Guidelines for Nitrous Oxide Use in Children Under 2 Years Old
Nitrous oxide can be safely administered at concentrations up to 70% for procedural sedation in children under 2 years old, with appropriate monitoring and equipment. 1
Safety Profile in Young Children
- Nitrous oxide is safe for children of all ages, including those under 2 years, when administered properly for procedural sedation 1
- Children aged 1-4 years actually demonstrate the lowest adverse event rates compared to other age groups 1
- Studies have shown that children under 2 years achieve minimal to moderate sedation with nitrous oxide, similar to older children 2
Recommended Administration Guidelines
Concentration and Administration
- For minimal sedation, use nitrous oxide at ≤50% concentration with the balance as oxygen, without other sedatives or opioids 3
- If nitrous oxide is used at concentrations >50% or combined with other sedating medications, follow guidelines for moderate or deep sedation based on patient response 3
- Equipment must deliver never less than 25% oxygen concentration at a flow rate appropriate to the child's size 3
Duration Considerations
- Shorter procedures (<15 minutes) have significantly fewer adverse events 1
- Procedures lasting 15-30 minutes or >30 minutes are 4.2 and 4.9 times more likely to have adverse events, respectively 1
Monitoring Requirements
- Continuous monitoring is essential during nitrous oxide administration 3
- For moderate sedation, both pulse oximetry and capnography should be used 3
- Patient should be able to maintain verbal communication throughout the procedure when minimal sedation is the goal 3
Potential Adverse Events
- Most common adverse events are mild and self-resolving:
- Serious adverse events are rare (0.2-0.3% of cases) 4, 1
- No significant difference in adverse event rates between nitrous oxide ≤50% and >50% 1, 2
Special Considerations for Children Under 2
- Young children may require additional behavioral management techniques as they cannot follow verbal instructions 3
- Passive cooperation is still needed - the child must be able to breathe through a mouthpiece or mask 3
- Biofeedback systems and animated applications may help increase acceptability in some young children 3
- For children who cannot cooperate with standard techniques, alternative sedation methods may need to be considered 3
Contraindications
- Avoid in children with cobalamin and folate deficiency or defects in their metabolic pathways 5
- Not recommended for children who cannot maintain verbal communication if minimal sedation is the goal 3
- Caution in children with significant respiratory compromise who cannot tolerate any decrease in oxygen saturation 3
Clinical Pearls
- Nitrous oxide provides effective analgesia for mildly to moderately painful pediatric procedures 1
- Higher concentrations (40-50%) likely provide more effective analgesia than lower concentrations (30%) 6
- The sedation level typically remains minimal even at concentrations >50% when using appropriate delivery systems 2
- Always use equipment specifically designed for nitrous oxide administration in children 3