Contraindications for Use with the Pediatric Patient

Contraindications for use with the pediatric patient are:

• Chronologically immature child. The effectiveness of nitrous oxide/oxygen analgesia/anxiolysis is largely dependent on psychologic reassurance. The patient, especially one who is anxious, must understand what nitrous oxide is all about and what to expect during the procedure. This can only be accomplished if the patient can understand verbal communication. Very young children (under the age of two years) may not have the maturity and ability to understand the goals and effects of nitrous oxide/oxygen analgesia/anesthesia. Physically restraining a hysterical toddler and administering a high concentration of nitrous oxide will not result in a cooperative patient. However, nitrous oxide/oxygen analgesia/anxiolysis is effective in the younger child when used as an adjunct to conscious sedation. (Conscious sedation should not be attempted unless the dental provider has undertaken appropriate training in its administration).

• Behaviorally immature child. The behaviorally immature child is one that does not behave in a manner appropriate to his/her age for reasons not due to intellectual or physical disability. Using common terminology, the child could be described as overindulged or obstinate. This child will be uncooperative for dental treatment, not because of excessive fear or anxiety or a physical or mental disability, but because they just don’t want to. Nitrous oxide/oxygen analgesia/anxiolysis cannot be successfully administered on this child until an appropriate behavior modification technique (voice control, non-verbal communication, positive reinforcement) is used to gain the child’s cooperation.

• Specific medical conditions. There are certain medical conditions in which nitrous oxide is contraindicated. Any condition that causes nasal obstruction such as the common cold or enlarged tonsils or adenoids that would reduce an effective amount of gas from reaching the patient’s lungs is contraindicated. Nitrous oxide should be administered with caution to patients with chronic respiratory problems such as emphysema, chronic bronchitis, pneumothorax, and cystic fibrosis because of hypoxia due to increased airway resistance.

• Nitrous oxide is not contraindicated in patients with asthma. It is nonirritating to the mucous membranes and since anxiety can trigger an asthmatic episode, its anti-anxiety effects can reduce the possibility of an occurrence. The same holds true for patients with sickle cell anemia. The increased levels of oxygen during nitrous oxide/oxygen analgesia/anxiolysis may reduce the occurrence of a crisis.

• Severe emotional disturbances or drug related dependencies. Nitrous oxide should be administered with caution to patients under psychiatric or psychologic care. Many patients are treated with anti-depressant or psychotropic drugs. While there is minimal risk of interaction with prescribed drugs, the nitrous oxide may exacerbate the underlying condition. Nitrous oxide can be administered to these patients with medical consultation. Because of the possibility of these patients hallucinating under the influence of nitrous oxide, it is imperative that a third party remain in the room during the administration.

• Middle ear and ophthalmic disturbances. Because nitrous oxide infiltrates the rigid, noncompliant area of the middle ear, increased pressure results. Also, the negative pressure from the rapid departure of nitrous oxide from the spaces at termination of administration can result in negative pressure. Therefore, nitrous oxide should be avoided in patients that have undergone surgical procedures and recent ear, nose, or throat infections. The same holds true for patients that have undergone recent ophthalmic surgery.

• Treatment with bleomycin sulfate. Bleomycin sulfate is an antineoplastic agent used for the treatment of lymphomas, testicular tumors, and squamous cell carcinoma. An increase in pulmonary fibrosis and disease may occur with nitrous oxide/oxygen administration.

• Latex sensitivity/allergy. Components of the nasal hoods used in nitrous oxide delivery may contain latex. For patients that are latex allergic or sensitive, non-latex delivery products may be substituted.

• Pregnancy. Nitrous oxide can interfere with Vitamin B12 metabolism, which is necessary for DNA production and subsequent cellular reproduction. Therefore, it should not be administered during the first trimester of pregnancy and only after medical consultation in subsequent trimesters.

• Children under 3 years of age. The FDA’s Anesthetic and Life Support Drugs Advisory Committee is investigating data from animal studies suggesting that exposure to anesthetic agents during the period of rapid brain growth produces widespread neuronal apoptosis with possible long-term functional consequences. When contemplating administration of nitrous oxide to pregnant women and to patients under three years of age the benefits and risks of the surgeries should be considered and explained to patients/parents. For medically necessary or emergency conditions, surgeries for pregnant women in the third trimester and children under three should not be delayed, however the exposure to the sedative or anesthesia should not last longer than 3 hours and should not exceed more than one exposure.^4,5

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