What are the long-term effects of repeated conscious sedation on children?

Long-Term Effects of Repeated Conscious Sedation on Children

Current evidence does not conclusively demonstrate permanent neurotoxic effects from repeated conscious sedation in children, but there are concerns about potential neurodevelopmental impacts, particularly in children under 3 years of age who receive multiple or prolonged sedation exposures.

Potential Concerns for Repeated Sedation in Children

Neurodevelopmental Concerns

• The American Academy of Pediatrics (AAP) guidelines specifically mention concerns about sedative medications on the developing brain, noting that "research in this area is preliminary and inconclusive at best, but it would seem prudent to avoid unnecessary exposure to sedation if the procedure is unlikely to change medical/dental management" 1

• The FDA has issued warnings regarding potential neurotoxicity of anesthetic and sedating drugs in children younger than 3 years, particularly with repeated or prolonged exposures 2, 3

• A 2019 study found that 11.1% of children under 3 years required repeated and/or prolonged sedation outside the operating room, potentially placing them at risk according to FDA neurotoxicity warnings 3

Delayed Recovery and Side Effects

• Common side effects after discharge include:

  • Motor imbalance (31%)
  • Gastrointestinal effects (23%)
  • Agitation (19%)
  • Restlessness (14%) 4

• Approximately 5% of children do not return to baseline activity until the second day after sedation procedures 4

• Infants under 12 months may experience more frequent delayed recovery (≥24 hours) compared to older children 4

• Some children (4% in one study) required medical advice after discharge, with a small percentage needing emergency department visits for excessive or prolonged sedation 4

Risk Factors for Adverse Effects

Age-Related Factors

• Neonates and former preterm infants require special consideration due to:

  • Immature hepatic and renal function
  • Altered ability to metabolize and excrete sedating medications
  • Increased risk for prolonged sedation
  • Need for extended post-sedation monitoring 1

• Children younger than 6 years and those with developmental delays often require deeper levels of sedation to control behavior, making them more vulnerable to sedating medication effects on:

  • Respiratory drive
  • Airway patency
  • Protective reflexes 1

Medication-Specific Considerations

• Chloral hydrate has been associated with more imbalance compared to midazolam 4

• Ketamine has a low rate of significant adverse events but can cause:

  • Respiratory depression (risk increases when combined with other sedatives/opioids)
  • Laryngospasm (0.9-1.4% in general settings, higher in specific procedures)
  • Emesis (7-14% of cases)
  • Recovery agitation (more common in younger children) 5

• Midazolam may cause prolonged sedation, particularly when combined with drugs that inhibit the cytochrome P450 system 6

Recommendations for Minimizing Long-Term Risks

Limiting Unnecessary Exposure

• The AAP recommends avoiding unnecessary exposure to sedation, particularly in young children, if the procedure is unlikely to change medical/dental management 1

• Consider alternative imaging or procedures that may not require sedation 3

• When possible, delay procedures until the child is older than 3 years to minimize potential neurodevelopmental concerns 3

Appropriate Medication Selection and Administration

• Carefully titrate doses to the minimum effective level 5

• Be aware of drug interactions that may prolong sedation effects 6

• Avoid drugs with long duration of action (e.g., intramuscular pentobarbital, phenothiazines) due to unpredictable responses and prolonged recovery 1

Monitoring and Follow-up

• Ensure appropriate monitoring during sedation according to the depth of sedation:

  • Minimal sedation: pulse oximetry, heart rate, blood pressure
  • Moderate sedation: add continuous capnography and ECG
  • Deep sedation: continuous capnography, ECG, and dedicated monitoring personnel 5

• Discharge only when children meet specific recovery criteria, including:

  • Return to baseline consciousness
  • Stable vital signs
  • Ability to maintain airway independently 5

• Provide clear instructions to parents/caregivers about potential delayed effects and when to seek medical attention 1

Conclusion

While the immediate safety profile of conscious sedation in children is generally good when properly administered, there remain concerns about potential long-term neurodevelopmental effects, particularly with repeated or prolonged exposures in children under 3 years of age. The decision to use sedation should carefully weigh the necessity of the procedure against potential risks, with consideration given to alternative approaches or delaying non-urgent procedures when possible.