Re: Re: Dental issues - NITROUS OXIDE may cause regression

[Guest guest]

,

I appreciate your sending this information, as I have heard from others

that nitrous oxide is not recommended for kids on the spectrum.

Personally, if there's even the slightest doubt in my mind as to whether

or not it could cause a problem, I'd refuse it. My ASD son had all 4

wisdom teeth removed this year and even his oral surgeon agreed that

nitrous oxide wasn't a good choice for him. Versed was among the meds

that were used, with no problems or aftereffects.

patti

On Tue, 06 Sep 2005 14:28:15 -0000 " nhokkanen " <nhokkanen@...>

writes:

>

> > " Using nitrous oxide (not usually covered by dental insurance, but

>

> that's OK) can easily calm a child being seen by a dentist. My

> son, 25, w/autism, calls it " magic gas. " I even get it to get my

> teeth cleaned, much less anything else. I'm called a " high anxiety

>

> patient. " I get anxious just thinking about anyone going to the

> dentist. I wish I could be put to sleep for any and all dental

> needs, but the gas helps even me a lot. "

>

>

> Unfortunately nitrous oxide can cause regression in children with

> deficiencies in methylcobalamin (B-12) and methionine... even death.

>

> The article, LTE and studies below explain rare instances when

> nitrous oxide is contraindicated. An anxiolytic such as Versed may

> be more suitable.

>

> Hokkanen

> Minneapolis

> ___________________________________

>

> Nitrous Oxide Anesthesia Implicated in Death of Child With MTHFR

> Deficiency

>

> By J. Brown, MD

>

> NEW YORK (Reuters Health) Jul 02, 2003 - Nitrous oxide anesthesia

> administered to a child born with an undiagnosed deficiency in a key

>

> metabolic enzyme appears to have caused the child's death, according

>

> to a report published in the July 3rd issue of The New England

> Journal of Medicine.

>

> The deficient enzyme, 5,10-methlyenetetrahydrofolate reductase

> (MTHFR), is involved in the metabolism of folate and in the

> production of methionine, which is needed for a variety of important

>

> biochemical reactions, senior author Dr. Kirk Hogan, from the

> University of Wisconsin in Madison, and colleagues note.

>

> In the current case, because of the enzyme deficiency, the child

> probably had baseline methionine levels that, although low, were

> survivable. Unfortunately, in this situation treatment with nitrous

>

> oxide, an agent known to block methionine synthesis, may have

> resulted in fatally low levels.

>

> The case involved a male infant who appeared normal until 3 months

> of age when he presented with a mass in the left leg. Excisional

> biopsy of the lesion was performed under anesthesia that included

> nitrous oxide. The procedure lasted 45 minutes and the pathology

> results indicated fibrosarcoma.

>

> The child was taken back to the OR four days later for complete

> resection of the mass. Once again, nitrous oxide-containing

> anesthesia was administered, but this time the procedure lasted 270

>

> minutes. Still, the patient was discharged on postoperative day 7 in

>

> seemingly good health.

>

> Seventeen days after discharge, the infant was admitted to the

> hospital with seizures and apnea episodes. The patient was found to

>

> be severely hypotonic and CT scan revealed generalized brain atrophy

>

> with enlarged prepontine and medullary cisterns. In addition, plasma

>

> methionine levels were low, while homocysteine levels were

> elevated--

> both findings consistent with a MTHFR deficiency.

>

> Forty-six days after surgery, the infant died after respiratory

> arrest. Postmortem examination showed extensive damage to the

> central nervous system.

>

> Although it was not known at the time of surgery, two of the child's

>

> relatives had elevated homocysteine levels. However, none had ever

> been treated with nitrous oxide.

>

> The case was initially reported in 1987, but at that time the

> technology was not available to test for MTHFR activity or for

> mutations in the corresponding gene, Dr. W. Erbe, co-author

>

> of a related editorial, told Reuters Health.

>

> When Dr. Hogan's team went back and tested fibroblast samples from

> the patient and his family, they found a novel MTHFR mutation

> associated with severely decreased enzyme activity.

>

> " I don't think these results should cause panic among the general

> public, " Dr. Erbe, from the University at Buffalo, noted. " There

> were clues in this particular case that suggested a problem before

> the nitrous oxide was given, " he added.

>

> Moreover, the MTHFR mutation in the current case appears to be

> rather rare, Dr. Erbe said. " There is a MTHFR mutation that is

> present in up to 50% of the population, but there is no evidence

> that nitrous oxide is unsafe for carriers of this mutation. "

>

> However, in children with developmental delay or altered

> homocysteine metabolism, methionine levels should be determined

> before using nitrous oxide-containing anesthesia, he noted.

> ______________________________________

>

> Arch Dis Child 2001;85:510 ( December )

> Letters to the editor

> Nitrous oxide and vitamin B12

>

> EDITOR,

>

> The paper by Kanagasundaram et al1 on the use of nitrous oxide to

> alleviate pain and anxiety during painful procedures fails to

> mention the effect of this gas on cobalamin metabolism. Nitrous

> oxide inactivates cobalamin (1), the active derivative of vitamin

> B12 and essential cofactor for the transfer of the methyl group from

>

> methyltetrahydrofolate to homocysteine to form methionine.

>

> For subjects with good body stores of cobalamin this effect is

> unimportant, but no-one using this agent should remain unaware of

> the potentially devastating complications in the nervous system of

> using nitrous oxide in subjects who are of borderline or deficient

> vitamin B12 status. Onset of subacute combined degeneration

> affecting the brain and spinal cord is a well documented event when

>

> individuals with low body stores of cobalamin are exposed to nitrous

>

> oxide.(2)

>

> There is a long list of situations which put children at special

> risk of cobalamin deficiency

> ----------

>

> for example, diets low in animal products, synthetic feeding of any

>

> description, small bowel malfunction, any prolonged illness with

> disturbance of feeding behaviour, especially if combined with

> increased metabolic demands

> ----------

>

> for example, systemic malignancy or chemotherapy. Children with

> chronic conditions often need painful procedures, and depleted

> cobalamin stores may not be apparent unless measurements of serum

> B12 are made routinely. What is more, repeated use of nitrous oxide

>

> depletes the body stores of cobalamin even in well people.

>

> Given the scale of use which would result from routine use of

> nitrous oxide in children undergoing painful procedures, there

> should be real concern about the potential for an accident in a

> child with occult cobalamin deficiency. The message must be: never

> forget vitamin B12 when thinking of using nitrous oxide.

>

> ISABEL SMITH

> Clinical Audit Department, Great Ormond Street Hospital, Great

> Ormond Street, London WC1N 3JH, smithi@g...

>

> References

>

> 1. Kanagasundaram SA, Lane LJ, Cavaletto BP, et al. Efficacy and

> safety of nitrous oxide in alleviating pain and anxiety during

> painful procedures. Arch Dis Child 2001;84:492-495[Abstract/Free

> Full Text].

>

> 2. Lee P, I, Piesowicz A, et al. Spastic parapareisis after

> anaesthesia. Lancet 1999;353:554[Medline].

>

> © 2001 by Archives of Disease in Childhood

> ____________________________________

>

> ALSO SEE:

> Adverse Effect of Nitrous Oxide in a Child with 5,10-

> Methylenetetrahydrofolate Reductase Deficiency

> R. Selzer, Ph.D., S. Rosenblatt, M.D., Renata Laxova,

>

> M.D., and Kirk Hogan, M.D., J.D.

>

>

>

>

>

>

[Guest guest]

omg, I wish I'd known this 5 months ago when my 4 yos had major dental work

done using nitrous, which after a lot of research (apparently not enough) we

felt was better than general anesthesia. We had a HORRIBLE couple of weeks

after the longest of his three appts., with only minor regression after the

other two appts. We thought it was just the trauma of people being in his

face, the sound of the gas (which he said really bothered him), the activity

in his mouth (as he doesn't even care for teeth brushing and has a lot of

food/oral issues) and the smells, lights, etc. After that one appt., it was

like we'd gone back 8 mths in time, yet we didn't realize it was the

nitrous. His cleaning is coming up next month -- we won't put it off for

fear of more major dental work being a result of not catching a problem in

time, but I guess we need to push more for the Versed or other option she

mentioned as a close-second to nitrous.

Re: Re: Dental issues - NITROUS OXIDE may cause regression

> ,

>

> I appreciate your sending this information, as I have heard from others

> that nitrous oxide is not recommended for kids on the spectrum.

> Personally, if there's even the slightest doubt in my mind as to whether

> or not it could cause a problem, I'd refuse it. My ASD son had all 4

> wisdom teeth removed this year and even his oral surgeon agreed that

> nitrous oxide wasn't a good choice for him. Versed was among the meds

> that were used, with no problems or aftereffects.

>

> patti

>

>

> On Tue, 06 Sep 2005 14:28:15 -0000 " nhokkanen " <nhokkanen@...>

> writes:

>>

>> > " Using nitrous oxide (not usually covered by dental insurance, but

>>

>> that's OK) can easily calm a child being seen by a dentist. My

>> son, 25, w/autism, calls it " magic gas. " I even get it to get my

>> teeth cleaned, much less anything else. I'm called a " high anxiety

>>

>> patient. " I get anxious just thinking about anyone going to the

>> dentist. I wish I could be put to sleep for any and all dental

>> needs, but the gas helps even me a lot. "

>>

>>

>> Unfortunately nitrous oxide can cause regression in children with

>> deficiencies in methylcobalamin (B-12) and methionine... even death.

>>

>> The article, LTE and studies below explain rare instances when

>> nitrous oxide is contraindicated. An anxiolytic such as Versed may

>> be more suitable.

>>

>> Hokkanen

>> Minneapolis

>> ___________________________________

>>

>> Nitrous Oxide Anesthesia Implicated in Death of Child With MTHFR

>> Deficiency

>>

>> By J. Brown, MD

>>

>> NEW YORK (Reuters Health) Jul 02, 2003 - Nitrous oxide anesthesia

>> administered to a child born with an undiagnosed deficiency in a key

>>

>> metabolic enzyme appears to have caused the child's death, according

>>

>> to a report published in the July 3rd issue of The New England

>> Journal of Medicine.

>>

>> The deficient enzyme, 5,10-methlyenetetrahydrofolate reductase

>> (MTHFR), is involved in the metabolism of folate and in the

>> production of methionine, which is needed for a variety of important

>>

>> biochemical reactions, senior author Dr. Kirk Hogan, from the

>> University of Wisconsin in Madison, and colleagues note.

>>

>> In the current case, because of the enzyme deficiency, the child

>> probably had baseline methionine levels that, although low, were

>> survivable. Unfortunately, in this situation treatment with nitrous

>>

>> oxide, an agent known to block methionine synthesis, may have

>> resulted in fatally low levels.

>>

>> The case involved a male infant who appeared normal until 3 months

>> of age when he presented with a mass in the left leg. Excisional

>> biopsy of the lesion was performed under anesthesia that included

>> nitrous oxide. The procedure lasted 45 minutes and the pathology

>> results indicated fibrosarcoma.

>>

>> The child was taken back to the OR four days later for complete

>> resection of the mass. Once again, nitrous oxide-containing

>> anesthesia was administered, but this time the procedure lasted 270

>>

>> minutes. Still, the patient was discharged on postoperative day 7 in

>>

>> seemingly good health.

>>

>> Seventeen days after discharge, the infant was admitted to the

>> hospital with seizures and apnea episodes. The patient was found to

>>

>> be severely hypotonic and CT scan revealed generalized brain atrophy

>>

>> with enlarged prepontine and medullary cisterns. In addition, plasma

>>

>> methionine levels were low, while homocysteine levels were

>> elevated--

>> both findings consistent with a MTHFR deficiency.

>>

>> Forty-six days after surgery, the infant died after respiratory

>> arrest. Postmortem examination showed extensive damage to the

>> central nervous system.

>>

>> Although it was not known at the time of surgery, two of the child's

>>

>> relatives had elevated homocysteine levels. However, none had ever

>> been treated with nitrous oxide.

>>

>> The case was initially reported in 1987, but at that time the

>> technology was not available to test for MTHFR activity or for

>> mutations in the corresponding gene, Dr. W. Erbe, co-author

>>

>> of a related editorial, told Reuters Health.

>>

>> When Dr. Hogan's team went back and tested fibroblast samples from

>> the patient and his family, they found a novel MTHFR mutation

>> associated with severely decreased enzyme activity.

>>

>> " I don't think these results should cause panic among the general

>> public, " Dr. Erbe, from the University at Buffalo, noted. " There

>> were clues in this particular case that suggested a problem before

>> the nitrous oxide was given, " he added.

>>

>> Moreover, the MTHFR mutation in the current case appears to be

>> rather rare, Dr. Erbe said. " There is a MTHFR mutation that is

>> present in up to 50% of the population, but there is no evidence

>> that nitrous oxide is unsafe for carriers of this mutation. "

>>

>> However, in children with developmental delay or altered

>> homocysteine metabolism, methionine levels should be determined

>> before using nitrous oxide-containing anesthesia, he noted.

>> ______________________________________

>>

>> Arch Dis Child 2001;85:510 ( December )

>> Letters to the editor

>> Nitrous oxide and vitamin B12

>>

>> EDITOR,

>>

>> The paper by Kanagasundaram et al1 on the use of nitrous oxide to

>> alleviate pain and anxiety during painful procedures fails to

>> mention the effect of this gas on cobalamin metabolism. Nitrous

>> oxide inactivates cobalamin (1), the active derivative of vitamin

>> B12 and essential cofactor for the transfer of the methyl group from

>>

>> methyltetrahydrofolate to homocysteine to form methionine.

>>

>> For subjects with good body stores of cobalamin this effect is

>> unimportant, but no-one using this agent should remain unaware of

>> the potentially devastating complications in the nervous system of

>> using nitrous oxide in subjects who are of borderline or deficient

>> vitamin B12 status. Onset of subacute combined degeneration

>> affecting the brain and spinal cord is a well documented event when

>>

>> individuals with low body stores of cobalamin are exposed to nitrous

>>

>> oxide.(2)

>>

>> There is a long list of situations which put children at special

>> risk of cobalamin deficiency

>> ----------

>>

>> for example, diets low in animal products, synthetic feeding of any

>>

>> description, small bowel malfunction, any prolonged illness with

>> disturbance of feeding behaviour, especially if combined with

>> increased metabolic demands

>> ----------

>>

>> for example, systemic malignancy or chemotherapy. Children with

>> chronic conditions often need painful procedures, and depleted

>> cobalamin stores may not be apparent unless measurements of serum

>> B12 are made routinely. What is more, repeated use of nitrous oxide

>>

>> depletes the body stores of cobalamin even in well people.

>>

>> Given the scale of use which would result from routine use of

>> nitrous oxide in children undergoing painful procedures, there

>> should be real concern about the potential for an accident in a

>> child with occult cobalamin deficiency. The message must be: never

>> forget vitamin B12 when thinking of using nitrous oxide.

>>

>> ISABEL SMITH

>> Clinical Audit Department, Great Ormond Street Hospital, Great

>> Ormond Street, London WC1N 3JH, smithi@g...

>>

>> References

>>

>> 1. Kanagasundaram SA, Lane LJ, Cavaletto BP, et al. Efficacy and

>> safety of nitrous oxide in alleviating pain and anxiety during

>> painful procedures. Arch Dis Child 2001;84:492-495[Abstract/Free

>> Full Text].

>>

>> 2. Lee P, I, Piesowicz A, et al. Spastic parapareisis after

>> anaesthesia. Lancet 1999;353:554[Medline].

>>

>> © 2001 by Archives of Disease in Childhood

>> ____________________________________

>>

>> ALSO SEE:

>> Adverse Effect of Nitrous Oxide in a Child with 5,10-

>> Methylenetetrahydrofolate Reductase Deficiency

>> R. Selzer, Ph.D., S. Rosenblatt, M.D., Renata Laxova,

>>

>> M.D., and Kirk Hogan, M.D., J.D.

>>

>>