Managing the uncooperative child often

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1 The effect of sleep on conscious The effect of sleep on cormscious sedation: a foliow-up study Brian J. Sanders This study evaluated the effect of preoperative sleep on the success of conscious sedation. Seventysix children, from 18 to 61 months oj age, participated in this study. Sixty-two children received chloral hydrate (50-60 rng/kg) and hydroxyzine (15-35 mg) and 14 chiidren received intramuscular meperidine hydrochloride (2.2 mgikg). Parents were asked to complete a questionnaire which asked several questions about their child s activity the previous day, and their bedtime. The operator ranked the sedations on a scale of.! to 4, with 1 being good and 4 being pooz The results were statistically evaluated using the Wilcoxon Rank sum test. The children that received a normal amount or greater amount of sleep preoperatively did not sho w any significantly higher degree of success (p<o.26) with their sedation appointment. The parents perception of their child s tiredness did demonstrate borderline (p<o.08) significance. Children greater than 36 months of age had a significantly higher (p<o.03) degree of suecessfid sedations. The results of this study demonstrated that there was no clear correlation between the child s preoperative sleep and the outcome of the sedation, but that a tired child may increase the likelihood of a poor sedation. In addition, the child s age at the time of the sedation may affect the outcome of the sedation. J Clin Pediatr Dent 21(2): ,1997 INTRODUCTION Managing the uncooperative child often requires the use of pharmacological agents to achieve the necessary behavior control to complete the dental procedures safely. Chloral hydrate with hydroxyzine, and meperidine hydrochloride are two of the more commonly administered sedative regimens in pediatric dentistry. Their pharmacological effects are different as are their reported success rate as sedative agents. Chloral hydrate is considered a sedative hypnotic. Its effect on the cerebral hemisphere causes only minim[al depression of the respiratory system and minimal effect on blood pressure. It has a wide margin of safety. It is detoxified in the liver and eliminated in the kidneys? Chloral hydrate may be utilized alone or a:; a comedication. A frequently prescribed co-medication is Hydroxyzine pamoate (Vistaril). Hydroxyzine is useful to reduce the anxiety associated with dental procedures. It is an antiemetic and it decreases gastric irritation. It functions by depressing the sul]corti- Address all correspondence to Brian J. Sanders, DDS, MS, Director of Predc)ctoral Pediatric Dentistry, Pediatric Dentistry Section, Department of Oral Facial Development, 1121 West Michigan Street, Indianapolis, Indiana Phone Fax 317-;! cal regions of the central nervous system which explains its wide margin of safety and its ability to calm the patient without impairing mental alertness. Hydroxyzine can potentate the effect of central nervous system depressants and must be used with caution when combined with other medications.z Meperidine hydrochloride is a synthetic narcotic analgesic with actions similar to morphine although its onset of action is more rapid and its duration shorter. The side effects may include respiratory depression, nausea and vomiting, constipation, and urinary retention.3 4 Inhaled nitrous oxide gas has been utilized in dentistry since 1844 and when used with oxygen, it can effectively and safely provide mild sedation and reduce dental anxiety. The absorption of nitrous oxide is through the alveoli and its clinical effects are rapid. It is not metabolized and is excreted through the lungs at a rate similar to its absorption.s The incidence of nausea and vomiting associated with nitrous oxide is low when used at concentrations below fifty percent and does not appear to be related to duration or patient age. Our previous publication attempted to determine if preoperative sleep deprivation or sleep excess could influence the outcome of a dental sedation when using chloral hydrate and hydroxyzine as the primary sedative agent. The treatment sessions of thirty patients sedated with chloral hydrate and hydroxyzine were evaluated and it was concluded that there was a ten-

2 dency toward a better dental sedation appointment if,the patient was well rested prior to the sedation. Because chloral hydrate is used primarily to facilitate sleep: it is possible that children sedated with this drug may be affected to a greater extent by preoperative sleep. Meperidine hydrochloride is primarily a narcotic analgesic; therefore, sleep may not play as significant of a role in the outcome of the sedation. The purpose of this study was to evaluate the effect of preoperative sleep on the success of conscious sedation dental appointments in children when either chloral hydrate with hydroxyzine or intramuscular meperidine hydrochloride, were used as the primary sedative agent. MATERIALS AND METHODS Seventy-six healthy (ASAl) children participated in this study. The protocol was submitted and approved by the Institutional Review Board. All of the children were seen for their initial exam in our clinic and determined to be negative (-) or very negative ( ) based on the Frankl rating scale of behavior. It was then recommended that these children return for completion of their dental work using conscious sedation. If the dentist assessing the child s behavior was a pediatric dental resident, the behavior of the patient and treatment plan were reviewed with a faculty member prior to making the decision to proceed with the conscious sedation. The parent agreed to this form of adjunctive care for their child. Prior to the sedation appointment the parent was given a list of presedation instructions which were also reviewed in detail by the doctor. An informed conseti form was signed by the parent, or guardian, the doctor, and a witness. On the day of their child s dental appointment the ]parents were asked to fill out a questionnaire (Figure 1) about their child s activity, diet and bedtime the previous day. The parents were not made aware of the purpose of the study, but were asked to complete the questionnaire at their leisure while the child was receiving dental treatment. The questionnaire was collected at the completion of the sedation procedure. After completion of the sedation appointment, the operator was also asked to rate the success of the sedation based on the behavior of the patient as judged on a[scale of one to four with one being excellent (++ on the Frankl scale) and four as the most unfavorable ( cm the Frankl scale). The conversion from the plus minus scale to a numerical scale was to enable statistical analysis of the results. All of the operator ratings were collected by the principal investigator. The operator s behavior rating of the patient was a summary assessment from the time the child was brought into the operatory until the treatment was completed for that day. The patients received oral clhloral hydrate (50-60 mg/kg and hydroxyzine 1:32 Fig. 1 Parent/Guardian-Please take a minute to complete the following questionnaire. Date Date of Birth 1. What time did your child go to bed last night? a. Is this your child s usual bedtime? b. If not, what is his/her usual bedtime? c. Did your child sleep well and is helshe well rested today?_ 2. What time did you get your child up this morning? a. IS this his/her usual time to get up b. If not, what is the usual time to get up? 3. What was your child s last meal? a. What time did he/she eat? 4. Please summarize your child s activity yesterday 5. Based on your knowledge of your child, does he/she appear to be more tired than usual, the same, or more active today? _ Do Not Fill Out BelowThis Line Medication given: (Route, Dose) Based on a scale of 1-4, how would you rate your sedation? _ (1 successful >4 not successful) pamoate (15-35 mg) or intramuscular meperidine hydrochloride (2.2 mg/kg). The effects of the sedations were enhanced with inhaled nitrous oxide (30Y0-50Yo) and oxygen in all of the patients. All of the patient appointments were completed in the morning, The drugs were administered between 8:00 and 9:00 A.M. After a waiting period of approximately forty-five minutes in those patients sedated with chloral hydrate and hydroxyzine, and thirty minutes with those patients sedated with meperidine hydrochloride, the children were transported to the operatory. The vital signs of all of the children were monitored in accordance with Guidelines for Conscious Sedation of the American Academy of Pediatric Dentistry. RESULTS The 76 participating children ranged in age from eighteen to sixty-one months of age. Sixty-tWo of the subjects were sedated using chloral hydrate with hydroxyzine and 14 subjects using meperidine hydrochloride. There was no effort to balance the groups according to gender. Forty-four of the subjects were less than 36 months of age and 32 subjects were greater than 36 months of age ( Table 1). The children older than 36 months in both experimental groups demonstrated a significantly higher rate of successful htpp://

3 II*U,!. WI i..-~ Table I Age of Patients L Sedation Rating Total Good (1) > Poor (4) c 36 months # (58%) % >36 months # (42~o) A Table II Amount of Sleep Prior to Sedation, Sedation Rating Total Good (1) > Poor (4) # (790/.) less than normal % # (2170) greater or normal % Table Ill Parenk Perception of Child /. Sedation Ftating Total Good (1) > Poor(4) more tired # (32%) % # (68%] normal activity v sedation ( p< 0.03) using the non-parametric Wllco<on ference between the two groups (pco.26) and their rel- Rank Sum test. ative success of sedation using the non-parametric The amount of sleep a child received the night prior Wilcoxon Rank Sum test. Because of the small sample to the dental appointment (Table 2) was comparecl to of children sedated with meperidine hydrochloride, no the sedaticm rating. The children who experienced a attempt was made to analyze the data separately. normal amount of sleep and those with greater than The perception by the parents of the level of tirednormal amount of sleep were paired together as one ness of their child and the success of the sedation group and compared to the group of children who (Table 3) demonstrated borderline significance experienced less than normal sleep. The statist:[cal (p<o.08) using the non-parametric Wilcoxon Rank analysis of the results did not show any significant dif- Sum test. The Journal of Clinical Pediatric Dentistry Volume 21, Number 2/ _

4 I ne enec~ ot sleep on conscious DISCUSSION Our initial study suggested that there may be some validity to the recommendation that a child be well rested prior to a sedation appointment based on the tendency towards a greater success during sedation with children that hacl received a normal or greater amount of sleep (p,<0.06). The results obtained from this larger sample of patients using two different sedation regimens may strengthen the argument that it is advisable to have a well-rested child prior to a conscious sedation appointment. However, we cannel, make such a conclusion based on the amount of preoperative sleep experienced by the children sincl~ there was no significant difference between the group of children that had a greater or normal amount of sleep and those children that had less preoperative sleep (p< 0.26). Interestingly, the parents perception of their child s level of tiredness did show a borderline correlation (p<o.os) toward a successful outcome with the sedation appointment. If the parent indicated that their child was more tired than usual, there was a greater tendency toward an ineffective level of sedation. This suggests that there are factors other than the amount of preoperative sleep that may influence the sedation Perhaps, excessive physical activity or high anxiety the day or night prior to the dental appointment may adversely affect the quality of the child s, preoperative sleep and result in fatigue the day of the appointment. The older preschool children (> 36 months) did show a statistically significant greater tendency towards a successful outcome (p <0.03) of their sedation appointment. This finding is consistent ~withthe results of the initial study and suggests that i~ successful sedation is not as dependent upon the choice of sedative, but on the child s improved ability to accommodate to their surroundings with age. This study with a larger sample size and the use of an additional sedative agent was an attempt to confirm the conclusions of the first study Multiple c)perators were utilized for this study ancl their ratings were not validated. A third study is planned that will validate the operators assessment of the child s behavior during a sedation. It is recognized that it is impossible to control all the variables that may affect the success of conscious sedation with children. Although this study failed to prove that the amount of preoperative sleep was an accurate predictor of sedation outcome, it did provide evidence to support the notion that a well rested child may contribute to improving the sedation outcome, Preoperative instructions may need to be broadened to include limiting the child s activity prior to a planned sedation. CONCLUSIONS 1. The data suggest that children over 36 months of age at the time of sedation will experience a more favorable outcome of their dental sedation appointment. 2. There was no clear correlation between the child s preoperative sleep and the outcome of the sedation. 3. The data does suggest that a tired child may worsen the outcome of a dental sedation appointment. REFERENCES 1. Duncan WK, Pruhs RJ, Ashifi MH, Post AC. Chloral hydrate and other drugs used in sedating young children: A servey of American Academy of Pedodontic Diplomats. 2. Ped Dent 5(4) , 19S3. Wright GZ, Stanley PE, Gardner DE. Minor Sedation For Apprehensive Young Children. In: Managing Children s Behavior In The Dental Office. Chap 19, St. Louis: Mosby, Physicians Desk References, 50th ed. Montrale, NJ. Medical Economics Company, , NeidIe EA. Yagiela JA eds. Pharmacology and Therapeutics For Dentistry. St. Louis: CV Mosby, Dionne RA, Phero JC, eds. Management of Pain and Anxiety in Dental Practice. New York: Elsevia, Matthewson RJ, Primosch RE, Robertson D. Fundamentals of Pediatric Dentistry, 2nd cd., Chicago: Quintessence, , Sanders BJ, Potter RH. Avery DR. The effect of sleep on conscious sedation. J Ped Dent 18: , Package insert Chloral hydrate syrup. Pharmaceutical Basus Inc., Morton Grove, Illinois :34 htpp://

5 The Journad of Clinical Pediatric Dentistv Volume 21, Number 4/1997. Errata Volume 21 No. 2, page 131 The effect of sleep on conscious sedation: a follow-up study Brian.J.Sanders/ David R. Avery Dr. Avery s name was inadvertently left off the article as a coauthor. Our sincerest apologies to him.