Doctors and dentists who sedate young patients need to monitor them closely for problems and have the tools and training to act quickly in case of emergency, according to updated guidelines issued Monday.
The guidelines are meant to prevent injuries and rare deaths such as that of 5-year-old Diamond Brownridge, a Chicago girl who never awoke from sedation after a Sept. 23 visit to a storefront dental clinic.
With more diagnostic and surgical procedures being performed outside hospitals, and with dentists seeing more young children with serious dental problems, the need for training is great, said Dr. Stephen Wilson, a pediatric dentist in Cincinnati who helped write the guidelines for the American Academy of Pediatrics and the American Academy of Pediatric Dentistry.
The guidelines, which appear in December's issue of the journal Pediatrics, have been under review for several years and were not written in response to the Chicago girl's death, the presidents of both groups said. The guidelines include assessing children for sedation risk factors, keeping size-appropriate resuscitation tools on hand and employing enough trained staff to monitor sedated patients.
Attorneys for the girl's parents welcomed the changes.
"They're sending a message to dentists that if you don't know what you're doing, don't do it," Jeffrey Kroll, an attorney for the girl's parents. "If you don't have the appropriate equipment, don't do it."
Young children often need deeper sedation than older children and adults because they haven't yet developed the self-control to keep from fighting back against medical staff during an uncomfortable procedure. But children are also particularly vulnerable to sedation's dangers.
The Cook County medical examiner's office determined Brownridge died from lack of oxygen caused by anesthesia. An anesthesia specialist testified at a state licensing hearing that the amount of Valium given was too much for someone weighing 35 pounds and that the girl's vital signs weren't adequately monitored.
Sedation, when used correctly, is safe, said Dr. Phil Hunke, president of the American Academy of Pediatric Dentistry.
A study of children and sedation outside the operating room, published earlier this year in Pediatrics, found that during 16 months there were no deaths in more than 30,000 cases at 26 clinics. Cardiopulmonary resuscitation was needed in one case. There were other less serious cases of blocked breathing, vomiting and blood oxygen levels dropping for more than 30 seconds.
"It's certainly extraordinarily dramatic and extraordinarily tragic when these events occur, but they're not common," said Dr. Jay Berkelhamer, president of the American Academy of Pediatrics.
Dentists, said Hunke, are seeing more extreme dental decay in younger children, leading to the types of procedures in which sedation is used. Complicated dental work could be prevented, he said, if parents got their children to a dentist starting at age 1 and if parents didn't allow babies and toddlers to tote around a bottle or sippy cup full of juice or milk, which causes cavities.