Literature Reviews

Updated AAP/AAPD Guidelines Published

By Amber Rogers, MD
Texas Children’s Hospital
Houston, Texas

The American Academy of Pediatrics and the American Academy of Pediatric Dentistry recently published an update of the pediatric procedural sedation guidelines entitled, “Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016.”  Charles Cote and Stephen Wilson again authored the paper, and although the majority of the document is similar to the 2006 version, there are several altered recommendations which are highlighted below. 

  1. Three new figures outlining algorithms for the suggested management of airway obstruction, laryngospasm, and apnea

  2. Expanded discussion of pre-sedation dietary precautions, noting additional literature related to the low risk of aspiration with variable fasting periods while emphasizing the continued need to balance the urgency of the procedure with the sedation risk in a non-fasted patient

  3. Discussion of the promethazine black box warning regarding fatal respiratory depression in children less than two and the FDA warning to avoid codeine use for post-procedure analgesia due to the potential risk of overdose in children with altered codeine metabolism 

  4. Suggestion that patients should be assessed for a history of prematurity and symptoms of sleep-disordered breathing during the health evaluation to better assess sedation risk

  5. Increased emphasis on sedation quality and safety, including advising to double check infusion pump settings with a separate individual, verbally confirm medication dosing prior to administration, calculate medication doses for obese patients using ideal body weight, using emergency checklists in all sedation locations (available at http://www.pedsanesthesia.org), and using simulation to train for rare emergencies

  6. Stronger recommendation regarding the need for capnography or pretracheal/precordial stethoscope use during moderate and deep sedations, with few exceptions noted due to procedure challenges or patient agitation

  7. Expanded discussion of local anesthetics, including a new table summarizing the treatment of local anesthetic toxicity

  8. Summary of Bispectral index monitoring and its sedation limitations

  9. Brief discussion about the special considerations of sedation of neonates and former preterm infants

The authors also praised the significant contribution of the Pediatric Sedation Research Consortium to the sedation knowledge base.  These guidelines are published in the journals and Pediatrics and Pediatric Dentistry (Pediatrics. 2016 Jul;138(1):e20161212. Pediatr Dent. 2016;38(4):13-39.).

Links to these articles can be found on the Repository of Guidelines page on the Society for Pediatric Sedation website.