LOCAL ANAESTHESIA

FOR CHILDREN

Dr. Mutyala Jhansi(JR-1)

Department of pediatric and preventive
dentistry
King george’s medical university
 CONTENTS
• Introduction
• Surface anaesthesia
• Non Pharmacological pain control
• Local anaesthetic solutions
• Techniques of local anaesthesia
• Recent advances in LA
• Complications of LA
• Contraindications to LA
• References
 INTRODUCTION

DEFINITION

Loss of sensation in a circumscribed area of

the body caused by a depression of
excitation in nerve endings or inhibition of
conduction process in peripheral nerve

Providing
operative pain Diagnostic tools
control.

Control of
haemorrhage.
 SURFACE ANAESTHESIA

Surface
anaesthesia

Physical Pharmacological
method method(topical
anaesthetics)

Application of volatile liquids such as ethyl chloride.

The latent heat of evaporation of this material reduces
the temperature of the surface tissue and this produces
anaesthesia.
Rarely used in children.
 INTRA-ORAL TOPICAL AGENT
• The success depends on the technique.
• Ethyl aminobenzoate (benzocaine), butacaine sulfate, cocaine,
dyclonine, Lidocaine are used.

Spray,
solution ,
cream &
ointment

Anesthetise
2-3 mm depth
Time of
application
-5min
 • Pre injection treatment
USES • Extraction of mobile primary teeth
 TOPICAL ANAESTHETICS FOR SKIN
• EMLA cream (5% Eutectic mixture of the prilocaine and lidocaine)

• Clinical trial of intra oral use of EMLA shown to be more effective

then conventional local anaesthesia
NON-PHARMACOLOGICAL PAIN CONTROL

This include the use of:

 Electrical stimulation(TENS)
 Radio waves
 Hypnosis
 Laser
 Refrigeration techniques
 ELECTROANALGESIA(TENS)
• It is shown to be effective in providing symptomatic pain
relief.
 MECHANISM

Acute pain Chronic

Threshold for electrical
stimulation Large
myelinated nerve fiber
smaller is less than
unmyelinated pain fibers
pain
Where the release of
endogenous painkillers
such as β-endorphins is
stimulated

Stimulation of these fibres

by the current from the
TENS machine closes the
‘gate’ to central
transmission of the signal
from the pain fibres.
• HYPNOSIS It can be used as an adjuctive to LA in children and most
effective in young children by decreasing the pulse rate and the
incidence of crying.
• RADIOWAVES high frequency waves are released which inturn
causes the release of endorphins.

ADVANTAGES

1) Systemic toxicity

2) Chance of self-inflected trauma

 LOCAL ANAESTHETIC SOLUTIONS
• A number of LA solutions lasting from 10mins to 6 hrs are
available.

2%
LIDOCAINE
+
ADRENALINE
 CLASSIFICATION OF LA
ESTERS
Butacaine
Cocaine
Benzocaine
Hexylcaine
Tetracaine
ESTERS OF PARAAMINOBENZOIC ACID
Chloroprocaine
Procaine
Propoxycaine
AMIDES QUINOLINE

Articaine Centbucridine
Bupivacaine
Dibucaine
Etidocaine
Lidocaine
Mepivacaine
Prilocaine
Ropivacaine
 OTHER AGENTS OF
LIGNOCAINE AMIDE GROUP

AGENTS OF ESTER GROUP

ALLERGIC TO BOTH
AMIDE AND ESTER 1% DIPHENHYDRAMINE
 TECHNIQUES

Patient Position

30 degree
from supine

• Sitting upright can increase the chance of fainting, whilst at

the other extreme(fully supine)
 METHODS OF LA ADMINISTRATION

 Infiltration anaesthesia
 Regional block anaesthesia
 Intra-ligamentary anaesthesia
 Intra osseous, inter septal and intrapulpal
 INFILTRATION ANAESTHESIA

• Method of choice in the maxilla.

• Infiltration of 0.5 to 1.0ml of local

anaesthetic is sufficient for pulpal
anaesthesia

• The objective is to deposit LA solution as

close as possible to the apex of tooth of
interest ( supra-periostelly).
• Buccal infiltration in the mandible is reliable for pulpal anaesthesia of
primary teeth and unreliable on permanent teeth, with exception of
lower incisors teeth (jaber et al. 2010)

• Oulis and association compared the effectiveness of mandibular

infiltration anaesthesia with mandibular block. Results reported that
manibular infiltration was less effective than mandibular block for
pulpotomy and extraction (p=0.05)
 REGIONAL BLOCK ANAESTHESIA
INFERIOR ALVEOLAR AND LINGUAL NERVE BLOCKS

Administration of this blocks are easier to perform successfully

in children than adults (because of the relative position
mandibular foramen to the occlusal level)

Best performed with child’s mouth fully open.

LANDMARKS
 Mucobuccal fold
 Anterior border of ramus of the mandible
 External oblique ridge
 Retromolar triangle
 Internal oblique ridge
 Pterygomandibular liigament
 Buccal sucking pad
 Pterygomandibular space
 LINGUAL NERVE BLOCK
• The lingual nerve is blocked by withdrawing the needle halfway,
aspirating again, and depositing most of the remaining solution at
this point.

• The final contents of the cartridge are expelled as the needle is

withdrawn through the tissue.

• A common fault is to contact bone only a few millimeters following

insertion.
• This lead to unsuccessful anaesthesia, occur because the angle of
entry is too obtuse
 LONG BUCCAL, MENTAL AND INCISIVE
NERVE BLOCKS
LONG BUCCAL INJECTIONS usually equates to a buccal infiltration in
children.
MENTAL AND INCISIVE NERVE BLOCKS readily administered in children
as the orientation of the mental foramen is such that it faces forward
rather than posteriorly as in adult.
• Blocked of transmission in the mental nerve provides
excellent soft tissue anaesthesia.

• The method of choice for pulpal anaesthesia in the

permanent lower incisors is a combination of buccal and
lingual infiltration.
 MAXILLARY NERVE BLOCK
• Regional block techniques are seldom required in a child’s
maxilla .

• Infraorbital, Greater palatine and nasopalatine nerve blocks

INFILTRATION
 INTRA-LIGAMENTARY ANAESTHESIA

• This is a method of intra osseous injection with LA reaching the

cancellous space in the bone via the periodontal ligament.

• The recommended dose per root is 0.2ml.

• Advantage Reduces the occurence of self mutilation of lip & tongue.

•30 gauge needle
•30degree angle
•Mesiobuccal aspect

Advance needle
until firm resistance
is met
• It is important not to inject too quickly:
about 15 sec per depression of the
specialized syringe lever is needed.

Wait for
5sec before
needle
withdrawal
 INTRA-OSSEOUS, INTER-SEPTAL AND
INTRAPULPAL INJECTION

• INTRA PULPAL it often provides the desired anaesthesia, but

the technique has the disadvantage of being initially painful,
although the onset of anaesthesia is usually rapid.
• INTRAOSSEOUS INJECTION techniques(of which interseptal injection
is one type)require the deposition of LA solution in the porous
alveolar bone.
• This technique is not particularly difficult in children because
their cortical bone is less dense than that of adult.

INDICATION
• This method is useful when the use of periodontal injection is
contraindicated due to periodontal ligament space infection.
 A
R D
E V
C A
E N
N C
T E
S
A. COMPUTERED-CONTROLLED LA DELIVERY
SYSTEM (WAND)
• The system includes conventional LA needle and a disposable
wand-like syringe held by a pen grasp.
• PRINCIPLE: To deliver local anesthetic solution at a constant
rate and slower speed to avoid causing discomfort to the
patient

• The system includes an aspiration cycle for use when

necessary.

• There are three modes of flow rate available: slow, fast and
turbo mode.

• Block, infiltration, palatal and periodontal ligament injections

are all reported to be more comfortable for the patient with
the wand than conventional injection techniques.
 COMFORT CONTROL SYRINGE
• It was marketed as an alternative to the Wand and has two
components; base unit and syringe no foot pedal.

• The most important functions of this unit is injection and

aspiration can be controlled directly from the syringe.
• Five different rate settings for specific applications like block,
infiltration, PDL, IO and Palatal regions.

• The unit uses two stage delivery rates for every injection.

• It initially expresses the LA solution at an extremely low rate and

after 10 seconds the rate slowly increases to the pre-
programmed value for the selected injection technique.

• Disadvantage The syringe is bulky and cumbersome to use when

compared to the wand hand piece.
 SINGLE-TOOTH ANESTHESIA [STA]
• In 2006, the manufacturers of the original CCLAD, introduced a
new device, Single Tooth Anesthesia (STA)

• PRINCIPLE It incorporates dynamic pressure-sensing (DPS)

technology that provides a constant monitoring of the pressure of
local anaesthetic solution during the drug administration.
• Since the pressure of the LA is strictly regulated by the STA system,
a greater volume of LA can be administered with increased comfort
and less tissue damage

• It has 3 modes for rate of injection: STA mode, normal mode and
turbo mode.
 NEW INJECTION TECHNIQUES

• With the development of CCLAD 2 new injection techniques have

evolved
1. Anterior middle superior alveolar nerve block (AMSA)
2. Posterior approach to anterior superior alveolar nerve block
(P-ASA)

• Though either may be administered with a traditional local

anesthetic syringe.
• For the AMSA, you slowly inject in the area between the
maxillary premolars and the palatal suture. You will see a
blanching of the palatal tissues. This will give you anesthesia
from second premolar to central incisor.
 B. JET INJECTORS
• PRINCIPLE It is based on the principle of using a mechanical
energy source to create a pressure ,sufficient to push a liquid
medication through a very small orifice so that it can penetrate
into the subcutaneous tissues without a needle.

• The solution is injected through orifice which is 7 times smaller

than the smallest available needle.
ADVANTAGES
a. Painless injection
b. Less tissue damage
c. Faster injection
d. Faster rate of drug absorption into the tissues
e. Successful in children with bleeding diatheses.
DRAWBACKS
a. Expensive equipments
b. Specialized syringes
c. Can’t be used for nerve blocks, only infiltration and surface
anesthesia are possible.
 C.INTRA-OSSEOUS ANESTHESIA
STABIDENT
• Stabident, an Intraosseous Injection delivery system has a
disadvantage that it can be used only in visible and readily
accessible area because while giving intraoral injection once the
perforator is withdrawn, it can be extremely difficult to locate the
perforation site with the anesthetic needle.
 X-TIP
• X-Tip uses the pilot drill which is a hollow tube through which a
27-gauge needle can pass.

• The initial drill stays in place, allowing the anesthetic to be placed

without hunting for the perforation that was just created.
 INTRAFLOW
• IntraFlow anesthesia system uses a single-step method which
allows entry into the penetration zone, injection, and
withdrawal in one continuous step, without the need to
relocate the perforation site.

• Reemers et al. reported that the IntraFlow system as a

primary technique provide reliable anesthesia of posterior
mandibular teeth compared with an inferior alveolar nerve
block.
 D. VIBROTACTILE DEVICES
• These devices work on the principle of ‘gate control’
theory thereby reduces pain.
VIBRAJECT
Vibraject has a battery operated device which is
attached to the standard anaesthetic syringe, causing
the syringe and needle apparatus to vibrate
 DENTAL VIBE
• Dental Vibe is a cordless hand held device which gently stimulates
the sensory receptors at the injection site causing the neural pain
gate to close.

• The tissues are vibrated before the needle penetration.

DISADVANTAGE
it is not directly attached to the syringe
and a separate unit is required,
so both hands are engaged.
 ACCUPAL

• Accupal is a cordless device which applies both vibration and

pressure at the injection site.
 E. SAFETY DENTAL SYRINGES

• It prevent the risk of accidental needle stick injury

occurring with a contaminated needle after local
anaesthesia administration.

• These syringes possess a sheath that locks over the

needle when it is removed from the patient’s tissues
preventing accidental needle stick injury.
F. DENTIPATCH [INTRAORAL LIGNOCAINE
PATCH]
• Dentipatch contains 10-20% lidocaine, which is
placed on dried mucosa for 15 minutes.
• Disadvantages include central nervous system and
cardiovascular system complications.
 CONTENTS OF LA
INGREDIENT FUNCTION
• L A agent conduction blocked
• Vasoconstrictor LA absorption into blood
• Sodium metabisulfite antioxident
• Methylparaben preservative, bacteriostatic
• Sodium chloride isotonicity of solution
• Sterile water diluent
C
O
M
P
L
I
C
A
A
T
I
O
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S
 GENERALIZED COMPLICATIONS

PSYCHOGENIC
• The most common psychogenic complication of LA is fainting.

• MANAGEMENT- sympathetic management and supine

position with legs slightly elevated.
 ALLERGY
• Very rare complication.
• Allergy can manifest in a verity of forms, ranging from a minor
localized reaction to the emergency of anaphylatic shock.
• If any suggestion that a child is allergic to LA they should be referred
to local dermatology or clinical pharmacology department.
• Taken advice for which alternative LA can be safely given to the child.
 TOXICITY

• Overdosage of LA leading to
toxicity is rarely a problem in adult
but can occur In children.

• Doses which are well below toxic

level in adult can produce
problem in children.

• All the drugs , dosages should be

related to body weight.
CLARK'S RULE
• Clark's Rule uses Weight in Lbs

FORMULA

Adult Dose X (Weight ÷ 150) = Childs Dose

Example
11 year old girl / 70 Lbs

500mg X (70 ÷ 150) = Child's Dose

500mg X .47 = 235mg

YOUNG'S RULE
• Youngs Rule uses age.

FORMULA
Adult Dose X (Age ÷ (Age+12)) = Child's Dose

DOSAGE BASED ON WEIGHT

• Based on weight in kgs.

• Example:
The prescription calls for 5mg per kg
20 x 5mg = 100mg
 CARDIOVASCULAR
EFFECTS
• Cardiovascular effects caused by the combined action of the
anaesthetic agent and vasoconstrictor.

• Their direct action on cardiac tissue and the peripheral vasculature.

• Indirectly via inhibition of the autonomic nerves that regulate

cardiac and peripheral vascular function.
 CNS EFFECTS
• The CNS is not immune to local anaesthetic agent.

• At low doses the effect is excitatory as CNS inhibitory fibers are

blocked.
• At high doses the effect is depressant and can lead to
unconsciousness and respiratory arrest.

• Fatalities due to LA overdose in children are generally the result

of central nervous tissue depression.
 METHAEMOGLOBINAEMIA

• Prilocaine causes cyanosis due to

methaemoglobinaemia.

• In this the ferrous iron of normal

haemoglobin is converted to the ferric
form, which cannot combine with
oxygen.
TREATMENT OF TOXICITY

• The best treatment of toxicity is prevention; aided by

1. Aspiration

2. Slow injection

3. Dose limitation.
• When toxic reaction occurs, the procedure is as follows:
1. Stop the dental treatment

.
2. Provide basic life support.

3. Call for medical assistance.

4. Protect the patient from injury.

5. Monitor vital signs

 DRUG INTERACTIONS

• Apparently innocuous drug combinations can interact and cause

significant problem in children.
• Example, an episode of methaemoglobinaemia has been
reported in a 3 months old child following the application of
EMLA.
• It was concluded in this case that prilocaine(in EMLA) had
interacted with a sulfonamide that the child was already
receiving.
 INFECTIONS

• The introduction of agent capable of producing a generalized

infection, such as human immunodeficiency virus(HIV)
infection and Hepatitis is a complication that should not occur
when appropriate cross-infection control measures are
employed.
 LOCALIZED COMPLICATIONS
NEEDLE BREAKAGE
• Most common with IAN block and then with PSA block.

CAUSES
1. Weakening of needle by bending
2. Unexpected movements by patient
3. Smaller gauge needles
MANAGEMENT
Fragment is visible use magill forceps or small hemostat.

Fragment not visible consult a oral surgeon.

 PARESTHESIA
• It is defined persistent anaesthesia or altered sensation well
beyond the expected duration of anaesthesia.

CAUSES
1. Trauma to any nerve or nerve sheath.
2. LA solution contaminated by alcohol.
3. Hemorrhage
MANAGEMENT
1. Be reassuring the pt, explain that it is not uncommon.
2. It normally persists for at least 2 months and may last upto 1
year.
3. Consultation with an oral surgeon or neurologist still the
sensory deficit is evident after 1 yr.
4. Dental treatment may continue.
 FACIAL NERVE PARALYSIS

• It occurs when anaesthetic introduced into the deep lobe of

parotid gland.
• It lasts no more than several hours depending on the LA
formulation, volume injected and proximity to the facial
nerve.

• Primary problem associated is persons face appears lopsided,

Unable to voluntarily close one eye.
MANAGEMENT

1. Reassure the patient, explain the situation is transient.

2. Contact lens should be removed.
3. An eye patch should be applied to the affected eye.
4. No contraindication for reanaesthetizing the pt.
 TRISMUS

• It is a prolonged tetanic spasm of the jaw muscle(locked jaw).

CAUSES
1. Most common etiologic factor is trauma to muscle or blood
vessels.
2. LA solution contaminated with alcohol.
3. Hemorrhage
4. Low grade infections after injection.
5. Multiple needle penetrations.
MANAGEMENT
• Heat therapy
• Warm saline rinses
• Analgesic
• Muscle relaxants
• Initiate physiotherapy

• Complete recovery may take about 6 weeks (4-20weeks)

• Surgical intervention to correct chronic dysfunction.
 SOFT TISSUE INJURY
• Lip and tongue are the most frequent sites involved.
• Caused by biting and chewing these tissues while still
anaesthetized.
• Trauma to anaesthetized tissue can lead to swelling and
significant pain when the anaesthetic effect resolves.

PREVENTION
• A cotton roll can be placed between the lip and teeth if they
are still anaesthetized at the time of discharge.
MANAGEMENT
It involves symptomatic treatment:
1. Analgesics for pain
2. Antibiotics
3. Lukewarm saline rinses
4. Petroleum jelly or other lubricants to minimize irritation.
 HEMATOMA
• The effusion of blood into extravascular spaces.
• Hematoma after the nicking of artery increases rapidly in size
then vein.
• Size also depends on the density of the surrounding tissue.
PROBLEM
• Complications include trismus and pain.
• Discoloration and swelling subside within 7-14 days.
• Hematoma associated with PSA block can be avoided by using
shorter needles.

MANAGEMENT
Immediate
• Direct pressure applied to the site of bleeding.
• Pressure applied should not be less then 2mins.
• IAN block pressure applied to the medial aspect of the
mandibular ramus.

• Infraorbital pressure applied to the skin over the foramen.

• Mental block pressure applied on mucosa or skin over the

foramen.

• PSA block apply pressure in medial and superior direction.

Subsequent
• Advice the pt not to apply heat for at least 4-6 hrs.

• Ice may be applied to the region immediately on recognition

of developing hematoma( analgesic and vasoconstrictor).

• With or without treatment hematoma will present for 7-14

days.
 PAIN ON INJECTION
CAUSES
• Careless injection techniques
• Use of dull needles
• Rapid deposition of LA
• Needles with barbs
PROBLEM
• Increased pt anxiety lead to sudden movements , risk of
needle breakage.

• No management is necessary.
 BURNING ON INJECTION
CAUSES
• Primary cause of mild burning sensation is the pH of LA
solution.
• Rapid injection of LA
• Contamination of LA cartridges
• Solutions warmed to normal body temperature.

 No treatment ,because it is transient and do not lead to

prolonged tissue involvement.
 INFECTION

CAUSES
• Contamination of the needle.
• Injecting LA solution into an area of infection.

MANAGEMENT
• Pts usually reports postinjection pain and dysfunction 1 or
more days after dental care.
• Keep the pt on anatibiotics for about 7-10 days.
 EDEMA
CAUSES
1. Trauma during injection
2. Infection
3. Allergy
4. Hemorrhage
5. Injection of irritating solutions
6. Hereditary angioedema
PROBLEM
• Edema is intense enough to produce airway obstruction.
MANAGEMENT
• Edema caused by traumatic injection or irritating solutions it
resolves in several days without formal treatment .
• After hemorrhage 7-14 days
• Edema by infection does not resolve but may become more
progressively intense, antibiotic therapy should be instituted.
• Allergy induced edema is potentially life threatening.
 SLOUGHING OF TISSUES
• Prolonged irritation or ischemia of gingival soft tissue.
CAUSES
1. Epithelial desqumation
2. Sterile abscess
MANAGEMENT
• Reasure the patient
• Symptomatic treatment: for pain aspirine or codeine and a
topically applied ointment(orabase) to reduce the irritation.
• Epithelial desquamation resolves within few days.
• Sterile abscess may run 7 to 10 days
 POSTANAESTHETIC INTRAORAL LESIONS
• This is the latent form of the disease process that was present
in the tissue before the injection.
• Patient report approximately 2 days after intraoral injection.
CAUSES
• Recurrent aphthous stomatitis
• Herpes simplex
MANAGEMENT
• Primary management is symptomatic.
• Objective is to keep the ulcerated area covered or
anesthetized.
 CONTRAINDICATIONS OF LA
• In certain children some LA agents will be contraindicated and
in others, specific techniques are not advised.

GENERAL CONTRAINDICATIONS
• Immaturity
• Mental or physical handicap
• Treatment factors
SPECIFIC CONTRAINDICATIONS

BISULFITE ALLERGY
• All esters and vasoconstrictor drugs (absolute)

• Amide group without vasoconstrictor

ATYPICAL PLASMA CHOLINESTERASE

• Esters (relative)

• Amide
METHEMOGLOBINEMIA
• Prilocaine(relative)

• Other amides and esters

LIVER DYSFUNCTION
• Amides (relative)

• Amides or esters
CARDIOVASCULAR AND HYPERTHYROIDISM
• High concentration of vasoconstrictors (relative)

• LA with epinephrine conc. Of 1:100,000 or 1:200,000 or

mepivacaine 3% or prilocaine 4%

RENAL DYSFUNCTION
• Amides or esters (relative)

• Amides or esters
POOR BLOOD SUPPLY
• Vasoconstrictor containing LA solutions like after
therapeutic irradiation.

SPECIFIC TECHNIQUES
• Bleeding diatheses
• Incomplete root formation
• Epilepsy : Therapeutic dosages do not interact with standard
antiepileptic drugs.
Electro-analgesia
 CONCLUSION
When pain free reliable local anaesthesia is achieved
in children confidence is gained by both the child and
operator, and a sound satisfactory professional
relationship is established.
References
1. Text book of Pediatric dentistry, 4th edition,
Richard Welbury.
2. Text book of Dentistry for the child and
adolescent, 1st asia edition, Jeffery A. Dean.
3. Text book of Local anaesthesia, 7th edition,
Richard C. Bennet.
4. Text book of Local anaesthesia, malamed, 5th
edition, stanely F. malamed.

5. Hochman MN, Chiarello D, Hochman CB,

Lopatkin R, Pergola S. Computerized Local
Anesthesia Delivery vs. Traditional Syringe
Technique. NY State Dent J. 1997;63:24-9.
6. Ferrari M, Cagidiaco MC, Vichi A, Goracci C.
Efficacy of the Computer-Controlled Injection
System STATM, and the dental syringe for
intraligamentary anesthesia in restorative
patients. Inter Dent SA. 2008;11(1):4-12.
7. Friedman MJ, Hochman MN. P-ASA block injection: a new palatal technique to
anesthetize maxillary anterior teeth. J Esthet Dent. 1999;11(2):63-71. 6.
8. Ran D, Peretz B. Assessing the pain reaction of children receiving periodontal
ligament anesthesia using a computerized device (Wand). J Clin Pediatr Dent.
2003;27(3):247-50.
9. Remmers T, Glickman G, Spears R, He J. The efficacy of IntraFlow intraosseous
injection as a primary anesthesia technique. J Endod 2008;34:280-3.
10. Nanitsos E, Vartuli R, Forte A, Dennison PJ, Peck CC: The effect of vibration on
pain during local anaesthesia injections. Aust Dent J 2010, 54:94-100.
11. Blair J. Vibraject from ITL dental. Dent Econ. 2002;92:90
12. Ogle OE, Mahjoubi G. Advances in local anesthesia in dentistry. Dent Clin
North Am 2011;55:481-99.
1. The most effective topical anaesthetic is
a. Lignocaine
b. Tetracaine
c. Ethyl amino benzoate
d. Dyclonine
2. Jet injection was introduced by
a. Figge and Scherer (1947)
b. Schroeder (1948)
c. Mckay (1952)
d. Frank (1966)
3. Gow gates mandibular block technique
anaesthetizes all EXCEPT
a. mandibular molars
b. Mylohyoid
c. Premolar
d. Mandibular incisors
4. Which of the following are advantages of intra
ligamentary injection
a. provides reliable pain control rapidly and easily
b. It provides pulpal anaesthesia for 30-45 minutes
c. it may be useful in young or disabled patients
where the postoperative trauma is common
d. useful in patients with bleeding disorders
e. all of the above
5. The maximum dose of lignocaine which can
be administered
a. 4.4 mg/kg body weight
b. 2 mg/kg body weight
c. 6.4 mg/kg body weight
d. 2 gm/kg body weight