-to-weight ratio and then reducing the morphine by 1~ of the required dosage. It should be pointed out that if the child is 4 years of age, but his weight is that of a 2 year old, then the morphine is calculated for a 2 year old as 2 mg before being reduced by ~. The younger children were secured on a Papoose Board ®. The older children were restrained with a seatbelt fastened around the waist, the arms remaining free. If the patient became restless as treatment progressed to the point of interfering with the treatment, the following choices of action were considered: (1) give 1 mg additional morphine sulfate deep IM in the deltoid muscle; (2) support the medication with nitrous oxide; (3) give 1 mg additional morphine sulfate and nitrous oxide; or (4) discontinue treatment and reschedule the patient. The decision as to which approach to consider depended on the apprehension of the child and the amount of treatPEDIATRIC DENTISTRY: December 1986/VoL 8 No. 4 281 TABLE 2. Morphine Sulfate and Hydroxyzine Pamoate. Total Treated Cases July, 1975-June, 1984"