Drug Metabolism and Pain in Children

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Questions and Answers

What are the main mechanisms by which CYP450 enzymes inactivate drugs during Phase I metabolism?

Renal filtration, protein binding

Bile secretion, tubular absorption

Hydroxylation, conjugation

Oxidation, reduction, hydrolysis (correct)

Which of the following factors is NOT relevant to renal elimination of drug metabolites?

Age-associated effects

Renal blood flow

Glomerular filtration rate

Absorption rate in the intestines (correct)

What distinguishes nociceptive pain from other types of pain?

It is associated with psychological factors rather than physical injury.

It arises from the stimulation of damaged nerve endings.

It occurs due to the stimulation of intact nociceptors caused by harmful stimuli. (correct)

It mainly results from chronic conditions and is typically dull and diffuse.

Which statement accurately characterizes somatic pain?

It originates from tissues such as skin, muscles, and joints, often described as sharp. Signup and view all the answers

What type of pain is typically described as a dull, diffuse ache, often located around the abdomen or chest?

Visceral pain Signup and view all the answers

What is the maximum daily dose of acetaminophen for children weighing less than 40 kg?

1,750 mg Signup and view all the answers

Which of the following statements about the use of opioids in children is true?

Tramadol is not advised according to pediatric guidelines. Signup and view all the answers

What is a primary consideration when administering acetaminophen to patients?

Hypersensitivity to paracetamol is a contraindication. Signup and view all the answers

Why has the use of aspirin decreased since the 1970s?

It is linked to Reye’s syndrome. Signup and view all the answers

For what purpose is clindamycin commonly prescribed?

Infections caused by gram-positive aerobic and anaerobic bacteria. Signup and view all the answers

Which combination of medications was shown to provide effective analgesia for children?

Acetaminophen and ibuprofen Signup and view all the answers

What mechanism does acetaminophen use to exert its analgesic effects?

Inhibits cyclooxygenase-3 (COX-3). Signup and view all the answers

What is a well-known adverse side effect associated with opioids?

Respiratory depression. Signup and view all the answers

What type of pain do non-opioid analgesics, such as acetaminophen and NSAIDs, primarily target?

Mild to moderate nociceptive pain Signup and view all the answers

Which scenario correctly describes a limitation of clindamycin?

Ineffective against viral infections. Signup and view all the answers

Study Notes

Drug Metabolism in Children

CYP450 enzymes are responsible for drug metabolism in the body, primarily through two phases: Phase I (oxidation, reduction, hydrolysis) and Phase II (hydroxylation, conjugation).
Neonates have reduced Phase I metabolism, which gradually increases in the first six months of life.

Drug Elimination

Drug metabolites are eliminated primarily through bile or kidneys.
Renal elimination depends on factors like plasma protein binding, renal blood flow, glomerular filtration rate, and tubular secretion, all of which can vary with age.

Pain in Children

Pain is a subjective experience unique to each child due to differences in perception.
Nociceptive pain arises from activation of pain receptors by harmful stimuli (heat, cold, pressure, chemicals).
Nociceptive pain can be divided into somatic pain (originating from skin, bones, muscles, joints) and visceral pain (arising from internal organs, typically described as a dull ache).

Pain Management in Children

Non-opioid analgesics (Acetaminophen and NSAIDs) are effective for mild to moderate pain.
Aspirin use has decreased due to its association with Reye's syndrome.
Opioids (codeine, oxycodone, hydrocodone, morphine, tramadol) are not recommended for children by the American Academy of Pediatrics.
Acetaminophen and ibuprofen combined provide effective analgesia without opioid side effects.

Acetaminophen

Also known as Tylenol.
Generally safe for children.
Contraindicated in hypersensitivity, hepatic and renal failure.
Analgesic and antipyretic properties.
Mechanism of action: Inhibits cyclooxygenase-3 (COX-3), mostly found in the brain.
Antipyretic effect through hypothalamus inhibition.
Dosage: 25-45 mg/kg/day divided every 12 hours for children 3 months to 40 kg.
Dosage: 500-875 mg every 12 hours for children ≥ 40 kg and adults.

Clindamycin

Alternative to penicillin and cephalosporin antibiotics.
Effective for infections caused by gram-positive aerobic and anaerobic bacteria.
Not recommended for endocarditis prophylaxis.

Pediatric Sedation

Sedation is commonly used in children to manage behavior during dental procedures.
Deeper sedation is often needed for children under 5 years old or those with special needs.
Unintentional deeper sedation is a risk.
Behavioral management techniques are effective alternatives for older children.

Behavior Guidance Techniques

Basic: Tell-Show-Do, distraction, positive reinforcement, desensitization, parental presence/absence, sensory-adapted environment, animal-assisted therapy.
Advanced: Protective stabilization, sedation (nitrous oxide, oral, IV), general anesthesia.

Goals of Sedation (AAPD)

Patient safety and welfare.
Minimize discomfort and pain.
Manage anxiety, minimize psychological trauma, enhance amnesia.
Modify behavior for safe procedure completion.
Safe discharge from medical supervision.

Minimal Sedation

Nitrous oxide sedation.
Drug-induced state where patients respond to verbal commands.
Cognitive function and coordination may be impaired, but ventilation and cardiovascular function remain unaffected.
Responsiveness: Patients are less anxious and calmer.
Monitoring: Clinical observation of skin color, respiratory effort, and pulse oximetry.

Moderate Sedation

Drug-induced depression of consciousness where patients respond to verbal commands with or without tactile stimulation.
Commonly used medications include Midazolam, Hydroxyzine, Meperidine.
Airway intervention is typically not required.
Cardiovascular function is usually maintained.

Indications for Moderate Sedation

Pre-school children and those with insufficient emotional or psychological maturity.
Individuals with cognitive, physical, or medical disabilities.
Patients with anxiety and fear.
Patients needing prolonged dental procedures or where minimal sedation is ineffective.

General Anesthesia

Drug-induced loss of consciousness where patients are unresponsive to painful stimuli.
Ventilation may be impaired, requiring positive pressure ventilation.
Airway management may be required.
Cardiovascular function may be compromised.

Indications for General Anesthesia

Lack of emotional or psychological maturity and/or complex medical disabilities.
Extensive dental treatment or immediate surgical procedures.
Protection of developing psyche.

ASA Physical Status Classification

ASA I: Healthy patient.
ASA II: Mild systemic disease.
ASA III: Severe systemic disease.
ASA IV: Severe systemic disease threatening life.
ASA V: Moribund patient unlikely to survive without surgery.
ASA VI: Brain-dead donor.

Sedation Considerations

ASA I and II: Appropriate candidates for minimal, moderate, or deep sedation.
ASA III and IV: Require individual considerations and specific management.
Special health care needs: Increased considerations.
Anatomic airway abnormalities and tonsillar hypertrophy: Special considerations for moderate and deep sedation.

Mallampati Classes

Mallampati classes I and II: Appropriate for moderate sedation.

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Description

This quiz covers the drug metabolism processes in children, focusing on CYP450 enzymes and the implications of age on drug elimination. Additionally, it explores the unique experience of pain in children, including nociceptive pain types. Test your knowledge on these important pediatric topics.