Chloral Hydrate and Other Drugs Used in Sedating Young Children: a Survey of American Academy of Pedodontics Diplomates

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

William K. Duncan, DDS, MEd Ronald J. Pruhs, DDS, MS Mahmoud H. Ashrafi, DMD, MS A. Charles Post, DDS

Abstract side effects. It can be used alone or as a comedication A survey of 325 American Board of Pedodontics agent. Recommendeddosage is 50 mg/kg but no more Diplomates was conducted to determine the use of than two grams in one dose. Chloral hydrate generally chloral hydrate and other sedative medications in is recommended over the barbiturates because of its treating young, uncooperative children needing relative safety; it does not have the same potential for extensive operative procedures. Seventy-one per cent respiratory depression with hypnotic doses. of the respondents returned usable surveys. Seventy- Various degrees of success with chloral hydrate have eight per cent of the Diplomates indicated they use been reported. Anderson2, using empirical methods, sedative agents for these patients. However, the reported excellent results in 280 children. In his study, results of the survey show a lack of consensus among patients selected were unmanageableor needed extensive pedodontists regarding the selection and dosage of restorative work. sedative drugs. More recently, Smith3 compared the effectiveness of chloral hydrate to a placebo in handicapped children. He In recent years, faculty and dental residents in the found no significant improvement in behavior using a Advanced Training Program in Pedodontics of Marquette dosage nomogram of 500-1,500 mg depending on body weight. His youngest patient was four years, three University and MilwaukeeChildren’s Hospital have been 4 successfully treating young, uncooperative children months of age. Barr and coworkers found no signifi- needing extensive operative procedures. Chloral hydrate, cant improvement in behavior with a chloral hydrate alone or as a comedication with other drugs, has been dosage schedule of 40 mg/kg. 5 used as a hypnotic sedative. Tobias and coworkers reported the effectiveness of Before starting a clinical research project on the pro- chloral hydrate in combination with hydroxyzine cedure, the authors wanted more information on the use pamoate on 39 children aged 1.75-10.5 years of age with of sedatives in current pedodontic practices. A survey of a meanage of 3.9 years. The dosage schedule was either American Board of Pedodontics Diplomates was con- 1,0.00 mg or 1,500 mg of chloral hydrate given one hour ducted to determine the extent of chloral hydrate use in preoperatively and 50 mg of hydroxyzine pamoate given pediatric dentistry, comedications commonlyused with the evening before, one hour preoperatively and in chloral hydrate, and other medications used for sedating ~elected cases between the time the child awakened and these children. one hour before the appointment. The average dosage of chloral hydrate was 75 mg/kg with a range of 36-130 Literature Review mg/kg. This dosage schedule is higher than those used A review of the literature shows three major categories in the other studies and would be expected to produce of sedative agents plus nitrous oxide/oxygen. moreof a hypnotic than a sedative effect in patients. King and Berlocher 6 recommendeda dosage of 750-1,250 mg Hypnotics or Sedative Hypnotics of chloral hydrate for the patient between 24 and 25 This category produces sedative effects, allaying anx- pounds. iety through depression of the sensory cortex. Medica- Harris7 stated that the barbiturates sedate quickly, tions commonlyused in this category include chloral have a high frequency of success, and a low frequency hydrate and the short-acting barbiturates, secobarbital, of side effects. Dudley8 recommendedoral dosages of and pentobarbital. Sire1 stated that chloral hydrate is 1.5-2.0 mg/lb of pentobarbital and suggested that den- reasonably fast acting, has a high safety factor, and few tists often prescribe insufficient dosage.

252 SEDATION OF CHILDREN -- AAP DIPLOMATE SURVEY: Duncan et aL Anti-anxiety or Psychosedation Agents reported excellent results using meperidine in combina- This group of drugs produces a calming or quiescent tion with promethazine and chlorpromazine, an anti- effect without loss of consciousness. Hydroxyzine,in the anxiety agent. Most of their subjects were three years of form of Atarax~ or Vistaril b is a popular medication in age or younger. They used intramuscular administration. this category. In addition to being sedative, the drug is Alphaprodine HCI is pharmacologically similar to antihistaminic, antispasmodic, antiemetic, and slightly morphine and meperidine except that onset is rapid and anticholinergic. Wright and McAulay9, in a 1973 survey the duration of action is short. It usually is used as a co- of 812 pedodontists, reported that whena single drug was medication,~7 most often with promethazine. selected for sedation, hydroxyzine was used most often. Alphaprodine HCI usually is administered via sub- Kopel:° reported its use as a sole premedicating agent mucosalinjection. The literature recently has recommend- and recommendedadministration of divided doses. He ed against intramuscular injection because absorption is also suggested its use in comedication with meperidine, too unpredictable,~ Recent literature also stresses safe- chloral hydrate, and nitrous oxide/oxygen ty precautions with the use of alphaprodine HCI.~3A9"22 psychosedation. Recommendationsinclude continuous oxygen administra- Diazepam(Valium) c is another popular sedative agent tion, coadministration of an antagonist, mechanical in the anti-anxiety group. It affects the limbic system, monitoring of blood pressure and heart rate, and precor- altering6 the experience and transmission of emotions. dial stethoscope monitoring. Most people receiving diazepam experience an amnesic effect. 11 Hargreaves12 recommendedoral administration Methods and Materials and divided doses. American Academy of Pedodontics Diplomates were Promethazine (Phenargan), d commonlyprescribed for chosen as the survey population. This decision was bas- its antihistiminic properties, also produces a state of ed on a survey in 1980 from which it was concluded that quiescence. Musselmanand McClure13 stated that used future studies of pedondontic procedures in use could be alone it is not very effective as a sedating agent, but that determined by polling the Diplomates (thus having an it can be used for a child who demonstrates minor ap- economical and valid alternative to conducting a survey prehension. However,it generally is used as a comedica- of23 more than 1,700 Academy members). tion with other drugs. Robbins14 used promethazine in The survey was conducted in October, 1981. Of the comedication with chloral hydrate and found less fre- 325 questionnaires sent, 237 (73%) of the Diplomates quent stomach upset than with chloral hydrate alone. responded with 168 (71%) of the responses usable. Promethazine commonly is used in comedication with The objectives of the survey were to determine: meperidine because of its additive sedative effect and to 1. Howmany pedodontists used sedative agents to control15,16 nausea. treat young, uncooperative patients needing extensive work Synthetic Narcotic Analgesics 2. Howmany pedodontists used chloral hydrate alone This third major group of premedication agents reduces or in combination to treat this group of patients acute pain, decreases apprehension and provides a 3. What dosages of chloral hydrate and other drugs sedative effect. Thesedative action of the drugs is a result (if used in comedications) were being administered of effects on the cerebrum. However,they also affect the 4. What other sedatives were being used alone or as medulla and can cause severe respiratory depression. comedications and their dosages. A national survey of American Society of Dentistry for Children membersin 1980 found that the most com- Results mon method of sedating children in dentistry was with Most of the Diplomates (75 %) responded that they use narcotic sedation. ~7 The narcotic agents most common- sedative agents for young children needing extensive ly used were meperidine (Demerol)e and alphaprodine operative procedures; 22%responded that they do not HCI (Nisentil). f Wright and McAulay9 reported that use sedation. A few respondents stated that if the child 35 % of pedodontists surveyed used meperidine and pro- could not be managed with traditional (nonphar- methazine as comedications. macological) techniques, general anesthesia in a hospital Musselman and McClure~3 recommended meperidine was their alternative means of management. for children younger than eight years of age who ex- Chloral hydrate is used alone or as a comedication by hibited~ overt disruptive behavior. Myers and Shoaf 62 %of the Diplomatessedating young children. It should be noted that this does not meanthey use it exclusively. aRoerig,a Divisionof Pfizer Pharmaceuticals;New York, N.Y. Several respondents who indicated they use chloral bpfizerLaboratories Division, Pfizer, Inc.; NewYork, N.Y. hydrate alone or as part of a comedication also listed CRocheLaboratories; Nutley, N.J. dWyethLaboratories; Philadelphia, Pa. other sedative agents in response to a further question eWinthropLaboratories; New York, N.Y. concerning the use of other drugs. fRocheLaboratories; Nutley, N.J. The responses were quite diverse in choice of drug and

PEDIATRICDENTISTRY: December 1983/Vol. 5 No. 4 253 Table 1. RespondentsUsing Chloral Hydrate Alone Ninety-four (52 %) of the Diplomates who premedicate children reported its use alone or as a comedication with Chloral Hydrate R* other drugs (Table 5). Dose Routeof Twenty-six (28 %o) of the Diplomates using meperidine Administration stated they use it alone. Half of these administered a 5-15 mg/kg Oral 6 dosage of 1 mg/kg intramuscularly or subcutaneously. 50-100mg/kg Oral 3 The other half administered a straight 10-75 mg dose. 250-1,000 mg Oral 8 Forty Diplomates (43%) use meperidine with pro- 750-2,000mg Oral 4 methazine. Doses of meperidine ranged from 15 to 50 mg and doses of promethazine from 6 to 20 mg. Slightly more Total 21 than half (23) used an oral route of administration as op- *Numberof respondingDiplomates. posed to an intramuscular or subcutaneous route (17). Twenty-eight (30%) of the Diplomates use meperidine dosage used (Tables 1-6). In order to makethe tables more as a comedication with other drugs. understandable, similar doses were grouped and listed as Several other drugs are used widely, especially hydrox- a range. Tables 1 and 2 were divided into two sections yzine, diazepam, and nitrous oxide/oxygen, all used to accommodate dosages given by body weight and alone (Table 6, page 256). Seven diplomates reported that straight milligram doses. they currently use alphaprodine HCI and six provided About 19% of the Diplomates using chloral hydrate the unsolicited information that they formerly used it, indicated they use it alone. The drug was administered but discontinued use when it was taken off the market orally in dosages of 5-100 mg/kg or doses of 250-2,000 in September, 1980. mg (Table 1). Approximately 52% of the Diplomates using chloral Discussion and Conclusion hydrate use it as a comedication with hydroxyzine The 1980 ASDC survey results published by (Vistaril or Atarax). Chloral hydrate is administered Aubuchon17 reported that the most commonmethod of

Chloral Hydrate Hydroxyzine R* Dose Routeof Dose Routeof Administration Administration Table 2. RespondentsUsing 5-25 mg/kg Oral 0.25-1 mg/kg Oral 11 Chloral Hydrate + 25-60 mg/kg Oral 0.5-1 mg/kg Oral 10 Hydroxyzine 250-750 mg Oral 10-30 mg Oral 6 500-1,500mg Oral 10-75 mg Oral 26 Dosesnot given 6 Total 59 *Numberof respondingDiplomates. dosages of 5-60 mg/kg or doses of 250-1,500 rag. Hydrox- sedating children in dentistry was by narcotic sedatives. yzine is given in dosages of 0.25-1 mg/kg or doses of The results of the current survey show an almost even 10-75 mg/kg (Table 2). The most popular dose (24 split betweenthe hypnotics (chloral hydrate) and the nar- Diplomates) is 500-1,500 mgof chloral hydrate and 10-75 cotics. Three respondents indicated they use chloral mg of hydroxyzine. hydrate and meperidine as comedications and these were About 10%of the Diplomates using chloral hydrate included in Table 1. If we include these in the meperidine indicated they use it as a comedication with nitrous ox- group and add the narcotics together, even including the ide/oxygen. Doses ranged from 500-1,200 mg of chloral "formerly used Nisentil" group, the total is 114. The hydrate with 20-70% nitrous oxide/oxygen (Table 3). Nineteen per cent of the Diplomates using chloral Table3. RespondentsUsing Chloral Hydrate+ Nitrous Oxide hydrate use it as a comedication with drugs other than hydroxyzine and nitrous oxide/oxygen (Table 4). Six Chloral Hydrate Nitrous Oxide & Oxygen R* Diplomates use oral combinations of chloral hydrate and Dose Routeof Dose Routeof promethazine (Phenergan). Three use chloral hydrate Administration Administration with meperidine (Demerol). Four use a combination 500-1,200mg Oral 20-70% N20 Inhalation chloral hydrate, hydroxyzine, and promethazineo The second most popular drug reported for Total 11 premeditating young patients was meperidine (Demerol). *Numberof respondingDiplomates.

254 SEDATIONOFCHILDREN -- AAP DIPLOMATE SURVEY: Duncan et al. Additional Chloral Hydrate Comedication Comedication R* Dose Route of Dose Route of Dose Route of Administration Administration Administration 500-2,000 mg Oral Promethazine Oral -- -- 7 Table 4. RespondentsUsing 10-25 mg Other Chloral Hydrate 500-1,000 mg Oral Meperidine Oral -- -- 3 Comedications 5-15 mg 500-1,500 mg Oral Hydroxyzine Oral Promethazine Oral 4 25-50 mg 12.5-50 mg 500-1,000 mg Oral Hydroxyzine Oral N20 20-50% Inhalation 2 25-75 mg Other Combinations 6 Total 22 *Numberof respondingDiplomates chloral hydrate users total 113. The current survey Dr. Duncanis associate director of dental services at Milwaukee specified "young" patient and there was no reference to Children’s Hospital, 1700 W. Wisconsin Ave., P.O. Box 1997, age mentioned in the ASDCsurvey; this may or may not Milwaukee,Wis. 53201.Dr. Pruhsis an associate professor and chair- man, Departmentof Pedodontics, and Dr, Ashrafi is a former assis- have affected the results. tant professor and director of graduate pedodontics,Marquette Univer- In 1973 Wright and McAulay found the most popular sity Schoolof Dentistry(currently in private pedodonticspractice in sedative drug used alone was hydroxyzine (Atarax or Brockport,N.Y.). Dr. Post is chief of dental services and director of Vistaril) followed by chloral hydrate. 9 The current the dental clinic, MilwaukeeChildren’s Hospital. Requestsfor reprints survey found 26 Diplomates using meperidine alone, 25 should be sent to Dr. Duncan. using hydroxyzine alone, and 21 using chloral hydrate 1. Sim, J.M. Chloral hydrate, in BehaviorManagement in Dentistry alone. for Children, Wright,G.Z., ed. Philadelphia;W.13. Saunders Co., The most frequently used comedication found by 1975, pp 165-69. lNright and McAulay was meperidine and promethazine. 2. Anderson,J. Use of chloral hydrate in dentistry. NorthwestDent 39:33-35,1960. The present survey found 59 Diplomates using chloral 3. Smith, R.C. Chloral hydrate sedation for handicappedchildren: hydrate and hydroxyzine and 40 using meperidine and a double blind study. AnesthProg 24:159-69,1977. promethazine. 4. Barr, E.S., Wynn,R.L., Spedding,R.H. Oral premedicationfor In conclusion, the results of the survey indicate a con- the problemchild: placeboand chloral hydrate. J Pedo1:272-80, tinued lack of consensus among pedodontists regarding 1977. 5. Tobias, M., Lipschultz, D.H., Album,M.M. A study of three the selection and dosage of drugs used for sedation. More preoperativesedative combinations.J DentChild 42:453-59, 1975. research in this area is needed before an attempt can be 6. King,D.L., Berlocher, W.C.Premedication in pedodontics-- at- made to formulate a consistent set of treatment guidelines. titudes and agents. Pediatr Dent 1:251-57, 1979.

Table 5. RespondentsUsing Meperidine Alone or in Comedication

Additional Meperidine Comedication Comedication R* Dose Route of Dose Route of Dose Route of Administration Administration Administration 1 mg/kg IM or Sub Q** ------13 10-75 mg IM or Sub Q .... 13 25-50 mg IM or Sub Q Promethazine 6-20 mg IM or Sub Q -- -- 17 15-50 mg Oral Promethazine 6-25 mg Oral -- -- 23 15-50 mg Oral Hydroxyzine 20-50 mg Oral -- -- 7 0.5 mg/kg IM Hydroxyzine 0.5 mg/kg IM -- -- 2 0.5 mg/kg IM Promethazine 0.25 mg/kg IM Thorazine 0.25 mg/kg IM 8 25-100 mg Sub Q Promethazine 25-50 mg Oral Hydroxyzine 25-50 mg Oral 3 Other combinations 8 Total 94 *Numberof respondingDiplomates. **Intramuscularlyor subcutaneously.

PEDIATRICDENTISTRY: December 1983/Vol. 5 No. 4 255 7. Harris, S.C. Panaceas or placebos. Dent Prog 3:103-5, 1963. Table 6. Other Premedications 8. Dudley,W. Premedicationand the use of analgesics in pediatric dentistry. Dent Clin North Am14:865-74, 1970. Medication Comedication R* 9. Wright, G.Z., McAulay,D.J. Current premedicating trends in pedodontics. ] Dent Child 40:185-88,1973. Dose Route of Dose Route of 10. Kopel, H.M.Hydroxyzine, in Behavior Managementin Dentistry Administration Administration for Children, Wright,G.Z., ed. Philadelphia; W.B.Saunders Co., Hydroxyzine Oral -- -- 25 1975, pp 155-58. 50-150 mg 11. Rattray, I.J. Observationon the use of diazepamin general dental practice. Br Dent] 125:495-98,1968. 12. Hargreaves,J.A. Diazepam,in BehaviorManagement in Dentistry Diazepam Oral -- -- 18 for Children, Wright,G.Z., ed. Philadelphia; W.B.Saunders Co., 2.5-10 mg 1975, pp 159-63. 13. Musselman, R.J., McClure, D.B. Promethazine, in Behavior Nitrous oxide Inhalation -- -- 16 Managementin Dentistry for Children, Wright, G.Z., ed. 30-50% Philadelphia; W.B.Saunders Co., 1975, pp 163-65. 14. Robbins, M.B. Chloral hydrate and promethazineor premedica- Promethazine Oral -- -- 9 tion for the apprehensivechild. ] DentChild 34:327-31,1967. 0.5 mg/kg 15. Kopel,H.M. The use of ataractics in dentistry for children. J Dent Child 26:14-24, 1959. 16. Album, M.M.Meperidine and promethazine hydrochloride for Promethazine Oral AIphaprodine Sub Q** 4 handicappedpatients. J Dent Res 40:1,036-41, 1961. 15-25 mg 0.6 mg 17. Aubuchon,R.W. Sedation liabilities in pedodontics.Pediatr Dent Special Issue, 4:171-80,1982. Alphaprodine HCI Sub Q -- -- 7 18. Myers, D.R., Shoal, H.K. The intramuscular use of a combina- 0.4-1.2 mg/kg tion of meperidine, promethazine,and chlorpromazinefor sedation of the child dental patient. J DentChild 44:453-56,1977. Formerly used ------6 19. Chen, D.T. Alphaprodine HCI: characteristics. Pediatr Dent alphaprodine HCl Special Issue, 4:158-63,1.982. 20. Creedon, R.L. Alphaprodinein twenty years of sedation ex- Other combinations ------7 perience. Pediatr DentSpecial Issue, 4:187-89,1982. 21. Forrester, D.J., Wagner,M.L., Fleming, J. Pediatric Dental Medicine.Philadelphia; Lea and Febiger, 1981, pp 537-81. Total 92 22. Trapp,L.D. Sedationof children for dental treatment. Pediatr Dent Special Issue, 4:164-67,t982. *Numberof respondingDiplomates. 23. Starkey, P., Avery,D., Klein, A., Koerber,L. Surveyof attitudes **Subcutaneously. and practices in behavior management.Pediatr Dent 3:246-50, 1981.

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256 SEDATIONOFCHILDREN -- AAPDIPLOMATE SURVEY: Duncan et al.