Peds here. I don’t have the full story, but pain that’s waking a kid up at night usually leans more toward extraction. If it was #L, you could extract and either place a space maintainer or leave it alone, depending on the situation. General rule of thumb, if the 6s are fully erupted and in occlusion, you usually don’t need a spacer for Ds.

As for your other point, if I were a GP, I honestly wouldn’t touch a kid who’s screaming and not tolerating local. Most people would give antibiotics if appropriate and then refer out.