Chloral hydrate and other drugs used in sedating young children: a survey of American Academy of Pedodontics Diplomates.

A survey of 325 American Board of Pedodontics Diplomates was conducted to determine the use of chloral hydrate and other sedative medications in treating young, uncooperative children needing extensive operative procedures. Seventy-one per cent of the respondents returned usable surveys. Seventyeight per cent of the Diplomates indicated they use sedative agents for these patients. However, the results of the survey show a lack of consensus among pedodontists regarding the selection and dosage of sedative drugs. In recent years, faculty and dental residents in the Advanced Training Program in Pedodontics of Marquette University and Milwaukee Children’s Hospital have been successfully treating young, uncooperative children needing extensive operative procedures. Chloral hydrate, alone or as a comedication with other drugs, has been used as a hypnotic sedative. Before starting a clinical research project on the procedure, the authors wanted more information on the use of sedatives in current pedodontic practices. A survey of American Board of Pedodontics Diplomates was conducted to determine the extent of chloral hydrate use in pediatric dentistry, comedications commonly used with chloral hydrate, and other medications used for sedating these children. Literature Review A review of the literature shows three major categories of sedative agents plus nitrous oxide/oxygen. Hypnotics or Sedative Hypnotics This category produces sedative effects, allaying anxiety through depression of the sensory cortex. Medications commonly used in this category include chloral hydrate and the short-acting barbiturates, secobarbital, and pentobarbital. Sire1 stated that chloral hydrate is reasonably fast acting, has a high safety factor, and few Ronald J. Pruhs, DDS, MS A. Charles Post, DDS side effects. It can be used alone or as a comedication agent. Recommended dosage is 50 mg/kg but no more than two grams in one dose. Chloral hydrate generally is recommended over the barbiturates because of its relative safety; it does not have the same potential for respiratory depression with hypnotic doses. Various degrees of success with chloral hydrate have been reported. Anderson2, using empirical methods, reported excellent results in 280 children. In his study, patients selected were unmanageable or needed extensive restorative work. More recently, Smith3 compared the effectiveness of chloral hydrate to a placebo in handicapped children. He found no significant improvement in behavior using a dosage nomogram of 500-1,500 mg depending on body weight. His youngest patient was four years, three months of age. Barr4 and coworkers found no significant improvement in behavior with a chloral hydrate dosage schedule of 40 mg/kg. Tobias and coworkers5 reported the effectiveness of chloral hydrate in combination with hydroxyzine pamoate on 39 children aged 1.75-10.5 years of age with a mean age of 3.9 years. The dosage schedule was either 1,0.00 mg or 1,500 mg of chloral hydrate given one hour preoperatively and 50 mg of hydroxyzine pamoate given the evening before, one hour preoperatively and in ~elected cases between the time the child awakened and one hour before the appointment. The average dosage of chloral hydrate was 75 mg/kg with a range of 36-130 mg/kg. This dosage schedule is higher than those used in the other studies and would be expected to produce more of a hypnotic than a sedative effect in patients. King and Berlocher 6 recommended a dosage of 750-1,250 mg of chloral hydrate for the patient between 24 and 25 pounds. Harris7 stated that the barbiturates sedate quickly, have a high frequency of success, and a low frequency of side effects. Dudley8 recommended oral dosages of 1.5-2.0 mg/lb of pentobarbital and suggested that dentists often prescribe insufficient dosage. 252 SEDATION OF CHILDREN -AAP DIPLOMATE SURVEY: Duncan et aL Anti-anxiety or Psychosedation Agents This group of drugs produces a calming or quiescent effect without loss of consciousness. Hydroxyzine, in the form of Atarax~ or Vistaril b is a popular medication in this category. In addition to being sedative, the drug is antihistaminic, antispasmodic, antiemetic, and slightly anticholinergic. Wright and McAulay 9, in a 1973 survey of 812 pedodontists, reported that when a single drug was selected for sedation, hydroxyzine was used most often. Kopel:° reported its use as a sole premedicating agent and recommended administration of divided doses. He also suggested its use in comedication with meperidine, chloral hydrate, and nitrous oxide/oxygen psychosedation. Diazepam (Valium)c is another popular sedative agent in the anti-anxiety group. It affects the limbic system, altering the experience and transmission of emotions. 6 Most people receiving diazepam experience an amnesic effect. 11 Hargreaves12 recommended oral administration and divided doses. Promethazine (Phenargan), d commonly prescribed for its antihistiminic properties, also produces a state of quiescence. Musselman and McClure13 stated that used alone it is not very effective as a sedating agent, but that it can be used for a child who demonstrates minor apprehension. However, it generally is used as a comedication with other drugs. Robbins14 used promethazine in comedication with chloral hydrate and found less frequent stomach upset than with chloral hydrate alone. Promethazine commonly is used in comedication with meperidine because of its additive sedative effect and to control nausea. 15,16 Synthetic Narcotic Analgesics This third major group of premedication agents reduces acute pain, decreases apprehension and provides a sedative effect. The sedative action of the drugs is a result of effects on the cerebrum. However, they also affect the medulla and can cause severe respiratory depression. A national survey of American Society of Dentistry for Children members in 1980 found that the most common method of sedating children in dentistry was with narcotic sedation. ~7 The narcotic agents most commonly used were meperidine (Demerol)e and alphaprodine HCI (Nisentil). f Wright and McAulay9 reported that 35 % of pedodontists surveyed used meperidine and promethazine as comedications. Musselman and McClure~3 recommended meperidine for children younger than eight years of age who exhibited overt disruptive behavior. Myers and Shoaf ~ aRoerig, a Division of Pfizer Pharmaceuticals; New York, N.Y. bpfizer Laboratories Division, Pfizer, Inc.; New York, N.Y. CRoche Laboratories; Nutley, N.J. dWyeth Laboratories; Philadelphia, Pa. eWinthrop Laboratories; New York, N.Y. fRoche Laboratories; Nutley, N.J. reported excellent results using meperidine in combination with promethazine and chlorpromazine, an antianxiety agent. Most of their subjects were three years of age or younger. They used intramuscular administration. Alphaprodine HCI is pharmacologically similar to morphine and meperidine except that onset is rapid and the duration of action is short. It usually is used as a comedication, most often with promethazine. ~7 Alphaprodine HCI usually is administered via submucosal injection. The literature recently has recommended against intramuscular injection because absorption is too unpredictable,~ Recent literature also stresses safety precautions with the use of alphaprodine HCI. ~3A9"22 Recommendations include continuous oxygen administration, coadministration of an antagonist, mechanical monitoring of blood pressure and heart rate, and precordial stethoscope monitoring. Methods and Materials American Academy of Pedodontics Diplomates were chosen as the survey population. This decision was based on a survey in 1980 from which it was concluded that future studies of pedondontic procedures in use could be determined by polling the Diplomates (thus having an economical and valid alternative to conducting a survey of more than 1,700 Academy members). 23 The survey was conducted in October, 1981. Of the 325 questionnaires sent, 237 (73%) of the Diplomates responded with 168 (71%) of the responses usable. The objectives of the survey were to determine: 1. How many pedodontists used sedative agents to treat young, uncooperative patients needing extensive work 2. How many pedodontists used chloral hydrate alone or in combination to treat this group of patients 3. What dosages of chloral hydrate and other drugs (if used in comedications) were being administered 4. What other sedatives were being used alone or as comedications and their dosages. Results Most of the Diplomates (75 %) responded that they use sedative agents for young children needing extensive operative procedures; 22% responded that they do not use sedation. A few respondents stated that if the child could not be managed with traditional (nonpharmacological) techniques, general anesthesia in a hospital was their alternative means of management. Chloral hydrate is used alone or as a comedication by 62 % of the Diplomates sedating young children. It should be noted that this does not mean they use it exclusively. Several respondents who indicated they use chloral hydrate alone or as part of a comedication also listed other sedative agents in response to a further question concerning the use of other drugs. The responses were quite diverse in choice of drug and PEDIATRIC DENTISTRY: December 1983/Vol. 5 No. 4 253 Table 1. Respondents Using Chloral Hydrate Alone